INR, nonresponse to coumadin therapy

What other meds is the patient on? Several medications (especially abx) can interfere with the way coumadin works.

Not unusual in my experience. One of our VAD patients (2 years post VAD) is on 40mg coumadin daily to keep his INR therapeutic.

In your case, with patient still hospitalized with multiple issues, we would NOT give coumadin. We would keep him on heparin infusion to control thrombosis risk until he had documented good GI function - if you're not absorbing the coumadin or have some other acute GI issue, it's pointless to give it.

What device does he have? That has a huge impact on the risk-benefit ratio of upping anticoagulation in someone with history of GI bleeds. If it's a non-pulsatile device such as Jarvik, Heartmate 2, then we have had people off all anticoagulation except aspirin multiple times when they had other medical issues.

Overall:
- in pt with current Afib and VAD, we would heparinize to therapeutic levels.
- if there are signs of HIT, we'd use bivalirudin infusion instead
- Needs scoping to figure out what's going on GI wise as this is affecting (potentially) both med absorption as well as target INR/PTT.
- H. pylori testing/eradication for ulcers?
- why has he had lung bleeding since VAD surgery? due to anticoagulation?
- does your center do a lot of VADs?

Pump speed? MAP? PI?

The fluid balance and speed balance is the most difficult thing with Ventrassist patients. Usually they are volume depleted postop, then become fluid overloaded. Our patients often end up on tons of diuretic plus lots of ACE-I.

Doctors need to get out of the habit of running the pump to get a certain flow number. It's not real. The flow is only an ESTIMATE based on pump power consumption, speed and Hct. It's much better to set pump speed by the amount of LV decompression ie suck the ventricle down enough to relieve HF symptoms (esp SOB and edema) but not enough to cause arrhythmias.

Most people on that device run 2000-2200rpm, but we've had people up to 2500rpm short term when retaining fluid. Particularly if patients have RV insufficiency you see problems like your patient is having with SOB, weight gain, esp pleural effusions. He may need inotrope infusion short term to tune up his right heart while you get the fluid off. Sometimes we have to increase pump speed and get est flows up to 9lpm while we diurese. In these patients, we run PI 20-30 to avoid suckdown.

Short term at my hospital, we would:
- do an echo and assess LV decompression (LVEDD), RV performance, whether or not aortic valve is opening
- depending on RV function: if bad, add inotrope infusion such as milrinone/dobutamine. If fine, turn up pump speed and increase diuresis to get patient euvolemic
- heparinize: particularly in the setting of positive cultures, you do not want to get a pump or LV thrombus
- keep mean pressure (measure via brachial doppler) between 70-90 to optimize flows

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Best advice I could give if this patient is a problem to docs is to ask them if you can get your ventracor clinical rep involved - they are excellent and can guide your medical team further or refer them to a physician at one of the two most experienced ventrassist centers.