Intracardiac thrombus (ICT) formation is a common complication of several cardiovascular diseases. Warfarin is recommended for treatment of ICT by guidelines based on observational studies occurring before the advent of nonvitamin K antagonist direct oral anticoagulants (DOACs). We aim to evaluate the current prescribing patterns at our institution and to compare the efficacy and safety profiles of warfarin versus DOACs for ICT. This is a retrospective review of adult patients treated with oral anticoagulation for ICT between May 2013 and December 2019. Our primary end point was complete thrombus resolution. Secondary outcomes included time to resolution of thrombus, treatment failure, and duration of therapy. Safety end points included stroke and systemic embolization (SSE) and bleeding events. A total of 123 patients were included (DOAC n = 61; warfarin n = 62). At baseline, more patients in the DOAC group had anemia [6 (10%) vs. 0 (0%), P = 0.013] and alcohol use disorder [6 (10%) vs. 0 (0%), P = 0.013]. Complete thrombus resolution occurred in 50 (82%) and 46 (74%) patients in the DOAC and warfarin groups, respectively (P = 0.298). There was a shorter time to thrombus resolution in the DOAC group versus the warfarin group {63 days [interquartile range (IQR) 40-138] vs. 123 days , P = 0.003}. There were no differences found in SSE or bleeding between the groups [DOAC 11 (19%) vs. warfarin 17 (28%), P = 0.213]. For patients with an ICT, treatment with a DOAC for at least 3 months may be a comparable alternative to warfarin in safety and efficacy.

The use of acute mechanical circulatory support (MCS) has increased over the last decade. For patients with left-ventricular failure, an Impella® (Abiomed, Danvers, MA) may be used to improve cardiac output. The purpose of this study is to describe Impella® anticoagulation patterns and evaluate the safety and effectiveness of our protocol. This is a retrospective review of all adult patients who required at least 24 h of Impella® support and received a heparin-based purge solution. In total, 109 patients were included in the final analysis. The most common indication for Impella® device insertion was cardiogenic shock (76%) with the remaining patients receiving a device for a high-risk procedures; typically coronary artery bypass grafting or percutaneous coronary intervention. A total of 9 thrombotic events occurred among 8 (7%) patients and 50 bleeding events occurred among 43 (39%) patients, with the most common classification being BARC 3a (60%). A univariate analysis revealed that patients were more likely to bleed if they were less than 65 years old, had an indication of cardiogenic shock for Impella®, inserted the device peripherally, were on dual antiplatelet therapy, or had an intra-aortic balloon pump prior to Impella® insertion, the latter of which was confirmed with a multivariate analysis (OR 2.5 [1.072–5.830]; p = 0.034). For those monitored by anti-Xa, the presence of two or more values greater than 0.40 IU/mL was a risk factor for bleeding ( p = 0.037). Our study identifies risk factors for bleeding in patients receiving temporary MCS with an Impella®.

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