Safety and Efficacy of Apixaban in HeartMate 3 Left Ventricular Assist Devices

BACKGROUND: Warfarin, the anticoagulant of choice for durable left ventricular assist devices (LVADs), has a narrow therapeutic index and extensive pharmacologic interactions that make dose optimization challenging. Inadequate time in the therapeutic range increases the risk of thrombotic and hemorrhagic complications. We sought to evaluate the safety and efficacy of apixaban as an alternative anticoagulant for HeartMate (HM) 3 LVADs. METHODS: We analyzed data for patients with HM3 LVADs treated at our center between 2018 and 2024, comparing thromboembolic and hemorrhagic events between patients receiving warfarin and those who transitioned to apixaban due to adverse events or labile therapeutic responses on warfarin. RESULTS: We included 47 patients, 16 of whom remained on warfarin, while 31 transitioned to apixaban. Both cohorts had identical baseline characteristics. Rates of all-cause bleeding per 100 patient-years were similar for warfarin (33) and apixaban (29), p = 0.24. The relative risk (RR) of major bleeding within the first 3 months of anticoagulation was significantly lower with apixaban-RR 0.08 (95% CI, 0.01-0.65, p = 0.01), with an incidence rate of 6.4% on apixaban versus 43.8% on warfarin. All-cause bleeding occurred less frequently with apixaban at 32% compared to 68.8%-RR 0.14 (95% CI 0.03-0.62, p = 0.009). Hemocompatibility improved in the apixaban group, evidenced by an increase in hemoglobin (11 ± 2 to 12 ± 2 g/dL, p < 0.001) and a decrease in lactate dehydrogenase (427 ± 129 to 221 ± 83 U/L, p < 0.001). Thrombotic events were identical. CONCLUSION: In patients with HM3 LVADs, apixaban may be a safe and clinically effective alternative to warfarin.