Reduction of Haemorrhagic Complications during Mechanically Assisted Circulation with the Use of a Multi-System Anticoagulation Protocol

Abstract

Two different anticoagulation protocols were used in 49 consecutive patients mechanically supported either for bridge to transplantation (11) or for recovery of myocardial function after cardiac surgery (35). In 46 patients a Biomedicus centrifugal pump was used and in 3 patients a Pierce-Donachy ventricles. Mechanical support was provided to the left ventricle in 14 patients, to the right ventricle in 6 and to both ventricles in 12 patients; an extra-corporeal membrane oxygenator (ECMO) support was used in 17 patients. Thirty-seven males and 12 females, aged 0.2 to 58 years, were supported for an average time of 6.3 days (range 1-43). Anticoagulation was either based on a continuous infusion of heparin in the first 27 patients (group A) or on a multi-system therapy (“La Pitié” protocol) in the other 22 patients (group B). Overall survival rate was 47%. Patients in group A had a 30% (8/27) survival rate, whereas in group B a 68% (15/22) survival rate was observed (p=0.006). Transplantation and ventricular assist device (VAD) removal was successfully obtained in 59% (16/27) and 91% (20/22) of patients in group A and group B respectively (p=0.05). Significant bleeding occurred in 21 patients (81%) in group A and in 2 (9%) of group B (p=0.001). In these patients bleeding averaged 230 ± 231 ml/kg in group A versus 55 ± 18 ml/kg in group B (p=0.001). Surgical revision was necessary for cardiac tamponade or persistent bleeding in 12 patients of group A (25 procedures: mean 0.9/ patient) and in 3 patients of group B (one each patient: mean 0.1/patient) (p=0.01). Infection, thrombo-embolism and brain hemorrhage were also less frequent in group A than in group B. Our data suggest that the “La Pitié” protocol provides a better control of bleeding than the conventional heparin infusion in patients receiving assist device, this reduction in thrombo-hemorrhagic complications might improve the results of mechanical circulatory support.