The use of direct oral anticoagulants in children with congenital and acquired heart disease.

Direct oral anticoagulants (DOACs), including the direct thrombin inhibitor, dabigatran, and factor Xa inhibitors (rivaroxaban, apixaban, and edoxaban), represent a significant advancement in pediatric anticoagulation therapy. Following U.S. FDA approvals for dabigatran and rivaroxaban in 2021 and apixaban in 2025, DOACs are now available for venous thromboembolism (VTE) prevention and treatment in pediatric patients; edoxaban has not yet received pediatric approval. Children with congenital and acquired heart disease (CAHD) constitute a particularly high-risk population for thromboembolic complications due to altered hemodynamics, prosthetic materials, and surgical interventions, necessitating effective anticoagulation strategies. This review summarizes current evidence regarding DOAC use in pediatric CAHD, evaluates safety and efficacy data from recent clinical trials, and highlights key knowledge gaps and future research priorities.