Challenges in Aortic Stenosis: Review of Antiplatelet/Anticoagulant Therapy Management with Transcatheter Aortic Valve Replacement (TAVR): TAVR with Recent PCI, TAVR in the Patient with Atrial Fibrillation, and TAVR Thrombosis Management
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Purpose of Review
This review aims to describe the current evidence and consensus recommendations around antiplatelet and anticoagulant management in three common clinical scenarios in transcatheter aortic valve replacement (TAVR): (1) recent percutaneous coronary intervention (PCI) preceding TAVR, (2) atrial fibrillation (AF) management in patients undergoing TAVR, and (3) bioprosthetic valve thrombosis management in TAVR.
Several small clinical trials have evaluated the use of single vs. dual antiplatelet therapy in patients undergoing TAVR, with most recent data favoring single antiplatelet therapy. There are several trials currently enrolling and in follow-up that evaluate the use of anticoagulants in combination with single and dual antiplatelet therapy for patients with AF undergoing TAVR, but as yet, there is no data to support a clear strategy. The use of DAPT after PCI continues to potentially shorten in patients undergoing elective PCI, thus prolonged DAPT may not be necessary post TAVR for the sake of PCI. Bioprosthetic valve thrombosis occurs more commonly than previously thought, but has uncertain clinical significance. In observational studies, antiplatelet therapy has little effect on bioprosthetic valve thrombosis, whereas anticoagulation is effective in both prevention and treatment of thrombosis.
DAPT is currently recommended for 1–6 months for all patients without an indication for oral anticoagulation who undergo TAVR; however, there is a growing amount of evidence for single antiplatelet therapy. In the special situation of patients who have recently undergone PCI, the length of DAPT will depend on stent selection (BMS vs. DES), but may not be significantly prolonged unless the patient experienced an acute coronary syndrome prior to TAVR. There is no clear, optimal antithrombotic strategy for patients with AF who undergo TAVR, but avoidance of triple therapy by using OAC and low-dose ASA seems to be reasonable. OAC, not DAPT, is now known to prevent bioprosthetic valve thrombosis in TAVR and SAVR patients; however, the optimal therapy remains unknown. For patients who develop bioprosthetic valve thrombosis, OAC for 3–6 months, and repeat imaging is recommended to document resolution.
KeywordsTAVR Aortic stenosis Atrial fibrillation PCI Thrombosis
Compliance with Ethical Standards
Conflict of Interest
Matthew W. Sherwood reports honoraria/consulting fees from Janssen, and honoraria from Medtronic.
Amit N. Vora declares no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
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- 6.Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP 3rd, Guyton RA, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63:2438–88.CrossRefGoogle Scholar
- 7.Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP III, Fleisher LA, et al. 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2017;70:252–89.CrossRefGoogle Scholar
- 8.Chopard R, Teiger E, Meneveau N, Chocron S, Gilard M, Laskar M, et al. Baseline characteristics and prognostic implications of pre-existing and new-onset atrial fibrillation after transcatheter aortic valve implantation: results from the FRANCE-2 registry. JACC Cardiovasc Interv. 2015;8:1346–55.CrossRefGoogle Scholar
- 14.•• Rodes-Cabau J, Masson JB, Welsh RC, et al. Aspirin versus aspirin plus clopidogrel as antithrombotic treatment following transcatheter aortic valve replacement with a balloon-expandable valve: the ARTE (Aspirin Versus Aspirin + Clopidogrel Following Transcatheter Aortic Valve Implantation) Randomized Clinical Trial. JACC Cardiovasc Interv. 2017;10(13):1357–65. https://doi.org/10.1016/j.jcin.2017.04.014 This study is the largest randomized controlled trial of antiplatelet therapy after TAVR. Although underpowered, it showed that patients on aspirin monotherapy had similar rates of stroke/MI/death and much lower rates of major bleeding compared with patients given dual antiplatelet therapy. CrossRefPubMedGoogle Scholar
- 15.Stabile E, Pucciarelli A, Cota L, Sorropago G, Tesorio T, Salemme L, et al. SAT-TAVI (single antiplatelet therapy for TAVI) study: a pilot randomized study comparing double to single antiplatelet therapy for transcatheter aortic valve implantation. Int J Cardiol. 2014;174:624–7.CrossRefGoogle Scholar
- 17.Kotronias RA, Kwok CS, George S, Capodanno D, Ludman PF, Townend JN, et al. Transcatheter aortic valve implantation with or without percutaneous coronary artery revascularization strategy: a systematic review and meta-analysis. J Am Heart Assoc. 2017;6.Google Scholar
- 21.• Ramee S, Anwaruddin S, Kumar G, et al. The rationale for performance of coronary angiography and stenting before transcatheter aortic valve replacement: from the Interventional Section Leadership Council of the American College of Cardiology. JACC Cardiovasc Interv. 2016;9:2371–5 This manuscript is a consensus statement on the utility of percutaneous coronary intervention in patients undergoing TAVR. There is no definitive evidence on the optimal strategy for PCI in TAVR, but provides a framework for this decision. CrossRefGoogle Scholar
- 24.Palmerini T, Della Riva D, Benedetto U, Bacchi Reggiani L, Feres F, Abizaid A, et al. Three, six, or twelve months of dual antiplatelet therapy after DES implantation in patients with or without acute coronary syndromes: an individual patient data pairwise and network meta-analysis of six randomized trials and 11 473 patients. Eur Heart J. 2017;38:1034–43.PubMedPubMedCentralGoogle Scholar
- 26.Bittl JA, Baber U, Bradley SM, Wijeysundera DN. Duration of dual antiplatelet therapy: a systematic review for the 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2016;134:e156–78.PubMedGoogle Scholar
- 27.Levine GN, Bates ER, Bittl JA, Brindis RG, Fihn SD, Fleisher LA, et al. 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2016;68:1082–115.CrossRefGoogle Scholar
- 31.Tarantini G, Mojoli M, Urena M, Vahanian A. Atrial fibrillation in patients undergoing transcatheter aortic valve implantation: epidemiology, timing, predictors, and outcome. Eur Heart J 2016, ehw456.Google Scholar
- 34.Tarantini G, Mojoli M, Windecker S, Wendler O, Lefèvre T, Saia F, et al. Prevalence and impact of atrial fibrillation in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement: an analysis from the SOURCE XT prospective multicenter registry. JACC Cardiovasc Interv. 2016;9:937–46.CrossRefGoogle Scholar
- 35.Urena M, Hayek S, Cheema AN, Serra V, Amat-Santos IJ, Nombela-Franco L, et al. Arrhythmia burden in elderly patients with severe aortic stenosis as determined by continuous electrocardiographic recording: toward a better understanding of arrhythmic events after transcatheter aortic valve replacement. Circulation. 2015;131:469–77.CrossRefGoogle Scholar
- 36.Vora AN, Dai D, Matsuoka R, Harrison JK, Hughes GC IV, Sherwood MW, et al. Incidence, management, and associated clinical outcomes of new-onset atrial fibrillation following transcatheter aortic valve replacement: an analysis from the STS/ACC TVT registry. JACC Cardiovasc Interv. 2018;11:1746–56.CrossRefGoogle Scholar