Anticoagulation in the ICU: a future for contact pathway inhibition?

© 2023 Springer Nature. This is the accepted manuscript version of an article which has been published in final form at https://doi.org/10.1007/s00134-023-07172-yBleeding and thrombotic complications are the main cause of morbidity and mortality in critically ill patients on the intensive care unit (ICU), receiving short-term percutaneous mechanical circulatory support (pMCS) by extracorporeal membrane oxygenation (ECMO), balloon pumps or microaxial flow pumps [1]. This is due to a bidirectional interplay of various factors influencing the haemostatic balance, including coagulopathy during critical illness, sepsis/inflammation, platelet consumption, hyperfibrinolysis, shear-induced acquired von Willebrand syndrome and direct contact pathway activation by the artificial surface of the pMCS device [2]. To prevent thrombotic complications and device-induced localised intravascular coagulopathy (LIC), anticoagulation is indicated. Unfortunately, all currently available anticoagulants carry an increased bleeding risk, further jeopardising patients’ outcomes [3]. Therefore, the search for safer anticoagulants continues: the holy grail for the treatment of patients on pMCS and by extension, all patients on anticoagulation is to prevent thrombosis without affecting haemostasis, thus lowering the bleeding riskPeer reviewe

Management of Bleeding and Hemolysis During Percutaneous Microaxial Flow Pump Support A Practical Approach

© 2023 The Author(s). This is an open access article distributed under the terms of the Creative Commons Attribution License (CC BY), https://creativecommons.org/licenses/by/4.0/Percutaneous ventricular assist devices (pVADs) are increasingly being used because of improved experience and availability. The Impella (Abiomed), a percutaneous microaxial, continuous-flow, short-term ventricular assist device, requires meticulous postimplantation management to avoid the 2 most frequent complications, namely, bleeding and hemolysis. A standardized approach to the prevention, detection, and treatment of these complications is mandatory to improve outcomes. The risk for hemolysis is mostly influenced by pump instability, resulting from patient- or device-related factors. Upfront echocardiographic assessment, frequent monitoring, and prompt intervention are essential. The precarious hemostatic balance during pVAD support results from the combination of a procoagulant state, due to critical illness and contact pathway activation, together with a variety of factors aggravating bleeding risk. Preventive strategies and appropriate management, adapted to the impact of the bleeding, are crucial. This review offers a guide to physicians to tackle these device-related complications in this critically ill pVAD-supported patient population.Peer reviewe