Anticoagulation in Severe Mitral Regurgitation with Atrial Fibrillation

Classification of Valvular Heart Disease

The European Heart Rhythm Association (EHRA) classifies valvular heart disease into two types: EHRA Type 1, which includes moderate-to-severe mitral stenosis and mechanical prosthetic valves, and EHRA Type 2, which includes mitral regurgitation, mitral valve repair, aortic stenosis, aortic regurgitation, tricuspid regurgitation, bioprosthetic valve replacements, and transcatheter aortic valve intervention (TAVI), with the latter being eligible for NOACs 1, 2, 3, 4

The American Heart Association (AHA), American College of Cardiology (ACC), and Heart Rhythm Society (HRS) recommend NOACs over warfarin in NOAC-eligible patients with atrial fibrillation, except in cases of moderate-to-severe mitral stenosis or mechanical heart valve 5
The European Society of Cardiology (ESC) and European Association for Cardio-Thoracic Surgery (EACTS) guidelines confirm that NOACs are not recommended in patients with moderate to severe mitral stenosis, but make no such restriction for mitral regurgitation 6, 7

Patients with mitral regurgitation were included in landmark NOAC trials, demonstrating comparable relative efficacy and safety versus warfarin in patients with versus without valvular disease 1, 2, 3
A post hoc analysis of the ROCKET-AF trial showed a higher bleeding risk with rivaroxaban versus warfarin in patients with valvular heart disease, although this did not change the overall recommendation 2, 3

For patients with severe mitral regurgitation and atrial fibrillation, calculate the CHA₂DS₂-VASc score, excluding valvular disease, to determine anticoagulation indication 1, 5
If the CHA₂DS₂-VASc score is ≥2 in men or ≥3 in women, anticoagulation is indicated, with NOACs chosen over warfarin as first-line therapy unless contraindications exist 5, 2
Assess renal function before initiating any NOAC and adjust dosing accordingly 1, 5

Do not confuse mitral regurgitation with mitral stenosis, as only moderate-to-severe mitral stenosis contraindicates NOACs 6, 5, 7
Do not use the outdated term "non-valvular AF" as it is misleading, and do not add aspirin to NOAC therapy without a specific indication 1, 4