The effectiveness and safety of oral anticoagulation therapy in patients undergoing transcatheter aortic valve replacement: a systematic review/meta-analysis.

backgroundPatients undergoing transcatheter aortic valve replacement (TAVR) often require anticoagulation therapy due to various comorbidities. However, the decision to continue anticoagulation therapy during the TAVR perioperative period and the optimal regimen for postoperative anticoagulation therapy remain debatable.

methodsWe searched the PubMed, EMBASE, MEDLINE, and Cochrane Library databases from their date of establishment to September 2024. We evaluated the choice of anticoagulation regimen in the TAVR perioperative and postoperative period. The primary outcomes were stroke, major bleeding, all-cause death, and net adverse clinical events (NACEs). The secondary outcomes were any bleeding, life-threatening bleeding, thrombotic events, and cardiovascular death. We conducted a meta-analysis with a RR and 95% CI. We performed subgroup analyses based on the follow-up duration, study design, and whether oral antiplatelet drugs (OAP) were used.

resultsWe compared four studies with peri-procedural continuation or discontinuation of oral anticoagulants (OACs). We did not observe a difference between the two groups with major bleeding, stroke, all-cause death, and NACEs (P > 0.05). Seventeen studies compared the effects of direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) after TAVR. The risk of NACEs (RR: 0.84, 95% CI :0.71-0.99, P = 0.04) and cardiovascular death (RR: 0.78, 95% CI: 0.69-0.87, P < 0.0001) was significantly lower in the DOACs than in the VKAs, but there were no statistically significant differences between the two groups with other outcomes. In the subgroup analysis, the beneficial effects of DOACs on NACEs were observed in the early postoperative (P < 0.05). During the long-term follow-up time after TAVR, DOACs had a lower risk of all-cause mortality and cardiovascular death compared to VKAs (P < 0.05), but an increased risk of any bleeding (P < 0.05). In RCTs, the risk of any bleeding owing to DOACs was higher (P < 0.05). In cohort studies, DOACs led to lower NACEs and cardiovascular death (P < 0.05). When administered in combination with OAP drugs, DOACs posed a lower risk for cardiovascular death and all-cause death than VKAs (P < 0.05). If not administered in combination with OAP drugs, DOACs posed a lower risk for all-cause death (P < 0.05).

conclusionIn patients undergoing TAVR with established indications for OACs, periprocedural continuation of OACs may offer comparable clinical outcomes to temporary discontinuation. Furthermore, DOACs after TAVR appear to be associated with more favorable clinical outcomes than VKAs, although this benefit must be weighed against a potentially increased risk of bleeding. Further large-scale RCTs are warranted to validate these findings.