Objective:

To synthesize available observational cohorts to quantify the efficacy and safety of oral anticoagulation and antiplatelet therapy regimens post-TMVR in patients with atrial fibrillation.

Approach:

• Systematic Review and Network Meta-Analysis: A systematic review and network meta-analysis of observational studies evaluating antithrombotic strategies after TMVR/TEER with atrial fibrillation, focusing on outcomes such as ischemic stroke, major bleeding, and all-cause mortality.

Key Findings:

• Oral anticoagulation strategies demonstrated a favorable profile compared with antiplatelet therapy for bleeding risk reduction.
• Direct oral anticoagulants showed heterogeneous results depending on comparator drug and study region.
• Mortality findings consistently favored oral anticoagulation, particularly direct oral anticoagulants, over antiplatelet therapy.
• Oral anticoagulation (phenprocoumon) showed better ischemic prevention compared to antiplatelet therapy.

Interpretation:

OAC strategies appeared to be associated with lower bleeding risk and potentially favorable mortality outcomes compared with antiplatelet therapy. However, conclusions regarding comparative efficacy, particularly for stroke prevention, should be interpreted cautiously due to the limited number of studies and the observational nature of the available evidence.

Limitations:

• The limited number of studies and observational design restrict the strength of conclusions.
• Heterogeneous comparators and inconsistent outcome definitions may affect the reliability of findings.
• Network geometry was limited, with most contrasts informed by only one or two studies.

Conclusion:

Randomized trials are urgently needed to guide antithrombotic management in this high-risk population.