Usefulness of Antiplatelet Therapy After Transcatheter Aortic Valve Implantation
Graphical abstract
All-cause mortality, stroke and bleeding rates in studies evaluating antiplatelet therapy following TAVI. DAPT = Dual antiplatelet therapy SAPT = Single antiplatelet therapy *Results are non-significant in all the studies.
Section snippets
Thromboembolic risks after TAVI
Multiple factors are involved in the pathophysiology of thromboembolism after TAVI. Patient-related factors (atrial fibrillation, left atrial appendage thrombus, low ejection fraction, carotid stenosis, etc.) and procedure-related factors (debris embolization/calcium dislodgement) are well-studied.5, 6, 7 However, evidence for valve-related factors, such as leaflet thrombosis – usually manifest as subclinical leaflet thrombosis (SCLT) on contrast-enhanced cardiac computed tomography – or
Evidence for antiplatelet therapy after TAVI
We searched Medline/PubMed, Ovid Journals, Clinicaltrials.gov, and the Cochrane Central Register of Controlled Trials for studies evaluating antiplatelet therapy after TAVI, which revealed 3 randomized trials, 5 systematic reviews and meta-analyses, 7 observational studies, and 5 ongoing clinical trials. Table 1 outlines all the studies. In these studies, SAPT was aspirin monotherapy and DAPT was either aspirin and clopidogrel or aspirin and ticlopidine. There are no studies to date evaluating
Bleeding risks in the TAVI population
Patients undergoing TAVI are typically elderly, with high bleeding risk.35 While bleeding-risk scores are rarely calculated in TAVI patients,36 many would have high bleeding-risk scores, as defined by the Academic Research Consortium.37 Risk profiles of TAVI patients are similar to those of patients enrolled in the high-bleeding-risk coronary-stent studies.38, 39, 40, 41 Table 3 outlines reported risk factors for bleeding that were present in the pivotal TAVI clinical trials42, 43, 44, 45, 46,
Consensus, future trial design, and recommendations
Major societal guidelines3,4 still recommend 1 to 6 months of DAPT after TAVI. Much of this evidence comes from consensus and low-quality evidence. In contrast, 3 months of OAC is recommended after SAVR with a bioprosthesis. There is no prospective or retrospective study supporting a DAPT regimen after SAVR. Conversely, no study has proven the benefit of OAC after TAVI, and all the available evidence convincingly shows that DAPT is not superior to aspirin monotherapy in preventing clinical
Conclusion
Overall, there are little to no data to support the use of DAPT following TAVI. Conversely, there is substantial evidence that DAPT is harmful in elderly patients. On balance, the evidence supports a default strategy of SAPT (i.e., aspirin monotherapy) after TAVI.
Disclosures
Ron Waksman – Advisory Board: Amgen, Boston Scientific, Cardioset, Cardiovascular Systems Inc., Medtronic, Philips, Pi-Cardia Ltd.; Consultant: Amgen, Biotronik, Boston Scientific, Cardioset, Cardiovascular Systems Inc., Medtronic, Philips, Pi-Cardia Ltd.; Grant Support: AstraZeneca, Biotronik, Boston Scientific, Chiesi; Speakers Bureau: AstraZeneca, Chiesi; Investor: MedAlliance.; Gary S. Mintz – Honoraria from Boston Scientific, Philips, Terumo, and Medtronic; Toby Rogers – Consultant and
References (56)
- et al.
Thrombotic versus bleeding risk after transcatheter aortic valve replacement: JACC review topic of the week
J Am Coll Cardiol
(2019) - et al.
Protection against cerebral embolism during transcatheter aortic valve replacement
J Am Coll Cardiol
(2017) - et al.
Subclinical leaflet thrombosis in surgical and transcatheter bioprosthetic aortic valves: an observational study
Lancet
(2017) - et al.
Subclinical leaflet thrombosis in transcatheter and surgical bioprosthetic valves: PARTNER 3 cardiac computed tomography substudy
J Am Coll Cardiol
(2020) - et al.
Assessment of platelet REACtivity after transcatheter aortic valve replacement: the REAC-TAVI trial
JACC Cardiovasc Interv
(2019) - et al.
Nitinol versus stainless steel stents: acute thrombogenicity study in an ex vivo porcine model
Biomaterials
(2002) - et al.
Dual antiplatelet therapy versus aspirin alone in patients undergoing transcatheter aortic valve implantation
Am J Cardiol
(2011) - 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) - 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) - et al.
Can TAVI patients receive aspirin monotherapy as patients after surgical aortic bioprosthesis implantation? Data from the Polish Registry - POL-TAVI
Int J Cardiol
(2017)