Direct oral anticoagulants versus vitamin K antagonists in the first 3 months after bioprosthetic valve replacement: a systematic review and meta-analysis

Link to article at PubMed

Eur J Cardiothorac Surg. 2023 Mar 27:ezad110. doi: 10.1093/ejcts/ezad110. Online ahead of print.


OBJECTIVES: We conducted a systematic review and meta-analysis of randomized controlled trials comparing direct oral anticoagulants (DOACs) to vitamin K antagonists (VKAs) in the first 90 days after bioprosthetic valve implantation.

METHODS: We systematically searched EMBASE, MEDLINE, and CENTRAL. We screened titles, abstracts, and full texts, extracted data, and assessed risk of bias in duplicate. We pooled data using the Mantel-Haenzel method and random effects modelling. We conducted subgroup analyses based on type of valve (transcatheter versus surgical) and timing of initiation of anticoagulation (<7 days versus >7 days after valve implantation). We assessed the certainty of evidence using the Grading of Recommendations, Assessments, Development and Evaluation (GRADE) approach.

RESULTS: We included 4 studies of 2284 patients with a median follow-up of 12 months. Two studies examined transcatheter valves (1877/2284 = 83%) and two examined surgical valves (407/2284 = 17%). We found no statistically significant differences between DOACs and VKAs with regard to thrombosis, bleeding, death, or subclinical valve thrombosis. However, there was a subgroup trend towards more bleeding with DOACs when initiated within 7 days of valve implantation.

CONCLUSIONS: In the existing randomized literature on DOACs versus VKAs in the first 90 days after bioprosthetic valve implantation, there appears to be no difference with regard to thrombosis, bleeding, or death. Interpretation of the data is limited by small numbers of events and wide confidence intervals. Future studies should focus on surgical valves and should include long-term follow-up to assess any potential impact of randomized therapy on valve durability.

PMID:36971601 | DOI:10.1093/ejcts/ezad110

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