State-of-the-Art Review
Antithrombotic Therapy After Transcatheter Aortic Valve Replacement

https://doi.org/10.1016/j.jcin.2021.06.020Get rights and content
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Highlights

  • TAVR carries thrombotic and bleeding risks that challenge antithrombotic management.

  • The authors appraised current evidence on antithrombotic management after TAVR.

  • In TAVR patients with no indications for OAC, aspirin is the standard of care.

  • In TAVR patients with indications for OAC, adding antiplatelet agents is unnecessary.

  • Several remaining questions in the field require dedicated trials.

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.

Key Words

antithrombotic therapy
aspirin
DAPT
oral anticoagulation
TAVR

Abbreviations and Acronyms

AF
atrial fibrillation
CI
confidence interval
DAPT
dual-antiplatelet therapy
DOAC
direct oral anticoagulant
ESC
European Society of Cardiology
HALT
hypoattenuated leaflet thickening
HPR
high platelet reactivity
MI
myocardial infarction
OAC
oral anticoagulation
PCI
percutaneous coronary intervention
TAVR
transcatheter aortic valve replacement
VKA
vitamin K antagonist

Cited by (0)

Takeshi Kimura, MD, served as Guest Editor for this paper.

The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.