Antithrombotic therapy after transcatheter mitral valve repair and replacement: a systematic review of outcomes and safety

Background: Transcatheter mitral valve intervention, including repair (e.g., edge-to-edge repair) and replacement, is now a cornerstone of treatment for severe mitral regurgitation (MR) in high-risk patients, providing a less invasive alternative to surgical treatment. The purpose of this systematic review is to assess the efficacy and safety of different antithrombotic strategies to prevent thromboembolic events and bleeding complications after transcatheter mitral valve repair (TMVR). Methods: According to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic literature search on PubMed, Embase, Web of Science, Scopus, and Cochrane Library was conducted from January 2015 to January 2025. Eligible studies included adult patients who underwent transcatheter mitral valve intervention (including repair and replacement procedures) and compared different antithrombotic regimens, including direct oral anticoagulants (DOACs), vitamin K antagonists (VKAs), and antiplatelet therapies. Two reviewers independently extracted data and assessed quality. The studies were too heterogeneous, so a narrative synthesis was performed. Results: Fifteen studies involving 20,956 patients were included. DOACs were associated with a lower risk of major bleeding compared to VKAs [hazard ratio (HR): 0.21, p = 0.02, in one large study], with similar rates of stroke. Mortality was lower with DOACs in several analyses (e.g., HR: 0.67). Triple therapy and dual antiplatelet therapy (DAPT) were associated with increased bleeding risk without providing additional thromboembolic protection. Discussion: DOACs have a safer profile in post-TMVR patients, with reduced bleeding risk and lower mortality compared with VKAs. Triple therapy and DAPT should only be used in high-risk patients with specific indications due to their greater risk of bleeding. Optimizing outcomes requires a tailored approach to antithrombotic therapy, considering patient factors and procedural considerations. Definitive standards may still demand further investigation, such as multicenter randomized controlled trials evaluating antithrombotic treatments after TMVR.