Direct oral anticoagulants in left ventricular assist devices: Where are we now?

Despite significant advances in left ventricular assist device (LVAD) technology, particularly with the HeartMate 3, hemocompatibility-related adverse events (HRAEs), especially bleeding, remain common due to complex patient-device interactions and the need for anticoagulation. This has prompted interest in exploring new and less aggressive antithrombotic strategies. Direct oral anticoagulants (DOACs) have gained attention for their predictable pharmacokinetics, fixed dosing, and lower bleeding risk in other populations. Among them, apixaban has emerged as the most extensively studied DOAC in the HeartMate 3 setting, standing out as a promising alternative to VKAs in carefully selected patients, with the potential to lower bleeding risk without compromising thrombotic protection. However, available evidence remains limited by small sample sizes, short follow-up, and selected patient populations. Important gaps persist regarding optimal dosing, timing of initiation, level monitoring, and safety in vulnerable subgroups, particularly patients awaiting heart transplantation. This review synthesizes the current evidence on DOAC use in HeartMate 3-supported patients, provides practical guidance for real-world decision-making, and highlights areas where further research is needed. Although more data are required to define its role, apixaban is increasingly positioned as a promising VKA alternative in LVAD-patients and could ultimately reshape anticoagulation practice in this population.