Ndakotsu Andrew, Pingili Adhvithi, Koskina Lida, Al Osta Soad, Feller Erika
Department of Medicine, MedStar Health Georgetown University, Baltimore, MD, USA.
Heart Fail Rev. 2025 Jun 17. doi: 10.1007/s10741-025-10537-8.
Anticoagulation management in patients supported by left ventricular assist devices (LVADs) is essential to prevent thromboembolic events while minimizing bleeding complications. Warfarin remains the standard therapy but is constrained by a narrow therapeutic index, dietary restrictions, and the need for frequent monitoring, prompting growing interest in direct oral anticoagulants (DOACs) as alternatives. The HeartMate 3 (HM3), now the predominant LVAD in clinical practice, features improved hemocompatibility and has demonstrated reduced rates of pump thrombosis and ischemic stroke compared to earlier-generation devices. These advances raise the possibility of simplified antithrombotic regimens tailored to specific device profiles. Retrospective studies suggest that DOACs, particularly apixaban, may provide comparable thromboembolic protection and potentially lower bleeding risk than warfarin, especially when aspirin is omitted. Additionally, DOACs offer more predictable pharmacokinetics, fewer interactions, and improved patient adherence due to reduced monitoring requirements. However, current evidence remains limited by small sample sizes, short follow-up durations, and heterogeneous study designs. Many existing studies include patients with older devices such as HeartMate II and HVAD, which are no longer implanted but remain in a substantial number of living patients. These legacy devices carry distinct thrombogenic risks that complicate generalizability. This review evaluates the emerging role of DOACs in the context of modern and legacy LVAD platforms. While initial data are promising, large-scale, prospective randomized trials are needed particularly in HM3-supported patients to define the optimal anticoagulation strategy.
对于接受左心室辅助装置（LVAD）支持的患者，抗凝管理对于预防血栓栓塞事件至关重要，同时要将出血并发症降至最低。华法林仍然是标准治疗方法，但受到治疗指数窄、饮食限制以及需要频繁监测的限制，这促使人们越来越关注直接口服抗凝剂（DOACs）作为替代方案。HeartMate 3（HM3）是目前临床实践中主要的LVAD，具有改善的血液相容性，与早期一代装置相比，已证明泵血栓形成和缺血性中风的发生率降低。这些进展增加了根据特定装置特点制定简化抗栓方案的可能性。回顾性研究表明，DOACs，尤其是阿哌沙班，可能提供与华法林相当的血栓栓塞保护，并且潜在出血风险更低，尤其是在不使用阿司匹林的情况下。此外，DOACs具有更可预测的药代动力学、更少的相互作用，并且由于监测要求降低，患者依从性得到改善。然而，目前的证据仍然受到样本量小、随访时间短和研究设计异质性的限制。许多现有研究纳入了使用HeartMate II和HVAD等旧装置的患者，这些装置已不再植入，但仍有大量存活患者使用。这些遗留装置具有独特的血栓形成风险使普遍性变得复杂。本综述评估了DOACs在现代和遗留LVAD平台背景下的新兴作用。虽然初步数据很有前景，但仍需要大规模、前瞻性随机试验，特别是在接受HM3支持的患者中，以确定最佳抗凝策略。
