Apixaban: Alternative Anticoagulation for HeartMate 3 Ventricular Assist Device

Abstract

Patients with left ventricular assist devices currently require long-term anticoagulation with warfarin. Warfarin requires frequent blood tests and is associated with adverse events when not in the therapeutic range. Apixaban is a possible alternative that is potentially better for compliance and requires no additional testing. The purpose of this study was to compare adverse events in patients with a HeartMate 3 LVAD receiving apixaban versus warfarin. Thirty-five patients underwent HM3 implantation between January 01, 2016 to January 31, 2021. The groups compared were apixaban (n = 15, 43%) and warfarin (n = 20, 57%). All patients received 325 mg aspirin daily. Stroke, bleeding, and death were identified as primary outcomes after LVAD implant. Univariate nonparametric statistical analysis was performed. The median duration of treatment with apixaban was 148 days (37–606 days). The groups were comparable in terms of age (56 vs. 54 years), gender (male, 85% vs. 75%), and renal function (Cr 1.5 vs. 1.4). The apixaban group had significantly higher mean pulmonary artery pressure (41 vs. 34, p = 0.03) and there were more (p < 0.05) ischemic cardiomyopathy and INTERMACS profile >3 in the warfarin group. At 6 months, thrombotic complications and death were not different between the groups. The two deaths in the apixaban group were from right heart failure. The apixaban group had clinically lower rates of bleeding complications (5% vs. 30%). The adverse events of bleeding, stroke, and death were similar in HM3 patients receiving warfarin or apixaban. Apixaban may be a safe alternative anticoagulant therapy in HM 3 LVAD patients.

New Antithrombotic Strategies to Improve Outcomes With the HeartMate 3

“…Although recent data showed lower incidence of bleeding events in a small cohort of HM3 patients treated with apixaban with respect to patients treated with warfarin, 13 we highlight high risk of thromboembolic complications associated with novel oral anticoagulants in the setting of LVAD support. 14…”

Letter to Editor Response RE: Apixaban: Alternative Anticoagulation for HeartMate 3 Ventricular Assist Device

“…We decided to report patient outcomes with the use of this drug in the HM3 population retrospectively. 2 Our findings were not driven by any clinical trial or investigation and were therefore not statistically powered to test any hypothesis. We agree that this study consists of a relatively small sample size.…”

Efficacy and safety of Apixaban and warfarin in the prevention of ischemic stroke：A systematic review and a meta-analysis

“…It is well known that long-term warfarin anticoagulation has become the gold standard for treatment to prevent thrombotic complications for patients using left ventricular assist devices. However, Whitehouse et al [24] compared adverse events of apixaban and warfarin in patients receiving the HeartMate 3 LVAD and found no significant difference in safety, so apixaban is a possible alternative and may be better in compliance, and no additional testing is required. In the future, more and more patients will use apixaban instead of warfarin.…”