HeartWare™ HVAD support without anticoagulation

Ventricular assist devices (VADs) are being increasingly used in pediatric patients as a bridge to heart transplant (HTx ) candidacy, significantly reducing waitlist mortality. We report a case of an 8-year-old girl with high-grade osteosarcoma who developed anthracycline-induced cardiomyopathy (AC), leading to acute systolic heart failure. Due to persistent dual-inotropic dependence, a HeartWare™ left ventricular assist device (HVAD) was placed. Complicating her course, she experienced a local recurrence of her malignancy, necessitating further chemotherapy. While on anticoagulation for her HVAD and due to thrombocytopenia, she developed refractory epistaxis which required discontinuation of anticoagulant and antiplatelet agents for over 110 days. After 21 months of remission, she was listed status 1A for HTx and successfully received a transplant after a 3-month wait. Our experience suggests that with careful clinical and laboratory monitoring, durable HVAD support can be maintained in certain critical situations, without the use of anticoagulant or antiplatelet agents. This case underscores the importance of a multidisciplinary team approach, along with enhanced patient and family education, to minimize complications and optimize outcomes. We also highlight the evolving antithrombotic strategies in VAD patients, with Antiplatelet Removal and Hemocompatibility Events with a HeartMate 3 (ARIES-HM3) trial supporting aspirin avoidance; however, applying these results to other VADs warrants considerable caution.