Rossi Michele, Serraino Giuseppe Filiberto, Jiritano Federica, Renzulli Attilio
Department of Cardiac Surgery, Magna Graecia University, Catanzaro, Italy.
Interact Cardiovasc Thorac Surg. 2012 Oct;15(4):733-40. doi: 10.1093/icvts/ivs297. Epub 2012 Jul 3.
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether there is an optimal antithrombotic management for patients supported with axial-flow left ventricular assist devices (LVADs). Altogether, more than 758 papers were found using the reported search, of which 17 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. These included seven prospective and three retrospective cohort studies with a total of 538 patients with axial-flow left ventricular assist device (LVAD) (HeartMate II, Jarvik 2000, INCOR, Thoratec assist device) implanted across the world as destination therapy or bridge to transplantation. We conclude that there is a substantial alteration of the prothrombotic profile in patients with axial-flow LVADs. These abnormalities appeared to be reversible with the removal of the device and are likely to be responsible for the high incidence of non-surgical bleeding episodes reported. Warfarin seems to offer a lower thromboembolic risk compared with unfractioned heparin or low molecular weight heparin. There are reports that suggest that managing axial-flow LVAD without anticoagulation, after major bleeding complications, is possible but in all probability, these papers are subject to publication bias as poor outcomes are unlikely to have been reported. All patients with axial-flow LVAD, showed severely impaired platelet function at point of care tests. The use of warfarin (INR target 2.5), in association with aspirin at 100 mg/day, or with point-of-care tests titrated antiplatelet therapy to inhibit 70%, seems to have the best bleeding-thrombosis, and in many cases a very small dose of aspirin of 25 mg twice a day and a dose of clopidogrel of 35 mg/day, were sufficient to achieve a reduction of the maximum aggregation to less than 30%. Finally, we would like to emphasize that such recommendations are addressed only to patients with axial-flow LVAD.
一篇心脏外科的最佳证据主题文章是根据结构化方案撰写的。所探讨的问题是，对于接受轴流式左心室辅助装置（LVAD）支持的患者，是否存在最佳的抗栓治疗方案。通过报告的检索方式，共找到758多篇论文，其中17篇代表了回答该临床问题的最佳证据。现将这些论文的作者、期刊、发表日期、国家、研究的患者群体、研究类型、相关结局和结果制成表格。这些研究包括7项前瞻性队列研究和3项回顾性队列研究，共有538例植入轴流式左心室辅助装置（LVAD）（HeartMate II、Jarvik 2000、INCOR、Thoratec辅助装置）的患者，这些患者分布于世界各地，作为终末期治疗或移植桥梁。我们得出结论，轴流式LVAD患者的促血栓形成特征有显著改变。这些异常在移除装置后似乎是可逆的，并且可能是所报道的非手术出血事件高发生率的原因。与普通肝素或低分子肝素相比，华法林似乎具有较低的血栓栓塞风险。有报告表明，在发生重大出血并发症后，不进行抗凝治疗来管理轴流式LVAD是可行的，但很可能这些论文存在发表偏倚，因为不良结局不太可能被报道。所有轴流式LVAD患者在即时检验时均显示血小板功能严重受损。使用华法林（国际标准化比值目标为2.5），联合每日100毫克阿司匹林，或使用即时检验滴定抗血小板治疗以抑制70%，似乎具有最佳的出血 - 血栓形成平衡，并且在许多情况下，每日两次25毫克的小剂量阿司匹林和每日35毫克的氯吡格雷剂量足以将最大聚集率降低至低于30%。最后，我们想强调，此类建议仅适用于轴流式LVAD患者。
