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

Abstract 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.