Journal of Thrombosis and Thrombolysis

, Volume 35, Issue 4, pp 476–482 | Cite as

Considerations in antithrombotic therapy among patients undergoing transcatheter aortic valve implantation

  • Donald R. LynchJr.
  • David Dantzler
  • Mark Robbins
  • David Zhao


Aortic stenosis (AS) accounts for the majority of valvular abnormalities requiring surgical intervention. Platelet dysfunction has been demonstrated among patients with severe aortic stenosis which may predispose patients to bleeding or ischemic events. Surgical aortic valve replacement (AVR) is the standard therapy for severe symptomatic AS; however, a number of patients have very high or prohibitive surgical risk. Transcatheter aortic valve implantation (TAVI) has been shown to be superior to medical therapy among inoperable patients and non-inferior to AVR in patients with high surgical risk. In comparison to AVR, TAVI has been associated with a higher incidence of ischemic cerebrovascular events, conduction abnormalities necessitating permanent pacemaker placement, and vascular complications. Current practice guidelines recommend dual antiplatelet therapy (DAPT) following TAVI using a combination of low dose aspirin and clopidogrel for 3–6 months. This regimen may be adjusted in patients with clinical bleeding events or indications for concomitant systemic anticoagulation. Recent and ongoing trials aim to clarify the optimum antithrombotic regimen and duration of therapy following TAVI. Collectively, early studies have not revealed additional benefit of adding clopidogrel to aspirin therapy in regards to reducing ischemic events, but have shown a trend towards increase in major bleeding. TAVI has proven successful, and as its breadth of utility is expanded, further studies are needed to define optimum antithrombotic therapy following TAVI. This article will review the current data for antiplatelet and anticoagulant therapy following TAVI.


Transcatheter aortic valve implantation Transcatheter aortic valve replacement Aortic valve replacement Antiplatelet therapy 


  1. 1.
    Otto CM, Pearlman AS, Gardner CL (1989) Hemodynamic progression of aortic stenosis in adults assessed by Doppler echocardiography. J Am Coll Cardiol 13(3):545–550 Epub 1989/03/01PubMedCrossRefGoogle Scholar
  2. 2.
    Warkentin TE, Moore JC, Morgan DG (1992) Aortic stenosis and bleeding gastrointestinal angiodysplasia: is acquired von Willebrand’s disease the link? Lancet 340(8810):35–37 Epub 1992/07/04PubMedCrossRefGoogle Scholar
  3. 3.
    Vincentelli A, Susen S, Le Tourneau T, Six I, Fabre O, Juthier F et al (2003) Acquired von Willebrand syndrome in aortic stenosis. N Engl J Med 349(4):343–349 Epub 2003/07/25PubMedCrossRefGoogle Scholar
  4. 4.
    Prohaska W, Zittermann A, Luth JU, Inoue K, Koster-Eiserfunke W, Baller D et al (2008) Prevalent platelet dysfunction in patients with aortic valve disease. J Heart Valve Dis 17(5):542–547 Epub 2008/11/05PubMedGoogle Scholar
  5. 5.
    Rodes-Cabau J, Gutierrez M, Bagur R, De Larochelliere R, Doyle D, Cote M et al (2011) Incidence, predictive factors, and prognostic value of myocardial injury following uncomplicated transcatheter aortic valve implantation. J Am Coll Cardiol 57(20):1988–1999 Epub 2011/05/14PubMedCrossRefGoogle Scholar
  6. 6.
    Rodes-Cabau J (2012) Transcatheter aortic valve implantation: current and future approaches. Nat Rev Cardiol 9(1):15–29 Epub 2011/11/16CrossRefGoogle Scholar
  7. 7.
    Diener HC, Bogousslavsky J, Brass LM, Cimminiello C, Csiba L, Kaste M et al (2004) Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients (MATCH): randomised, double-blind, placebo-controlled trial. Lancet 364(9431):331–337 Epub 2004/07/28PubMedCrossRefGoogle Scholar
  8. 8.
    Amat-Santos IJ, Rodes-Cabau J, Urena M, de Larochelliere R, Doyle D, Bagur R et al (2012) Incidence, predictive factors, and prognostic value of new-onset atrial fibrillation following transcatheter aortic valve implantation. J Am Coll Cardiol 59(2):178–188 Epub 2011/12/20PubMedCrossRefGoogle Scholar
  9. 9.
    Hart RG, Pearce LA, Aguilar MI (2007) Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med 146(12):857–867 Epub 2007/06/20PubMedCrossRefGoogle Scholar
  10. 10.
    Connolly SJ, Pogue J, Hart RG, Hohnloser SH, Pfeffer M, Chrolavicius S et al (2009) Effect of clopidogrel added to aspirin in patients with atrial fibrillation. N Engl J Med 360(20):2066–2078 Epub 2009/04/02PubMedCrossRefGoogle Scholar
  11. 11.
    Faxon DP (2012) How to manage antiplatelet therapy for stenting in a patient requiring oral anticoagulants. Curr Treat Options Cardiovasc Med 15(1):11–20 Epub 2012/11/28CrossRefGoogle Scholar
  12. 12.
    Dewilde W, Berg JT (2009) Design and rationale of the WOEST trial: what is the optimal antiplatelet and anticoagulant therapy in patients with oral anticoagulation and coronary stenting (WOEST). Am Heart J 158(5):713–718 Epub 2009/10/27PubMedCrossRefGoogle Scholar
  13. 13.
    Heras M, Chesebro JH, Fuster V, Penny WJ, Grill DE, Bailey KR et al (1995) High risk of thromboemboli early after bioprosthetic cardiac valve replacement. J Am Coll Cardiol 25(5):1111–1119 Epub 1995/04/01PubMedCrossRefGoogle Scholar
  14. 14.
    Moinuddeen K, Quin J, Shaw R, Dewar M, Tellides G, Kopf G et al (1998) Anticoagulation is unnecessary after biological aortic valve replacement. Circulation 98(19 Suppl):II95–II98 discussion II8-9, Epub 1998/12/16PubMedGoogle Scholar
  15. 15.
    Sundt TM, Zehr KJ, Dearani JA, Daly RC, Mullany CJ, McGregor CG et al (2005) Is early anticoagulation with warfarin necessary after bioprosthetic aortic valve replacement? J Thorac Cardiovasc Surg 129(5):1024–1031 Epub 2005/05/04PubMedCrossRefGoogle Scholar
  16. 16.
    Blair KL, Hatton AC, White WD, Smith LR, Lowe JE, Wolfe WG et al (1994) Comparison of anticoagulation regimens after Carpentier-Edwards aortic or mitral valve replacement. Circulation 90(5 Pt 2):II214–II219 Epub 1994/11/01PubMedGoogle Scholar
  17. 17.
    Gherli T, Colli A, Fragnito C, Nicolini F, Borrello B, Saccani S et al (2004) Comparing warfarin with aspirin after biological aortic valve replacement: a prospective study. Circulation 110(5):496–500 Epub 2004/08/04PubMedCrossRefGoogle Scholar
  18. 18.
    Whitlock RP, Sun JC, Fremes SE, Rubens FD, Teoh KH (2012) Antithrombotic and thrombolytic therapy for valvular disease: antithrombotic therapy and prevention of thrombosis, 9th ed: american college of chest physicians evidence-based clinical practice guidelines. Chest 141(2 Suppl):e576S–e600S Epub 2012/02/15PubMedCrossRefGoogle Scholar
  19. 19.
    Colli A, Verhoye JP, Heijmen R, Strauch JT, Hyde JA, Pagano D et al (2008) Antithrombotic therapy after bioprosthetic aortic valve replacement: ACTION registry survey results. Eur J Cardiothorac Surg 33(4):531–536 Epub 2008/01/22PubMedCrossRefGoogle Scholar
  20. 20.
    Grube E, Laborde JC, Gerckens U, Felderhoff T, Sauren B, Buellesfeld L et al (2006) Percutaneous implantation of the CoreValve self-expanding valve prosthesis in high-risk patients with aortic valve disease: the Siegburg first-in-man study. Circulation 114(15):1616–1624 Epub 2006/10/04PubMedCrossRefGoogle Scholar
  21. 21.
    Ussia GP, Scarabelli M, Mule M, Barbanti M, Sarkar K, Cammalleri V et al (2011) Dual antiplatelet therapy versus aspirin alone in patients undergoing transcatheter aortic valve implantation. Am J Cardiol 108(12):1772–1776 Epub 2011/09/13PubMedCrossRefGoogle Scholar
  22. 22.
    SAT-TAVI (2011) A prospective, randomized trial of single vs. dual anti-platelet therapy after transcatheter aortic valve replacement in high-risk patients with aortic stenosis. In: Stabile ESG, Pucciarelli A, Cota L, et al (eds) Transcatheter cardiovascular therapeutics San Francisco, 2011Google Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Donald R. LynchJr.
    • 1
  • David Dantzler
    • 1
  • Mark Robbins
    • 1
  • David Zhao
    • 1
  1. 1.Division of Cardiology, Vanderbilt Heart and Vascular InstituteVanderbilt University Medical CenterNashvilleUSA

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