Use of Apixaban in Heart Transplant Patients Receiving Biopsies: A Case Series

Abstract

Purpose The need for routine biopsies poses a challenge in the management of heart transplant recipients with an indication for anticoagulation. Per local institutional protocol, all patients receive at least 7 endomyocardial biopsies within 90 days of transplant to assess for rejection. Apixaban is a direct acting anticoagulant with a short half-life allowing for minimal time off anticoagulation to accommodate a biopsy. To our knowledge, apixaban has never been evaluated in the setting of routine biopsies. The objective of this study was to determine the safety and efficacy of apixaban in heart transplant patients undergoing biopsies. Methods This retrospective case series evaluated patients who received a heart transplant and were treated with apixaban within 90 days post-transplant. This research was approved by the Eastern Virginia Medical School IRB. Per institutional protocol, apixaban was held for 1-2 doses prior to routine biopsy and restarted the night following biopsy. The primary outcome was the occurrence of a bleeding or thrombotic event. Results A total of 13 patients received apixaban within 90 days following heart transplant. The median age was 54 years (IQR 37-59) with a median weight of 96 kg (IQR 72-101). None of the patients had either a bleeding or thromboembolic event while on apixaban. During therapy, patients underwent an average of 8 biopsies. The median time from transplant to initiation of apixaban was 39.5 ± 26.1 days (range 9-77). The number of patients on apixaban for their biopsies during post-op weeks 3-6 are as such: 3, 6, 6, 7. No patients required reversal therapy at any point and patients remained on therapy for a median of 276 (IQR 45-245) days. Indication for apixaban was stroke prevention with atrial fibrillation (15%), acute DVT (70%), and both (15%). Of the DVTs 30% were femoral while 70% were upper extremity. Compliance with the apixaban dosing protocol was excellent. Dosing was adjusted according to indication and renal function. Conclusion Based on the data from this case series, apixaban is safe to use for anticoagulation of heart transplant recipients undergoing routine biopsies in the setting of an established institutional protocol. Using apixaban allows for a short duration off anticoagulation to accommodate a biopsy without any increased risk of bleeding.