Key result
NOACs match warfarin for thromboembolism and major bleeding after bioprosthetic aortic valve replacement.
Why the study?
The optimal anticoagulation strategy following aortic valve replacement remains poorly defined, particularly when comparing NOACs with warfarin.
Do NOACs compared to warfarin reduce thromboembolic events and major bleeding in adult patients after aortic bioprosthetic valve replacement?
Meta-Analysis (n=93,510)
Do NOACs compared to warfarin reduce thromboembolic events and major bleeding in adult patients after aortic bioprosthetic valve replacement?
Hazard Ratio: 0.91 (95% CI 0.76–1.09)
p-value: p=0.31
NOACs demonstrate similar efficacy and safety to warfarin for preventing thromboembolic events and major bleeding after aortic bioprosthetic valve replacement, supporting their potential use as an alternative to VKAs.
NOACs appear noninferior to warfarin post-bioprosthetic AVR; extends options for individualized therapy while leaving optimal strategy open pending RCTs.
The optimal postaortic valve replacement (AVR) anticoagulation strategy remains poorly defined, particularly when comparing nonvitamin K antagonist oral anticoagulants (NOACs) versus warfarin. This systematic review and meta-analysis aimed to evaluate the safety and efficacy of NOACs compared with warfarin in these patients. Our study was registered on PROSPERO (ID CRD420251028998). A search of the PubMed, EMBASE, and Cochrane databases was conducted on April 9, 2025, for studies published between 2015 and 2025 that compared NOACs to warfarin after aortic bioprosthetic valve replacement. Inclusion criteria included randomized controlled trials (RCTs) and observational studies reporting thromboembolic events, major bleeding, and mortality with at least 6 months of follow-up. Studies on mechanical valves, case reports, and publications that could not be translated into English were excluded. Data extraction was conducted based on study design, patient demographics, clinical outcomes, and effect sizes, expressed as hazard ratios (HRs) with 95% confidence intervals (CIs) using a random effects model. Risk of bias was assessed using the ROBINS-I tool. Seventeen studies (n = 93,510 participants) were included. NOACs were associated with an HR of 0.91 for thromboembolic events (95% CI: 0.76-1.09) and a pooled HR of 1.22 for major bleeding (95% CI: 0.88-1.68). Several studies have suggested a trend toward lower all-cause mortality and major bleeding with NOACs, particularly in patients with lower bleeding risk. In patients undergoing aortic bioprosthetic valve replacement, NOACs show similar efficacy and safety to warfarin for preventing thromboembolic events and major bleeding. However, anticoagulation decisions should be individualized, and larger RCTs are needed to determine the optimal approach.
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Chaudhri et al. (2025) conducted a meta-analysis in Aortic bioprosthetic valve replacement (n=93,510). Nonvitamin K antagonist oral anticoagulants (NOACs) vs. Warfarin or other vitamin K antagonists (VKAs) was evaluated on Thromboembolic events (HR 0.91, 95% CI 0.76-1.09, p=0.31). In patients undergoing aortic bioprosthetic valve replacement, NOACs showed similar efficacy to warfarin for preventing thromboembolic events (HR 0.91) and major bleeding (HR 1.22).
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