Antithrombotic Therapy During and After Transcatheter Aortic Valve Implantation



Transcatheter aortic valve implantation (TAVI) has become the therapy of choice for patients with severe aortic stenosis (AS) who are deemed to be inoperable or at high/intermediate risk for conventional surgical aortic valve replacement (SAVR). Despite improving experience and techniques, ischaemic and bleeding events in the periprocedural period and months after TAVI still remain a relevant concern and impair survival in this generally old and comorbid-rich population. Empirically, dual antiplatelet therapy (DAPT) is currently recommended after TAVI with oral anticoagulation (OAC) restricted for specific indications. However, atrial fibrillation is common after the procedure and embolic material often thrombin-rich. For patients on OAC, a combination of OAC and aspirin or thienopyridine is generally used. Recent evidence has therefore questioned this approach, suggesting that DAPT may be futile compared with aspirin alone and that OAC could be a relevant alternative. Future randomised and appropriately powered trials comparing different strategies of antithrombotic therapy, including new antiplatelet and anticoagulant agents, are necessary to increase the available evidence on this topic. Temporarily, it remains rational to follow the current guidelines, with routine DAPT and recourse to OAC when specifically indicated.


Anticoagulant Antiplatelet Severe aortic stenosis TAVI Atrial fibrillation 


  1. 1.
    Rodés-Cabau J, Dauerman HL, Cohen MG, Mehran R, Small EM, Smyth SS, Costa MA, Mega JL, O’Donoghue ML, Ohman EM, Becker RC. Antithrombotic treatment in transcatheter aortic valve implantation: insights for cerebrovascular and bleeding events. J Am Coll Cardiol. 2013;62:2349–59.CrossRefGoogle Scholar
  2. 2.
    Amat-Santos IJ, Rodés-Cabau J, Urena M, DeLarochellière R, Doyle D, Bagur R, et al. Incidence, predictive factors, and prognostic value of new-onset atrial fibrillation following transcatheter aortic valve implantation. J Am Coll Cardiol. 2012;59(2):178–88.CrossRefGoogle Scholar
  3. 3.
    Leon MB, Smith CR, Mack M, Miller DC, Moses JW, Svensson LG, et al. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med. 2010;363(17):1597–607.CrossRefGoogle Scholar
  4. 4.
    Holmes DR, Mack MJ, Kaul S, Agnihotri A, Alexander KP, Bailey SR, et al. ACCF/AATS/SCAI/STS expert consensus document on transcatheter aortic valve replacement. J Am Coll Cardiol. 2012;59(13):1200–54.CrossRefGoogle Scholar
  5. 5.
    Levison JA, Faust GR, Halpern VJ, Theodoris A, Nathan I, Kline RG, et al. Relationship of protamine dosing with postoperative complications of carotid endarterectomy. Ann Vasc Surg. 1999;13(1):67–72.CrossRefGoogle Scholar
  6. 6.
    Thompson KA, Philip KJ, Schwarz ER. Clinical applications of bivalirudin in the cardiac catheterization laboratory. J Cardiovasc Pharmacol Ther. 2011;16(2):140–9.CrossRefGoogle Scholar
  7. 7.
    Dangas GD, Lefèvre T, Kupatt C, Tchetche D, Schäfer U, Dumonteil N, 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.CrossRefGoogle Scholar
  8. 8.
    Baumgartner H, Falk V, Bax JJ, De Bonis M, Hamm C, Holm PJ, et al. ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J. 2017;38(36):2739–91.CrossRefGoogle Scholar
  9. 9.
    Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Fleisher LA, et al. 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease. J Am Coll Cardiol. 2017;70(2):252–89.CrossRefGoogle Scholar
  10. 10.
    Whitlock RP, Sun JC, Fremes SE, Rubens FD, Teoh KH. Antithrombotic and thrombolytic therapy for valvular disease. Chest. 2012;141(2):e576S–600S.CrossRefGoogle Scholar
  11. 11.
    Webb J, Rodés-Cabau J, Fremes S, Pibarot P, Ruel M, Ibrahim R, et al. Transcatheter aortic valve implantation: a Canadian cardiovascular society position statement. Can J Cardiol. 2012;28(5):520–8.CrossRefGoogle Scholar
  12. 12.
    Hassell MECJ, Hildick-Smith D, Durand E, Kikkert WJ, Wiegerinck EMA, Stabile E, et al. Antiplatelet therapy following transcatheter aortic valve implantation. Heart. 2015;101(14):1118–25.CrossRefGoogle Scholar
  13. 13.
    Ussia GP, Scarabelli M, Mulè M, Barbanti M, Sarkar K, Cammalleri V, et al. Dual antiplatelet therapy versus aspirin alone in patients undergoing transcatheter aortic valve implantation. Am J Cardiol. 2011;108(12):1772–6.CrossRefGoogle Scholar
  14. 14.
    Stabile E, Pucciarelli A, Cota L, Sorropago G, Tesorio T, Salemme 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.CrossRefGoogle Scholar
  15. 15.
    Poliacikova P, Cockburn J, de Belder A, Trivedi U, Hildick-Smith D. Antiplatelet and antithrombotic treatment after transcatheter aortic valve implantation—comparison of regimes. J Invasive Cardiol. 2013;25(10):544–8.PubMedGoogle Scholar
  16. 16.
    Durand E, Blanchard D, Chassaing S, Gilard M, Laskar M, Borz B, et al. Comparison of two antiplatelet therapy strategies in patients undergoing transcatheter aortic valve implantation. Am J Cardiol. 2014;113(2):355–60.CrossRefGoogle Scholar
  17. 17.
    Rodés-Cabau J, Masson J-B, Welsh RC, Garcia Del Blanco B, Pelletier M, Webb JG, 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(13):1357–65.CrossRefGoogle Scholar
  18. 18.
    Sardella G, Calcagno S, Mancone M, Lucisano L, Pennacchi M, Stio RE, et al. Comparison of therapy with Ticagrelor, Prasugrel or high Clopidogrel dose in PCI patients with high on treatment platelet reactivity and genotype variation. TRIPLETE RESET trial. Int J Cardiol. 2015;194:60–2.CrossRefGoogle Scholar
  19. 19.
    Sardella G, Calcagno S, Mancone M, Palmirotta R, Lucisano L, Canali E, et al. Pharmacodynamic effect of switching therapy in patients with high on-treatment platelet reactivity and genotype variation with high clopidogrel dose versus prasugrel: the RESET GENE trial. Circ Cardiovasc Interv. 2012;5(5):698–704.CrossRefGoogle Scholar
  20. 20.
    Lip GYH, Halperin JL. Improving stroke risk stratification in atrial fibrillation. Am J Med. 2010;123(6):484–8.CrossRefGoogle Scholar
  21. 21.
    Friberg L, Rosenqvist M, Lip GYH. Net clinical benefit of warfarin in patients with atrial fibrillation: a report from the Swedish atrial fibrillation cohort study. Circulation. 2012;125(19):2298–307.CrossRefGoogle Scholar
  22. 22.
    Ntaios G, Lip GYH, Makaritsis K, Papavasileiou V, Vemmou A, Koroboki E, et al. CHADS2, CHA2S2DS2-VASc, and long-term stroke outcome in patients without atrial fibrillation. Neurology. 2013;80(11):1009–17.CrossRefGoogle Scholar
  23. 23.
    De Marchena E, Mesa J, Pomenti S, Marin Y, Kall C, Marincic X, Yahagi K, et al. Thrombus formation following transcatheter aortic valve replacement. JACC Cardiovasc Interv. 2015;8(5):728–39.CrossRefGoogle Scholar
  24. 24.
    Latib A, Naganuma T, Abdel-Wahab M, Danenberg H, Cota L, Barbanti M, et al. Treatment and clinical outcomes of transcatheter heart valve thrombosis. Circ Cardiovasc Interv. 2015;8(4):e001779.CrossRefGoogle Scholar
  25. 25.
    Makkar RR, Fontana G, Jilaihawi H, Chakravarty T, Kofoed KF, De Backer O, et al. Possible subclinical leaflet thrombosis in bioprosthetic aortic valves. N Engl J Med. 2015;373(21):2015–24.CrossRefGoogle Scholar
  26. 26.
    Ruile P, Neumann F-J. Valve thrombosis after TAVI. Eur Heart J. 2017;38(36):2700–1.CrossRefGoogle Scholar
  27. 27.
    Sondergaard L, Sigitas C, Chopra M, Bieliauskas G, De Backer O. Leaflet thrombosis after TAVI. Eur Heart J. 2017;38(36):2702–3.CrossRefGoogle Scholar
  28. 28.
    Camm AJ, Lip GYH, De Caterina R, Savelieva I, Atar D, Hohnloser SH, et al. 2012 focused update of the ESC guidelines for the management of atrial fibrillation: an update of the 2010 ESC guidelines for the management of atrial fibrillation. Developed with the special contribution of the European heart rhythm association. Eur Heart J. 2012;33(21):2719–47.CrossRefGoogle Scholar
  29. 29.
    Lip GYH, Windecker S, Huber K, Kirchhof P, Marin F, Ten Berg JM, et al. Management of antithrombotic therapy in atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing percutaneous coronary or valve interventions: a joint consensus document of the European Society of Cardiology Working Group on thrombosis, European heart rhythm association (EHRA), European Association of Percutaneous Cardiovascular Interventions (EAPCI) and European Association of Acute Cardiac Care (ACCA) endorsed by the Heart Rhythm Society (HRS) and Asia-Pacific Heart Rhythm Society (APHRS). Eur Heart J. 2014;35(45):3155–79.CrossRefGoogle Scholar
  30. 30.
    Capodanno D, Lip GYH, Windecker S, Huber K, Kirchhof P, Boriani G, et al. Triple antithrombotic therapy in atrial fibrillation patients with acute coronary syndromes or undergoing percutaneous coronary intervention or transcatheter aortic valve replacement. EuroIntervention. 2015;10(9):1015–21.CrossRefGoogle Scholar
  31. 31.
    Nijenhuis VJ, Bennaghmouch N, Hassell M, Baan J, van Kuijk JP, Agostoni P, et al. Rationale and design of popular-TAVI: antiPlatelet therapy for patients undergoing transcatheter aortic valve implantation. Am Heart J. 2016;173:77–85.CrossRefGoogle Scholar
  32. 32.
    Collet J-P, Berti S, Cequier A, Van Belle E, Lefevre T, Leprince P, 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.CrossRefGoogle Scholar
  33. 33.
    Windecker S, Tijssen J, Giustino G, Guimarães AHC, Mehran R, Valgimigli M, et al. Trial design: rivaroxaban for the prevention of major cardiovascular events after transcatheter aortic valve replacement: rationale and design of the GALILEO study. Am Heart J. 2017;184:81–7.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric SciencesUmberto I Hospital, Sapienza University of RomeRomeItaly

Personalised recommendations