Abstract Body (Do not enter title and authors here): Introduction:
Optimal anticoagulation strategies after transcatheter mitral valve replacement (TMVR) remain unknown with no randomized trial data. Current practices for anticoagulation after TMVR vary widely as a result. We aimed to compare clinical outcomes between vitamin K antagonists (VKA) and direct oral anticoagulation (DOAC) after TMVR at our institution.

Methods:
We included consecutive patients who underwent valve in valve (ViV) or valve in ring (ViR) TMVR between 2012 and 2022. Clinical outcomes and valve hemodynamics were compared between VKA and DOAC. Primary outcome was major adverse cardiovascular (MACE), defined as composite of all-cause death, stroke, or valve thrombosis.

Results:
A total of 148 patients (84 VKA and 64 DOAC) were included. The VKA group had a higher prevalence of myocardial infarction, atrial fibrillation/flutter, and pacemakers. There was no significant difference in MACE between VKA and DOAC at 30 days, 6 months, 1 year (2.4% vs. 3.2%, p = 1; 14.3% vs. 17.6%, p = 0.61; 18.9% vs. 25.5%, p = 0.39, respectively). Survival analysis showed no significant difference in cumulative survival free of MACE over 1 year (p = 0.68). At 1 year, 80.4% of VKA group and 75.6% of DOAC group remained on their respective medications. Mitral valve mean gradient significantly reduced after intervention (12.9 mmHg to 7.8 mmHg in VKA patients and 10.7 mmHg to 7.5 mmHg in DOAC patients) and was maintained over 1 year without difference between groups (7.6 mmHg and 7.6 mmHg, respectively).

Conclusion:
In this study, there was no difference in outcomes between DOAC and VKA after TMVR. Data from randomized clinical trials is still needed to assess efficacy and safety in a larger populations.