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.

Keywords: DAPT; TAVR; antithrombotic therapy; aspirin; oral anticoagulation.

Conflict of interest statement

Funding Support and Author Disclosures Dr Capodanno has received consulting and speaker fees from Bayer, Daiichi-Sankyo, and Sanofi outside the present work. Dr Collet has received consulting and lecture fees from AstraZeneca, Bayer, Bristol Myers Squibb, Fédération Française de Cardiologie, Lead-Up, and WebMD; and his institution has received grants from Bristol Myers Squibb and Medtronic. Dr Dangas has received research grants from Daiichi-Sankyo, Bayer, Janssen, and AstraZeneca. Dr Montalescot has received research grants to the institution and consulting or speaker fees from Abbott, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Boston Scientific, Bristol Myers Squibb, Cell Prothera, CSL Behring, Europa, Idorsia, IRIS-Servier, Medtronic, Merck Sharpe & Dohme, Novartis, Pfizer, Quantum Genomics, and Sanofi Aventis. Dr ten Berg has received lecture or consultancy fees from AstraZeneca, Eli Lilly, Daiichi-Sankyo, The Medicines Company, Accu-Metrics, Boehringer Ingelheim, Bristol Myers Squibb, Pfizer, Bayer, Ferrer, and Idorsia; has received institutional research grants from ZonMw and AstraZeneca; and is the principal investigator of the POPular TAVI trial. Dr Windecker has received research and educational grants to the institution from Abbott, Amgen, Astra Zeneca, Bristol Myers Squibb, Bayer, Biotronik, Boston Scientific, Cardinal Health, CardioValve, CSL Behring, Daiichi-Sankyo, Edwards Lifesciences, Guerbet, InfraRedx, Johnson & Johnson, Medicure, Medtronic, Novartis, Polares, OrPha Suisse, Pfizer, Regeneron, Sanofi, Sinomed, Terumo, and V-Wave; serves as an unpaid member of the steering and executive groups for trials funded by Abbott, Abiomed, Amgen, AstraZeneca, Bristol Myers Squibb, Boston Scientific, Biotronik, Cardiovalve, Edwards Lifesciences, MedAlliance, Medtronic, Novartis, Polares, Sinomed, V-Wave, and Xeltis (but has not received personal payments from pharmaceutical companies or device manufacturers); is a member of the steering or executive committee groups of several investigated-initiated trials that receive funding from industry without impact on his personal remuneration; and is an unpaid member of the Pfizer Research Award selection committee in Switzerland. Dr Angiolillo has received consulting fees or honoraria from Abbott, Amgen, Aralez, AstraZeneca, Bayer, Biosensors, Boehringer Ingelheim, Bristol Myers Squibb, Chiesi, Daiichi-Sankyo, Eli Lilly, Haemonetics, Janssen, Merck, PhaseBio, PLx Pharma, Pfizer, Sanofi, and The Medicines Company; has received payments for participation in review activities from CeloNova and St. Jude Medical, outside the present work; and has received research grants to his institution from Amgen, AstraZeneca, Bayer, Biosensors, CeloNova, CSL Behring, Daiichi-Sankyo, Eisai, Eli Lilly, Gilead, Janssen, Matsutani Chemical Industry, Merck, Novartis, Osprey Medical, Renal Guard Solutions, and the Scott R. MacKenzie Foundation.

Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.