Eliquis Should NOT Be Used After Mitral Valve Replacement
Eliquis (apixaban) is contraindicated for anticoagulation after any prosthetic valve replacement, including mitral valve replacement, due to excessive thrombotic complications. 1, 2
Critical Contraindication
- Direct oral anticoagulants (DOACs) including apixaban, rivaroxaban, and dabigatran are explicitly contraindicated for any prosthetic valve based on the GALILEO trial demonstrating excessive thrombotic complications. 1, 2
- The RE-ALIGN trial specifically showed increased thromboembolic and bleeding complications with dabigatran compared to warfarin in patients with mechanical heart valves. 3
- This contraindication applies to both mechanical and bioprosthetic valves. 1, 2
Correct Anticoagulation Strategy for Mitral Valve Replacement
For Bioprosthetic Mitral Valve Replacement:
Warfarin (INR 2.0-3.0) should be used for at least 3 months and may be extended up to 6 months in patients at low bleeding risk. 3, 1, 2
- The stroke risk is substantially elevated during the first 90-180 days post-operatively, with incidence rates of 4.6% within 30 days for bioprosthetic valves. 3, 1
- After completing the initial 3-6 month warfarin course, transition to low-dose aspirin (75-100 mg daily) alone for patients without additional risk factors. 1, 2
Continue warfarin indefinitely (INR 2.0-3.0) plus aspirin 75-100 mg daily if the patient has: 1, 2
- Atrial fibrillation
- History of thromboembolism
- Left ventricular dysfunction
- Hypercoagulable conditions
- Enlarged left atrium (>5.5 cm)
For Mechanical Mitral Valve Replacement:
Lifelong warfarin targeting INR 3.0 (range 2.5-3.5) plus aspirin 75-100 mg daily is required. 3
- This higher INR target for mechanical mitral valves reflects the greater thrombogenicity compared to aortic position. 3
- A recent trial confirmed that even low-dose warfarin (INR 2.0-2.5) failed to achieve noninferiority compared to standard dosing (INR 2.5-3.5) for mechanical mitral valves. 4
Common Pitfalls to Avoid
- Never substitute DOACs for warfarin in any valve replacement patient, regardless of perceived convenience or bleeding risk concerns. 1, 2
- Do not discontinue anticoagulation prematurely in bioprosthetic valve patients—the first 3-6 months carry the highest thrombotic risk. 3, 1
- Ensure patients with bioprosthetic valves who stop warfarin after 3-6 months are monitored closely for development of atrial fibrillation, which would necessitate resuming anticoagulation. 3, 1