The only valvular heart disease uniformly excluded from all the NOAC trials were signi cant (moderate or severe) mitral stenosis and mechanical heart valves. A meta-analysis of the four phase 3 AF trials comparing NOAC with warfarin found that although patients with valvular heart disease are at higher risk compared with those without valvular disease, the ef cacy and safety of NOACs vs warfarin are consistent regardless of the presence or absence of valvular heart disease.239 AF patients with mechanical heart valves should only be prescribed VKAs. Data from the only phase II trial of an NOAC, dabigatran, in patients with mechanical heart valves (RE-ALIGN trial) demonstrated inferior ef cacy and more bleeding.440 However, patients with bioprosthetic valves were included in the ARISTOTLE (apixban),theEffectiveAnticoagulationwith Factor Xa Next Generation in Atrial Fibrillation Thrombolysis In Myocardial Infarction study 48 (ENGAGE AF-TIMI 48) (edoxaban), and the relative ef cacy and safety of NOACs compared with warfarin was consistent in these patients, although the number of patients with bioprosthetic valves was limited (< 300). In keeping with a recent European consensus document, with endorsement by international learned societies, we propose that the term valvular AF is outdated. Given that any de nition ultimately relates to the evaluated practical use of oral anticoagulation (OAC) type, we propose a functional EHRA (Evaluated Heart valves, Rheumatic or Arti cial) categorization in relation to the type of oral anticoagulation (OAC) use in patients with AF (Table 11). This classi cation would have the advantage that it may easily evolve or be updated (type 1 may become type 2 or vice versa) when there are new results. For example, transcatheter mitral valve interventions (eg, to include both MitraClip and Mitral valve replacement) are emerging as a possible but more data are awaited, especially in relation to OAC use. 