Abstract
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.
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References
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 1989/03/01
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 1992/07/04
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 2003/07/25
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 2008/11/05
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 2011/05/14
Rodes-Cabau J (2012) Transcatheter aortic valve implantation: current and future approaches. Nat Rev Cardiol 9(1):15–29 Epub 2011/11/16
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 2004/07/28
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 2011/12/20
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 2007/06/20
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 2009/04/02
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 2012/11/28
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 2009/10/27
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 1995/04/01
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 1998/12/16
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 2005/05/04
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 1994/11/01
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 2004/08/04
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 2012/02/15
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 2008/01/22
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 2006/10/04
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 2011/09/13
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, 2011
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Lynch, D.R., Dantzler, D., Robbins, M. et al. Considerations in antithrombotic therapy among patients undergoing transcatheter aortic valve implantation. J Thromb Thrombolysis 35, 476–482 (2013). https://doi.org/10.1007/s11239-013-0886-z
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DOI: https://doi.org/10.1007/s11239-013-0886-z