Postoperative bleeding following durable left ventricular assist device (LVAD) implantation is one of the most common early complications, occurring in around 48% of patients. The incidence of bleeding requiring blood product transfusion or reoperation is 31%–81%. Postoperative bleeding is frequently mediastinal or within the thoracic-pleural space. Once chest and mediastinal tube output has stabilized, systemic anticoagulation with heparin is initiated. Long-term recommendations for anticoagulation in LVAD patients include an antiplatelet agent (aspirin 81–325 mg) and warfarin to reduce the risk of thrombosis. A major risk of subtherapeutic international normalized ratio (INR) in patients supported on LVAD is stroke, and those who experience stroke have a 2-fold higher risk of death compared to those without stroke. Thrombosis can occur within areas of stagnant blood flow such as the aortic valve and root, left atrium, left ventricle, device inflow cannula, or device outflow cannula. Patients can develop worsening heart failure symptoms, thromboembolism, or even complete obstruction of flow through the device and pump failure. Risk factors for pump thrombosis include surgical implant technique, lower pump speeds, concurrent infection, and subtherapeutic INR. In cases of hemodynamic instability, emergent pump exchange or urgent heart transplantation is recommended. Gastrointestinal bleeding is another significant sequela of LVAD implantation, and a separate chapter is devoted to this topic.
Conventional and alternative sites for left ventricular assist device inflow and outflow cannula placement
