Introduction: Left ventricular assist devices (LVADs) are a therapy for the management of end-stage heart failure. LVADs are typically managed with long-term therapeutic anticoagulation with warfarin to prevent thrombotic complications. Direct oral anticoagulants (DOACs) are easier to manage than warfarin for other medical conditions requiring therapeutic anticoagulation. There is limited data regarding DOAC safety in patients with LVADs.
Hypothesis: There is no significant difference in outcomes for patients with LVAD when on DOAC compared to warfarin.
Methods: In a single-center retrospective analysis from February 2019 to May 2023, patients with LVAD who were switched to the DOAC apixaban (due to warfarin complications or compliance problems) were compared to patients who remained on warfarin. Overall survival, number of hospitalizations, bleeding, and thrombotic complications were compared within/between groups.
Results: 72 patients were included. DOAC group vs warfarin group: n=12 vs 60, mean age = 52.5 vs 54.2 years; Male 75% vs 81.7%; black 66.7%; vs58.3%. For DOAC group, 10 out of 12 were on warfarin prior to DOAC. Of these 10, incidence rates for bleeding-related admissions were 4.2 per 1000 days on initial warfarin and 0.76 per 1000 days after switching to DOAC. Relative risk reduction of bleeding-related admissions decreased by 81.9%. In the DOAC group, thrombosis-related admissions on initial warfarin were 0, compared to 1 after switching to DOAC. When comparing DOAC and warfarin groups, there were no statistically significant differences in bleeding or thrombotic complications (HR = 0.61; 95%CI= 0.21 to 1.46; HR= 0.74;95%CI= 0.02 to 6.08, respectively) or mortality (HR = 0.44; 95%CI: 0.01 to 3.12). Incidence rates for bleeding-related admissions were 0.98 per 1000 days and 1.59 per 1000 days, for DOAC and Warfarin, respectively. Incidence rates for thrombotic-related admissions were 0.16 per 1000 days and 0.22 per 1000 days, for DOAC and Warfarin, respectively.
Conclusions: There was no statistically significant difference in bleeding, thrombotic events, or mortality in LVAD patients receiving DOAC compared to Warfarin. Switching to DOAC improved bleeding rates in LVAD patients who suffered bleeding complications with Warfarin.

Apixaban versus Warfarin for LVAD Anticoagulation

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