Early versus delayed oral anticoagulation initiation after transcatheter aortic valve replacement in patients with atrial fibrillation: a retrospective cohort study.

The optimal timing of oral anticoagulation (OAC) initiation after transcatheter aortic valve replacement (TAVR) in patients with atrial fibrillation remains uncertain. This study compared early (within 2 days) versus delayed (5-7 days) OAC initiation on clinical outcomes in this population. In this retrospective cohort study using the TriNetX US Collaborative Network (data through 2024), we identified patients aged ≥ 18 years with atrial fibrillation or flutter undergoing TAVR via percutaneous femoral approach. Patients were categorized by OAC initiation timing post-TAVR. The index date was the TAVR procedure day; outcomes were assessed at 30 days, 90 days, and 1 year. Analyses used risk ratios (RRs), hazard ratios (HRs), Kaplan-Meier curves, and log-rank tests. After 1:1 propensity score matching, 3,372 patients remained in each cohort. Early OAC was associated with lower net adverse clinical events (NACE; all-cause mortality, stroke, arterial embolism or thrombosis, or major hemorrhage including transfusion) at 30 days (RR 0.754, 95% CI 0.683-0.832, p < 0.001), 90 days (RR 0.780, 95% CI 0.719-0.846, p < 0.001), and 1 year (RR 0.839, 95% CI 0.789-0.893, p < 0.001). All-cause mortality, major hemorrhage, and acute kidney injury were also significantly reduced with early OAC across all time points. Corresponding hazard ratios confirmed sustained benefit (30-day NACE HR 0.74, 95% CI 0.66-0.82; 1-year HR 0.79, 95% CI 0.73-0.85). Early OAC initiation within 2 days after TAVR was associated with lower NACE, mortality, hemorrhage, and acute kidney injury compared with initiation at 5-7 days in patients with atrial fibrillation. Prospective trials are warranted to confirm these findings.