Recent advances and knowledge gaps in anticoagulation strategy with durable left ventricular assist devices.

Driven by technological advancements, donor shortages, and an aging population, utilization of left ventricular assist devices (LVAD), both as a bridge to transplant and as destination therapy, has risen in recent years for symptomatic patients with end-stage heart failure. With wide blood flow pathways, friction-free movement, and intrinsic pulsatility that reduce shear stress and promote more favorable intrapump blood flow, the incidence of adverse events such as device failure and thromboembolism has been significantly reduced in patients receiving the latest LVAD, the HeartMate 3 (HM3; Abbott Laboratories, Abbott Park, IL, US). However, hemocompatibility related complications, especially bleeding, remain common and a major cause of morbidity and hospitalization. This has prompted interest in less aggressive antithrombotic strategies for LVAD patients. Recent evidence has demonstrated that aspirin can be safely omitted in most HM3 recipients, substantially reducing bleeding without increasing thromboembolic events. Moreover, the direct oral anticoagulant apixaban has emerged as a promising alternative to warfarin in selected LVAD patients, with the potential to reduce bleeding risk without compromising protection against thrombotic complications. However, randomized phase III evidence remains limited, and important knowledge gaps persist in this population. This review summarizes contemporary antithrombotic strategies in HM3 recipients, evaluates emerging evidence supporting apixaban and aspirin withdrawal, and highlights remaining knowledge gaps. We also outline future directions, including ongoing randomized clinical trials, novel anticoagulants targeting factors XI and XII, and artificial intelligence-based approaches to individualized anticoagulation. As the field continues to evolve, personalized antithrombotic strategies have the potential to optimize hemocompatibility while improving clinical outcomes and quality of life in patients receiving durable LVAD.