Management of Patients with Left Ventricular Assist Devices requiring Teeth Extraction: Is Halting Anti-Coagulation Appropriate?

Publication date: Available online 31 October 2017
Source:Journal of Oral and Maxillofacial Surgery
Author(s): Visakha Suresh, Muath Bishawi, Michael W. Manning, Chetan Patel, Joseph Rogers, Carmelo Milano, Jacob Schroder, Mani Daneshmand, David Powers
IntroductionAn increasing number of end-stage heart failure patients are supported with left ventricular assist device (LVAD) implantation and must be maintained on a consistent anticoagulation regimen. Preemptive extraction of carious teeth in these patients is necessary to seeding of the implanted device and endocarditis. Thus, the objective of this study was to evaluate bleeding complications after minor oral surgery, specifically teeth extractions, in this unique patient population requiring chronic anticoagulation.MethodsThis study was a retrospective single center review. Adult patients supported on an implanted, continuous flow LVAD from January 1, 2007 to December 31, 2016 were included. Baseline characteristics were collected via retrospective chart review and the institutional LVAD registry. All extractions were performed in the operating room, under local anesthesia with moderate sedation or general anesthesia with nasal intubation, while LVAD settings were monitored by a trained perfusionist. Preoperative and postoperative hematology lab values, such as hemoglobin, international normalized ratio (INR), were collected via chart review. Continuous variables were presented as mean ± standard deviations, and compared using the Student t-test. Categorical variables were presented as proportions and percentages, and compared using chi-squared test or Fisher Exact test as appropriate. Statistical significance was established at a p < 0.05.ResultsAfter screening 798 patients, 32 (4%) were found to have undergone dental extractions after LVAD implantation. The sample was composed of 32 subjects with a mean age of 60.13 years and 81.25% were male. The average time from LVAD implantation to extraction was 445.19 ± 1108.53 days. Average pre-operative INR was 1.76 ± 0.47. Pre-operative FFP was not administered to any patients. 28 (87.5%) patients were on coumadin pre-operatively. In 11 (39.3%) of the 28, Coumadin was held preoperatively. The average post-operative change in hemoglobin was -0.79 ± 1.45. Only one patient (3%) required post-operative blood transfusion for a hemoglobin of 7.6 that responded appropriately. There were no re-operations for bleeding.ConclusionsMinor oral surgical procedures can be performed safely for patients being supported on LVAD therapy. With primary closure of the gingiva at the site of extraction, dental extractions can be performed without the full reversal of anticoagulation.



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