Factor Xa inhibitors in patients with continuous-flow left ventricular assist devices
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ORIGINAL ARTICLE
Factor Xa inhibitors in patients with continuous‑flow left ventricular assist devices Vishal Y. Parikh1 · Umang M. Parikh1 · Angel Moctezuma‑Ramirez1 · Harveen K. Lamba1 · Joggy K. George1 · Savitri Fedson1 · Ajith P. Nair1 · O. H. Frazier1 · Reynolds M. Delgado2 Received: 13 January 2020 / Accepted: 17 April 2020 © The Japanese Association for Thoracic Surgery 2020
Abstract Objective Warfarin is standard anticoagulation therapy for patients with a continuous-flow left ventricular assist device (CF-LVAD). However, warfarin requires regular monitoring and dosage adjustments and fails for many patients, causing thromboembolic and bleeding events. Factor Xa inhibitors have been shown to be noninferior to warfarin in preventing strokes and are associated with less intracranial hemorrhage in patients with atrial fibrillation. We evaluated treatment safety and effectiveness in CF-LVAD patients who switched from warfarin to a factor Xa inhibitor (apixaban or rivaroxaban) after warfarin failure. Methods This was a retrospective, single-center study of patients treated between 2008 and 2018. We assessed the occurrence of stroke, non-central nervous system (CNS) embolism, pump thrombosis, and major gastrointestinal bleeding and intracranial hemorrhage during therapy. Results We identified seven patients: five were male, the average body mass index was 30 kg/m2, and average age was 56 years. Preimplantation comorbidities included hypertension (all patients) and diabetes mellitus, ischemic cardiomyopathy, atrial fibrillation, and previous myocardial infarction (four patients each). Overall, patients received warfarin for 3968 days and apixaban/rivaroxaban for 1459 days. The warfarin group was within the therapeutic INR range (2.0–3.0) 30% of the time. Complication rates did not differ between warfarin and apixaban/rivaroxaban: strokes, 0.20 vs none, non-CNS embolism, 0.54 vs none; pump thrombosis, 0.27 vs none; major gastrointestinal bleeding, 0.20 vs 0.50; intracranial hemorrhage, 0.13 vs none. Conclusions Factor Xa inhibitors may be viable treatment options for CF-LVAD patients for whom warfarin therapy has failed. Large prospective studies are necessary to confirm these results. Keywords Atrial fibrillation · Bleeding · Coagulation/anticoagulation · Circulatory support devices · Thrombosis
Introduction Vishal Y. Parikh and Umang M. Parikh contributed equally to this work. Meeting presentation: This manuscript is based on an oral presentation with a similar title at the International Society of Heart and Lung Transplantation on April 6, 2019. The abstract was published in the conference supplement (J Heart Lung Transplant 38(4 Supplement):S425). * Vishal Y. Parikh [email protected] 1
Division of Cardiothoracic Transplantation and Circulatory Support, Baylor College of Medicine, 6720 Bertner Ave, Houston, TX 77030, USA
Department of Cardiology, Texas Heart Institute, 6770 Bertner Ave, Houston, TX 77030, USA
2
Patients with end-stage heart failure who have received a continuous-flow left
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