Non-Vitamin K Oral Anticoagulant After Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis

Anticoagulation therapy and related outcomes among Asian patients after bioprosthetic valve replacement

IMPORTANCE

An inadequate number of studies focused on Asian populations have investigated the safety of warfarin usage among Asian patients with tissue valve aortic valve replacement (AVR) or mitral valve replacement (MVR).

OBJECTIVE

This study aimed to identify the optimal international normalized ratio (INR) range for Asian patients during a 1-year follow-up after tissue valve replacement.

DESIGN, SETTING, PARTICIPANTS

We conducted a retrospective cohort study of patients who underwent tissue valve AVR, MVR, and double valve replacement (DVR) between January 1, 2001, and December 31, 2018. Data were sourced from the Chang Gung Research Database, an electronic structured medical database covering 4 regional hospitals and 3 medical centers. The exposure of interest was INR level.

MAIN OUTCOMES AND MEASURES

The outcomes of primary and secondary interest were composite thromboembolic events and bleeding events during the 1-year follow-up, respectively. The relationship between INR level and the risk of thromboembolic events was explored using a logistic regression model in which the INR value was treated as a flexible restricted cubic spline. Because having atrial fibrillation (AF) greatly would greatly affect the INR control result, the analysis was stratified by AF status.

RESULTS

A total of 1059 participants were eligible for this study. The mean patient age was 65.5 (11.9) years; 592 (55.9%) participants were men, and 467 (44.1%) were women. A total of 447 had AF and 612 did not. The lowest bleeding risk was observed at an INR level around 1.9 to 2.0. An INR level of 1.84 (hazard ratio [HR], 0.49; 95% confidence interval [CI]: 0.36-0.67) and 1.7 (HR, 0.78; 95% CI: 0.62-0.99) corresponded to the lowest risk of thromboembolic events in patients with pre-existing AF and those without, respectively. The INR level corresponding to the lowest risk of thromboembolic events was approximately 1.7 in patients without AF but with MVR, DVR, or isolated AVR.

CONCLUSIONS AND RELEVANCE

For patients who underwent tissue valve replacement, the bleeding risk was elevated when the INR was greater than 2.0, but the risk of thromboembolic event increased only when the INR was lower than 1.84 in the AF group and 1.7 in the non-AF group, regardless of whether the patient received AVR, MVR, or DVR.

Continuation Versus Interruption of Anticoagulation During Transcatheter Aortic Valve Implantation: A Systematic Review and Meta-Analysis

Transcatheter aortic valve implantation (TAVI) involves complex decisions regarding perioperative anticoagulation, with continuation or interruption of oral anticoagulation presenting distinct risks and benefits. This systematic review and meta-analysis compared the clinical outcomes of these two strategies during TAVI. We conducted a comprehensive literature search across multiple electronic databases, including PubMed, Embase, Cochrane Library, and Web of Science, from inception to November 2024. Three studies with 2,591 patients (1,132 in the continuation group and 1,459 in the interruption group) met the inclusion criteria. The primary outcomes included all-cause mortality, myocardial infarction (MI), stroke, and major bleeding within one month of the procedure. Risk ratios (RRs) with 95% confidence intervals (CIs) were calculated using a random-effects model. Analysis revealed no significant differences between continuation and interruption groups for all-cause mortality (RR: 0.87, 95% CI: 0.53-1.41, P-value: 0.56), MI (RR: 0.68, 95% CI: 0.23-1.97, P-value: 0.48), stroke (RR: 0.67, 95% CI: 0.42-1.08, P-value: 0.10), or major bleeding (RR: 0.93, 95% CI: 0.69-1.26, P-value: 0.63). No substantial heterogeneity was observed across studies for any outcome. While continued anticoagulation showed a trend toward lower stroke risk, this difference did not reach statistical significance. The findings suggest that both strategies may be reasonable options, though the limited number of studies and short follow-up duration highlights the need for larger randomized controlled trials (RCTs). Until more definitive evidence emerges, the choice between continuation and interruption of oral anticoagulation during TAVI should be individualized based on patient-specific thromboembolic and bleeding risk factors.

Optimizing Anticoagulation in Valvular Heart Disease: Navigating NOACs and VKAs

BACKGROUND/OBJECTIVES

Non-vitamin K antagonist oral anticoagulants (NOACs) have demonstrated similar effectiveness and safety profiles to vitamin K antagonists (VKAs) in treating nonvalvular atrial fibrillation (AF). Given their favorable pharmacological profile, including the rapid onset and offset of action, fixed dosing, and predictable pharmacokinetics with a consistent dose-response relationship, reducing the need for frequent blood tests, researchers have investigated the potential of NOACs in patients with AF and valvular heart disease (VHD).

METHODS

Clinical trials, excluding patients with mechanical prosthetic valves or moderate/severe mitral stenosis, have shown the benefits of NOACs over VKAs in this population. However, there is a need for further research to determine if these findings apply to mechanical valve prostheses and NOACs.

RESULTS

Several ongoing randomized controlled trials are underway to provide more definitive evidence regarding NOAC treatment in moderate to severe rheumatic mitral stenosis. Importantly, recent trials that included patients with atrial fibrillation and bioprosthetic valves (also transcatheter heart valves) have provided evidence supporting the safety of NOACs in this specific patient population. Ongoing research aims to clearly define the specific scenarios where NOACs can be safely and effectively prescribed for various types of VHD, including moderate/severe mitral stenosis and mechanical valves.

CONCLUSIONS

The aim of this review is to accurately identify the specific situations in which NOACs can be prescribed in patients with VHD, with a focus centered on each type of valvulopathy.

Bioprosthetic aortic valve thrombosis under effective direct oral anticoagulant therapy

With the increase in transcatheter procedures, the use of bioprosthetic valves has become more frequent in clinical practice. However, the optimal antithrombotic management of patients with bioprosthetic valves remains controversial. In this case report, we describe a patient with a bioprosthetic aortic valve who developed a thrombus while receiving effective dose direct oral anticoagulant (DOAC) therapy. A 73-year-old male patient with a bioprosthetic aortic valve replacement 2 years prior presented with a mobile thrombus and early degeneration of the valve, detected during routine follow-up while being treated with apixaban. Although the valve thrombus regressed after switching to a different anticoagulant drug, we observed that the decreased but still high gradient persisted due to the early degeneration. Anticoagulant management of bioprosthetic valve patients demands careful attention. Although evidence supporting the use of DOACs is growing, close patient follow-up and further evaluation in case of doubt remain critical. The development of a thrombus in a bioprosthetic valve patient who is receiving anticoagulation therapy, as in this case, highlights the need for optimal management to prevent thromboembolic complications and valve degeneration.

Post-TAVR patients with atrial fibrillation: are NOACs better than VKAs?-A meta-analysis

Objective

This study aimed to compare the efficacy of novel oral anticoagulants (NOACs) with traditional anticoagulants vitamin K antagonists (VKAs) in patients with atrial fibrillation (AF) post transcatheter aortic valve replacement (TAVR).

Methods

Studies comparing the usage of NOACs and VKAs in AF patients with oral anticoagulant indication post-TAVR were retrieved from PubMed, EMBASE, Medline, and Cochrane databases from their building-up to Jan. 2023. The literature was screened in line of inclusion and exclusion criteria. Risk ratio (RR) or odds ratio (OR),95% confidence interval (CI) and number needed to treat (NNT) were calculated for four main indexes that composite endpoints composed mainly of any clinically relevant risk events, stroke, major bleeding, and all-cause mortality. Subsequently, a meta-analysis was performed using the RevMan5.3 and Stata 16.0 software.

Results

In the aggregate of thirteen studies, contained 30388 post-TAVR patients with AF, were included in this meta-analysis. Our results indicated that there was no significant difference in stroke between the NOACs group and the VKAs group, and the NOACs group had a numerically but non-significantly higher number of composite endpoint events compared with the other group. Nevertheless, the incidence of major bleeding [11.29% vs. 13.89%, RR 0.82, 95%CI (0.77,0.88), P < 0.00001, I² = 69%, NNT = 38] and all-cause mortality [14.18% vs. 17.61%, RR 0.83, 95%CI (0.79,0.88), p < 0.00001, I² = 82%, NNT = 29] were significantly lower in the NOACs group than another group.

Conclusion

Taken together, our data indicated that the usage of NOACs reduced the incidence of major bleeding and all-cause mortality compared to VKAs in post-TAVR patients with AF.

Comparing Vitamin K Antagonists and Direct Oral Anticoagulants in Patients With Atrial Fibrillation Undergoing Transcatheter Aortic Valve Replacement: A Meta-Analysis

Aortic stenosis (AS) is the most prevalent valvular disease in the elderly population and the prevalence of atrial fibrillation (AF) increases in the elderly population. Transcatheter aortic valve replacement (TAVR) becomes an important treatment for patients with AS at high surgical risk. This metanalysis aimed to compare the efficacy and safety of vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs) in patients with AF undergoing TAVR. We searched the different databases for articles published before January 31, 2022. In total, 7 studies including 25,255 patients were analyzed. Data on demographics, comorbidities, CHA2DS2-VASc score, Society of Thoracic Surgeons (STS) score, and incidences of all-cause mortality, major bleeding, intracranial hemorrhage (ICH), stroke, and thromboembolic events were obtained and analyzed. The VKA group had a lower CHA2DS2-VASc score (3.2  ±  1.2 vs 3.3  ±  1.2; P < .001) and a higher STS score (6.6  ±  3.2 vs 6.1  ±  2.9; P < .001) than the DOAC group. The risks of all-cause mortality (odds ratio [OR]: 0.88; 95% confidence interval [CI], 0.67-1.16), ischemic stroke (OR: 1.06; 95% CI, 0.90-1.24), and thromboembolism (OR: 1.24; 95% CI, 0.63-2.47) in the DOAC group were comparable to the VKA group. The risks of major bleeding (OR: 0.77; 95% CI, 0.71-0.84) and ICH (OR: 0.62; 95% CI, 0.42-0.90) were lower in the DOAC group compared to the VKA group. DOACs were associated with lower risks of major bleeding and ICH, and comparable risks of all-cause mortality, ischemic stroke, and thromboembolism in patients with AF undergoing TAVR compared to VKAs.

Novel oral anticoagulants versus vitamin K antagonists in transcatheter aortic valve replacement treated patients-Patients' vulnerability still matters

Current meta‐analysis suggests that outcomes with novel oral anticoagulants (NOACs) do not significantly differ compared to vitamin K antagonists (VKAs) after transcatheter aortic valve replacement (TAVR) in patients with atrial fibrillation (AF), in particular, NOACs failed to demonstrate a better safety profile than VKAs in this clinical setting.

Accordingly, the choice between NOACs and VKAs in AF patients after TAVR is left to clinical judgment.

Future large‐scale clinical trials are warranted to establish a clinically superior anticoagulant regime in this clinical setting, based on risk profile and need for concomitant antiplatelet therapy.