Pall T. Onundarson and Mandeep Mehra on Diverse Approaches to Anticoagulation in LVAD Patients
Pall T. Onundarson, Professor Emeritus at Landspitali University Hospital, shared C Michael Gibson‘s post on LinkedIn, adding:
”On anticoagulation in LVAD patients.
This is a fascinating and illuminating lecture on LVADs delivered in a low-keyed manner by Dr. Mandeep Mehra at Brigham and Women’s Hospital, Harvard, Boston.
From an anticoagulation perspective, he notes that with “good” warfarin management – defined as time in therapeutic range (TTR) >56% – thrombotic events are relatively rare.
While I would argue that >56% is not truly optimal warfarin control, it is certainly better than <56%.
Despite this, bleeding remains a major clinical problem, occurring at a rate of roughly 30% per year.
There is therefore a clear urgency to reduce bleeding risk without compromising antithrombotic efficacy.
As Dr. Mehra discusses, one potential strategy is the use of newer agents such as tecarfarin, which may offer improved pharmacologic stability.
At present, DOACs do not have an established role in LVAD management.
This raises another question: what about improving anticoagulation stability not by changing the drug, but by changing the monitoring method?
Specifically, replacing PT-INR monitoring with the Fiix test (Fiix-INR) to stabilize warfarin therapy – or potentially tecarfarin, should it become available – in LVAD patients.
In our studies, Fiix monitoring has reduced anticoagulation variability substantially.
INR variability – measured as variance growth rate (VGR) or as dose-adjustment frequency (“oscillation,” as Dr. Mehra describes it) – was reduced by approximately 33% in patients with target INR 2.0–3.0, and by about 50% in those with targets 2.5–3.5. Clinically, Fiix-monitored warfarin reduced total thromboembolic events by roughly 50% without increasing bleeding.
These data are derived mainly from NVAF subpopulations in our smaller studies, including one randomized controlled trial.
An important next question is what might occur if lower INR targets were used in conjunction with Fiix monitoring – for example 1.7–2.7, or 2.2–3.2 in higher-risk patients.
We would expect less oscillation, more stable dosing, and easier clinical management. My hypothesis is that bleeding could be reduced without substantial loss of efficacy.
Under such conditions, Fiix-monitored warfarin – or Fiix-monitored tecarfarin – could emerge as a superior anticoagulation strategy in LVAD care.
Naturally, this hypothesis would need to be tested in properly funded, prospective clinical studies.”
C Michael Gibson, President and CEO at Baim Institute for Clinical Research, shared on LinkedIn:
”The recording from today’s Baim Grand Rounds with Mandeep Mehra (London) on ‘Hearts of Steel – The Evolution and Future of Heart Replacement Therapy’ is now available on the Baim website.
You can find it here.”
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