If the HAS BLED score shows low bleeding risk then I would anticoagulate him irrespective of the CHA2DS2 VASc score nd if the bleeding risk is high, espl in an elderly patient, I would give antiplatelets.

This advise would have Level of recommendation 'C' 

Hi Theingi,

I would call this valvular afib and anticoagulate him. The reason is the underlying structural disease of left  atrium and left ventricle. Hypertrophic ventricles and dilated atriae are risk factors for thrombus formation. On top of that you may have (or may not have) elevated pulmonary pressures and some degree of right heart dysfunction. 

What seems debatable is to know if you may prescribe new anticoagulants. As the bioprosthesis is not the reason for prescription, I would think you can. 

Hope this is informative for you!

Best regards,

Thierry

Hi Theingi, 

A good state-of-the-art answer is given in this week issue JACC. 

Bosmans J., Bleiziffer S., Gerckens U., et al for the ADVANCE Study Investigators. The incidence and predictors of early- and mid-term clinically relevant neurological events after transcatheter aortic valve replacement in real-world patients. J Am Coll Cardiol 2015; 66: 209-217.

ADVANCE suggests that a history of AF may be an important risk factor for neurological events (stroke/TIA) early after TAVR. These results strongly suggest that, in order to reduce neurological complications after TAVR, anticoagulation therapy should be started immediately after diagnosis of the AF episode and continued for several months. No clear guidelines actually exist on anticoagulation therapy after short episodes of postoperative AF (13). However, patients undergoing TAVR are at high risk for thromboembolism in cases of atrial arrhythmia, and a more aggressive antithrombotic treatment should probably be implemented in these cases. Although dual antiplatelet therapy with aspirin and clopidogrel has been empirically recommended after TAVR, future randomized studies will have to evaluate the more appropriate antithrombotic treatment after these procedures and the potential role for systematic anticoagulant therapy either with warfarin or direct thrombin inhibitors in this setting.

Wishes,

Thierry

The focused thing in this case is atrial fibrillation, so one should follow the CHA2DS2 VASc  score in deciding the anticougulant therapy. Considering  findings from the ADVANCE study, one is to aware of the increased risk of thromboembolism in TAVR patient. Weighing the risk for bleeding ( BLED score ), I may opt for anti-cougulants if the bleeding risk is low.

Thanks for the info. The current 2014 AHA/ACC/HRS Afib guideline recommends to Anticoagulate anyone with valvular AFib only with warfarin ( "Nonvalvular AF was defined as AF in the absence of rheumatic mitral stenosis, a mechanical or bioprosthetic heart valve, or mitral valve repair" ) despite of CHA2DS2-VASc score. However it does not specify which particular bioprosthetic heart valve. What about Tricuspid or pulmonic bioprosthetic valves?

I am not also aware of any trial of newer anticoagulants has specified it clearly?

Considering the present available findings, we understand that role of the NOACs  in the coditions Dr Theingi state is yet to be defined. So we have to wait till the things are definite and in the mean time we have to opt for warfarin in most of the clinical situations