Direct Oral Anticoagulants in Patients with Atrial Fibrillation and Bioprosthetic Heart Valves: A Systematic Review

Abstract

Introduction: The use of direct oral anticoagulants (DOACs) in patients with atrial fibrillation (AF) and a bioprosthetic mitral or aortic valve is an area of clinical uncertainty. Warfarin has traditionally been the standard of care in this setting. This review assesses the evidence for DOACs.

Methods: A systematic search was conducted for RCTs and large observational studies comparing DOACs to warfarin in patients with AF and a bioprosthetic heart valve implanted for more than 3 months. Outcomes were stroke/systemic embolism and major bleeding.

Results: The review identified two RCTs and several cohort studies. The results suggest that DOACs are non-inferior to warfarin for the prevention of thromboembolic events. The risk of major bleeding with DOACs appeared to be similar to or lower than with warfarin.

Discussion: The evidence, while still evolving, is reassuring for the use of DOACs in patients with AF and a bioprosthetic valve in the stable phase (beyond 3 months post-op). DOACs are contraindicated in patients with mechanical heart valves.

Conclusion: DOACs appear to be a reasonable and safe alternative to warfarin for patients with atrial fibrillation and a bioprosthetic valve.