Direct Oral Anticoagulants Versus Vitamin K Antagonists in Chronic Kidney Disease Patients Undergoing Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis.

Chronic kidney disease (CKD) complicates anticoagulation in transcatheter aortic valve replacement (TAVR) patients in some cases. The aim of this review was to compare the efficacy and safety of direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKAs) in this group. We conducted a meta-analysis of 13 studies (32,508 patients) from databases like PubMed, MEDLINE (Medical Literature Analysis and Retrieval System Online), Embase, and Cochrane Library up to September 2024, focusing on all-cause mortality and major bleeding as primary outcomes, with stroke and intracranial hemorrhage as secondary outcomes. DOACs were found associated with reduced mortality (risk ratio (RR): 0.90, 95%CI: 0.81-0.99, p=0.04), particularly in moderate CKD (RR: 0.94, 95%CI: 0.90-0.98, p=0.01). Major bleeding was significantly lower with DOACs in moderate CKD (RR: 0.70, 95%CI: 0.50-0.98, p=0.03), alongside decreased stroke (RR: 0.42, 95%CI: 0.18-0.97) and intracranial hemorrhage (RR: 0.58, 95%CI: 0.36-0.94). DOACs demonstrate superior efficacy in reducing mortality and comparable safety to VKAs in CKD patients post TAVR, especially in moderate CKD. These findings advocate for DOACs as a preferable anticoagulation strategy, with cautious application in severe CKD pending further research.