Non-vitamin K antagonist oral anticoagulants (NOACs) after transcatheter aortic valve replacement (TAVR): a network meta-analysis.

Summary

Across 4 RCTs (n=4808), rivaroxaban and possibly apixaban increased all-cause mortality compared with antiplatelet therapy in patients without an OAC indication after TAVR, and rivaroxaban increased major bleeding. In patients with an OAC indication, apixaban was similar to VKA, whereas edoxaban likely increased major bleeding versus VKA. No NOAC was superior across outcomes.

Key Findings

• Without OAC indication: rivaroxaban increased all-cause mortality (RR 1.67, 95% CI 1.13–2.46) and major bleeding (RR 1.98), apixaban may increase mortality (RR 1.71).
• With OAC indication: apixaban showed similar efficacy and bleeding to VKA; edoxaban increased major bleeding vs VKA (RR 1.44).
• No NOAC demonstrated superiority across primary outcomes; evidence certainty varied (often low to moderate).

Clinical Implications

After TAVR: (a) without OAC indication, favor antiplatelet therapy over rivaroxaban or apixaban; (b) with OAC indication, apixaban is comparable to VKA for ischemic outcomes, while edoxaban increases major bleeding—prefer VKA or apixaban. Individualize based on bleeding risk.

Limitations

• High risk of bias for blinding across included trials; absence of dabigatran data
• Heterogeneity in populations and follow-up (6–18 months) with limited number of trials

Future Directions

Head-to-head RCTs comparing NOACs post-TAVR in indication-defined strata; longer-term outcomes (valve thrombosis, subclinical leaflet thrombosis) and patient-centered endpoints.