XXX HEALTHCARE
CENTERFORTRANSPLANTATION / POLICY/PROCEDURETITLE: VADPatient
Anticoagulation Protocol
DISTRIBUTETO: / []ADMINISTRATIVE[X]CLINICAL
PAGE1OF3
RELATEDTO:
[X]PatientCare[X ]TJC
[]NursingPractice[]Title22[]MedCtrPolicy(MCP)Stds[]QA
[]Other[]UNOS
[]CMS / EffectiveDate:ReviewedorRevised:10/1/2010
Unit/DepartmentofOrigin:CenterforTransplantation–HeartTransplantandVADprogram
OtherApproval:
Policy/ProcedureCommitteeApproval:

I.PURPOSE

ToprovideguidelinesforthemanagementofpatientswithimmediateorpriorhistoryofVentricularAssistDevice(VAD)placement.

II.INDICATIONS

Patientwithanticoagulant/antiplatelettherapypost-VAD(HMII-BTTorDTTAH)placement.

III.TREATMENTGUIDELINES

HeartmateII

TheHeartMateIIhasuniqueanticoagulantproperties,includingacquiredvonWillebranddiseaseandproteolyticcleaving,whichaffectshowanticoagulationismanaged.

1.LabData

a.CBCstatonarrivaltoICU;thenevery6hoursx24hours;thendailywhileinICU

b.PT,PTT,INRstatonarrivaltoICU;thenevery6hoursx24hours;thendailywhileinICU

c.TEG(thromboelastogram),Bleedingtimes,Plateletaggregation,andothercoaglabswillbeorderedonanasneededbasis

2.MedicationsGuidelines

Timing / Action
PriortoleavingOR / Completelyreversetheanticoagulation
Immediatepostoperativeperiod / Generally,noaction.
Patientswithatrialfibrillation,historyofLVAorLAthrombus,orlowLVADflowshouldbetreatedwithanticoagulants(heparin)
Oncepatientmedicallystable(Day2to5) / Oncethereisnobleedingandthechesttubesareout:
BeginWarfarin-INRtargetrange1.5to2.0unlessanotherindicationforCoagulationexists.
Beginaspirinatadoseof81to325mgdaily.
Durationofsupport / MaintainonaspirinandWarfarin.Inpatientswithhighriskofbleeding,Warfarinmaybeheld

TAH(TotalArtificialHeart)

AfterTAHimplantation,ahypercoagulablestatesisexpressedthatisdependentonpumpdesignandpatientcharacteristics.Counterbalancingthismultifactorialhypercoagulableconditionrequiresanindividualizedthromboprophylaxisregimenconsistingofanticoagulantsincombinationwithantiplatelettherapy.

1.Labs

a.CBCstatonarrivaltoICU;thenevery6hoursx24hours;thendailywhileinICU

b.PT,PTT,INRstatonarrivaltoICU;thenevery6hoursx24hours;thendailywhileinICU

c.Fibrinogendailyasneeded

d.ThromboElastogram(TEG)dailyasneeded

e.BleedingTimedailyasneeded

f.PlateletAggregationasneeded

g.AntithrombinIIIasneeded

h.Pre-Albumin(targetweeklybutasneeded)

2.Medications

a.Heparin;start2-5units/kg/hrbeginningPOD1-3basedonCTdrainage(CTdrainage

<30ml/hrx4hours)

i.Goal:TitrateheparindosetomaintainnormocoaguabilitybyTEGw/oheparinase

b.Warfarin;start2.5-5mg/daybeginningPOD7-14andfollowingrecoveryofhepaticandrenalfunctionandimprovementinnutritionalstatus

i.Goal:titratedosetomaintainnormocoaguabilitybyTEG

ii.OverlapheparinuntilpatientisnormocoaguabilitybyTEGw/oheparinasex2days

c.Aspirin;start40-81mg/dayPOD1-3basedonpltcountandCTdrainage

i.Goal:pertherapeuticbleedingtimeandplateletaggregationstudy

d.Dipyridamole;start75-100mgq8hourspostoperatively

i.Goal:increasedoseby100mgevery6–8hoursforplateletincreaseby100,000;donotexceed300mgevery6hoursor400mgevery8hours

e.Pentoxifylline;start200-400mgevery8hourspostoperatively

i.Monitorfornausea/vomiting;decreasedoseifnecessarybasedonsideeffects

f.AggrenoxmaybesubstitutedforAspirinandPersantinforlongtermanticoagulationtherapy

Reviewed and Approved by:

Date

Executive Director, Thoracic Organ Transplant Programs

Date

Surgical Director, Heart Transplant & VAD Program

.Date

Medical Director, Heart Transplant & VAD Program

Date

Administrative Director, Center for Transplantation