Impact of Delayed Heparin Bridging on Bleeding and Stroke After Left Ventricular Assist Device Implantation

Although the latest generation left ventricular assist device (LVAD) HeartMate 3 carries a lower thromboembolic risk than earlier devices, reoperations for early postoperative bleeding remain common. In an effort to reduce early bleeding, we revised our anticoagulation strategy by delaying early heparin bridging. In this single-center retrospective study, we compared two anticoagulation protocols after HeartMate 3 implantation. Under the old protocol, heparin was initiated 24-48 hours after implantation if chest drain output was acceptable. In May 2022, our protocol was revised to withhold unfractionated heparin for greater than or equal to 48 hours after implantation. The primary efficacy endpoint was early (< 30 days) postoperative bleeding requiring reoperation. The primary safety endpoint was early ischemic stroke. We analyzed 193 consecutive patients (106 old protocol, 87 new). The 30 day cumulative incidence of early bleeding requiring reoperation was lower with the new protocol (42.4% vs. 24.1%, p = 0.006). Stroke incidence did not differ significantly (6.6% vs. 8.0%, p = 0.72). Total hospital stay (28 vs. 24 days, p = 0.04) and intensive care unit (ICU) stay (7 vs. 5 days, p = 0.03) were shorter with the new protocol. Delaying heparin initiation beyond 48 hours after HeartMate 3 implantation was associated with reduced early bleeding-related reoperations and shorter ICU and hospital stays, without a significant increase in stroke risk.