Dear Rui, non-valvular atrial fibrilation is not a classification, but a marker to treatment. If there are valvular patology, including valvular prosthesis, responsible for atrial fibrilation the new anticoagulant drugs (Dabigatran, Rivaroxiban) are not indicated.

I totally agree with you. I think the division is clear for prosthetic heart valves and probably hypertrophic cardiomyopathy and severe valvular disease. However, what is your opinion concerning moderate valvular disease? do you consider that a patient with AF and moderate aortic stenosis with a CHA2DS2VASc of 0 should be anticoagulated? If we consider that he has non valvular AF probably no, but if we consider that it is valvular he does have an indication. And what about a light stenosis or regurgitation?

I think that in valvular disease there are chanfes in the valvular tissue and fibrosis in left atrium due to rheumatic disease that increase the risk of embolism in atrial fibrilation

This is an interesting question with a difficult answer. As far as I know there isn't an "official" definition of non-valvular AF. Most of the clinical trials with new anticoagulant agents define this population as "patients without significant aortic or mitral valve disease". In my experience and what I really do in my clinical practice in patients with AF:

- If mitral reumatic valve disease is present, even mild, I consider this patient is in a high risk of tromboembolism and, in my opinion, might be consider as a valvular AF.

- Degenerative mitral stenosis, for instance, by mitral annulus calcification, rarely become severe and this population normally has other risk factors for tromboembolism (hypertension, diabetes, > 75y) to use oral anticoagulation but I think this AF shouldn't be considered as valvular AF.

- Severe mitral regurg (functional or organic) definitely should be considered as valvular AF.

- In the case of mild/moderate mitral regurg, I think the valvular disease is not the main etiology of the AF development and shouldn't be considered as valvular AF. And this is the same idea for mild/moderate aortic stenosis and regurgitation.

- Regarding the severe aortic stenosis and regurgitation, the role of AF development could be important (mainly in the stenosis case) and probably we could define this as valvular AF.

I hope this ideas could help you,

Guillermo Isasti

dear colleagues: with a background in LAA occlusion I would like to take a different approach: in the AFIb ESC Guidelines 2011 you find on page 2382 a clear definition, namely "mitral stenosis or prosthetic heart valve". In these cases thrombi in AF come from the free atrial space, not the LAA. In all other cases (mitral regurg, aortic stenosis, aortic regurg etc.) 90% of thrombi come from the LAA. So either NOAC´s or LAA occluder should be considered. Admittetely, RE-LY and other studies excluded any patient with "severe heart failure" - so thats why those patients are excluded..

I think that the valvular AF should be considered in any rheumatic valvular disease and in significant non rheumatic valvular disease

Dear Zied. I agree with you, but I think that your answer is obvious.

Dear colleagues,

I have heard ESC is preparing an official position document for defining Non-valvular AF.

I agree with answer of Guillermo Isasti and I would like to give him my compliments for complete and articolate thinking about theme.NVAF exclude only prosthetic(mechanical or biological )valves or severe valvular diseases....We must waite ESC position document....

I'm agree with Martin Bergmann. Actually the only "official definition" of valvular AF is "mitral stenosis or prosthetic heart valve" even if the other considerations are also correct.

Dear colleagues,

Definition and the choice of antiagregan theraphy of non-valvular atrial fibrillation should be made according to major clinical trials and guidelines . According to recent Atrial fibrillation guideline (2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation-JACC, 16 APRIL 2014, online article in press); patients with mechanical heart valves or hemodynamically significant mitral stenosis were excluded from all 3 major trials (RE-LY, ROCKET AF, and ARISTOTLE); therefore, these patients should be managed with warfarin. Patients with aortic stenosis or aortic insufficiency who, in the estimation of the local RCT principal investigator, would not need a surgical procedure before the conclusion of the trial were included. The RE-ALIGN (Randomized, Phase II Study to Evaluate the Safety and Pharmacokinetics of Oral Dabigatran Etexilate in Patients After Heart Valve Replacement) trial, a phase 2 dose-ranging study of the use of dabigatran compared with warfarin in patients with mechanical heart valves, was stopped because dabigatran users were more likely to experience strokes, MI, and thrombus forming on the mechanical heart valves than were warfarin users . There was also more bleeding after valve surgery in the dabigatran users than in the warfarin users, thus dabigatran is contraindicated for use in patients with mechanical heart valves. Similar drug safety and efficacy information is lacking for rivaroxaban and apixaban and mechanical heart valves. Bioprosthetic heart valves have not been studied with any of the newer anticoagulants.

Therefore this description should be used only the patients have mitral stenosis and mechanical heart valves but not mitral regurgitation (unclear), aortic stenosis (unclear), aortic regurgitation (unclear), hypertrophic cardiomyopathy (unclear) or bioprostethic heart valves (unclear).

To All!! I can suggest the paper which answers the question:

What is 'valvular' atrial fibrillation? A reappraisal.

De Caterina R, et al. Eur Heart J. 2014.

http://www.ncbi.nlm.nih.gov/m/pubmed/25265975/?i=24&from=de%20caterina%20r.