Evolving anticoagulation paradigms in left ventricular assist device (LVAD) patients: a focus on direct oral anticoagulants

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.