Comparison of direct oral anticoagulants and vitamin-k antagonists after transcatheter mitral valve implantation

Background No recommendation exists regarding antithrombotic treatment after transcatheter mitral valve implantation (TMVI). By analogy with surgical mitral bioprosthesis, vitamin-k antagonists (VKA) are mostly used after TMVI. Purpose To compare, in a prospective cohort of trans-septal TMVI using a prosthesis of the SAPIEN family, the bleeding and thrombotic risks according to the anticoagulant treatment by direct oral anticoagulants (DOAC) or VKA. Methods We included all consecutive patients undergoing trans-septal TMVI in our center from March 2011 to August 2022. Patients were followed up after the procedure at 1 month, 6 months and 1 year. The primary endpoint was the occurrence of bleeding under anticoagulant treatment. Patients were treated with VKA until October 2019 and with DOAC thereafter. Results A total of 145 patients were included. The mean age was 65.4 ± 18.6 years old and 96 patients (66.2%) were women. The mean EuroSCORE II was 10.3 ± 9,3 %. Regarding treatment, 24 patients were treated with DOAC and 121 patients with VKA. The occurrence of the primary endpoint was observed in 48 (40%) patients in the VKA group and 2 (8%) patients in the DOAC group (multivariate HR 0.21, 95%CI [0.05-0.97], p=0.047). In multivariate analysis, there were less vascular complications and stay duration was shorter in the DOAC group. There were no significant differences between groups regarding thromboembolic events, stroke, and death. Conclusion Treatment with DOAC after TMVI compared with VKA appears to decrease the risk of bleeding complications and to decrease the length of stay of patients without a significant increase in the risk of thromboembolic events.