APTT: Activated Partial Thromboplastin Time; ASA: Acetylsalicylic Acid; CT: Computed Tomography; FDP: Fibrinogen Degradation Product; Hb: Haemoglobin; HF: Heart Failure; HVAD: Heart Ware Ventricular Assistance Device; INR: International Normalised Ratio; IV: Intravenous; LDH: Lactate Dehydrogenase; 

Case: The patient was a 67 years old male. The patient experienced an episode of LVAD thrombosis. Device replacement was not possible due to high surgical risk. Pharmacological strategy was adopted with intraventricular fibrinolysis+intravenous Tirofiban infusion. Outcome: Despite thrombosis resolution, two episodes of bleeding occurred. Thus we lowered antithrombotic drugs dose with subsequent relapse risk. At the end, a successful therapeutic strategy was achieved. Conclusion: Our case report shows how the balance between anticoagulation and bleeding is a tricky feature of LVAD thrombosis management. When device replacement is not an option, trying to remove the clot soon with aggressive antithrombotic therapy can be a winning strategy and can quickly stop the haemolysis. Unfortunately, it can produce major bleeding events, harmful and potentially life-threatening. To be aware of potential cause of bleeding and looking for the appropriate dosage of antithrombotic drugs can be useful to manage these complications. *Corresponding authors: Perna E, De Gasperis Cardio Center, Niguarda Ca’ Granda Hospital, Piazza Ospedale Maggiore 3, 20162 Milan, Italy, Tel: +393332106609; Fax: 02 64442566; E-mail: enrico.perna@ospedaleniguarda.it Cipriani MG, De Gasperis Cardio Center, Niguarda Ca’ Granda Hospital, Piazza Ospedale Maggiore 3, 20162 Milan, Italy, Tel: +393332106609; Fax: 02 64442566; E-mail: manlio.cipriani@ospedaleniguarda.it Received January 04, 2016; Accepted February 10, 2016; Published February 15, 2016 Citation: Perna E, Cipriani MG, Marco DF, Macera F, Milazzo F, et al. (2016) Between Scylla and Charybdis: Difficult Balance between Anticoagulation and Bleeding in the Management of LVAD Thrombosis: A Case Report. Cardiovasc Pharm Open Access 5: 173. doi:10.4172/2329-6607.1000173 Copyright: © 2016 Perna E, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. months he remained in satisfactory clinical condition and HVAD parameters were within normal limits. On May 2014, haematuria occurred and he was readmitted to our hospital. No clinical signs of pulmonary or abdominal congestion or signs of cardiogenic shock were observed during first physical examination. HVAD parameters showed a progressive increase of Power (P 2.8→3.6 W) and calculated flow (F 3.9→6 L/min), with a Speed (S) of 2360 rpm. Laboratory tests showed a significant elevation of serum lactate dehydrogenase (LDH) >1547 U/L and plasma-free haemoglobin (pfHg) >1046 mg/L, a decrease in haptoglobin and anemia (Hb 12.7 g/dL): major haemolysis was occurring. The anticoagulation profile was in range (INR 2.6, APTT 44 sec). Transesophageal echocardiography was performed: no clot was found at the inflow and outflow cannula site, but there was left ventricle dilatation with frequent aortic valve opening. A diagnosis of suspect HVAD thrombosis was made. Our patient had a high surgical risk, so since the beginning we ruled out device replacement. A continuous infusion of intravenous heparin (target activated partial thromboplastin time of 50-60 seconds) was started, adding greater aspirin dose, 300 mg/die. Nevertheless, HVAD parameters continued to worsen (F>10) and after 24 hours patient became “cold and wet” (peripheral hypoperfusion, central venous pressure >19 mm Hg). Therefore, the decision to perform fibrinolysis