DOAC vs VKA: Which antithrombotic agent must be used after TMVR?

Patients who received direct oral anticoagulants (DOACs) following transcatheter mitral valve replacement (TMVR) seem to have a lower risk of bleeding complications and shorter length of hospital stay, with no significant increase in the risk of thrombotic events, than those treated with vitamin K antagonists (VKAs), a study has shown.

A team of investigators conducted this study to compare bleeding and thrombotic events associated with DOACs or VKAs in a prospective cohort of TMVR patients. A total of 156 patients (mean age 65 years, 66 percent women) who underwent transseptal TMVR using a SAPIEN family prosthesis between 2011 and 2023 were included. Bleeding occurrence served as the primary outcome.

Patients received VKAs until October 2019, after which they were treated with DOACs. Of these, 20.5 percent received DOACs and 79.5 percent VKAs. The median EuroSCORE II was 7.48 percent.

Over a median follow-up of 4.7 months, bleeding occurred in significantly more patients in the VKA group than in those treated with DOACs (40 percent vs 9 percent; adjusted hazard ratio, 0.21, 95 percent confidence interval, 0.06‒0.74; p=0.02). In addition, patients in the DOAC group had a much shorter length of hospital stay.

In terms of thrombotic events, major vascular complications, stroke, or death, no significant differences were observed between the two treatment groups.

“There is currently no established recommendation for antithrombotic treatment following TMVR,” according to the investigators. “However, based on the analogy with surgical mitral bioprosthesis, VKAs are predominantly used.”