Direct Oral Anticoagulants for Rheumatic Heart Disease-Associated Atrial Fibrillation Post-Bioprosthetic Mitral Valve Replacement

Ayman R Fath; Amro Aglan; Osamah Altaee; Hendre Fichardt; Hend Mansoor; Ahmed Almomani; Muhammad Hammadah; Ariel Vinas; Hemal Nayak; Hani Jneid; Marwan Saad; Islam Y Elgendy

doi:10.1016/j.jacep.2024.08.005

Direct Oral Anticoagulants for Rheumatic Heart Disease-Associated Atrial Fibrillation Post-Bioprosthetic Mitral Valve Replacement

JACC Clin Electrophysiol. 2024 Sep 19:S2405-500X(24)00746-1. doi: 10.1016/j.jacep.2024.08.005. Online ahead of print.

Authors

Ayman R Fath¹, Amro Aglan², Osamah Altaee³, Hendre Fichardt⁴, Hend Mansoor³, Ahmed Almomani⁴, Muhammad Hammadah⁴, Ariel Vinas⁴, Hemal Nayak⁴, Hani Jneid⁵, Marwan Saad⁶, Islam Y Elgendy⁷

Affiliations

¹ Division of Cardiology, University of Texas Health Science Center, San Antonio, Texas, USA. Electronic address: aymanfath.md@gmail.com.
² Cardiology Department, Westchester Medical Center, New York Medical College, Valhalla, New York, USA.
³ Department of Pharmacy, Practice and Science, College of Pharmacy University of Kentucky, Lexington, Kentucky, USA.
⁴ Division of Cardiology, University of Texas Health Science Center, San Antonio, Texas, USA.
⁵ Division of Cardiology, University of Texas Medical Branch, Galveston, Texas, USA.
⁶ Lifespan Cardiovascular Institute, Providence, Rhode Island, USA; Department of Cardiology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.
⁷ Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, Kentucky, USA.

PMID: 39365213
DOI: 10.1016/j.jacep.2024.08.005

Abstract

Background: The efficacy of direct oral anticoagulants (DOACs) in preventing ischemic and thromboembolic events may be suboptimal in atrial fibrillation (AF) patients with rheumatic mitral stenosis. However, their safety and effectiveness after mitral valve replacement (MVR) using bioprosthetic valves is unclear.

Objectives: This study sought to evaluate the safety and effectiveness of DOACs vs warfarin among patients with rheumatic heart disease (RHD)-associated AF after bioprosthetic MVR.

Methods: We performed an observational analysis identifying patients with RHD and AF who underwent bioprosthetic MVR. Primary effectiveness and safety outcomes were ischemic events and major bleeding, respectively. Secondary outcomes included all-cause mortality, cardiac thrombosis, myocardial infarction, and all-cause hospitalization. Propensity score matching was performed to account for the differences in baseline characteristics and comorbidities.

Results: A total of 3,950 patients were identified; 76% were on warfarin and 24% on DOAC post-MVR. The DOAC group had a higher burden of baseline comorbidities and prior cardiovascular procedures compared with the warfarin group. The propensity score matching balanced baseline characteristics in 1,832 patients (916 in each group), with a mean age of 69 years. At the 5-year follow-up, DOACs were associated with a lower incidence of major bleeding compared with warfarin (HR: 0.76; 95% CI: 0.62-0.94), with no significant difference in ischemic events, mortality, cardiac thrombosis, myocardial infarction, or hospitalization.

Conclusions: Among patients with RHD-associated AF patients post-bioprosthetic MVR, DOACs are associated with lower major bleeding and comparable effectiveness, indicating a potential alternative to warfarin. Further randomized controlled trials are warranted to validate these findings in this population.

Keywords: atrial fibrillation; bioprosthetic mitral valve replacement; direct oral anticoagulant; rheumatic heart disease; vitamin K antagonist; warfarin.