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Anticoagulant Bridge Comparison in Mechanical Circulatory Support Patients

Cosgrove, Richard H.*; Basken, Robyn L.*; Smith, Richard G.; Hsu, Chiu-Hsieh; Kazui, Toshinobu§; Martinez, Brandon K.*; Burt, Richard W.§; Crawford, Eric S.§; Lick, Scott D.§; Khalpey, Zain§

doi: 10.1097/MAT.0000000000000747
Adult Circulatory Support

Maintaining mechanical circulatory support (MCS) device patients in a specified therapeutic range for anticoagulation remains challenging. Subtherapeutic international normalized ratios (INRs) occur frequently while on warfarin therapy. An effective anticoagulant bridge strategy may improve the care of these patients. This retrospective review of MCS patients with subtherapeutic INRs compared an intravenous unfractionated heparin (UFH) strategy with a subcutaneous enoxaparin or fondaparinux strategy. Native thromboelastography (n-TEG) was used to evaluate anticoagulant effect with coagulation index (CI) as the primary outcome measure. Enoxaparin 0.5 mg/kg subcutaneously (SC) every 12 hours or fondaparinux 2.5–5 mg SC daily were compared with an initial UFH rate of 5 units/kg/hr and titrated to stated n-TEG goal range. The anticoagulant groups UFH, enoxaparin, and fondaparinux were found to be statistically similar with regard to frequency in n-TEG goal range, above range (hypercoagulability), or below range (hypocoagulability). Clinical outcomes were similar among groups with three gastrointestinal bleeds in UFH, one in enoxaparin, and one in fondaparinux groups. Device thrombosis occurred in one UFH patient, while UFH and fondaparinux groups had one ischemic cerebrovascular accident event each. These strategies provided comparable n-TEG results and clinical outcomes when compared with intravenous UFH. Low-dose enoxaparin or fondaparinux may provide an alternative anticoagulant bridging option in MCS patients presenting with subtherapeutic INR.

From the *Department of Pharmacy, Banner University Medical Center Tucson, Tucson, Arizona

Artificial Heart Department, Banner University Medical Center Tucson, Tucson, Arizona

Department of Epidemiology and biostatistics, University of Arizona, Tucson, Arizona

§Division of Cardiothoracic Surgery, Department of Surgery, University of Arizona, Tucson, Arizona.

Submitted for consideration May 2017; accepted for publication in revised form December 2017.

Disclosure: The authors have no conflicts of interest to report.

Correspondence: Richard H. Cosgrove, Department of Pharmacy, Banner University Medical Center Tucson, 1501 North Campbell Avenue, Tucson, AZ 85724. Email:

Copyright © 2019 by the American Society for Artificial Internal Organs