Veasey Tara M, Floroff Catherine K, Strout Sara E, McElray Krista L, Brisco-Bacik Meredith A, Cook Jennifer L, Toole John M, Craig Michael L, Van Bakel Adrian B, Meadows Holly B, Uber Walter E
Department of Pharmacy Services, Allegheny General Hospital, Pittsburgh, Pennsylvania.
Department of Pharmacy Services, Sentara Norfolk General Hospital, Norfolk, Virginia.
Artif Organs. 2019 Aug;43(8):736-744. doi: 10.1111/aor.13456. Epub 2019 Apr 24.
Continuous-flow left ventricular assist device (LVAD) placement has become a standard of care in advanced heart failure treatment. Bleeding is the most frequently reported adverse event after LVAD implantation and may be increased by antithrombotic agents used for prevention of pump thrombosis. This retrospective cohort included 85 adult patients implanted with a Heartmate II LVAD. Major bleeding was defined as occurring >7 days after implant and included intracranial hemorrhage, events requiring 2 units of packed red blood cells within a 24-h period, and death from bleeding. Primary outcome was intensity of anticoagulation between patients with or without at least one incidence of nonsurgical major bleeding. Major bleeding occurred in 35 (41%) patients with 0.48 events per patient year and a median (IQR) time to first bleed of 134.5 (39.3, 368.5) days. The median (IQR) INR at time of bleed was 1.7 (1.4, 2.5). Median INR during follow-up did not differ between groups and patients with major bleeding were not more likely to have a supra-therapeutic INR. Patients who bled were more likely to have received LVAD for destination therapy, to have lower weight, worse renal function, and lower hemoglobin at baseline. Duration of LVAD support and survival were similar between groups with no difference in occurrence of thrombosis. Incidence of nonsurgical major bleeding was not significantly associated with degree of anticoagulation. Certain baseline characteristics may be more important than anticoagulation intensity to identify patients at risk for bleeding after LVAD implant. Modification of anticoagulation alone is not a sufficient management strategy and early intervention may be required to mitigate bleeding impact.
持续血流左心室辅助装置（LVAD）置入已成为晚期心力衰竭治疗的标准治疗方法。出血是LVAD植入后最常报告的不良事件，用于预防泵血栓形成的抗血栓药物可能会增加出血风险。这项回顾性队列研究纳入了85例植入Heartmate II LVAD的成年患者。非手术大出血定义为植入后7天以上发生的出血，包括颅内出血、24小时内需输注2单位浓缩红细胞的事件以及因出血导致的死亡。主要结局是有无至少一次非手术大出血事件的患者之间的抗凝强度。35例（41%）患者发生了大出血，每位患者每年的大出血事件发生率为0.48次，首次出血的中位（IQR）时间为134.5（39.3，368.5）天。出血时的中位（IQR）国际标准化比值（INR）为1.7（1.4，2.5）。随访期间的中位INR在两组之间无差异，大出血患者的INR超过治疗范围的可能性并不更高。发生出血的患者更有可能接受LVAD作为目标治疗，基线体重更低、肾功能更差且血红蛋白水平更低。两组之间LVAD支持的持续时间和生存率相似，血栓形成的发生率无差异。非手术大出血的发生率与抗凝程度无显著相关性。某些基线特征可能比抗凝强度更重要，有助于识别LVAD植入后出血风险较高的患者。仅调整抗凝并非充分的管理策略，可能需要早期干预以减轻出血影响。
