Anticoagulation for Percutaneous Ventricular Assist Device-Supported Cardiogenic Shock: JACC Review Topic of the Week.

Interest in the use of mechanical circulatory support for patients presenting with cardiogenic shock is growing rapidly. The Impella (Abiomed Inc), a microaxial, continuous-flow, short-term, ventricular assist device (VAD), requires meticulous postimplantation management. Because systemic anticoagulation is needed to prevent pump thrombosis, patients are exposed to increased bleeding risk, further aggravated by sepsis, thrombocytopenia, and high shear stress-induced acquired von Willebrand syndrome. The precarious balance between bleeding and thrombosis in percutaneous VAD-supported cardiogenic shock patients is often the main reason that patient outcomes are jeopardized, and there is a lack of data addressing optimal anticoagulation management strategies during percutaneous VAD support. Here, we present a parallel anti-Factor Xa/activated partial thromboplastin time-guided anticoagulation algorithm and discuss pitfalls of heparin monitoring in critically ill patients. This review will guide physicians toward a more standardized (anti)coagulation approach to tackle device-related morbidity and mortality in this critically ill patient group.

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Funding Support and Author Disclosures Drs Vandenbriele, Meyns, Chieffo, Schrage, and Westermann have received research and/or travel funding, as well as speaker fees, from Abiomed outside of this paper. Dr Vandenbriele has received grant support from University Hospitals Leuven (Klinische onderzoeks-en opleidingsraad); and is funded by MRC Uk (MR/V037633/1). Dr Polzin has received support from the Forschungskommission of the Medical Faculty of the Heinrich Heine University (No. 18-2019) and from the German Research Foundation (PO 2247/2-1 and SFB1116). Dr Vranckx has received personal fees from Bayer, Daiichi-Sankyo, and CLS Behring. Dr Schrage has received speaker fees from AstraZeneca. Dr Chieffo has received consultant/speaker fees from Abbott, Biosensor, Boston Scientific, Edwards, and Magenta. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.