The novelty of anticoagulation in LVAD Therapy: Current Practice, the Role of Direct Oral Anticoagulants, and Future Directions

Left ventricular assist devices (LVADs) are an established therapy for end-stage heart failure as bridge-to-transplant and destination therapy. Despite advances with fully magnetically levitated devices such as the HeartMate 3, hemocompatibility-related adverse events, most notably bleeding, remain frequent and drive morbidity and readmissions. Bleeding risk is multifactorial, reflecting anticoagulation, comorbidities, vascular abnormalities, and acquired hematologic disorders.

We conducted a narrative review of thrombotic and bleeding outcomes associated with anticoagulation strategies in continuous-flow LVAD patients. From 417 screened records, 10 studies were included, focusing on direct oral anticoagulants (DOACs).

The 10 studies comprised 174 LVAD-supported patients treated with DOACs, primarily apixaban; most were on the HeartMate 3 (n=146). Among factor Xa inhibitor studies, thrombotic event rates ranged from 0% to 12.5% and bleeding from 6% to 20% - broadly comparable to or lower than warfarin (bleeding: 6% vs. 30% in one retrospective cohort [p=0.1]; composite death or major hemocompatibility-related events: 12.5% vs. 43% at two-year follow-up [p=0.087]). Dabigatran, a direct thrombin (factor IIa) inhibitor was associated with a 50% rate of pump thrombosis in a pilot randomized trial, leading to early termination. Significant heterogeneity in patient selection, regimens, and study design limits definitive conclusions.

Anticoagulation management remains a major unmet need in LVAD therapy. Factor Xa inhibitor–based anticoagulation, particularly apixaban, may be associated with comparable thrombotic outcomes and lower bleeding risk versus warfarin in selected patients. Dabigatran carries high thrombotic risk and should be avoided. Adequately powered randomized trials are required to define optimal anticoagulation strategies in this population