Comparing direct oral anticoagulants versus vitamin K antagonist in patients with atrial fibrillation after transcatheter aortic valve replacement: an updated meta-analysis

Background

Oral anticoagulation therapy is indicated for patients undergoing transcatheter aortic valve replacement (TAVR) with concomitant or new onset atrial fibrillation (AF). However the data on optimal anticoagulation regimen in this population remains unclear.

Purpose

To compare efficacy and safety outcomes of direct oral anticoagulants (DOACs) versus Vitamin K antagonists (VKA) in patients with AF post TAVR.

Methods

We searched electronic databases (PubMed, Embase, Scopus, Cochrane) from inception to February28th, 2022 using MeSH terms and keywords for DOACs, AF or TAVR. Primary outcome of interest was all-cause stroke or systemic embolic event. Secondary safety outcomes were major bleeding and all-cause mortality. Pooled risk ratio (RR) and 95% confidence interval (CI) were calculated using a random-effects model. Interstudy heterogeneity was assessed using the Higgins I 2 value. All statistical analysis were performed using RevMan 5.4.1 software.

Results

We identified five eligible studies (1RCT, 4 observational) including 3694 patients (DOAC n=1581, VKA n=2113). The mean age was 81.4±0.9 years. The mean follow-up was 12.4±14.3 months. Type of DOACs included apixaban (n=394, 24.9%), rivaroxaban (n=354, 22.4%), dabigatran (n=119, 7.5%) and edoxaban (n=714, 45.2%).There was no significant difference in primary outcome of stroke or systemic embolic event (RR: 0.93; CI: 0.65–1.33; p>0.05; I2=5%), or in secondary outcomes of major bleeding (RR: 1.02; CI: 0.78–1.34; p>0.05; I2=44%) and all-cause mortality (RR: 0.87; CI: 0.59–1.27; p>0.05; I2=56%) between DOACs and VKA groups.

Conclusion

This meta-analysis shows anticoagulation therapy with DOACs has similar safety and efficacy outcomes compared to VKA in patients with AF undergoing TAVR.

Funding Acknowledgement

Type of funding sources: None.

To compare efficacy and safety of direct oral anticoagulants in patients with concurrent atrial fibrillation and bioprosthetic heart valve repair or replacement: a systematic review and meta-analysis

Background

Use of direct oral anticoagulants (DOACs) is contraindicated in patients with mechanical valves. However data on their use in patients with atrial fibrillation (AF) and bioprosthetic valves (BV) is still limited.

Purpose

To assess the safety and efficacy of DOACs versus Vitamin K antagonist (VKA) in patients with AF after BV repair or replacement.

Methods

We performed a comprehensive review of electronic databases (PubMed, Embase, Scopus, Cochrane) using MeSH terms and keywords for DOACs, AF and BVs from inception through December 2021. Randomized clinical trials (RCT) or observational studies that reported clinical outcomes comparing DOACs versus VKA in patients with AF and BVs were eligible for inclusion. Ten articles were reviewed for full text. Primary outcome was a composite of all cause stroke or systemic embolic event.

Secondary outcomes included major bleeding and all-cause mortality. Subgroup analysis stratified by study design was performed. Pooled risk ratio (RR) and 95% confidence interval (CI) were calculated using Mantel-Haenszel method with DerSimonian-Laird estimator for tau2 for random effects model.

Interstudy heterogeneity was assessed using the Higgins I 2 value. All statistical analysis was performed using RevMan 5.4.1 software.

Results

Ten studies (5 RCTs, 5 observational studies) with a total of 5,333 patients (DOACs n=2434; VKA n=2899) were included. Aortic, mitral and mixed BV repair or replacement were 74.2%, 25.6% and 0.02% respectively. The mean age was 72.6±11.9 years. The mean follow-up was 15.7±12.9 months. Type of DOACs included apixaban (n=553, 22.7%), rivaroxaban (n=893, 36.7%), dabigatran (n=151, 6.2%) and edoxaban (n=837, 34.4%). There was no significant difference in primary outcome of stroke or systemic embolic event (RR: 0.79; CI: 0.56–1.11; p>0.05; I2=12%) or secondary outcomes of major bleeding (RR: 0.84; CI: 0.64–1.11; p>0.05; I2=45%), and all-cause mortality (RR: 0.84; CI: 0.64–1.11; p>0.05; I2=29%) between DOACs compared with VKA.

Conclusion

In patients with AF and BV, DOACs are non-inferior to VKA for risk of stroke or systemic embolism, major bleeding, and all-cause mortality. Thus, DOACs can serve as a viable alternative to VKAs which have a narrow therapeutic index, multiple drug interactions, and require frequent monitoring.

Funding Acknowledgement

Type of funding sources: None.

Noninvasive tissue adhesive for cardiac implantable electronic device pocket closure: the TAPE pilot study

PURPOSE

Device infection is a serious complication of cardiac implantable electronic devices (CIED). Ensuring complete pocket closure can be time consuming, but remains vital to prevent infection. The Zip® Surgical Skin Closure (ZIP) is a noninvasive adhesive device applied to the skin as an alternative to subcuticular sutures for skin closure. We hypothesized that using this device would decrease pocket closure times without increasing the risk of pocket infections. This is a single center, retrospective cohort study to compare pocket closure times and infection rates between ZIP and standard suture for CIED pocket closure.

METHODS

Two separate groups of consecutive new intravenous implants, upgrades, and pulse generator replacements from October 2015 to April 2017 were included. A total of 175 patients were included, using either ZIP (n = 80) or suture (n = 95). Total procedure time (local anesthetic to dressing application) and pocket closure time (fascial suture to dressing application) were compared. Pocket infections were defined as infections leading to CIED extraction or wound dehiscence requiring repeat procedure. Statistical analysis was performed using chi square test and Student's t test.

RESULTS

Pocket closure time and procedure time were significantly shorter for the ZIP group (14.9 ± 6.8 vs 20.1 ± 11.09 min, p = 0.0003) and (65.02 ± 30.4 vs 83.83 ± 40.3 min, p = 0.0008), respectively. No pocket infections occurred in the Zip group, while the suture group had 2:1 wound dehiscence and 1 pocket infection.

CONCLUSION

The ZIP device resulted in significantly shorter pocket closure and procedure times without increasing device pocket infections.