Skip to main content

Advertisement

Log in

Antithrombotic therapy after transcatheter aortic valve replacement

  • Invited Review Article
  • Published:
Cardiovascular Intervention and Therapeutics Aims and scope Submit manuscript

Abstract

Aortic stenosis is a major valvular disease, which affects prognosis, and its prevalence is increasing due to an aging population. Transcatheter aortic valve replacement (TAVR) is a well-established therapy for symptomatic severe aortic stenosis across the entire risk spectrum, and the number of patients who undergo TAVR is increasing worldwide. Generally, ischemic and bleeding events after TAVR are not rare and can be devastating. Thus, antithrombotic therapy is recommended to prevent thromboembolic events after TAVR. Recently, a lot of randomized control trials have been published on antithrombotic therapy following TAVR, and the situation regarding the optimal antithrombotic regiment following TAVR is dramatically changing. This report reviews the current status and remaining issues in the field of optimal antithrombotic therapy following TAVR and leaflet thrombosis.

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

Access this article

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

Instant access to the full article PDF.

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Cribier A, Eltchaninoff H, Bash A, et al. Percutaneous transcatheter implantation of an aortic valve prosthesis for calcific aortic stenosis: first human case description. Circulation. 2002;106:3006–8.

    Article  Google Scholar 

  2. Mack MJ, Leon MB, Thourani VH, et al. Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients. N Engl J Med. 2019;380:1695–705.

    Article  Google Scholar 

  3. Popma JJ, Michael Deeb G, Yakubov SJ, et al. Transcatheter aortic-valve replacement with a self-expanding valve in low-risk patients. N Engl J Med. 2019;380:1706–15.

    Article  Google Scholar 

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

    Article  CAS  Google Scholar 

  5. Eggebrecht H, Mehta RH. Transcatheter aortic valve implantation (TAVI) in Germany: more than 100,000 procedures and now the standard of care for the elderly. EuroIntervention. 2019;14:E1549–52.

    Article  Google Scholar 

  6. Carroll JD, Mack MJ, Vemulapalli S, et al. STS-ACC TVT registry of transcatheter aortic valve replacement. J Am Coll Cardiol. 2020;76:2492–516.

    Article  CAS  Google Scholar 

  7. Mangieri A, Montalto C, Poletti E, et al. Thrombotic versus bleeding risk after transcatheter aortic valve replacement. J Am Coll Cardiol. 2019;74:2088–101.

    Article  Google Scholar 

  8. Saito Y, Nazif T, Baumbach A, et al. Adjunctive antithrombotic therapy for patients with aortic stenosis undergoing transcatheter aortic valve replacement. JAMA Cardiol. 2020;5:92–101.

    Article  Google Scholar 

  9. Mangieri A, Montalto C, Poletti E, et al. Thrombotic versus bleeding risk after transcatheter aortic valve replacement: JACC review topic of the week. J Am Coll Cardiol. 2019;74:2088–101.

    Article  Google Scholar 

  10. Brueck M, Kramer W, Vogt P, et al. Antiplatelet therapy early after bioprosthetic aortic valve replacement is unnecessary in patients without thromboembolic risk factors. Eur J Cardio-Thorac Surg. 2007;32:108–12.

    Article  Google Scholar 

  11. Mehran R, Rao SV, Bhatt DL, et al. Standardized bleeding definitions for cardiovascular clinical trials a consensus report from the bleeding Academic Research Consortium. Circulation. 2011;123:2736–47.

    Article  Google Scholar 

  12. Urban P, Mehran R, Colleran R, et al. Defining high bleeding risk in patients undergoing percutaneous coronary intervention: a consensus document from the Academic Research Consortium for High Bleeding Risk. Eur Heart J. 2019;40:2632–53.

    Article  CAS  Google Scholar 

  13. Urban P, Mehran R, Colleran R, et al. Defining high bleeding risk in patients undergoing percutaneous coronary intervention. Circulation. 2019;140:240–61.

    Article  Google Scholar 

  14. Watanabe H, Domei T, Morimoto T, Natsuaki M, Shiomi H. Details on the effect of very short dual antiplatelet therapy after drug - eluting stent implantation in patients with high bleeding risk : insight from the STOPDAPT - 2 trial. Cardiovasc Interv Ther. 2021;36:91–103.

    Article  Google Scholar 

  15. Laudani C, Greco A, Occhipinti G, et al. Short duration of DAPT versus de-escalation after percutaneous coronary intervention for acute coronary syndromes. JACC Cardiovasc Interv. 2022;15:268–77.

    Article  Google Scholar 

  16. Natsuaki M, Sonoda S, Yoshioka G, Hongo H, Kaneko T, Kashiyama K. Antiplatelet therapy after percutaneous coronary intervention : current status and future perspectives. Cardiovasc Interv Ther. 2022;37:255–63.

    Article  Google Scholar 

  17. Liu PY, Su CH, Yu F, et al. Prasugrel switching from clopidogrel after percutaneous coronary intervention for acute coronary syndrome in Taiwanese patients : an analysis of safety and efficacy. Cardiovasc Interv Ther. 2022;37:269–78.

    Article  CAS  Google Scholar 

  18. Dangas G, Baber U, Sharma SK, et al. Safety and efficacy of ticagrelor monotherapy according to drug-eluting stent type: the TWILIGHT-STENT study. EuroIntervention. 2021;18:1330–9.

    Google Scholar 

  19. Capodanno D, Alfonso F, Levine GN, et al. ACC/AHA versus ESC guidelines on dual antiplatelet therapy. JACC Guidel Compar. 2018;72:2915–31.

    Article  Google Scholar 

  20. Valgimigli M, Cao D, Angiolillo DJ, et al. Duration of dual antiplatelet therapy for patients at high bleeding risk undergoing PCI. J Am Coll Cardiol. 2021;78:2060–72.

    Article  CAS  Google Scholar 

  21. Ozaki Y, Hara H, Onuma Y, Katagiri Y, Amano T, Kobayashi Y. CVIT expert consensus document on primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) update. Cardiovasc Interv Ther. 2022;37:1–34.

    Article  Google Scholar 

  22. Nakamura M, Kimura K, Kimura T, et al. JCS 2020 guidelines focused update on antithrombotic therapy in patients with coronary artery disease. Circ J. 2020;84:831–65.

    Article  Google Scholar 

  23. Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease. JACC. 2016;68:1082–115.

    Article  Google Scholar 

  24. Valgimigli M, Bueno H, Byrne RA, et al. ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS. Eur J Cardiothorac Surg. 2017;39:213–54.

    Google Scholar 

  25. Mizutani K, Nakazawa G, Yamaguchi T, et al. Academic Research Consortium High Bleeding Risk Criteria associated with 2-year bleeding events and mortality after transcatheter aortic valve replacement discharge: a Japanese Multicentre Prospective OCEAN-TAVI Registry Study. Eur Hear J Open. 2021;1:1–11.

    Google Scholar 

  26. Thyregod HGH, Steinbrüchel DA, Ihlemann N, et al. Transcatheter versus surgical aortic valve replacement in patients with severe aortic valve stenosis: 1-year results from the all-comers NOTION randomized clinical trial. J Am Coll Cardiol. 2015;65:2184–94.

    Article  Google Scholar 

  27. Manoharan G, Van Mieghem NM, Windecker S, et al. 1-Year outcomes with the evolut R self-expanding transcatheter aortic valve: from the International FORWARD Study. JACC Cardiovasc Interv. 2018;11:2326–34.

    Article  Google Scholar 

  28. Carroll JD, Vemulapalli S, Dai D, et al. Procedural experience for transcatheter aortic valve replacement and relation to outcomes: the STS/ACC TVT Registry. J Am Coll Cardiol. 2017;70:29–41.

    Article  Google Scholar 

  29. Généreux P, Cohen DJ, Mack M, et al. Incidence, predictors, and prognostic impact of late bleeding complications after transcatheter aortic valve replacement. J Am Coll Cardiol. 2014;64:2605–15.

    Article  Google Scholar 

  30. Ignatius A, Eng MH, Frisoli TM. Neurologic complications in transcatheter aortic valve replacement. Interv Cardiol Clin. 2021;10:519–29.

    Google Scholar 

  31. Holmes DR, Hopkins LN. Interventional cardiology and acute stroke care going forward: JACC review topic of the week. J Am Coll Cardiol. 2019;73:1483–90.

    Article  Google Scholar 

  32. 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;126:3041–53.

    Article  Google Scholar 

  33. Kahlert P, Al-Rashid F, Döttger P, et al. Cerebral embolization during transcatheter aortic valve implantation: a transcranial doppler study. Circulation. 2012;126:1245–55.

    Article  Google Scholar 

  34. Schmidt T, Leon MB, Mehran R, et al. Debris heterogeneity across different valve types captured by a cerebral protection system during transcatheter aortic valve replacement. JACC Cardiovasc Interv. 2018;11:1262–73.

    Article  Google Scholar 

  35. Nazif TM, Moses J, Sharma R, et al. Randomized Evaluation of TriGuard 3 cerebral embolic protection after transcatheter aortic valve replacement: REFLECT II. JACC Cardiovasc Interv. 2021;14:515–27.

    Article  Google Scholar 

  36. Butala NM, Makkar R, Secemsky EA, et al. Cerebral embolic protection and outcomes of transcatheter aortic valve replacement: results from the transcatheter valve therapy registry. Circulation. 2021;143:2229–40.

    Article  Google Scholar 

  37. Shimamura J, Kuno T, Malik A, et al. Safety and efficacy of cerebral embolic protection devices in patients undergoing transcatheter aortic valve replacement: a meta-analysis of in-hospital outcomes. Cardiovasc Interv Ther. 2022;37:549–57.

    Article  Google Scholar 

  38. Rodés-Cabau J, Masson JB, Welsh RC, 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;10:1357–65.

    Article  Google Scholar 

  39. Brouwer J, Nijenhuis VJ, Delewi R, et al. Aspirin with or without clopidogrel after transcatheter aortic-valve implantation. N Engl J Med. 2020;383:1447–57.

    Article  CAS  Google Scholar 

  40. Maes F, Stabile E, Ussia GP, et al. Meta-analysis comparing single versus dual antiplatelet therapy following transcatheter aortic valve implantation. Am J Cardiol. 2018;122:310–5.

    Article  Google Scholar 

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

    Article  CAS  Google Scholar 

  42. Hioki H, Watanabe Y, Kozuma K, et al. Pre-procedural dual antiplatelet therapy in patients undergoing transcatheter aortic valve implantation increases risk of bleeding. Heart. 2017;103:361–7.

    Article  Google Scholar 

  43. Dangas GD, Tijssen JGP, Wöhrle J, et al. A controlled trial of rivaroxaban after transcatheter aortic-valve replacement. N Engl J Med. 2020;382:120–9.

    Article  CAS  Google Scholar 

  44. Collet J, Berti S, Cequier A, et al. Oral anti-Xa anticoagulation after trans-aortic valve implantation for aortic stenosis : the randomized ATLANTIS trial. Am Heart J. 2018;200:44–50.

    Article  CAS  Google Scholar 

  45. Maeno Y, Abramowitz Y, Kawamori H, et al. A highly predictive risk model for pacemaker implantation after TAVR. JACC Imaging. 2017;10:1139–47.

    Article  Google Scholar 

  46. Collet J, Van BE, Thiele H, et al. Apixaban vs standard of care after transcatheter aortic valve implantation: the ATLANTIS trial. Eurr J Heart. 2022;43:2783–97.

    Article  Google Scholar 

  47. Park DW, Ahn JM, Kang DY, ADAPT-TAVR Investigators, et al. Edoxaban versus dual antiplatelet therapy for leaflet thrombosis and cerebral thromboembolism after TAVR: the ADAPT-TAVR randomized clinical trial. Circulation. 2022;146:466–79.

    Article  CAS  Google Scholar 

  48. Connolly SJ, Eikelboom J, Joyner C, AVERROES Steering Committee and Investigators, et al. Apixaban in patients with atrial fibrillation. N Engl J Med. 2011;364:806–17.

    Article  CAS  Google Scholar 

  49. Nijenhuis VJ, Brouwer J, Delewi R, et al. Anticoagulation with or without clopidogrel after transcatheter aortic-valve implantation. N Engl J Med. 2020;382:1696–707.

    Article  CAS  Google Scholar 

  50. Murphy SA, Wiviott SD, Halperin JL, et al. Edoxaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2013;369:2093–104.

    Article  Google Scholar 

  51. Patel MR, Mahaffey KW, Garg J, et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med. 2011;365:883–91.

    Article  CAS  Google Scholar 

  52. Granger CB, Alexander JH, McMurray JJ, et al. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2011;365:981–92.

    Article  CAS  Google Scholar 

  53. Collet JP, Van BE, Thiele H, et al. Apixaban vs standard of care after transcatheter aortic valve implantation: the ATLANTIS trial. Eur Heart J. 2022;43:2783–97.

    Article  Google Scholar 

  54. Van Mieghem NM, Unverdorben M, Hengstenberg C, et al. Edoxaban versus vitamin K antagonist for atrial fibrillation after TAVR. N Engl J Med. 2021;385:2150–60.

    Article  Google Scholar 

  55. Chakravarty T, Søndergaard L, Friedman J, et al. Subclinical leaflet thrombosis in surgical and transcatheter bioprosthetic aortic valves: an observational study. Lancet. 2017;389:2383–92.

    Article  Google Scholar 

  56. Bogyi M, Schernthaner RE, Loewe C, et al. Subclinical leaflet thrombosis after transcatheter aortic valve replacement: a meta-analysis. JACC Cardiovasc Interv. 2021;14:2643–56.

    Article  Google Scholar 

  57. Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease. J Am Coll Cardiol. 2021;77:e25–197.

    Article  Google Scholar 

  58. Baumgartner H, Falk V, Bax JJ, et al. ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 2017;38:2739–86.

    Article  Google Scholar 

  59. Ito S, Taniguchi T, Shirai S, et al. The impact of baseline thrombocytopenia on late bleeding and mortality after transcatheter aortic valve implantation (from the Japanese Multicenter OCEAN-TAVI Registry ). Am J Cardiol. 2020;141:86–92.

    Article  Google Scholar 

  60. Kobari Y, Inohara T, Saito T, et al. Aspirin versus clopidogrel as single antithrombotic therapy after transcatheter aortic valve replacement: insight from the OCEAN-TAVI Registry. Circ Cardiovasc Interv. 2021;14:523–31.

    Article  Google Scholar 

  61. Kawashima H, Watanabe Y, Hioki H, et al. Direct oral anticoagulants versus vitamin K antagonists in patients with atrial fibrillation after TAVR. JACC Cardiovasc Interv. 2020;13:2587–97.

    Article  Google Scholar 

  62. Hioki H, Watanabe Y, Kozuma K, et al. Short-term dual anti-platelet therapy decreases long-term cardiovascular mortality after transcatheter aortic valve replacement. Heart Vessels. 2021;36:252–9.

    Article  Google Scholar 

  63. Capodanno D, Collet JP, Dangas G, et al. Antithrombotic therapy after transcatheter aortic valve replacement. JACC Cardiovasc Interv. 2021;14:1688–703.

    Article  Google Scholar 

Download references

Acknowledgements

The authors thank all investigators and centers that participated in the OCEAN-TAVI registry.

Funding

The OCEAN-TAVI registry was supported by Edwards Lifesciences, Abbott, Medtronic, Boston Scientific, and Daiichi-Sankyo Company.

Author information

Authors and Affiliations

Authors

Consortia

Contributions

YK, TI, and KH had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Kobari, Inohara, and Hayashida. Acquisition, analysis, or interpretation of data: Kobari, Inohara, and Hayashida. Drafting of the manuscript: Kobari, Inohara, and Hayashida. Critical revision of the manuscript for important intellectual content: Kobari, Inohara, and Hayashida. Study supervision: Kobari, Inohara, and Hayashida.

Corresponding author

Correspondence to Kentaro Hayashida.

Ethics declarations

Conflict of interest

Dr. Hayashida is a clinical proctor for Edwards Lifesciences, Medtronic, and Abbott Medical Japan.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kobari, Y., Inohara, T., Hayashida, K. et al. Antithrombotic therapy after transcatheter aortic valve replacement. Cardiovasc Interv and Ther 38, 9–17 (2023). https://doi.org/10.1007/s12928-022-00893-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12928-022-00893-9

Keywords

Navigation