Apixaban as an alternative to warfarin for patients with a left ventricular assist device

Maintaining therapeutic anticoagulation is a significant challenge for patients requiring continuous-flow left ventricular assist device (CF-LVAD) support.1 Warfarin is the current standard of care, while limitations include the need for routine international normalized ratio (INR) monitoring, complex dosing regimens, and significant drug-drug interactions.2 Direct oral anticoagulants (DOACs) are an attractive option given their lack of routine coagulation monitoring and ease of dosing. However, clinical experience in this population is limited. Therefore, this case series explored outcomes associated with DOAC use in patients with a CF-LVAD managed at a single center. This case series was approved by the quality improvement committee of the University of Pittsburgh Medical Center. We retrospectively evaluated patients with a CF-LVAD who were prescribed apixaban, after warfarin discontinuation, between January 2015 and December 2019. In this report, apixaban was the only DOAC used based on the discretion of the physicians and pharmacists making up the local VAD team. Data collected included patient demographics, reasons for warfarin discontinuation, bleeding and thromboembolic events, and laboratory values on the day of conversion (serum creatinine and hemoglobin levels) after the initiation of apixaban for each patient. Adverse events were evaluated according to the Interagency Registry of Mechanically Assisted Circulatory Support definitions for major bleeding and suspected and confirmed pump thrombosis.3 Types of bleeding events after apixaban initiation were also determined. Data on historical bleeding and thromboembolic events before apixaban use were also collected. The primary outcome evaluated was the incidence of bleeding and thromboembolic events during apixaban treatment.