Peri-Perative Transfusion Requirements and ICU Length of Stay after Heart Transplantation for Patients with LVADs Anticoagulated with Apixaban - Initial Experience.

Apixaban has been proposed to be a suitable alternative to vitamin K antagonists (VKAs) in patients with left ventricular assist devices (LVADs). Important considerations for its use in bridge to transplant (BTT) patients with LVADs are perioperative transfusion requirements and intensive care unit length of stay (ICU LoS). While the recombinant competitive inhibitor andexanet-alpha has been shown to reverse factor Xa inhibition, the agent is not available globally. We report our initial experience in three LVAD patients anticoagulated with apixaban and transplanted without andexanet-alpha available. On notification of successful donor matching, patients withheld any further apixaban doses. Data for blood product requirements, post-operative ICU LoS and 30-day survival were recorded. Data from the apixaban group were compared to historical data of VKA treated BTT LVAD patients undergoing transplantation from our institution. All patients transplanted had Abbott HeartMate-3 (HM3) devices and were anticoagulated with apixaban 2.5mg twice daily. The median (range) age was 51 (10-51) years. Duration of LVAD support was 6.4 (1.8-12.7) months. The time between recipient call and operating theatre time was 17.4 (15.4-18.7) hours. Operation duration was 6.1 (5.6-7.6) hours. Intra-operative packed red blood cell (PRBC) product use in these three patients ranged from 0 to 3 units. In historical data, 132 patients transplanted after LVAD explantation at our institution received a median of 2 (IQR 1-3) PRBC units. Other peri-operative blood product usage is outlined in Table 1. The ICU LoS ranged from 5 to 9 days. All patients were alive at 30 days. Despite the lack of the competitive inhibitor at our centre, the pharmacodynamics of apixaban allowed for safe transplantation in these patients. Further studies confirming the safety of apixaban in this population are warranted. [ABSTRACT FROM AUTHOR]