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

Abstract

Objective: We aimed to compare non-vitamin K oral anticoagulants (NOACs) with a traditional antithrombotic such as vitamin K antagonist (VKA) and antiplatelet agents in patients after transcatheter aortic valve replacement (TAVR).Methods: We conducted a search in PubMed, EMBASE, and the Cochrane Library until November 2021 for studies involving comparisons of any type of NOACs, including dabigatran, apixaban, rivaroxaban, and edoxaban, with VKA or antiplatelet agents after TAVR. A comparison of NOACs versus VKA was performed in patients with an indication for oral anticoagulation. In addition, we compared NOACs versus antiplatelet in patients without such indication. We calculated the hazard ratios with 95% confidence intervals (CIs) to determine long-term outcomes. The primary outcome was a combined endpoint consisting of all-cause mortality, stroke, major bleeding, or any related clinical adverse events. Secondary outcomes were all-cause mortality, major bleeding, and stroke, respectively.Results: A total of 10 studies including 10,563 patients after TAVR were included in this meta-analysis. There were no significant differences in any of the long-term outcomes between the NOAC and VKA groups. Although there were no significant differences in the combined endpoint, major bleeding, or stroke, a significant difference was observed in the all-cause mortality (HR 1.74, 95% CI 1.25–2.43, p = 0.001) between the NOAC and antiplatelet groups.Conclusion: For patients with an indication for oral anticoagulation after TAVR, NOACs seem to be associated with noninferior outcomes compared with VKA therapy. However, for patients without an indication for oral anticoagulation, NOACs appear to be associated with a higher risk of all-cause death as compared with antiplatelet treatment.Systematic Review Registration:https://clinicaltrials.gov/, identifier CRD42020155122.

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

“…These results confirm those of other recently published meta‐analysis on the same field, 2,3 which include the newly available ATLANTIS trial (presented at the American College of Cardiology Congress 2021) and ENVISAGE‐TAVI AF trial, 4 and focus on patients with an indication for OAC. There are several limitations acknowledged by the authors, among them the absence of a patient‐level data, heterogeneity of the populations, and definition of the outcomes (i.e., the definition of major bleeding was accepted as reported by individual studies and the rate of gastrointestinal bleeding is unknown).…”

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

“…Previous meta-analyses for comparing DOACs versus VKA after TAVR included randomized controlled and observational studies and enrolled patients with concomitant indication for oral anticoagulation, and thus, not all enrolled studies comprised only patients with AF. 19–21 These meta-analyses for comparing DOACs versus VKA after TAVR showed different mortality and thromboembolic outcomes. 19–21…”

“…19–21 These meta-analyses for comparing DOACs versus VKA after TAVR showed different mortality and thromboembolic outcomes. 19–21…”

Bioprosthetic aortic valve thrombosis under effective direct oral anticoagulant therapy

“…Anticoagulant therapy in patients with bioprosthetic valves who require long‐term anticoagulation is a subject of debate due to limited data on drug selection. Recently, studies on TAVI patients have shown that DOACs have similar efficacy and safety profiles to warfarin 13,14 . Furthermore, there is growing evidence that DOACs not only provide a safe and effective option but also offer net clinical benefits in patients with a history of surgical valve repair 15,16 .…”

“…Recently, studies on TAVI patients have shown that DOACs have similar efficacy and safety profiles to warfarin. 13,14 Furthermore, there is growing evidence that DOACs not only pro-vide a safe and effective option but also offer net clinical benefits in patients with a history of surgical valve repair. 15,16 However, there is…”