A Multidisciplinary Team-Based Process Improves Outpatient Anticoagulation Quality in Patients with Continuous-Flow Left-Ventricular Assist Devices

Abstract

Purpose: Direct oral anticoagulants (DOACs) were recently approved for deep vein thrombosis (DVT) and atrial arrhythmia. The use of DOACs has not been assessed in cardiac transplant recipients, who often take interacting medications and have renal dysfunction, and the purpose of this study is to investigate the efficacy and safety of DOACs compared to traditional anticoagulants in cardiac transplant recipients. Methods: We conducted a retrospective cohort study of all patients who underwent heart transplantation between 1/2012 and 6/2015. We excluded patients who did not survive the initial hospitalization after surgery and those with hematologic disorders. Results: Among 55 eligible patients, 18 patients required anticoagulation therapy for atrial fibrillation/flutter (n= 7) or treatment of DVT (n= 11). The incidence of post operative DVT was 16.4% (9/55), and was 12.7% for post operative atrial arrhythmia. Of 18 patients, 11 used traditional anticoagulants (group I) with low molecular weight heparin (n= 3), fondaparinux (n= 7), or warfarin (n= 1), and 7 patients received DOACs (group II) depending on the preference of physicians and insurance coverage (Table 1). All patients used tacrolimus, and there was no difference between the two groups in terms of age, gender, weight, creatinine clearance, history of DVT, prior VAD use, concurrent antiplatelet therapy, or the duration of anticoagulation therapy. Overall safety and treatment success were similar in the two groups. There was only one episode of bleeding in group II as compared to none in group I (p= 0.39) and no case of recurrence of DVT. Two (18.2%) patients in group I demonstrated incomplete resolution of DVT which required the extension of treatment, and similarly two (28.6%) patients in group II did as well (P> 0.99). There were no cases of stroke. Conclusion: DOACs may be a reasonable option for anticoagulation post transplant, even with interacting medications. A larger study is needed to confirm this finding.