Skip to main content
SpringerLink
Log in

Adjuvant Antithrombotic Therapy in TAVR

  • New Therapies for Cardiovascular Disease (KW Mahaffey, Section Editor)
  • Published:
Current Cardiology Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

Transcatheter aortic valve replacement (TAVR) has developed into an important alternative to surgical aortic valve replacement (SAVR) for patients with severe aortic stenosis (AS). Adjuvant antithrombotic therapies are commonly used during and after TAVR to decrease the risk of valve thrombosis and thromboembolic cerebrovascular events (CVEs) but consequently increase the risk of bleeding. This article reviews the past and current clinical data regarding adjuvant antithrombotic therapies in TAVR.

Recent Findings

Cerebrovascular and bleeding events during and after TAVR are associated with substantial morbidity and mortality. Bivalirudin, a direct thrombin inhibitor, has been shown to be safe alternative to unfractionated heparin (UFH) as procedural anticoagulation during TAVR; however, sparse evidence exists to guide use of antiplatelet and anticoagulant therapies in patients after TAVR. Multiple studies comparing different antithrombotic regimens in the post-TAVR setting are currently underway.

Summary

Current guidelines recommend intra-procedural anticoagulation with UFH for during TAVR and with dual antiplatelet therapy (DAPT) after TAVR. There is a need to better understand the role of adjuvant antithrombotic therapies in TAVR. The results of ongoing studies are needed to develop evidence-based guidance for the use of adjuvant antithrombotic therapies after TAVR.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Popma JJ, Adams DH, Reardon MJ, et al. Transcatheter aortic valve replacement using a self-expanding bioprosthesis in patients with severe aortic stenosis at extreme risk for surgery. J Am Coll Cardiol. 2014;63(19):1972–81.

    Article  PubMed  Google Scholar 

  2. Leon MB, Smith CR, Mack M, et al. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med. 2010;363(17):1597–607.

    Article  CAS  PubMed  Google Scholar 

  3. Smith CR, Leon MB, Mack MJ, et al. Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med. 2011;364(23):2187–98.

    Article  CAS  PubMed  Google Scholar 

  4. Adams DH, Popma JJ, Reardon MJ, et al. Transcatheter aortic-valve replacement with a self-expanding prosthesis. N Engl J Med. 2014;370(19):1790–8.

    Article  CAS  PubMed  Google Scholar 

  5. Leon MB, Smith CR, Mack MJ, et al. Transcatheter or surgical aortic-valve replacement in intermediate-risk patients. N Engl J Med. 2016;374(17):1609–20.

    Article  CAS  PubMed  Google Scholar 

  6. Nombela-Franco L, Webb JG, de Jaegere PP, et al. Timing, predictive factors, and prognostic value of cerebrovascular events in a large cohort of patients undergoing transcatheter aortic valve implantation. Circulation. 2012;126(25):3041–53.

    Article  PubMed  Google Scholar 

  7. Stortecky S, Windecker S, Pilgrim T, et al. Cerebrovascular accidents complicating transcatheter aortic valve implantation: frequency, timing and impact on outcomes. EuroIntervention. 2012;8(1):62–70.

    Article  PubMed  Google Scholar 

  8. Tamburino C, Capodanno D, Ramondo A, et al. Incidence and predictors of early and late mortality after transcatheter aortic valve implantation in 663 patients with severe aortic stenosis. Circulation. 2011;123(3):299–308.

    Article  PubMed  Google Scholar 

  9. Miller DC, Blackstone EH, Mack MJ, et al. Transcatheter (TAVR) versus surgical (AVR) aortic valve replacement: occurrence, hazard, risk factors, and consequences of neurologic events in the PARTNER trial. J Thorac Cardiovasc Surg. 2012;143(4):832–43. e13

    Article  PubMed  Google Scholar 

  10. Gilard M, Eltchaninoff H, Iung B, et al. Registry of transcatheter aortic-valve implantation in high-risk patients. N Engl J Med. 2012;366(18):1705–15.

    Article  CAS  PubMed  Google Scholar 

  11. Schymik G, Lefèvre T, Bartorelli AL, et al. European experience with the second-generation Edwards SAPIEN XT transcatheter heart valve in patients with severe aortic stenosis: 1-year outcomes from the SOURCE XT registry. J Am Coll Cardiol Intv. 2015;8(5):657–69.

    Article  Google Scholar 

  12. Holmes DR, Brennan JM, Rumsfeld JS, et al. Clinical outcomes at 1 year following transcatheter aortic valve replacement. JAMA. 2015;313(10):1019–28.

    Article  CAS  PubMed  Google Scholar 

  13. Linke A, Wenaweser P, Gerckens U, et al. Treatment of aortic stenosis with a self-expanding transcatheter valve: the international multi-centre ADVANCE study. Eur Heart J. 2014;35(38):2672–84.

    Article  PubMed  Google Scholar 

  14. Nuis R-J, Van Mieghem NM, Schultz CJ, et al. Frequency and causes of stroke during or after transcatheter aortic valve implantation. Am J Cardiol. 2012;109(11):1637–43.

    Article  PubMed  Google Scholar 

  15. Szeto WY, Augoustides JG, Desai ND, et al. Cerebral embolic exposure during transfemoral and transapical transcatheter aortic valve replacement. J Card Surg. 2011;26(4):348–54.

    Article  PubMed  Google Scholar 

  16. Kahlert P, Al-Rashid F, Döttger P, Mori K, Plicht B. Cerebral embolization during transcatheter aortic valve implantation: a transcranial doppler study. Circulation. 2012.

  17. Sharma A, Arbab-Zadeh A, Dubey D, Shani J, Lazar J, Frankel R. Access site bleeding after transcatheter aortic valve implantation. J Thromb Thrombolysis. 2013;35(4):463–8.

    Article  PubMed  Google Scholar 

  18. • Borz B, Durand E, Godin M, et al. Incidence, predictors and impact of bleeding after transcatheter aortic valve implantation using the balloon-expandable Edwards prosthesis. Heart. 2013;99(12):860–5. This prospective observational study showed that life-threatening bleeding during or after TAVR is associated with higher 30-day and 1-year mortality

    Article  PubMed  Google Scholar 

  19. Généreux P, Head SJ, Van Mieghem NM, et al. Clinical outcomes after transcatheter aortic valve replacement using valve academic research consortium definitions: a weighted meta-analysis of 3,519 patients from 16 studies. J Am Coll Cardiol. 2012;59(25):2317–26.

    Article  PubMed  Google Scholar 

  20. Généreux P, Cohen DJ, Williams MR, et al. Bleeding complications after surgical aortic valve replacement compared with transcatheter aortic valve replacement: insights from the PARTNER I trial (placement of aortic transcatheter valve). J Am Coll Cardiol. 2014;63(11):1100–9.

    Article  PubMed  Google Scholar 

  21. Holmes DR, Mack MJ, Kaul S, et al. 2012 ACCF/AATS/SCAI/STS expert consensus document on transcatheter aortic valve replacement. J Am Coll Cardiol. 2012;59(13):1200–54.

    Article  PubMed  Google Scholar 

  22. Webb J, Rodés-Cabau J, Fremes S, et al. Transcatheter aortic valve implantation: a Canadian cardiovascular society position statement. Can J Cardiol. 2012;28(5):520–8.

    Article  PubMed  Google Scholar 

  23. Nishimura RA, Otto CM, Bonow RO, et al. 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 practice guidelines. J Am Coll Cardiol. 2014;63(22):e57–e185.

    Article  PubMed  Google Scholar 

  24. Vahanian A, Alfieri O, Andreotti F, et al. Guidelines on the management of valvular heart disease (version 2012). Eur Heart J. 2012;33:2451–96.

    Article  PubMed  Google Scholar 

  25. Stone GW, Witzenbichler B, Guagliumi G, et al. Bivalirudin during primary PCI in acute myocardial infarction. N Engl J Med. 2008;358(21):2218–30.

    Article  CAS  PubMed  Google Scholar 

  26. Bangalore S, Pencina MJ, Kleiman NS, Cohen DJ. Heparin monotherapy or bivalirudin during percutaneous coronary intervention in patients with non-ST-segment-elevation acute coronary syndromes or stable ischemic heart disease: results from the evaluation of drug-eluting stents and ischemic events registry. Circ Cardiovasc Interv. 2014;7(3):365–73.

    Article  CAS  PubMed  Google Scholar 

  27. Valgimigli M, Frigoli E, Leonardi S, et al. Bivalirudin or unfractionated heparin in acute coronary syndromes. N Engl J Med. 2015;373(11):997–1009.

    Article  CAS  PubMed  Google Scholar 

  28. Steg PG, van 't Hof A, Hamm CW, et al. Bivalirudin started during emergency transport for primary PCI. N Engl J Med. 2013;369(23):2207–17.

    Article  CAS  PubMed  Google Scholar 

  29. Schulz S, Richardt G, Laugwitz K-L, et al. Comparison of prasugrel and bivalirudin vs clopidogrel and heparin in patients with ST-segment elevation myocardial infarction: design and rationale of the Bavarian reperfusion alternatives evaluation (BRAVE) 4 trial. Clin Cardiol. 2014;37(5):270–6.

    Article  PubMed  Google Scholar 

  30. Shahzad A, Kemp I, Mars C, et al. Unfractionated heparin versus bivalirudin in primary percutaneous coronary intervention (HEAT-PPCI): an open-label, single centre, randomised controlled trial. Lancet. 2014;384(9957):1849–58.

    Article  CAS  PubMed  Google Scholar 

  31. Rao SV. The multidimensionality of cardiovascular procedures. J Am Coll Cardiol. 2015;66(25):2869–71.

    Article  PubMed  Google Scholar 

  32. Kini A, Yu J, Cohen MG, et al. Effect of bivalirudin on aortic valve intervention outcomes study: a two-centre registry study comparing bivalirudin and unfractionated heparin in balloon aortic valvuloplasty. EuroIntervention. 2014;10(3):312–9.

    Article  PubMed  Google Scholar 

  33. •• Dangas GD, Lefèvre T, Kupatt C, et al. Bivalirudin versus heparin anticoagulation in transcatheter aortic valve replacement: the randomized BRAVO-3 trial. J Am Coll Cardiol. 2015;66(25):2860–8. This randomized trial of TAVR procedural anticoagulation demonstrated that bivalirudin was non-inferior to heparin with regard to major bleeding and net adverse cardiovascular events

    Article  CAS  PubMed  Google Scholar 

  34. Stabile E, Pucciarelli A, Cota 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(3):624–7.

    Article  PubMed  Google Scholar 

  35. Grube E, Laborde JC, Gerckens U, et al. Percutaneous implantation of the CoreValve self-expanding valve prosthesis in high-risk patients with aortic valve disease: the Siegburg first-in-man study. Circulation. 2006;114(15):1616–24.

    Article  PubMed  Google Scholar 

  36. Nijenhuis VJ, Bennaghmouch N, van Kuijk J-P, Capodanno D, Berg Ten JM. Antithrombotic treatment in patients undergoing transcatheter aortic valve implantation (TAVI). Thromb Haemost. 2015;113(4):674–85.

    Article  PubMed  Google Scholar 

  37. Ussia GP, Scarabelli M, Mulè M, et al. Dual antiplatelet therapy versus aspirin alone in patients undergoing transcatheter aortic valve implantation. Am J Cardiol. 2011;108(12):1772–6.

    Article  CAS  PubMed  Google Scholar 

  38. Rossi JE, Noll A, Bergmark B, et al. Variability in antithrombotic therapy regimens peri-TAVR: a single academic center experience. Cardiol Ther. 2015;4(2):1–5.

    Article  CAS  Google Scholar 

  39. Durand E, Blanchard D, Chassaing S, et al. Comparison of two antiplatelet therapy strategies in patients undergoing transcatheter aortic valve implantation. Am J Cardiol. 2014;113(2):355–60.

    Article  PubMed  Google Scholar 

  40. Mok M, Urena M, Nombela-Franco L, et al. Clinical and prognostic implications of existing and new-onset atrial fibrillation in patients undergoing transcatheter aortic valve implantation. J Thromb Thrombolysis. 2013;35(4):450–5.

    Article  PubMed  Google Scholar 

  41. Abdul-Jawad Altisent O, Durand E, Muñoz-García AJ, et al. Warfarin and antiplatelet therapy versus warfarin alone for treating patients with atrial fibrillation undergoing transcatheter aortic valve replacement. J Am Coll Cardiol Intv. 2016;9(16):1706–17.

    Article  Google Scholar 

  42. Nijenhuis VJ, Bennaghmouch N, Hassell M, et al. Rationale and design of POPular-TAVI: antiplatelet therapy for patients undergoing transcatheter aortic valve implantation. Am Heart J. 2016;173:77–85.

    Article  PubMed  Google Scholar 

  43. Makkar RR, Fontana G, Jilaihawi H, et al. Possible subclinical leaflet thrombosis in bioprosthetic aortic valves. N Engl J Med. 2015;373(21):2015–24.

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Falk Cardiovascular Research Center, Stanford University School of Medicine, 870 Quarry Road, Stanford, CA, 94305, USA

    Ryan G. O’Malley

  2. Department of Medicine, Division of Cardiovascular Medicine, Stanford Center for Clinical Research, Stanford University School of Medicine, 300 Pasteur Drive, Grant S102, Stanford, CA, 94305, USA

    Kenneth W. Mahaffey

  3. Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Room A260 MC:5319, Stanford, CA, 94305, USA

    William F. Fearon

Authors
  1. Ryan G. O’Malley
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Kenneth W. Mahaffey
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. William F. Fearon
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Ryan G. O’Malley.

Ethics declarations

Conflict of Interest

Ryan G. O’Malley and William F. Fearon declare that they have no conflict of interest.

Kenneth W. Mahaffey’s financial disclosures can be viewed at http://med.stanford.edu/profiles/kenneth-mahaffey.

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.

Additional information

This article is part of the Topical Collection on New Therapies for Cardiovascular Disease

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

O’Malley, R.G., Mahaffey, K.W. & Fearon, W.F. Adjuvant Antithrombotic Therapy in TAVR. Curr Cardiol Rep 19, 41 (2017). https://doi.org/10.1007/s11886-017-0850-1

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11886-017-0850-1

Keywords

Search

Navigation