Antithrombotic Therapy After Transcatheter Aortic Valve Replacement.

Abstract

Transcatheter aortic valve replacement (TAVR) is a treatment option for symptomatic patients with severe aortic stenosis who are candidates for a bioprosthesis across the entire spectrum of risk. However, TAVR carries a risk for thrombotic and bleeding events, underscoring the importance of defining the optimal adjuvant antithrombotic regimen. Antithrombotic considerations are convoluted by the fact that many patients undergoing TAVR are generally elderly and present with multiple comorbidities, including conditions that may require long-term oral anticoagulation (OAC) (eg, atrial fibrillation) and antiplatelet therapy (eg, coronary artery disease). After TAVR among patients without baseline indications for OAC, recent data suggest dual-antiplatelet therapy to be associated with an increased risk for bleeding events, particularly early postprocedure, compared with single-antiplatelet therapy with aspirin. Concerns surrounding the potential for thrombotic complications have raised the hypothesis of adjunctive use of OAC for patients with no baseline indications for anticoagulation. Although effective in modulating thrombus formation at the valve level, the bleeding hazard has shown to be unacceptably high, and the net benefit of combining antiplatelet and OAC therapy is unproven. For patients with indications for the use of long-term OAC, such as those with atrial fibrillation, the adjunctive use of antiplatelet therapy increases bleeding. Whether direct oral anticoagulant agents achieve better outcomes than vitamin K antagonists remains under investigation. Overall, single-antiplatelet therapy and OAC appear to be reasonable strategies in patients without and with indications for concurrent anticoagulation. The aim of the present review is to appraise the current published research and recommendations surrounding the management of antithrombotic therapy after TAVR, with perspectives on evolving paradigms and ongoing trials.

• Authors: Davide Capodanno, Jean-Philippe Collet, George Dangas, Gilles Montalescot, Jurrien M Ten Berg, Stephan Windecker, Dominick J Angiolillo
• Journal: JACC. Cardiovascular interventions (JACC Cardiovasc Interv) Vol. 14 Issue 15 Pg. 1688-1703 (08 09 2021) ISSN: 1876-7605 [Electronic] United States
• PMID: 34353601 (Publication Type: Journal Article, Research Support, Non-U.S. Gov't, Review)
• Copyright: Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Chemical References

• Anticoagulants
• Fibrinolytic Agents
• Platelet Aggregation Inhibitors

Topics

• Aged
• Anticoagulants (adverse effects)
• Aortic Valve (diagnostic imaging, surgery)
• Aortic Valve Stenosis (diagnostic imaging, surgery)
• Fibrinolytic Agents (adverse effects)
• Humans
• Platelet Aggregation Inhibitors (adverse effects)
• Risk Factors
• Transcatheter Aortic Valve Replacement (adverse effects)
• Treatment Outcome