title: The use of eptifibatide for suspected pump thrombus or thrombosis in patients with left ventricular assist devices.
abstract: BACKGROUND
  Pump thrombosis in patients with left ventricular assist devices (LVADs) continues to present treatment challenges. Anti-coagulation strategies used to treat this complication are empiric and without firm data for guidance. The addition of a platelet glycoprotein IIb/IIIa inhibitor to intravenous anti-coagulation has been suggested by several case series and recent guidelines. The aim of this study was to evaluate our use of eptifibatide for the treatment of suspected pump thrombus/thrombosis.
  
  
  METHODS
  This retrospective, single-center cohort study was performed at Barnes-Jewish Hospital. The medical informatics system was queried to identify all LVAD patients who received eptifibatide for suspected pump thrombus/thrombosis from January 1, 2011, through April 30, 2013.
  
  
  RESULTS
  A total of 17 patients (16 HeartMate II [Thoratec, Pleasanton, CA], 1 HeartWare [HeartWare International Inc, Framingham, MA]) with 22 separate administration attempts received eptifibatide (dose range, 0.1-2 μg/kg/min) for suspected pump thrombus/thrombosis presenting as one or more of the following findings: elevated lactate dehydrogenase, decreased haptoglobin, elevated plasma free hemoglobin, LVAD dysfunction, or new, persistently high LVAD power. The mean time from device implantation to eptifibatide therapy was 47.34 days (range, 3.88-397.67 days). Of the 22 attempts, 5 (22.7%) resulted in resolution of 1 or more patient-specific indicators of LVAD thrombus/thrombosis. Three patients (17.6%) had resolution of an indicator while also remaining free from continued hemolysis, death, pump exchange, or emergent heart transplant. Bleeding events were common, with 11 patients (64.7%) experiencing bleeding during the infusion. Seven patients (41.2%) died, with intraparenchymal hemorrhage as the cause of death in 2 patients. Pump exchange was performed in 3 patients.
  
  
  CONCLUSIONS
  Our limited experience indicates the risk of using eptifibatide outweighs the proposed benefit of salvaging the existing LVAD in the setting of suspected pump thrombus/thrombosis at our institution.
authors.affiliation: Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri. Electronic address: brt2093@bjc.org.
authors.forename: Bethany R
authors.initials: BR
authors.lastname: Tellor
authors.affiliation: Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri.
authors.forename: Jennifer R
authors.initials: JR
authors.lastname: Smith
authors.affiliation: Department of Cardiothoracic Surgery, Washington University, St. Louis, Missouri.
authors.forename: Sunil M
authors.initials: SM
authors.lastname: Prasad
authors.affiliation: Department of Cardiology, Washington University, St. Louis, Missouri.
authors.forename: Susan M
authors.initials: SM
authors.lastname: Joseph
authors.affiliation: Department of Cardiothoracic Surgery, Washington University, St. Louis, Missouri.
authors.forename: Scott C
authors.initials: SC
authors.lastname: Silvestry
mesh_terms: D000328:Adult; D000368:Aged; D015415:Biomarkers / Q000097:blood; D015331:Cohort Studies; D000077542:Eptifibatide; D005260:Female; D006242:Haptoglobins / Q000378:metabolism; D006333:Heart Failure / Q000628:therapy*; D006353:Heart-Assist Devices / Q000009:adverse effects*; D006454:Hemoglobins / Q000378:metabolism; D006470:Hemorrhage / Q000453:epidemiology; D006801:Humans; D015994:Incidence; D007770:L-Lactate Dehydrogenase / Q000097:blood; D008297:Male; D008875:Middle Aged; D010455:Peptides / Q000627:therapeutic use*; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use*; D012189:Retrospective Studies; D013927:Thrombosis / Q000188:drug therapy* / Q000209:etiology*; D016896:Treatment Outcome; D018487:Ventricular Dysfunction, Left / Q000628:therapy*
chemical_list: D015415:Biomarkers; D006242:Haptoglobins; D006454:Hemoglobins; D010455:Peptides; D010975:Platelet Aggregation Inhibitors; D007770:L-Lactate Dehydrogenase; D000077542:Eptifibatide
keywords: anti-coagulation; bleeding; eptifibatide; left ventricular assist device; pump thrombosis