title: Activated Hemostatic Biomarkers in Patients with Implanted Left Ventricle Assist Devices: Are Heparin and/or Clopidogrel Justified?
abstract: BACKGROUND
  Adequate anticoagulation represents a major problem for left ventricle assist device (LVAD) utilization in patients awaiting heart transplantation as well as for regeneration of the native heart. The proper management of hemostatic abnormalities during LVAD support may improve survival by reducing the incidence of hemorrhagic and/or thromboembolic complications.
  
  
  METHODS
  A 40-year-old man with implanted pulsatile LVAD due to dilated cardiomyopathy received aspirin and warfarin. The patient underwent serial weekly monitoring of hemostatic biomarkers including international normalization ratio, prothrombin time, prothrombin activity, activated partial thromboplastin time, fibrinogen, D-dimer, platelet aggregation induced by adenosine diphosphate and arachidonic acid, platelet count, and mean platelet volume. The external pump was exchanged three times - twice because of a clot formation in the blood chamber of the pump, and once according to the standard protocol.
  
  
  RESULTS
  LVAD use was consistently associated with enhanced adenosine diphosphate-induced platelet aggregation independent from the timing of clot formation or external pump exchange. Among coagulation indices, increased D-dimer holds predictive value for clot formation. The fibrinogen level peaked before the first pump exchange and was twice as high than the average values. Gradual improvement in exercise capacity was observed 2 years after implantation, after which the patient underwent a controlled stress test in the stop mode of the LVAD and the device was successfully explanted.
  
  
  CONCLUSIONS
  Serial assessment of hemostatic biomarkers may benefit and triage LVAD patients. Consistent platelet activation during long-term LVAD may justify the addition of clopidogrel, while high D-dimer and/or elevated fibrinogen may indicate adding heparin to the conventional antithrombotic regimen. Randomized evidence is needed to test such a hypothesis.
authors.affiliation: Department of Cardiac Surgery and Transplantation, Division of Advanced Heart Failure and Mechanical Circulatory Support, Silesian Center for Heart Disease, Zabrze, Poland.
authors.forename: Jerzy
authors.initials: J
authors.lastname: Pacholewicz
authors.forename: Wiktor
authors.initials: W
authors.lastname: Kuliczkowski
authors.forename: Jacek
authors.initials: J
authors.lastname: Kaczmarski
authors.forename: Michał
authors.initials: M
authors.lastname: Zakliczyński
authors.forename: Marcin
authors.initials: M
authors.lastname: Garbacz
authors.forename: Marian
authors.initials: M
authors.lastname: Zembala
authors.forename: Victor
authors.initials: V
authors.lastname: Serebruany
mesh_terms: D000328:Adult; D000925:Anticoagulants / Q000627:therapeutic use*; D001241:Aspirin / Q000627:therapeutic use; D015415:Biomarkers / Q000097:blood*; D000077144:Clopidogrel; D004359:Drug Therapy, Combination; D005338:Fibrin Fibrinogen Degradation Products; D005340:Fibrinogen; D006333:Heart Failure / Q000097:blood*; D006352:Heart Ventricles / Q000601:surgery; D006353:Heart-Assist Devices / Q000009:adverse effects*; D006493:Heparin / Q000627:therapeutic use*; D006801:Humans; D008297:Male; D015539:Platelet Activation / Q000187:drug effects; D010974:Platelet Aggregation / Q000187:drug effects; D013988:Ticlopidine / Q000031:analogs & derivatives* / Q000627:therapeutic use; D014859:Warfarin / Q000627:therapeutic use
chemical_list: D000925:Anticoagulants; D015415:Biomarkers; D005338:Fibrin Fibrinogen Degradation Products; C036309:fibrin fragment D; D014859:Warfarin; D005340:Fibrinogen; D006493:Heparin; D000077144:Clopidogrel; D013988:Ticlopidine; D001241:Aspirin