Impact of delayed heparin bridging on bleeding and stroke after heartmate 3 left ventricular assist device implantation

Introduction Anticoagulation is crucial after left ventricular assist device (LVAD) implantation, but postoperative bleeding and the need for reoperations remain significant, negatively impacting clinical outcomes. Due to the high rate of early postoperative bleeding, we implemented our internally developed anticoagulation protocol, which delays the initiation of heparin bridging. Purpose This study evaluates the efficacy and safety of this new anticoagulation protocol. Methods This single-center retrospective study compared postoperative outcomes between two anticoagulation protocols following HeartMate 3 (HM3) LVAD implantation. In July 2022, we introduced a new anticoagulation protocol, delaying heparin bridging initiation to beyond 48 hours. In contrast, within the previous protocol, heparin bridging was initiated after 24 hours. The primary outcomes were early (<30 days) postoperative bleeding or tamponade events requiring reoperation and ischemic stroke incidence. Secondary outcomes included hospital and intensive care unit (ICU) length of stay, and 30-day mortality. Results A total of 167 patients were analyzed (106 old protocol, 61 new protocol). The median age was 57.1 years and 75.7% were male, and 49.3% underwent LVAD implantation as destination therapy. The incidence of bleeding or tamponade events requiring reoperation was significantly lower with the new protocol (42% vs 21%, p= 0.006). Stroke incidence did not differ significantly (7.5% vs 13.1%, p = 0.23). Both total hospital stay (26 [27–42] vs. 22 [20–33] days, p = 0.003) and ICU stay (6 [3–9] vs. 3 [2–5] days, p = 0.020) were significantly shorter with the new protocol. 30-day mortality was comparable between groups (p=0.13). Conclusions Delaying anticoagulation initiation after HM3 LVAD implantation significantly reduced early bleeding and tamponade-related reoperations while shortening hospital and ICU stay, without an increased risk of ischemic stroke. Larger studies are needed to confirm the optimal anticoagulation approach in the early post-LVAD period.