Objectives: This study investigated the relationship between anti-factor Xa (anti-FXa) and activated partial thromboplastin time (aPTT) for monitoring intravenous unfractionated heparin (IV-UFH) in patients with continuous-flow left ventricular assist devices (CF-LVADs). Background: CF-LVADs have become mainstream therapy for patients with advanced heart failure. Thromboembolic events, device thrombosis, and bleeding continue to be a challenge with this technology. Adequate anticoagulation is required to prevent these adverse events. Methods: A prospective study of consecutive patients implanted with a CF-LVAD was conducted. Paired samples were considered concordant if aPTT values fell into expected ranges for subtherapeutic, therapeutic, and supratherapeutic anti-FXa levels. Heparin dosing was on the basis of anti-Xa levels. Results: A total of 340 paired values from 38 patients were evaluated. Anti-FXa and aPTT were discordant in 253samples (74.4%), with a high degree of variability in aPTT for any given anti-FXa level (r2= 0.57). Results were discordant in 104 samples (63.8%) from patients undergoing bridging therapy with warfarin and in 149 samples (84.2%) from patients with device obstruction and/or hemolysis (p< 0.001). The most common pattern of discordance was a supratherapeutic aPTT value despite a therapeutic anti-FXa level (49.1% for bridging vs. 75.8% for device obstruction and/or hemolysis; p< 0.001). Conclusions: Levels of aPTT were disproportionately prolonged relative to the corresponding anti-FXa levels in CF-LVAD patients, particularly those with device obstruction. Hemolysis and warfarin administration may falsely elevate aPTT, resulting in overestimation of heparin concentration and under-anticoagulation. Use of aPTT and anti-FXa to guide heparin therapy may lead to different estimates of heparin concentration in the same patient.
Bibliographical noteFunding Information:
Dr. Zantek has a minority equity interest in Endo International PLC; and has received research funding from Sekisui Diagnostics. Drs. Uriel and Eckman are consultants for Thoratec and HeartWare Inc. Dr. John has received research grants from Thoratec and HeartWare Inc.; and is a consultant for Thoratec. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
© 2015 American College of Cardiology Foundation.
- Activated partial thromboplastin time
- Anti-factor Xa
- Continuous-flow left ventricular assist device
- Intravenous unfractionated heparin