Use and Safety of Direct Oral Anticoagulants Immediately Following Bioprosthetic Valve Replacement in Patients with Atrial Fibrillation
Boma Legg-Jack, William Kendrick, Kellie Ball, Jeff Lewis
Background: Direct oral anticoagulants (DOACs) are preferred for stroke prevention in atrial fibrillation (A-fib) patients. However, current American Heart Association guidelines suggest warfarin indefinitely for mechanical valves, at least 3 months after surgical bioprosthetic valve replacement, and possibly after transcatheter valve replacement with indication for anticoagulation. After 3 months, DOACs may be considered, though data during the initial 90 days after implantation is limited. This study assesses the efficacy of DOACs in patients who underwent surgical or transcatheter bioprosthetic valve replacement within the first 90 days after implantation.
Methods: This is an Institutional Review Board-approved retrospective chart review conducted within the University of Tennessee Medical Center Knoxville (UTMCK). Patients were included if they were ≥ 18 years old, had a surgical or transcatheter bioprosthetic valve replacement at UTMCK between January 2020 and February 2025, a-fib indication, and evidence of follow-up. The primary outcome was the composite of stroke, transient ischemic attack (TIA), systemic embolism (deep vein thrombosis or pulmonary embolism), valve thrombosis, intracardiac thrombus, or death from any cause during the first 90 days after initiating oral anticoagulation following bioprosthetic valve replacement. Secondary outcomes included major bleeding during the first 90 days after initiating oral anticoagulation, clinically relevant non-major bleeding, death from any cause, and 30-day and 90-day readmission rate.
Results: Among 191 patients, 5.8% of those receiving a DOAC experienced a thrombotic event
[BK1] within 90 days of valve replacement. Nonmajor and major bleeding occurred in six and two patients, respectively. Readmissions occurred in 19 patients within 30 days of discharge, and 18 patients within 90 days of discharge.
Conclusion: Although thromboembolic and mortality events were observed, the overall event rate was 5.8% among 191 patients, lower than rates reported in existing literature. Given the limited sample size, further studies are needed to more fully evaluate the safety and efficacy of DOACs during the first 90 days after valve replacement.
