Comparative Effectiveness and Safety of Direct Oral Anticoagulants versus Vitamin K Antagonists in Patients with Atrial Fibrillation Undergoing Transcatheter Aortic Valve Replacement: A Propensity Score–Matched Analysis from a Large Nationwide Registry

Background: Atrial fibrillation (AF) is highly prevalent among patients undergoing transcatheter aortic valve replacement (TAVR) and is associated with increased thromboembolic and bleeding risks. Although direct oral anticoagulants (DOACs) are widely used in AF, their comparative effectiveness and safety relative to vitamin K antagonists (VKAs) in the post-TAVR population remain incompletely defined. Objectives: To compare clinical outcomes associated with DOACs versus VKAs in patients with AF undergoing TAVR using a large nationwide registry and propensity score–matched analysis. Methods: This retrospective cohort study included patients with documented AF who underwent TAVR and were discharged on oral anticoagulation therapy. Patients receiving DOACs were compared with those treated with VKAs. Propensity score matching was performed to balance baseline demographic, clinical, and procedural characteristics. The primary effectiveness endpoint was a composite of ischemic stroke, systemic embolism, and cardiovascular death. The primary safety endpoint was major bleeding according to the Bleeding Academic Research Consortium (BARC) criteria. Secondary outcomes included all-cause mortality, valve thrombosis, and rehospitalization for heart failure. Patients were followed for up to 24 months. Results: Among 6,842 eligible patients, 3,210 received DOACs and 3,632 received VKAs. After propensity score matching, 2,750 well-balanced pairs were analyzed. DOAC therapy was associated with a significantly lower incidence of the primary effectiveness endpoint compared with VKAs (hazard ratio [HR] 0.82; 95% confidence interval [CI], 0.70–0.96; p = 0.014). DOACs were also associated with reduced major bleeding events (HR 0.74; 95% CI, 0.61–0.89; p = 0.002). No significant differences were observed in valve thrombosis rates between groups. Additionally, DOAC use was associated with lower all-cause mortality (HR 0.85; 95% CI, 0.74–0.98; p = 0.027) and fewer heart failure hospitalizations (p = 0.041). Conclusions: In patients with AF undergoing TAVR, DOAC therapy was associated with improved effectiveness and safety outcomes compared with VKAs. These findings support the preferential use of DOACs in appropriately selected TAVR patients with AF, although randomized controlled trials remain necessary to confirm these observational results and guide clinical decision-making.