Medication management for left ventricular assist device thrombosis

Current strategies for prevention and treatment of "pump thrombosis" associated with the use of left ventricular assist devices (LVADs) are discussed.

LVADs provide morbidity, mortality, and quality-of-life benefits in patients with advanced heart failure. Since continuous-flow LVADs came into wide use, there have been increased reports of pump thrombosis (clot formation in the LVAD system that can lead to pump dysfunction and clinical complications). Anticoagulation and antiplatelet therapies are important for preventing pump thrombosis, although the optimal antithrombotic regimen remains unclear. International Normalized Ratio goals should be determined according to specific device characteristics and patient risk factors. Medication therapy for pump thrombosis provides a less invasive option than surgical pump exchange or heart transplantation but is associated with high risks of bleeding events, recurrent pump thrombosis, and mortality. Decisions regarding medical versus surgical management should be based on clinical status and surgical candidacy. Management of pump thrombosis may include intensified i.v. anticoagulation, i.v. or intraventricular thrombolytics, or glycoprotein IIb/IIIa inhibitors. Optimization and close monitoring of anticoagulation and antiplatelet therapy can help reduce the risk of pump thrombosis.

Intensive clinical and laboratory monitoring are important in identifying signs and symptoms of LVAD thrombosis. Medical management of LVAD thrombosis can be considered an early treatment strategy before thrombi become too large and unresponsive to pharmacotherapies, but antithrombotic medications carry a high risk of bleeding complications and should be used judiciously. More definitive treatment with pump exchange or heart transplantation in appropriate candidates may be required.