Department of Internal Medicine, Internal Medicine Residency Program, Baylor College of Medicine, Houston, TX, USA.
Am J Case Rep. 2021 Dec 9;22:e934787. doi: 10.12659/AJCR.934787.
BACKGROUND Direct oral anticoagulants (DOAC) are currently the preferred agents for long-term anticoagulation in the appropriate patient with venous thromboembolism, non-valvular atrial fibrillation, and left ventricular thrombi because of their ease of use, fixed dosing, lack of need for routine monitoring, and limited dietary and drug interactions. However, warfarin is still the agent of choice for preventing thromboembolic events in patients with left ventricular assist devices (LVAD). In this case report, we explore the outcome of using apixaban in a patient with an LVAD. CASE REPORT A 56-year-old woman with morbid obesity and stage D congestive heart failure status after HeartWare ventricular assist device (HVAD) placement 2 years prior, who was on long-term anticoagulation with apixaban after failure of warfarin therapy, presented to the Emergency Department with 2 months of worsening fatigue, dark urine, and 1 day of low-flow alarms from her HVAD. Laboratory and radiographic data were consistent with a diagnosis of pump thrombosis. She underwent pump exchange and was started on a heparin drip. Genetic testing for warfarin resistance was negative. Detailed history-taking revealed that the failure to maintain a therapeutic international normalized ratio (INR) was likely due to dietary factors. She was re-challenged with warfarin, and a therapeutic INR level was reached shortly after initiation. She was later discharged on a stable dose of warfarin and remained in a good clinical state without any major adverse events at the 1-year follow-up. CONCLUSIONS Apixaban can be associated with an increased risk of thrombosis in patients with HVADs and should be used with caution and only in select patients.
直接口服抗凝剂（DOAC）由于使用方便、固定剂量、无需常规监测以及饮食和药物相互作用有限，目前是静脉血栓栓塞、非瓣膜性心房颤动和左心室血栓患者长期抗凝的首选药物。然而，华法林仍然是预防左心室辅助装置（LVAD）患者血栓栓塞事件的首选药物。在本病例报告中，我们探讨了在 LVAD 患者中使用阿哌沙班的结果。
一名 56 岁女性，患有病态肥胖症和充血性心力衰竭，2 年前因 HeartWare 心室辅助装置（HVAD）放置后处于 D 期，在华法林治疗失败后长期接受阿哌沙班抗凝治疗，因 HVAD 出现 2 个月的疲劳加重、深色尿液和 1 天的低流量警报而到急诊科就诊。实验室和影像学数据与泵血栓形成的诊断一致。她接受了泵置换，并开始使用肝素滴注。华法林耐药的基因检测结果为阴性。详细的病史询问表明，未能维持治疗国际标准化比值（INR）可能是由于饮食因素。她重新接受了华法林治疗，在开始治疗后不久就达到了治疗性 INR 水平。随后，她出院时服用稳定剂量的华法林，在 1 年的随访中没有出现任何重大不良事件，临床状况良好。
阿哌沙班可使 HVAD 患者的血栓形成风险增加，应谨慎使用，并仅在特定患者中使用。
