Vandenbriele: Anticoagulation and Protected PCI

Prof. Dr. Christophe Vandenbriele, a cardiologist and intensivist at University Hospital (UZ) Leuven, Belgium, discusses his paper recently published in the European Heart Journal Supplement as part of a series on best practices in Protected PCI. Prof. Vandenbriele is the senior author of the paper titled, “What is known in pre-, peri-, and post-procedural anticoagulation in micro-axial flow pump protected percutaneous coronary intervention?”

Prof. Vandenbriele describes the importance of anticoagulation in patients supported with percutaneous mechanical circulatory support (MCS) devices. He emphasizes the use of protocols and strategies for managing bleeding complications and the difference between anticoagulation strategies in the cath lab and in the intensive care unit (ICU). “I think for the Protected PCI patients, we can rely on the ACT for the test…  But once the patient moves back to the ICU, I would certainly not rely on the ACT anymore; but then we need to aim for stability and there we need to rely on the aPTT (activated partial thromboplastin time) and the anti-Xa to achieve proper and stable heparin anticoagulation levels, because we should not forget that most of those patients also have dual antiplatelet therapy (DAPT) on board and that they do encounter quite high bleeding risk.”

Prof. Vandenbriele discusses the role of DAPT and P2Y12 inhibitors in patients undergoing PCI, noting that many questions still need to be answered, including how to properly anticoagulate patients, how to protect stents, and how to avoid bleeding complications. “So there’s still lots of work to do,” he states.

An important topic about the use of Impella® heart pumps in Protected PCI is the use of heparin in the Impella purge fluid. Prof. Vandenbriele explains that in the United States, the FDA has approved the use of sodium bicarbonate in the purge fluid* for heparin-intolerant patients, such as those with heparin-induced thrombocytopenia (HIT). When asked about using bicarb in the purge fluid, Prof. Vandenbriele answers, “I would certainly use it in heparin-induced thrombocytopenia, although this is quite rare in pMCS-supported patients. I would also use it in patients with major bleeding issues on the Impella device. But probably in the near future we will use it in every Impella-supported patient and just swap the heparin in the purge for bicarb because it makes life easier.”