What is the recommended anticoagulation regimen to manage bleeding risk after a Mitral Valve Transcatheter Edge-to-Edge Repair (MTEER) procedure?

Anticoagulation Management After MTEER Procedure

For patients after Mitral Valve Transcatheter Edge-to-Edge Repair (MTEER), dual antiplatelet therapy (DAPT) with aspirin and clopidogrel for 1-6 months followed by single antiplatelet therapy is recommended to manage bleeding risk. 1

Evidence-Based Anticoagulation Protocol After MTEER

For Patients WITHOUT Pre-existing Anticoagulation Indication:

• Initial therapy: DAPT (aspirin + clopidogrel) for 1-6 months
• Maintenance therapy: Single antiplatelet therapy (typically aspirin) for up to 12 months
• Target INR: Not applicable (no warfarin)

For Patients WITH Pre-existing Anticoagulation Indication:

• Continue oral anticoagulation (OAC) that was established before the procedure
• Continuation of OAC is safe in patients already receiving it
• The rates of cerebral and thromboembolic events after MTEER are similar with various regimens (DAPT, OAC, OAC+SAPT, OAC+DAPT) 1

Rationale and Evidence

The 2025 consensus statement in Nature Reviews Cardiology provides the most recent guidance on anticoagulation after MTEER procedures. It specifically notes that OAC should not be initiated after MTEER due to the low thrombogenicity of the device, unlike transcatheter mitral valve implantation 1.

The 2024 AHA/ACC guideline acknowledges that "there are no evidence-based recommendations for antiplatelet/anticoagulant therapy after the TEER procedure" but notes that "DAPT with aspirin and clopidogrel for up to 6 months is commonly used in patients with sinus rhythm after MV TEER" 1.

Special Considerations

Bleeding Risk Management:

• Avoid protamine use during or after TEER except in emergent situations (cardiac perforation or tamponade) 1
• For patients with high bleeding risk, consider shorter duration of DAPT
• Monitor for signs of bleeding complications, especially in the first 11 days after discharge (median time to mortality events) 2

Procedural Factors:

• Maintain sufficient intraprocedural anticoagulation (activated clotting time 200–300s) during the procedure to minimize thrombus formation 1
• Ensure meticulous de-airing of all delivery components to prevent air embolization 1

Risk Stratification:

• Patients with ≥moderate residual mitral regurgitation after MTEER have higher 30-day out-of-hospital mortality 2
• Older age, lower baseline hemoglobin, and poor baseline health status are associated with higher mortality risk 2

Important Caveats and Pitfalls

• Do not initiate new oral anticoagulation after MTEER unless there's another indication (e.g., atrial fibrillation)
• Do not use protamine routinely after MTEER procedures
• Avoid DAPT in patients at high bleeding risk - consider single antiplatelet therapy
• Monitor for bleeding complications especially in the first two weeks after discharge
• Ensure adequate medical therapy optimization - lack of ACE inhibitors/ARBs at discharge is associated with higher 30-day mortality 2

By following this evidence-based anticoagulation protocol after MTEER, clinicians can effectively balance the risks of thromboembolism and bleeding complications to optimize patient outcomes.