Direct oral anticoagulants (DOACs) are generally not recommended for patients with atrial fibrillation who have a prosthetic heart valve requiring anticoagulation, including those with mechanical valves. However, for patients with a tissue (bioprosthetic) aortic valve replacement performed more than one year ago, DOACs may be considered appropriate for stroke prevention in atrial fibrillation, as these patients are typically classified as having non-valvular atrial fibrillation.
The MHRA specifically contraindicates dabigatran in patients with prosthetic heart valves due to increased risk of thromboembolic and bleeding events, but this warning primarily concerns mechanical valves rather than tissue valves. NICE guidelines and the European Heart Rhythm Association support the use of DOACs (apixaban, dabigatran, edoxaban, rivaroxaban) for stroke prevention in non-valvular atrial fibrillation, which includes patients with tissue valve replacements after the initial postoperative period.
Therefore, in a patient with atrial fibrillation and a tissue aortic valve replacement done ten years ago, DOACs can be used for anticoagulation, provided there are no other contraindications or cautions such as antiphospholipid syndrome or significant renal impairment.