Preventing blood clots after TMVR—what is the best anticoagulant for the job?
Treating patients with direct oral anticoagulants (DOACs) after transcatheter mitral valve replacement (TMVR) instead of vitamin K antagonists (VKAs) is associated with multiple key benefits, according to new findings published in the Journal of the American College of Cardiology.[1]
“While transcatheter mitral valve repair therapies are now commonly performed, TMVR is primarily limited to patients with bioprosthesis or annuloplasty ring failure or those with severe mitral annulus calcification (MAC),” wrote corresponding author Marina Urena, MD, PhD, an interventional cardiologist with Bichat–Claude Bernard Hospital in Paris, and colleagues. “The latest guidelines recommend the use of TMVR for patients with bioprosthesis failure at high risk for surgical reintervention. Although it is widely acknowledged that antithrombotic therapy is essential after TMVR, the optimal antithrombotic regime remains to be determined.”
Urena et al. focused on data from 156 patients treated with TMVR at a single facility from 2011 to 2023. The mean patient age was 65 years old, and 66% were women. The median follow-up period was 4.7 months.
Interventional cardiologists performed each TMVR, using both transesophageal echocardiography and contrast CT scans to detect any potential concomitant diseases, evaluate the risk of left ventricular outflow tract obstruction and finalize the size of the transcatheter heart valve. Patients received a Sapien XT or Sapien 3 transcatheter heart valve from Edwards Lifesciences. Indications for TMVR were bioprosthesis failure (62.6%), ring annuloplasty failure (23.2%) and severe MAC (14.2%).
Following TMVR, the hospital’s antithrombotic treatment strategy of choice was at least three months of VKAs. In October 2019, however, a practice-wide change was implemented, and a majority of patients were prescribed DOACs from that point forward.
“In patients without an indication for lifelong anticoagulation, anticoagulants were discontinued after three to six months if imaging tests (transesophageal echocardiography and/or computed tomography) confirmed the absence of valve thrombosis,” the authors wrote. “These patients were prescribed lifelong aspirin therapy.”
While 124 patients were prescribed VKAs following TMVR, and another 32 patients were prescribed DOACs. Apixaban was the most common DOAC of choice, followed by rivaroxaban and dabigatran.
Overall, there were no deaths among the study’s patient population after 30 days. Bleeding events were seen in 35% of VKA patients, but 9% of DOAC patients. Major bleeding events, meanwhile, were seen in 14% of VKA patients, but 0% of DOAC patients. This was seen as a statistically significant difference in both instances.
In addition, the median hospital lengths of stay was significantly shorter for DOAC patients (4.5 days) than VKA patients (8 days). When it came to the risks of vascular complications or stroke, however, there was no noteworthy difference between the two groups.
“The findings of this study have significant implications for clinical practice,” the authors wrote. “Although the specific impact of bleeding after TMVR has not yet been fully understood, it is well-known that bleeding events are associated with increased mortality after percutaneous interventions, including transcatheter aortic valve replacement and percutaneous coronary interventions. Given the association between bleeding and adverse events, all efforts should be made to minimize the risk of bleeding events in these patients.”
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Michael has more than 18 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.