Patients with atrial fibrillation can safely continue oral anticoagulation (OAC) while undergoing transcatheter aortic valve replacement (TAVR), suggests a retrospective study published Jan. 7 in the American Journal of Cardiology.
“Performing invasive procedures in patients on therapeutic OAC is still feared because of the perceived higher risk of bleeding complications,” lead author Norman Mangner, MD, with Heart Center Dresden in Germany, and colleagues wrote. “But several controlled studies proved the opposite in the field of ablation therapy for atrial fibrillation and non-cardiac operations.”
To investigate this relationship in the setting of TAVR, Mangner et al. studied the outcomes of patients with AFib who were on OAC at the time of admission and underwent transfemoral TAVR at a single center in Germany. The 598-patient cohort was divided into three groups: 299 individuals were on an interrupted vitamin K antagonist (iVKA) regimen which included bridging with heparin; 117 were on continuous treatment with a VKA (cVKA) such as warfarin; and 182 were treated continuously with direct oral anticoagulants (DOACs), most often rivaroxaban.
Scores assessing the risks of stroke and bleeding were similar between all groups. Baseline patient characteristics were also similar, other than the interrupted VKA group having higher rates of diabetes and previous myocardial infarction.
Patients in the DOAC group demonstrated the best safety outcomes at 30 days—only 13.2 percent met the composite endpoint of death, stroke, life-threatening bleeding, acute kidney injury stage 2 or 3, coronary obstruction requiring intervention, major vascular complications or valve-related dysfunction causing a repeat procedure. Those on continuous VKA treatment experienced that endpoint at a 19.7 percent clip, which wasn’t significantly different from those on interrupted VKA therapy (23.1 percent).
One-year mortality rates were 20.1 percent in the interrupted group, 13.7 percent in the continuous VKA arm and 8.8 percent among those managed on DOACs. After multivariable adjustment, DOACs were associated with a 44 percent reduction in one-year mortality compared to interrupted VKA regimens.
“In our study, DOAC showed superior early safety compared to iVKA whereas no safety concerns were noticed in cVKA compared to iVKA indicating that (TAVR) under continued OAC, either with VKA or DOAC, seems to be safe and effective,” Mangner and coauthors wrote. “Numerically lower rates of life-threatening/major bleedings and stroke were noticed in DOAC despite a high risk for bleeding and stroke.”
The researchers acknowledged their study was limited by its non-randomized, single-center design and may not be generalizable to other cohorts. Uncaptured clinical characteristics could have also influenced decisions on whether to continue or interrupt OAC, which would further bias the results.