Eptifibatide for the treatment of HeartMate II left ventricular assist device thrombosis.

L eft ventricular assist device (LVAD) thrombosis is a life-threatening complication occurring in ≈6% of patients receiving a HeartMate II (HMII) LVAD (Thoratec Corp, Pleasanton, CA) within 24 months after implantation. 1 Prophylactic therapy with aspirin and warfarin to an international normalized ratio (INR) of 1.5 to 2.5 is recommended to prevent LVAD thrombosis in most HMII recipients. 2 For device malfunction because of pump thrombosis, surgical device exchange may be necessary but carries a high risk of morbidity and mortality. Alternate treatment approaches include the addition of clopidogrel, tirofiban, and thrombolysis. 3 We report our experience with eptifibatide (Merck & Co, Inc, Whitehouse Station, NJ), a platelet glycoprotein IIb/IIIa receptor inhibitor, for the treatment of LVAD thrombosis in 2 patients. A 66-year-old male with ischemic cardiomyopathy who underwent HMII implantation as a bridge to cardiac trans-plantation developed LVAD thrombosis 42 days after his surgery while taking 325 mg of aspirin and warfarin. His INR was subtherapeutic at 1.3. Hematuria, a lactate dehy-drogenase level of 2326 IU/L, direct bilirubin of 0.8 mg/dL, a lower pulsatility index, and pump flow compared with previous levels, which suggested hemolysis and possible device thrombosis (Table 1). The patient was initially treated with weight-based intravenous unfractionated heparin to target an activated partial thromboplastin time between 60 and 80 seconds (1.5–2.5×normal) for 5 days without significant improvement in serological markers of hemolysis or device parameters. Given the lack of clinical response, eptifibatide, 180 µg/kg bolus followed by a 1 µg/kg per minute infusion, was initiated in addition to intravenous unfractionated heparin with marked improvement of hemolysis indexes and LVAD pulsatility index at 72 hours. A transthoracic echocardiogram at the time of presentation revealed opening of the aortic valve with every cardiac cycle and intermittent opening after resolution of the thrombus. His hospital course was complicated by upper gastrointestinal bleeding secondary to peptic ulcer disease on day 3 of eptifibatide therapy after the improvement of LVAD parameters. This was treated successfully with local epinephrine injection therapy, clip placement, and blood transfusion. There was no clinical evidence of systemic embo-lization. The patient has had no further LVAD thrombosis (day 386 since HMII LVAD implantation). A 25-year-old woman with doxorubicin-induced cardiomy-opathy who underwent HMII LVAD placement as a bridge to transplantation developed LVAD thrombosis 33 days after surgery while taking 325 mg of aspirin and warfarin. Her INR was subtherapeutic at 1.4. Her HMII LVAD parameters revealed an increased …