Long-term outcomes of apixaban as main anticoagulant in patients with HeartMate 3 left ventricular assist devices.

Aims: HeartMate 3 (HM3) left ventricular assist devices (LVADs) offer improved haemocompatibility-related outcomes for end-stage heart failure patients, facilitating the exploration of alternative anticoagulation therapies beyond warfarin. This study presents a long-term evaluation of thrombotic and bleeding outcomes in HM3 LVAD patients transitioned from warfarin to apixaban.

Methods: We retrospectively identified HM3 LVAD patients at our single centre who transitioned from warfarin to apixaban. Baseline characteristics were described at discharge from implant hospitalization and at the last follow-up on each anticoagulation regimen. We reported survival, thrombo-embolic events (including LVAD pump thrombosis, stroke, arterial thrombo-embolic events and pump exchange) and bleeding events on both warfarin and apixaban.

Results: Eight patients were identified between May 2018 and June 2022 who transitioned from warfarin to apixaban 5 mg twice daily. Patients were followed for a mean of 1233 days after LVAD implantation and 789 days after transition to apixaban. All patients were transitioned due to difficulty maintaining a therapeutic international normalized ratio (INR), including five patients who experienced bleeding complications on warfarin. No patients encountered LVAD pump thrombosis, stroke events, arterial thrombo-embolic event, pump exchange or death. While on warfarin, five patients had eight bleeding events: one major [requiring 2 units of packed red blood cells (pRBCs)] and seven minors (five gastrointestinal bleeds, one episode of haematuria and one episode of haemoptysis). After switching to apixaban, one patient with angioectasia had a major gastrointestinal bleed requiring two pRBCs and endoscopic clipping.

Conclusions: Apixaban demonstrated safe and favourable long-term outcomes in a cohort of HM3 LVAD patients over a mean follow-up of more than 2 years. To our knowledge, our report provides the longest follow-up duration for this patient population to date. Larger prospective studies are needed before this can be adopted as the standard of care.