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Review
. 2025 May 26;17(5):e84846.
doi: 10.7759/cureus.84846. eCollection 2025 May.

Postoperative Anticoagulation After Mitral Bioprosthetic Valve Surgery: A Systematic Review and Meta-Analysis of Non-vitamin K Antagonist Oral Anticoagulants Versus Warfarin

Moiuz Chaudhri  1 , Mohamed Ellebedy  2 , Ahmed D Al Mahrizi  3 , Pranesh Rajendran  4 , Arjun Ramachandran  5 , Areej Shahzad  6 , Aiman Nadeem  7 , Neil Patel  8 , Frederick Acquah  1 , Christian Kaunzinger  8 , Muhammad R Raza  8
Affiliations
Review

Postoperative Anticoagulation After Mitral Bioprosthetic Valve Surgery: A Systematic Review and Meta-Analysis of Non-vitamin K Antagonist Oral Anticoagulants Versus Warfarin

Moiuz Chaudhri et al. Cureus. .

Abstract

The optimal anticoagulation strategy following mitral bioprosthetic valve replacement (BPVR) remains unclear. This meta-analysis evaluates the safety and efficacy of non-vitamin K antagonist oral anticoagulants (NOACs) compared to warfarin in this context. We systematically searched PubMed, Embase, Cochrane, and other databases for studies published between 2015 and 2025, comparing NOACs to warfarin in adults with mitral bioprostheses. Eligible studies reported thromboembolic and/or bleeding outcomes, with a minimum of six months' follow-up. Random-effects meta-analysis was performed, calculating odds ratios (ORs) with 95% confidence intervals (CIs). Heterogeneity was assessed using the I² statistic, and publication bias was assessed via funnel plot and Egger's test. Eight studies met the inclusion criteria, comprising 1,506 patients (709 on NOACs and 797 on warfarin). Included studies were randomized controlled trials (RCTs) and observational cohorts. NOACs studied were apixaban, rivaroxaban, and dabigatran. Three studies were included in the quantitative synthesis for each primary outcome. For stroke/systemic embolism, the pooled OR for NOACs was 0.57 (95% CI: 0.02-16.87, p = 0.55; I² = 33.7%). For major bleeding, the pooled OR was 1.06 (95% CI: 0.12-9.47, p = 0.94; I² = 74.9%). No significant publication bias was detected. Qualitative findings suggested NOACs had similar or lower rates of stroke, major and minor bleeding, and all-cause mortality. Valve thrombosis and rehospitalization were infrequently reported and comparable. NOACs appear to be a safe and effective alternative to warfarin after mitral BPVR. However, current evidence is limited by heterogeneity and wide CIs. Further large-scale RCTs are needed to confirm these findings.

Keywords: major bleeding complications; mitral bioprosthetic valve replacement; new oral anticoagulants (noacs); non-vitamin k antagonist oral anticoagulants; warfarin.

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Conflict of interest statement

Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Figures

Figure 1
Figure 1. PRISMA Flow Diagram of Study Selection
PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses
Figure 2
Figure 2. Forest Plot for Major Bleeding
References: [9,16,22]
Figure 3
Figure 3. Funnel Plot for Major Bleeding
References: [9,16,22]
Figure 4
Figure 4. ROBINS-E Risk of Bias Assessment Results
References: [9,16-22] ROBINS-E, Risk of Bias in Non-randomized Studies - of Exposures
See this image and copyright information in PMC

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