Patients with advanced coronary artery disease (CAD), severely reduced left ventricular (LV) ejection fraction, and prior coronary artery bypass grafting (CABG) present with complex revascularization challenges requiring individualized, multidisciplinary decision-making and pre-procedural strategy planning. Protected percutaneous coronary intervention (PCI) using percutaneous temporary mechanical circulatory support, such as the Impella™ microaxial flow pump, may enable complex revascularization in carefully selected patients at high risk of peri-procedural haemodynamic compromise. We describe a male patient with advanced ischaemic cardiomyopathy, severe functional mitral regurgitation, and complex multivessel CAD, including chronic total occlusion (CTO) of the left anterior descending artery, following prior CABG. After Heart Team discussion and in the context of prohibitive surgical risk, a staged strategy was carefully planned pre-procedurally and then pursued with mitral transcatheter edge-to-edge repair, followed by prophylactic Impella-assisted PCI. Under haemodynamic support, retrograde CTO PCI via a patent saphenous vein graft was performed with drug-eluting stent implantation and intravascular ultrasound-confirmed optimization, achieving TIMI 3 flow. The patient remained haemodynamically stable, with an uneventful post-procedural course and no vascular or cardiac complications. This case illustrates how a staged Impella-protected PCI strategy can facilitate revascularization in post-CABG patients with advanced LV dysfunction and be integrated into a timely, planned, and patient-tailored approach accounting for ventricular function, valvular disease, and complex coronary anatomy when surgery is not feasible.

Injectable antiplatelet agents can provide immediate and effective platelet inhibition in patients with acute coronary syndromes (ACS). These agents are able to overcome many of the limitations of oral antiplatelet agents, and maybe of particular benefit in patients with ST-elevation myocardial infarction (STEMI), especially those presenting with cardiogenic shock or rescuscitated cardiac arrest. In these patients, factors such as vomiting, altered physiology, sedation, mechanical ventilation or therapeutic hypothermia can impair drug absorption, reducing the intended antiplatelet effect and increasing ischaemic risk. Intravenous aspirin is used widely in patients with ACS, while the absorption of oral P2Y12 inhibitors is often delayed, and the intravenous P2Y12 inhibitor cangrelor can achieve almost complete platelet inhibition within minutes. While use of the glycoprotein IIb/IIIa inhibitors (GPI) eptifibatide and tirofiban is decreasing, typically reserved for thrombotic complications or no reflow following PCI, recently zalunfiban, a novel subcutaneously administered GPI has been shown to improve reperfusion before revascularisation in patients with STEMI when given at first medical contact. In this review, we dicuss the rationale and potential benefits of injectable antiplatelet medications, including currently available agents and those in development or being tested in clinical trials. While the benefit of injectable medications on hard clinical endpoints such as major adverse cardiac events remains unclear for an allcomers ACS population, there is emerging data that these agents achieve rapid platelet inhibition, improve coronary flow and clinical outcomes particular in high risk ACS patients, such as those with cardiogenic shock.

BACKGROUND:The microaxial flow pump (mAFP) has demonstrated improved outcomes in selected patients with ST-segment elevation acute myocardial infarction and cardiogenic shock (STEMI-CS). However, its use has been associated with bleeding events. OBJECTIVES:The authors analyzed bleeding in the international multicenter randomized DanGer Shock (Danish German Shock) trial. METHODS:A total of 355 patients with ST-segment elevation acute myocardial infarction and cardiogenic shock were randomized to either mAFP (n = 179) or standard care alone (n = 176). Bleeding events were classified according to Bleeding Academic Research Consortium (BARC) type 3-5. RESULTS:In the mAFP group, 47 patients (26.3% [95% CI: 20.3%-33.2%]) experienced BARC type 3-5 bleeding, compared with 27 (15.3% [95% CI: 10.7%-21.4%]) in the standard care group; P < 0.001. Median follow-up was 121 days (Q1-Q3: 3-180 days). Among the 210 patients treated with any mechanical circulatory support (MCS), 2 of 74 bleeding events (2.7%) occurred in the cath lab, 35 (47.3%) while on MCS, and 37 (50.0%) after the MCS was removed. Bleeding increased with complexity of MCS: OR for BARC 3-5 bleeding with mAFP was 4.94 (95% CI: 2.30-10.65); P < 0.001, with venoarterial extracorporeal membrane oxygenation (VA-ECMO) 8.06 (95% CI: 2.81-23.09); P < 0.001, and with combined mAFP+VA-ECMO 27.40 (95% CI: 9.82-76.43); P < 0.001, no device as reference. Multivariable logistic regression identified use of mAFP, renal replacement therapy, and escalation to VA-ECMO as predictors of BARC type 3-5 bleeding. CONCLUSIONS:Patients randomized to mAFP experienced more bleeding than the standard care group. Bleeding was associated with the complexity of MCS, with one-half of the bleeding events occurring after device removal. (Danish Cardiogenic Shock Trial [DanShock]; NCT01633502).

Abstract Background/Introduction Timely diagnosis and treatment of cardiogenic shock (CS) are critical, with baseline arterial lactate being one of the earliest prognostic biomarkers [2]. A threshold of ≥2 mmol/L is considered clinically significant [3]. However, arterial sampling is often difficult in critical settings such as ongoing resuscitation, severe vasoconstriction, or during ECMO cannulation. This raises the clinical question of whether venous lactate can reliably substitute arterial lactate for diagnosis and monitoring in CS patients. Purpose To investigate the correlation and agreement between arterial and mixed venous lactate levels in critically ill cardiac patients, and to assess whether venous lactate can be used interchangeably with arterial lactate in this population. Methods A retrospective study was performed in 1,579 patients admitted to a quaternary cardiac intensive care unit (86% surgical, 14% non-surgical), all monitored with pulmonary artery catheters. Simultaneous radial arterial and mixed venous blood gas lactate levels were obtained, resulting in 4,801 paired samples (median interval 8 min, IQR 3–18). Data were analyzed using regression, Bland-Altman analysis, and mixed-effects modeling. Results Patients were predominantly male (67%), mean age 59.6 ± 16.3 years, with high illness severity (mean VIS 19.8 ± 13.6, ICU mortality 31.4%). Arterial and venous lactate values were strongly correlated across the entire cohort (p < 0.0001, R² = 0.99), with a mean difference of 0.02 ± 0.32 mmol/L. In samples with arterial lactate 2–5 mmol/L [3] (n = 1,250), venous and arterial lactates remained highly correlated (R² = 0.95; mean difference 0.04 ± 0.30 mmol/L). In samples with arterial lactate >5 mmol/L [3] (n = 591), correlation was preserved (R² = 0.97; mean difference 0.05 ± 0.71 mmol/L). Mixed-effects modeling confirmed no significant difference between sampling sites (p = 0.653), nor any significant interaction over time (p = 0.219). Conclusion(s) This is the first large-scale study in cardiac ICU patients (1,579 patients; 4,801 paired samples) to demonstrate strong and consistent correlation and agreement between arterial and mixed venous lactate levels across a wide range of concentrations. The interchangeability of these measures supports faster decision-making when arterial access is difficult, reduces redundant blood sampling, and has important implications during ECMO cannulation and cardiopulmonary resuscitation. Moreover, as persistent arterial–venous correlation has previously only been shown in septic shock [4,5], this study extends these findings to CS, highlighting mechanistic differences between shock types while validating clinical flexibility. Finally, the results provide rationale for integrating continuous lactate monitoring into pulmonary artery catheter systems, advancing precision care in circulatory failure.Paired art. vs ven. lactate

Ischemic left ventricle dysfunction (ILVD) is the leading cause of heart failure and is commonly encountered in cardiac catheterisation laboratories. Patients presenting with ILVD are typically older and often have complex coronary anatomy, making revascularisation challenging. Although coronary artery bypass grafting (CABG) improves long-term survival in patients with ILVD compared to medical therapy, the benefit emerges only after a decade and appears limited to younger patients, leaving many older, frail, or comorbid individuals at untenable risk. Such patients are frequently considered for complex high-risk indicated percutaneous coronary intervention (CHIP), where the primary determinant of procedural risk is intraprocedural haemodynamic instability due to limited ventricular reserve and anticipated prolonged ischemia. Registry data underscores the heightened risk in patients with multiple CHIP features, including ejection fraction (EF) ≤30%, left main or multivessel percutaneous coronary intervention (PCI), and extensive calcification. Here, temporary mechanical circulatory support (tMCS) has emerged as a strategy to mitigate haemodynamic compromise during CHIP procedures. Although trial data has demonstrated no early benefit with the intra-aortic balloon pump (IABP), long-term follow-up suggests improved survival. Alternatively, micro-axial flow pumps (mAFP), such as Impella™, can offer robust haemodyanic support and a reduction in late major adverse events. Although results from the ongoing randomized clinical trials with Impella are pending, careful Heart Team evaluation and procedural planning remain essential to ensure the best possible patient outcomes. Here, we illustrate a structured approach to Impella-supported CHIP in an elderly patient with the presence of ILVD, severely impaired ventricular reserve, and heavily calcified multivessel disease.

Cardiogenic shock is a complex clinical syndrome with a high mortality risk. As heterogeneity of patient presentation is high and diagnosis not standardized, a timely diagnosis and thus initiation of treatment are oftentimes not achieved, further worsening the prognosis of affected patients. We therefore propose standardized criteria for the diagnosis of cardiogenic shock, based on three essential pillars: (i) an evidence of end-organ hypoperfusion at rest, (ii) which is primarily caused by haemodynamic abnormalities and a direct consequence of (iii) an underlying cardiac dysfunction commensurate with the state of shock.

Bleeding and thrombosis are major complications of micro-axial flow pump (mAFP) support in cardiogenic shock (CS), yet contemporary data on their incidence, temporal trends, and prognostic impact remain unclear. We retrospectively analyzed patients supported with mAFP between 2010 and 2023 across eleven high-volume European centers. Bleeding and thrombotic events during support were adjudicated and normalized to annual implant volumes. Kaplan–Meier analysis assessed 180-day survival, and multivariable logistic regression identified independent predictors of bleeding and thrombosis. Among 1,043 patients (61

AIMS:Optimal positive end-expiratory pressure (PEEP) selection in cardiogenic shock (CS) remains poorly defined despite the frequent use of invasive mechanical ventilation in this population. We aimed to evaluate whether a respiratory mechanics-guided PEEP titration protocol results in clinically relevant changes in ventilator settings and to assess the hemodynamic consequences of these adjustments. METHODS AND RESULTS:A prospective physiological study was conducted in mechanically ventilated patients with CS undergoing a decremental PEEP titration protocol (15 to 5 cmH2O). The final PEEP was selected according to maximal respiratory system compliance without evidence of derecruitment, overdistension, or hemodynamic deterioration. Hemodynamic, echocardiographic, and respiratory parameters were assessed at each step. Twenty-five patients were included, including 15 with acute myocardial infarction-related CS (AMI-CS) and 10 with heart failure-related CS (HF-CS). PEEP titration resulted in modification of ventilatory settings in 88% of patients. PEEP reduction occurred predominantly in AMI-CS, whereas PEEP escalation was more common in HF-CS. Respiratory mechanics and oxygenation improved following titration, with higher static compliance (62.5 ± 11 vs. 74.7 ± 11.5 mL/cmH2O; p = 0.003) and PaO2/FiO2 ratio (244 ± 89 vs. 276 ± 65; p = 0.001). Right atrial pressure (RAP) varied significantly across PEEP levels (p < 0.001) and changes were greater in HF-CS and in patients with RV dysfunction. Patients with impaired RV function showed greater RAP increase and reduced tolerance to higher PEEP levels. CONCLUSION:Respiratory mechanics-guided PEEP titration frequently modifies ventilatory settings in CS and reveals marked variability in hemodynamic tolerance according to CS phenotype and RV function. Individualized PEEP titration may help balance respiratory benefit, congestion, and hemodynamic stability in mechanically ventilated patients with cardiogenic shock.

Complex distal left main (LM) coronary artery disease with bifurcation involvement and chronic total occlusion (CTO) is usually treated with coronary artery bypass grafting (CABG). Patient refusal of surgery necessitates high-risk percutaneous revascularization that may require mechanical circulatory support. Here, we present a case of a 66-year-old male with Canadian Cardiovascular Society Class III angina and preserved left ventricular ejection fraction (LVEF; 60%) who was diagnosed with severe calcified distal LM stenosis extending into the left ostial circumflex (LCx), and a proximal left anterior descending (LAD) CTO. CABG was recommended but declined by the patient and high-risk PCI was performed with haemodynamic support using Impella CP™ with SmartAssist. Lesion preparation included rotational atherectomy followed by intravascular lithotripsy of the LM, LAD, and LCx. The LAD CTO was successfully recanalized and treated with two drug-eluting stents and two drug-coated balloons. A double-kissing culotte two-stent strategy was applied for the distal LM bifurcation, guided by intravascular ultrasound. Haemodynamics remained stable, with Impella support successfully preventing instability during hypotensive phases and during extensive lesion modification of the LM using rotational atherectomy. The patient was discharged on dual antiplatelet therapy and remained free of angina with preserved LVEF and an excellent angiographic result at 6-month follow-up. This case demonstrates how Impella support enabled safe, complete revascularization of high-risk LM bifurcation CTO disease when CABG was declined. Moreover, it illustrates that protected PCI with an Impella device can provide a safe alternative to surgery in anatomically complex LM disease, ensuring procedural stability and complete revascularization.

AIMS:Out-of-hospital cardiac arrest (OHCA) represents a major public health challenge, with high mortality and significant neurological impairments among survivors. Haemodynamic instability, particularly hypotension (a mean arterial blood pressure <65 mmHg), may be a key contributor to post-resuscitation morbidity and mortality. METHODS AND RESULTS:After return of spontaneous circulation, hypotension can result from various causes, including arrhythmias, mechanical complications, thromboembolism, or different types of shock, as well as sedation, temperature control and positive pressure ventilation. Differentiating between hypotension with vs. without hypoperfusion is critical to avoid unnecessary interventions while ensuring adequate cerebral and myocardial perfusion. Clinical assessment and repeated echocardiography should be routine in all patients. Therapeutic targets should include evidence of preserved end-organ function, including urine output, and normal or decreasing lactate. In selected cases, advanced haemodynamic monitoring with pulmonary artery catheters may be necessary to diagnose the shock-type and monitor treatment effects. Causal treatment of the precipitating cause of hypotension is crucial as well as symptomatic treatment with fluids, vasopressors and inotropes if needed. Mechanical circulatory support may be employed for refractory shock unresponsive to other treatment. CONCLUSION:This clinical consensus statement by the Association for Acute CardioVascular Care (ACVC) of the European Society of Cardiology (ESC) provides clinical guidance for the haemodynamic monitoring and management of hypotension in OHCA patients in intensive care. The document advocates for a multidisciplinary approach that integrates clinical assessment, imaging, and haemodynamic parameters to guide treatment, with the overarching goal of improving survival rates and neurological outcomes.

Ischaemic left ventricular dysfunction (ILVD) is the leading cause of heart failure and is commonly encountered in cardiac catheterization laboratories. Patients presenting with ILVD are typically older and often have complex coronary anatomy, making revascularization challenging. Although coronary artery bypass grafting improves long-term survival in patients with ILVD compared with medical therapy, the benefit emerges only after a decade and appears limited to younger patients, leaving many older, frail, or comorbid individuals at untenable risk. Such patients are frequently considered for complex high-risk indicated percutaneous coronary intervention (CHIP), where the primary determinant of procedural risk is intra-procedural haemodynamic instability due to limited ventricular reserve and anticipated prolonged ischaemia. Registry data underscore the heightened risk in patients with multiple CHIP features, including ejection fraction ≤30%, left main or multivessel percutaneous coronary intervention, and extensive calcification. Here, temporary mechanical circulatory support has emerged as a strategy to mitigate haemodynamic compromise during CHIP procedures. Although trial data have demonstrated no early benefit with the intra-aortic balloon pump, long-term follow-up suggests improved survival. Alternatively, microaxial flow pumps, such as Impella™, can offer robust haemodynamic support and a reduction in late major adverse events. Although results from the ongoing randomized clinical trials with Impella are pending, careful Heart Team evaluation and procedural planning remain essential to ensure the best possible patient outcomes. Here, we illustrate a structured approach to Impella-supported CHIP in an elderly patient with the presence of ILVD, severely impaired ventricular reserve, and heavily calcified multivessel disease.

BackgroundDual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) with stenting is standard of care but increases bleeding risk, particularly in patients requiring veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for acute myocardial infarction-cardiogenic shock. Evidence guiding optimal antithrombotic strategies in this high-risk population remains limited.MethodsWe conducted a retrospective observational study at a high-volume ECMO center. From January 2018 to December 2022, 351 VA-ECMO patients were screened, and 72 who underwent PCI immediately prior to or during ECMO were included. Patients were grouped by initial post-PCI antiplatelet strategy: aspirin alone (n = 33), augmented therapy (n = 25), or no antiplatelet therapy (n = 14). The primary objective was to evaluate the safety and efficacy of an aspirin-only strategy for preventing in-stent thrombosis. Efficacy was assessed by the incidence of in-stent thrombosis during ECMO hospitalization, and safety was assessed by the occurrence of major bleeding events.ResultsGroups were similar in age, race, gender, and BMI. No patient developed clinically overt in-stent thrombosis. Major bleeding occurred in 33.3% of aspirin, 48% of augmented, and 50% of no-antiplatelet patients (p = 0.396). Most common bleeding events were hemoptysis, intracranial hemorrhage, and gastrointestinal bleeding.ConclusionsAmong patients undergoing PCI with concurrent VA-ECMO support, no differences in stent thrombosis or major bleeding were observed between aspirin monotherapy, augmented antiplatelet therapy, or no antiplatelet therapy. However, intracranial hemorrhage occurred more frequently in the Augmented AP group. These findings suggest that aspirin monotherapy may provide adequate protection against stent thrombosis while potentially minimizing bleeding risk in this critically ill population.

Dual antiplatelet therapy (DAPT) is required to prevent atherothrombotic events in patients with acute coronary syndrome (ACS) treated with percutaneous coronary intervention (PCI). The default DAPT strategy, namely a potent P2Y12 inhibitor combined with aspirin for 12 months, exposes many patients to excess bleeding risk. Over the past years, alternative antithrombotic regimens have been proposed to reduce bleeding (DAPT abbreviation or de-escalation) or ischaemic (prolonged dual antithrombotic therapy) events. Abbreviation or de-escalation of DAPT is supported by (i) multiple trials showing these strategies to significantly reduce bleeding, particularly for the 20-40% of patients classified as high bleeding risk (HBR); (ii) low prevalence of stent thrombosis and recurrent myocardial infarction beyond 1-3 months post-ACS with the latest generation of drug-eluting stents, and (iii) the recognition that HBR is far more prevalent than high ischaemic risk. Amongst patients at HBR, standard DAPT, in comparison to abbreviated or de-escalated DAPT, increases the net risk of major adverse events, even in the presence of high ischaemic risk. Conversely, amongst patients at high ischaemic risk, without HBR, prolonged dual antithrombotic therapy reduces longer-term thrombotic risk. Recognizing risk factors and assessing the magnitude of bleeding and ischaemic risks are essential. Since there are no ideal scoring systems to balance ischaemic and bleeding risks, and many overlap, focus should be on managing the risk most amenable to modification, namely bleeding, which should dominate the decision-making over ischaemic risk when choosing a DAPT regimen. This document provides practical advice regarding best practice for personalizing DAPT in patients with ACS undergoing PCI, with evidence-based clinical consensus statements on selecting the most appropriate antiplatelet strategy to optimize clinical outcomes.

Extracorporeal cardiopulmonary resuscitation (ECPR) has emerged as a lifesaving strategy for refractory cardiac arrest, restoring systemic perfusion when conventional cardiopulmonary resuscitation fails. However, ECPR profoundly disrupts haemostasis, driven by the combined effects of whole-body ischaemia–reperfusion injury, systemic inflammation, endothelial activation, platelet dysfunction, and blood contact with extracorporeal surfaces. Together, these processes create a highly dynamic and unstable thromboinflammatory milieu, marked by the simultaneous risk of thrombosis and life-threatening bleeding. Systemic anticoagulation is required to maintain circuit patency and prevent thromboembolic complications, yet optimal strategies remain uncertain. Haemostasis during ECPR is highly dynamic, shaped by the underlying aetiology of cardiac arrest, patient-specific characteristics, and circuit-related factors. This complexity underscores the limitations of fixed anticoagulation targets and the need for individualized, context-sensitive management guided by continuous clinical and laboratory assessment. Despite the increasing global adoption of ECPR, high-quality evidence to guide anticoagulation practices remains scarce. Current strategies are largely extrapolated from other extracorporeal life support populations, contributing to substantial inter-centre variability. This review synthesizes the available evidence on coagulopathy and anticoagulation in adult patients receiving ECPR and discusses emerging approaches to monitoring and anticoagulation management.

Inflammation is a key driver of coronary syndromes across the continuum from chronic coronary syndromes to acute coronary syndromes. It contributes to atherogenesis, plaque destabilization, and ischaemic events and influences myocardial injury, repair, and remodelling. Inflammatory activity is further amplified by metabolic and autoimmune comorbidities such as diabetes, obesity, and connective tissue diseases, with obesity representing a major driver of chronic low-grade inflammation through adipose tissue dysfunction and cytokine activation, while psychosocial stress and environmental exposures including air pollution serve as additional triggers. Genetic variations, including human leucocyte antigen genotypes, modulate individual susceptibility to vascular inflammation and myocardial injury. This expert consensus from the European Society of Cardiology's Association for Acute CardioVascular Care summarizes the current understanding of inflammation across the full spectrum of coronary syndromes, including underlying mechanisms, relevant biomarkers, and imaging approaches that characterize vascular inflammation, and integrates insights from experimental and clinical studies. Importantly, this document provides explicit consensus-based guidance on when, how, and in whom inflammation should be assessed and treated in routine clinical practice. While the causal association between inflammation and atherosclerotic cardiovascular disease is well established, pharmacological modification of inflammation has produced conflicting evidence. Some agents, such as low-dose colchicine, have demonstrated modest reductions in cardiovascular events, although results across trials have been inconsistent. Other anti-inflammatory therapies have not shown clinical benefit, whereas selective cytokine inhibition with canakinumab has reduced cardiovascular risk at the cost of increased infection rates. The present manuscript also focuses on the evaluation of inflammatory activity in cardiovascular patients in routine clinical practice. It further discusses criteria for patient selection and clinical decision-making regarding the introduction of anti-inflammatory therapy in individuals with established atherosclerotic cardiovascular disease.

Background Managing unfractionated heparin (UFH) during percutaneous mechanical circulatory support for cardiogenic shock (CS) is challenging due to potential discrepancies between coagulation tests. Objectives To study the causes and consequences of discrepancies between anti-Xa and activated partial thromboplastin time (APTT) for UFH monitoring during microaxial flow pump support (Impella) for CS. Methods We assessed patients in CS supported with Impella in 2 tertiary care centers over 62 months. UFH was titrated based on anti-Xa levels with parallel APTT measurements. In-range anti-Xa levels were considered between 0.20 and 0.30 IU/mL or 0.31 and 0.50IU/mL, and the corresponding APTT values were 40 to 55 seconds and 56 to 80 seconds, respectively. Pearson correlation was calculated between anti-Xa and APTT. Samples with in-range anti-Xa but prolonged APTT were analyzed for abnormalities in international normalized ratio (INR; ≥1.5) and/or fibrinogen (<1.5g/L). Mortality during Impella support was then compared in those with and without additional coagulation abnormalities (chi-squared test). Results Correlation between anti-Xa and APTT was weak (r = 0.50, P < .001, N = 2447). When anti-Xa was in range (N = 1914 samples), 24% had short, 52% had in-range, and 24% had prolonged APTT. Of the 57 patients with prolonged APTT, 28 had abnormal same-day INR and/or fibrinogen, whereas 29 had normal fibrinogen and INR. Mortality was higher in patients with abnormal INR and/or fibrinogen than in those with normal fibrinogen and INR (32% vs 10%; P = .043). Conclusion Anti-Xa/APTT discrepancies are frequent during percutaneous mechanical circulatory support for CS, highlighting the importance of a multiple testing strategy. Outcomes of patients with prolonged APTT were related to the presence of abnormal INR and/or fibrinogen, suggesting a serious concomitant underlying disease.

Despite significant advances in left ventricular assist device (LVAD) technology, particularly with the HeartMate 3, hemocompatibility-related adverse events (HRAEs), especially bleeding, remain common due to complex patient-device interactions and the need for anticoagulation. This has prompted interest in exploring new and less aggressive antithrombotic strategies. Direct oral anticoagulants (DOACs) have gained attention for their predictable pharmacokinetics, fixed dosing, and lower bleeding risk in other populations. Among them, apixaban has emerged as the most extensively studied DOAC in the HeartMate 3 setting, standing out as a promising alternative to VKAs in carefully selected patients, with the potential to lower bleeding risk without compromising thrombotic protection. However, available evidence remains limited by small sample sizes, short follow-up, and selected patient populations. Important gaps persist regarding optimal dosing, timing of initiation, level monitoring, and safety in vulnerable subgroups, particularly patients awaiting heart transplantation. This review synthesizes the current evidence on DOAC use in HeartMate 3-supported patients, provides practical guidance for real-world decision-making, and highlights areas where further research is needed. Although more data are required to define its role, apixaban is increasingly positioned as a promising VKA alternative in LVAD-patients and could ultimately reshape anticoagulation practice in this population.