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Current periprocedural anticoagulation in transcatheter aortic valve replacement: could bivalirudin be an option? Rationale and design of the BRAVO 2/3 studies

Abstract

Transcatheter aortic valve replacement (TAVR) is considered an important option in the management of patients with critical aortic valve stenosis that are either inoperable or have a high surgical risk. Despite continued advances in the procedural aspects of TAVR and decreasing complications rates, the risks of major vascular complications and stroke remain significant, which may in turn confer worse clinical outcomes and impact morbidity and mortality. In this review, we outline certain limitations of the currently recommended periprocedural anticoagulation in TAVR, namely unfractionated heparin that is guided by activated clotting times and protamine use if the bleeding risk is high. We will explore the potential for bivalirudin in this setting, which has become a frontrunner in acute coronary syndrome management because of favorable pharmacokinetics and lower bleeding complications. Finally, we will describe an ongoing large multicenter multinational trial that compares intravenous bivalirudin to unfractionated heparin during TAVR procedures using standardized clinical endpoints.

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Abbreviations

ARNO:

Antithrombotic regimens and outcome

ARMYDA-7 BIVALVE:

Anti-thrombotic strategy for reduction of myocardial damage during angioplasty-bivalirudin versus heparin

BARC:

Bleeding academic research consortium

BRAVO:

Effect of bivalirudin on aortic valve intervention outcomes

HORIZONS-AMI:

Harmonizing outcomes with revascularization and stents in acute myocardial infarction

ISAR-REACT-3:

Intracoronary stenting and antithrombosis regimen, rapid early action for coronary treatment 3

PARTNER:

Placement of aortic transcatheter valves

TAVR:

Transcatheter aortic valve replacement

VARC:

Valve academic research consortium

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Confict of interest

Ziad Sergie, Socrates Kakoulides and Usman Baber have no conflict of interest. Jochen Reinöhl—research funding: the Medicines Company, Edwards Lifescience, consulting: Medtronic, the Medicines Company. Eric Van Belle—research funding: the Medicines Company, consulting: AstraZeneca, Bayer. Roxana Mehran—research funding: the Medicines Company, BMS/Sanofi; consulting: AstraZeneca, Janssen. George D. Dangas—research funding: the Medicines Company, BMS/Sanofi; consulting: AstraZeneca, Janssen.

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Correspondence to George D. Dangas.

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Sergie, Z., Lefèvre, T., Van Belle, E. et al. Current periprocedural anticoagulation in transcatheter aortic valve replacement: could bivalirudin be an option? Rationale and design of the BRAVO 2/3 studies. J Thromb Thrombolysis 35, 483–493 (2013). https://doi.org/10.1007/s11239-013-0890-3

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Keywords

  • Unfractionated heparin
  • Protamine
  • Bivalirudin
  • Transcatheter aortic valve replacement