Direct Oral Anticoagulants Versus Warfarin in Durable Left Ventricular Assist Device Recipients Without Atrial Fibrillation

Lifelong anticoagulation is essential in durable left ventricular assist device recipients to mitigate thrombotic complications, but the optimal anticoagulant strategy remains undefined. Direct oral anticoagulants offer pharmacological advantages over warfarin, yet large-scale outcomes data in the left ventricular assist device population, particularly among patients without atrial fibrillation, are limited. Using the TriNetX Research Network, we conducted a retrospective cohort study of adult left ventricular assist device recipients without atrial fibrillation or atrial flutter who received either a direct oral anticoagulant (n = 1,150) or warfarin (n = 3,052). After 1:1 propensity score matching, 955 patients per group were included. Time-to-event analyses over 12 months used Kaplan-Meier methods and Cox proportional hazards regression. The primary outcome was major bleeding, defined as gastrointestinal hemorrhage or intracranial hemorrhage. Secondary outcomes included thrombotic complications, all-cause mortality, and all-cause hospitalization. Direct oral anticoagulant use was associated with a significantly lower risk of major bleeding (hazard ratio [HR] 0.46, 95% confidence interval 0.36 to 0.58; p <0.001), but a significantly higher risk of thrombotic complications (HR 2.22, 95% confidence interval 1.88 to 2.61; p <0.001), compared with warfarin. All-cause mortality did not differ between groups (HR 0.90, 95% confidence interval 0.70 to 1.15; p = 0.389). In conclusion, among left ventricular assist device recipients without atrial fibrillation, direct oral anticoagulant therapy was associated with a lower incidence of major bleeding, but a higher risk of thrombotic events compared with warfarin, suggesting the need for prospective trials to define the optimal anticoagulation strategy in this population.