Antithrombotic therapy after transcatheter aortic valve implantation

ABSTRACT

Introduction

Transcatheter aortic valve implantation (TAVI) is a treatment option for patients with symptomatic severe aortic stenosis across the entire spectrum of surgical risk. TAVI conveys some risk for thrombotic complications, requiring antithrombotic drugs for their prevention. Bleeding events represent the major drawback of antithrombotic therapy, which should be carefully tailored over the individual patient’s risk profile.

Areas covered

This review aimed at exploring the rationale for the adoption of a tailored antithrombotic therapy after successful TAVI, with a description and analysis of common complications and their impact on therapy selection. In addition, we aimed at reviewing and discussing current knowledge in this area, with a main focus on the high-quality evidence supporting latest guideline recommendations. Finally, ongoing studies and future directions on antithrombotic therapy after TAVI were outlined.

Expert opinion

Initial experience with antithrombotic therapy after TAVI was derived from percutaneous coronary intervention practice. Accruing evidence in the field led to the current monotherapy paradigm, which prioritizes oral anticoagulant and single antiplatelet therapy in patients with or without an established indication for long-term anticoagulation, respectively. Future studies will investigate the role of alternative antithrombotic strategies to improve clinical outcomes of TAVI patients by minimizing both thrombotic and bleeding complications.

Plain Language Summary

Aortic stenosis is the most common primary valve disease requiring treatment. Transcatheter aortic valve implantation (TAVI) is a percutaneous treatment option for patients with symptomatic severe aortic stenosis across the entire spectrum of surgical risk. To prevent several complications of TAVI, antithrombotic drugs (i.e. antiplatelets or anticoagulants) are required after the intervention. The major drawback of such therapies is represented by bleeding, which makes important a careful consideration of the individual patient’s risk profile. This review article explores the rationale for the adoption of a tailored antithrombotic therapy after TAVI, with a description and analysis of common complications and their impact on therapy selection. In addition, we reviewed and discussed current knowledge in this area, with a main focus on the evidence supporting latest guideline recommendations and their potential evolution. Finally, ongoing studies and future directions on antithrombotic therapy after TAVI were presented.

KEYWORDS:

• Antiplatelet agents
• antithrombotic therapy
• aortic stenosis
• direct oral anticoagulants
• oral anticoagulation
• pharmacotherapy
• transcatheter aortic valve implantation
• valvular heart disease

Article highlights

• Transcatheter aortic valve implantation (TAVI) is a treatment option for patients with symptomatic severe aortic stenosis across the whole spectrum of surgical risks.

• TAVI patients display some inherent risks for both thrombotic and bleeding events, potentially influencing patient morbidity and mortality, and costs for the healthcare systems.

• Thrombotic events, determined by both platelet-mediated and thrombin-mediated factors, mandate the administration of a proper antithrombotic regimen. However, stacking drugs is not a viable option because of the substantial increase in the risk of bleeding.

• Current guidelines recommend in favour of monotherapies, namely oral anticoagulant and single antiplatelet therapy in patients with and without an established indication for long-term anticoagulation, respectively.

• Several risk factors and comorbidities can enhance the complexity of antithrombotic therapy selection. In particular, patients at high bleeding risk or requiring specific antithrombotic regimens due to concomitant indications represent major challenges.

• Several gaps in knowledge remain when it comes to select the optimal antithrombotic treatment after TAVI, particularly in complex scenarios. A number of studies are currently ongoing and are expected to provide significant contributions in the field of antithrombotic therapy after TAVI.

Declaration of interest

Davide Capodanno reports consulting and speaker’s honoraria from Daiichi Sankyo, Sanofi and Terumo, and fees paid to the Institution from Medtronic. Other authors have no conflicts of interest. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewers disclosure

Peer reviewers on this manuscript have no relevant financial relationships or otherwise to disclose.

Additional information

Funding

This paper was not funded.