Impact of mitral versus aortic bioprosthetic valve position on thromboembolism and bleeding risk in patients with atrial fibrillation

Bioprosthetic Valve Positions in Patients With Atrial Fibrillation - Insights From the BPV-AF Registry

Background

Data on the impact of valve position on clinical outcomes in patients with atrial fibrillation (AF) and bioprosthetic valves (BPVs) are limited.

Methods and Results

The BPV-AF Registry was a multicenter, prospective, observational study involving 894 patients with BPVs and AF. In this post-hoc substudy, patients were classified according to BPV position: aortic (n=588; 65.8%), mitral (n=195; 21.8%), or both (n=111; 12.4%). The primary outcome was a composite of stroke/systemic embolism, major bleeding, heart failure requiring hospitalization, all-cause death, or BPV reoperation. During a mean follow up of 15.3±4.0 months, the primary outcome occurred in 90 (15.3%) patients (12.7/100 patient-years) in the aortic group, 25 (12.8%; 10.2/100 patient-years) in the mitral group, and 16 (14.4%; 11.8/100 patient-years) in the both-valves group (log-rank P=0.621). The unadjusted and adjusted risks were not significant for the mitral and both-valves groups relative to the aortic group (unadjusted hazard ratio [95% confidence interval] 0.80 [0.52-1.25] and 0.92 [0.54-1.57]; adjusted hazard ratio 0.89 [0.51-1.54] and 1.10 [0.58-2.09], respectively). There was no significant difference in the incidence of stroke/systemic embolism or major bleeding among the 3 groups (log-rank P=0.651 and 0.156, respectively).

Conclusions

In patients with BPVs and AF, the risk for the composite outcome was comparable regardless of the BPV position.

Comparison of Direct Oral Anticoagulants and Warfarin in Patients With Atrial Fibrillation and an Aortic Bioprosthetic Valve

BACKGROUND

Current guidelines equally recommend direct oral anticoagulants (DOACs) and warfarin for atrial fibrillation (AF) patients with a bioprosthetic valve (BPV); however, there are limited data comparing DOACs and warfarin in AF patients with an aortic BPV.

METHODS AND RESULTS

This post-hoc subgroup analysis of a multicenter, prospective, observational registry (BPV-AF Registry) aimed to compare DOACs and warfarin in AF patients with an aortic BPV. The primary outcome was a composite of stroke, systemic embolism, major bleeding, heart failure requiring hospitalization, all-cause death, or BPV reoperation. The analysis included 479 patients (warfarin group, n=258; DOAC group, n=221). Surgical aortic valve replacement was performed in 74.4% and 36.7% of patients in the warfarin and DOAC groups, respectively. During a mean follow up of 15.5 months, the primary outcome occurred in 45 (17.4%) and 32 (14.5%) patients in the warfarin and DOAC groups, respectively. No significant difference was found in the primary outcome between the 2 groups (adjusted hazard ratio: 0.88, 95% confidence interval: 0.51-1.50). No significant multiplicative interaction was observed between the anticoagulant effects and type of aortic valve procedure (P=0.577).

CONCLUSIONS

Among AF patients with an aortic BPV, no significant difference was observed in the composite outcome of adverse clinical events between patients treated with warfarin and those treated with DOACs, suggesting that DOACs can be used as alternatives to warfarin in these patients.