From 1992 to 2001, 609 patients with rheumatic heart disease underwent aortic valve replacement with either mitral valve repair (n = 201) or mitral valve replacement (n = 408). Follow-up extended to 10 years. Thirty-day mortality was 1.4% for mitral valve repair and 0.7% for mitral valve replacement (p = 0.4). Survival at 9 years was 96.5 ± 1.4% after mitral valve repair and 89.7 ± 7.8% after mitral valve replacement (p = 0.73). Freedom from major bleeding at 9 years was 94.8 ± 2.4% after mitral valve repair and 81 ± 7.2% after mitral valve replacement (p = 0.03). Freedom from other valve-related complications and from mitral valve re-operation was similar for the two groups. This study showed that in patients with rheumatic heart disease the results of mitral valve repair with aortic valve replacement were comparable to those of double valve replacement. Major bleeding was less frequent after mitral valve repair with aortic valve replacement. Therefore, whenever feasible, mitral valve repair should be attempted in patients with rheumatic heart disease who need concomitant aortic valve replacement.

Background: Direct oral anticoagulants (DOACs) are the standard treatment for stroke prevention in AF. However, high-quality head-to-head comparisons of DOACs are lacking. This study compared oral anticoagulants in patients with AF. Methods: Data were retrieved from eligible randomised controlled trials (RCTs). Interventions were ranked using the surface under the cumulative ranking curve (SUCRA) and the frequentist random effects model was applied. Efficacy outcomes included stroke, systemic embolism, MI, and all-cause mortality; the safety outcome was major bleeding. A composite outcome of efficacy and net clinical benefit was also evaluated. Results: From 23,152 records, 11 eligible RCTs were identified and included in the study. Rivaroxaban was superior to vitamin K antagonists (VKA) in net clinical benefit (RR 0.75; 95% CI [0.59–0.94]; p=0.0133), but there were no significant differences between other DOACs and VKA or among the DOACs themselves. Rivaroxaban reduced the risk of the composite outcome of efficacy compared with dabigatran (RR 0.85; 95% CI [0.75–0.98]; p=0.02) and edoxaban (RR 0.84; 95% CI [0.75–0.95]; p=0.0051), but not apixaban (RR 0.89; 95% CI [0.89–1.02]; p=0.087). All DOACs showed superiority over VKA in efficacy, without an increased risk of major bleeding. Based on the SUCRA, rivaroxaban showed a favourable risk–benefit profile compared with the other anticoagulants. Conclusion: This study showed that DOACs are superior to VKA in efficacy without increasing major bleeding risk, with rivaroxaban demonstrating the most balanced risk–benefit profile. Well-designed RCTs are needed to validate these findings.

In Asia, especially Vietnam, AF is a common arrhythmia and is linked to a higher risk of stroke and systemic embolism. Anticoagulation therapy for stroke prevention in AF patients can result in bleeding complications. To effectively manage AF, adopting appropriate anticoagulation and addressing modifiable risk factors are crucial. Vietnamese clinicians are particularly interested in non-vitamin K antagonist oral anticoagulants (NOACs), a recent development in AF treatment. However, the lack of head-to-head trials comparing NOACs makes selecting a specific NOAC challenging. This review aims to provide a comprehensive overview of the available clinical evidence on NOACs for stroke prevention in AF to assist clinicians in making informed decisions and improving treatment outcomes in patients with AF. The first part of this review will present the current landscape of AF in Vietnam, focusing on AF prevalence and highlighting gaps in clinical practice. Furthermore, this part extensively discusses the anticoagulation strategy for both primary and secondary stroke prevention in AF.

Part 1 of this review provided an overview of AF in Vietnam, with a particular focus on primary and secondary stroke prevention. Part 2 explores the management of AF in special, high-risk and clinically common patient populations including those with renal impairment, diabetes, the elderly, and those with coronary artery disease. Furthermore, Part 2 addresses the challenges posed by patients with AF who have a bioprosthetic valve, a group situated in a grey area of consideration. Managing AF in these patient groups presents unique clinical challenges that require careful consideration. Physicians are tasked with addressing specific clinical questions to identify the optimal anticoagulation strategy for each individual. To inform these decisions, subgroup analyses from pivotal studies are presented alongside real-world data derived from clinical practice. By synthesising available information and considering the nuanced clinical context, the aim is to provide informed perspectives that align with current medical knowledge and contribute to the enhancement of patient care in these challenging scenarios.

Aims: Baseline Heart Failure Association–International Cardio-Oncology Society (HFA-ICOS) scores and serial left ventricular global longitudinal strain (LV-GLS) measurements have been found to be useful in predicting cancer therapy-related cardiac dysfunction (CTRCD). However, their integration for the purpose of improving prognostic accuracy remains unclear; and we aimed to develop a predictive model for CTRCD using baseline HFA-ICOS scores and the relative decline of LV-GLS in patients on anthracycline or trastuzumab. Methods: We prospectively enrolled 443 chemotherapy-naïve women with breast cancer and cardiovascular risk factors, scheduled to receive anthracycline (n = 333) or trastuzumab (n = 110). Participants were stratified by the HFA-ICOS risk score. The left ventricular ejection fraction (LVEF) and LV-GLS were evaluated using echocardiography at baseline, before each treatment cycle, and every 3 months in the first year post-chemotherapy. CTRCD was a new LVEF reduction ≥10 percentage points to an LVEF < 50%, irrespective of symptoms. Results: In terms of HFA-ICOS stratification, 258 patients (58.2%) were low risk, 180 (40.6%) were moderate risk and 5 (1.2%) were high risk. The proportions of low- and moderate-risk patients were similar in the anthracycline and trastuzumab groups. Twenty-four (7.2%) and seven (6.4%) patients treated with anthracycline and trastuzumab, respectively, displayed asymptomatic CTRCD. The addition of the baseline HFA-ICOS risk score did not improve the performance of the significant relative decline of LV-GLS > 15% in predicting both anthracycline [area under the receiver-operating characteristic curve (AUC) 0.93, 95% confidence interval (CI) 0.89–0.96, sensitivity 87.5%, specificity 93.2%] and trastuzumab (AUC 0.97, 95% CI 0.88–0.99, sensitivity 85.7%, specificity 93.2%)-related cardiac dysfunction. Conclusions: Contemporary anthracycline and trastuzumab-based regimens resulted in similarly low incidences of CTRCD. In this context, LV-GLS evolution was the best predictor of CTRCD.

Objectives: Little is known about the fate of untreated moderate aortic regurgitation after mitral valve replacement for rheumatic heart disease. The aim of this study was to compare the progression to significant aortic valve disease of untreated moderate and mild aortic regurgitation after mitral valve replacement for rheumatic heart disease. Methods: Among patients who underwent mitral valve replacement for rheumatic heart disease without concomitant aortic valve intervention at our institution between January 2005 and December 2017, we selected 338 patients with pure aortic regurgitation (273 patients with mild and 65 patients with moderate aortic regurgitation). Results: After a median follow-up of 10.0 years, 16 patients developed significant aortic valve disease. Freedom from significant aortic valve disease at 3 years, 8 years, and 14 years was 100%, 97.8 ± 1.1%, and 93.5 ± 2.3% in patients with mild aortic regurgitation, and 98.5 ± 1.5%, 94.5 ± 3.2%, and 80.6 ± 7.5% in patients with moderate aortic regurgitation (log-rank test: p = 0.007). Seven patients with mild aortic regurgitation and two patients with moderate aortic regurgitation underwent aortic valve replacement. Conclusions: After mitral valve replacement for rheumatic heart disease, untreated moderate aortic regurgitation progressed more frequently to significant aortic valve disease compared to untreated mild aortic regurgitation. A marked difference in freedom from significant aortic valve disease occurred after eight years. Aortic valve replacement was rarely needed.