Validation of the -VASc risk schema in patients with VHD (excluding moderate to severe rheumatic MS and mechanical heart valves) has been performed in confirming the applicability of this score. Bioprosthetic valves do not appear to be independent predictors of thromboembolic events in patients with AF.19 2. The coexistence of AF and rheumatic MS is com- mon and confers a substantial risk of throm- boembolic events. These patients have been specifically excluded from NOAC trials, yet a single registry study and a US claims database analysis do suggest that NOACs may be poten- These findings need further validation, and currently the use of NOACs can- not be supported over VKA (target international normalized ratio [INR] of 2.5). 3. Postoperative AF after VHD intervention is associated with increased stroke and mortality irrespective of the CHA2 -VASc score. Anticoagulation in this setting may reduce these endpoints. There are conflicting data about the safety and efficacy of NOAC therapy in patients early after implantation of a bioprosthesis.5,6,23 Until more data are available, the writing com- mittee favors using VKA for patients with AF in the first 3 months after surgical or transcath- eter bioprosthetic valve implantation to prevent thromboembolic events. The optimal duration of anticoagulation is not well defined. Repeat evaluation is encouraged in all patients to detect arrhythmia recurrence in the context of their -VASc scores. 4. The phase II study comparing dabigatran to warfarin (RE-ALIGN [Randomized, Phase II Study to Evaluate the Safety and Pharmacokinetics of Oral Dabigatran Etexilate in Patients after Heart Valve Replacement]) was halted prematurely because of excess stroke and Figure 1. Anticoagulation for AF in Patients With VHD. Colors correspond to Table 2. AF indicates atrial fibrillation; MS, mitral stenosis; NOAC, non vitamin K oral anticoagulant; VHD, valvular heart disease; and VKA, vitamin K antagonist. 