Perspective:

Up to 50% of patients undergoing TAVR for aortic stenosis have an indication for chronic OAC use (e.g., atrial fibrillation). This study provides evidence that there is little difference in bleeding risk between use of NOAC and VKA medications. However, it raises the possibility that NOAC use in the setting of TAVR might be associated with more ischemic events. Based on the cumulative incidence curves, there is some suggestion that the difference in thromboembolic risk may increase over time and that studies with longer follow-up are needed. Many patients and clinicians favor use of NOACs following TAVR given their relative ease of use and overall lower risk of intracranial hemorrhage. However, if the increased thromboembolic risk identified in this retrospective analysis were confirmed in prospective studies, that would change clinical practice. Current American College of Cardiology/American Heart Association (ACC/AHA) valvular heart disease guidelines do not stipulate if VKAs or NOACs are preferred in patients with TAVR who have another indication for OAC use. And the ACC/AHA atrial fibrillation guidelines only indicate that mechanical heart valves are a contraindication to NOAC use. Until prospective data are available, clinicians should alert their patients to the possibility of increased thromboembolic risk if NOAC use is selected over VKA following TAVR.