DOACs with Bioprosthetic Valves — EECC MCQ
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Correct answer: B — A DOAC is acceptable with a bioprosthetic valve and AF
The 2024 ESC AF Guidelines and 2025 ESC VHD Guidelines confirm that DOACs are appropriate for AF anticoagulation in patients with bioprosthetic valves (both surgical and transcatheter). The absolute contraindication to DOACs applies to mechanical heart valves (based on the RE-ALIGN trial showing excess thromboembolism with dabigatran) and moderate-to-severe rheumatic mitral stenosis. The RIVER trial (rivaroxaban vs warfarin in AF patients with bioprosthetic mitral valves) demonstrated non-inferiority and a trend toward fewer bleeding events. Standard DOAC dosing criteria apply (renal function, weight, age). Apply this conclusion only to the clinical circumstances stated, with appropriate specialist review, contraindication checks, shared decision-making and follow-up. Reassess if the physiology, treatment response or competing risk changes. The competing options would require a different haemodynamic profile, diagnosis, procedural indication or risk balance from the one described here.
Reference: ESC (2024): Guidelines for the Management of Atrial Fibrillation; ESC/EACTS (2025): VHD Guidelines: https://bnf.nice.org.uk/drugs/warfarin-sodium/