Montalto A, Comisso M, Cammardella A, Nicolò Francesca, Gherli R, Palermo A, Pulcinelli F, Musumeci F
Department of Cardiac Surgery and Heart Transplantation, San Camillo Hospital, Rome, Italy.
Department of Cardiac Surgery and Heart Transplantation, San Camillo Hospital, Rome, Italy.
Transplant Proc. 2019 Nov;51(9):2986-2990. doi: 10.1016/j.transproceed.2019.04.099.
Left ventricular assist device (LVAD) management is very challenging since many adverse events can occur in ongoing patients. Inadequate anticoagulation treatment can lead to life-threatening situations like ischemic stroke or pump thrombosis. The main intention of our study was to investigate if early identification of aspirin nonresponders by using aggregometry can improve anticoagulation management, reducing the risk of pump thrombosis.
From December 2010 to May 2018, 24 patients were implanted with a HeartMate II (HMII), 6 received a HeartWare HVAD system--full support VAD (HVAD), and 22 received a HeartMate III (HMIII). All patients were maintained with a target INR of 2.0 to 3.0. When the aggregometry test revealed a normal platelet function, 100 mg of aspirin were initiated. Only aspirin nonresponders were early identified by repeating the aggregometry after 7 days of aspirin administration. In acetylsalicylic acid nonresponder patients, 75 mg of clopidogrel was used, and the patients were tested again. Ticlopidine (250 mg) was used when clopidogrel was unsuccessful.
Four patients required modification in antiplatelet therapy. Three patients (5%), 2 HVAD and 1 HMII, suffered from pump thrombosis. One patient died as a consequence of a large intracranial hemorrhagic event following thrombolytic treatment. One patient required a pump exchange; in 1 patient, thrombolytic infusion was conducted successfully.
Reported rates of pump thrombosis at 12 months for patients implanted with commonly used LVADs were 6% to 12% for axial-flow pumps and 8% with centrifugal-flow devices. In our series, the reported 5% overall incidence of pump thrombosis encourages the routine use of an aggregometry test for early identification of aspirin nonresponders.
左心室辅助装置（LVAD）的管理极具挑战性，因为在使用该装置的患者中可能会发生许多不良事件。抗凝治疗不足可能导致危及生命的情况，如缺血性中风或泵血栓形成。我们研究的主要目的是调查通过血小板聚集试验早期识别阿司匹林无反应者是否能改善抗凝管理，降低泵血栓形成的风险。
2010年12月至2018年5月，24例患者植入了HeartMate II（HMII），6例接受了HeartWare HVAD系统——全支持VAD（HVAD），22例接受了HeartMate III（HMIII）。所有患者的国际标准化比值（INR）目标维持在2.0至3.0。当血小板聚集试验显示血小板功能正常时，开始服用100毫克阿司匹林。仅在阿司匹林给药7天后重复血小板聚集试验，早期识别阿司匹林无反应者。对于乙酰水杨酸无反应的患者，使用75毫克氯吡格雷，并再次对患者进行检测。当氯吡格雷治疗无效时，使用噻氯匹定（250毫克）。
4例患者需要调整抗血小板治疗。3例患者（5%），2例HVAD和1例HMII，发生了泵血栓形成。1例患者因溶栓治疗后发生大面积颅内出血事件死亡。1例患者需要更换泵；1例患者成功进行了溶栓输注。
对于植入常用LVAD的患者，轴流泵在12个月时报告的泵血栓形成率为6%至12%，离心流装置为8%。在我们的系列研究中，报告的5%的泵血栓形成总发生率鼓励常规使用血小板聚集试验来早期识别阿司匹林无反应者。
