Letter by Consolo and Pappalardo Regarding Article, “Comprehensive Analysis of Stroke in the Long-Term Cohort of the MOMENTUM 3 Study: A Randomized Controlled Trial of the Heartmate 3 Versus the Heartmate II Cardiac Pump”
Authors: Filippo Consolo, Federico Pappalardo
Journal: Circulation (2019)

The article by Colombo et al 1 revealed an extremely low rate of stroke events in patients supported with the HeartMate 3.This study follows previous reports that showed that the HeartMate 3 has abated the incidence of pump thrombosis 2 and confirms the low thrombogenic potential of this pump.The analysis included patients managed with oral anticoagulation alone (warfarin or heparin, with a targeted international normalized ratio of 2.0-3.0),antiplatelet therapy alone (aspirin 81-325 mg daily), or both.We believe that this study has important implications that need to be discussed which might contribute to further reducing HeartMate 3 hemocompatibility-related adverse events.The authors showed in detail that antithrombotic management with oral anticoagulation alone was associated with lower rates of both ischemic stroke and hemorrhagic stroke compared with antiplatelet therapy; this was particularly evident in the case of hemorrhagic stroke (57% versus 86%, respectively). 1 In addition, no differences were found in the occurrence of ischemic stroke and hemorrhagic stroke in patients managed with anticoagulation alone compared with those who received combined anticoagulation and antiplatelet therapy. 1 These data suggest that aspirin might not have a role in preventing stroke in the setting of HeartMate 3 support and that, on the other hand, reduced antithrombotic therapy with oral anticoagulation alone might be effective and safe for reducing the likelihood of these complications.In light of these data, we question the rationale of using aspirin during Heart-Mate 3 support.Indeed, previous experience has shown that aspirin might enhance bleeding susceptibility in patients on the HeartMate 3 and that its discontinuation avoided hemorrhage recurrence and was not associated with thromboembolism. 3imilar trend profiles were also previously reported in the setting of HeartMate II support (EU-TRACE [Study of Reduced Anti-Coagulation/Anti-platelet Therapy in Patients With the HeartMate II] study). 4Furthermore, although we agree that reduced antithrombotic therapy might effectively improve the HeartMate 3 hemocompatiblity, we wonder whether therapeutic strategies other than low-intensity anticoagulation (international normalized ratio target, 1.5-1.9)associated with aspirin therapy might be implemented to this target.As a matter of fact, low-intensity anticoagulation has not been shown to completely blunt the incidence of recurrent bleeding episodes. 5In addition, the study by Colombo et al 1 now suggests that reduced anticoagulation levels might portend a potential higher risk of stroke.According to this real-world clinical scenario, we envision the need for a prospective, randomized, controlled study evaluating the role of aspirin administration on hemocompatibility-related adverse events in the HeartMate 3; in particular, we question the benefit of aspirin administration and the potential benefit and safety of primary warfarin monotherapy after discharge.