scholarly journals Procedural outcomes in patients with dual versus single antiplatelet therapy prior to transcatheter aortic valve replacement

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Hatim Seoudy ◽  
Maren Thomann ◽  
Johanne Frank ◽  
Matthias Lutz ◽  
Thomas Puehler ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Aortic Valve Replacement ◽  
Antiplatelet Therapy ◽  
Valve Replacement ◽  
Transcatheter Aortic Valve Replacement ◽  
Bleeding Complications ◽  
Bleeding Events ◽  
Transcatheter Aortic Valve ◽  
Life Threatening ◽  
The Impact

AbstractThe impact of uninterrupted dual antiplatelet therapy (DAPT) on bleeding events among patients undergoing transcatheter aortic valve replacement (TAVR) has not been well studied. We conducted an analysis of 529 patients who underwent transfemoral TAVR in our centre and were receiving either DAPT or single antiplatelet therapy (SAPT) prior to the procedure. Accordingly, patients were grouped into a DAPT or SAPT group. Following current guidelines, patients in the SAPT group were switched to DAPT for 90 days after the procedure. The primary endpoint of our analysis was the incidence of bleeding events at 30 days according to the VARC-2 classification system. Any VARC-2 bleeding complications were found in 153 patients (28.9%), while major/life-threatening or disabling bleeding events occurred in 60 patients (11.3%). Our study revealed no significant difference between the DAPT vs. SAPT group regarding periprocedural bleeding complications. Based on multivariable analyses, major bleeding (HR 4.59, 95% CI 1.64–12.83, p = 0.004) and life-threatening/disabling bleeding (HR 8.66, 95% CI 3.31–22.65, p < 0.001) events were significantly associated with mortality at 90 days after TAVR. Both pre-existing DAPT and SAPT showed a comparable safety profile regarding periprocedural bleeding complications and mortality at 90 days. Thus, DAPT can be safely continued in patients undergoing transfemoral TAVR.

scholarly journals Duration of Antiplatelet Therapy Following Transcatheter Aortic Valve Replacement: Systematic Review and Network Meta‐Analysis

2021 ◽  
Author(s):  
Toshiki Kuno ◽  
Yujiro Yokoyama ◽  
Alexandros Briasoulis ◽  
Makoto Mori ◽  
Masao Iwagami ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Aortic Valve Replacement ◽  
Antiplatelet Therapy ◽  
Valve Replacement ◽  
Transcatheter Aortic Valve Replacement ◽  
Therapy Group ◽  
Meta Analysis ◽  
Transcatheter Aortic Valve ◽  
All Cause Mortality ◽  
Life Threatening

Background Although current guidelines recommend dual antiplatelet therapy (DAPT) for 3 to 6 months following transcatheter aortic valve replacement (TAVR), there are no studies directly comparing outcomes of different durations of DAPT following TAVR. Methods and Results PubMed, EMBASE, and Cochrane Database were searched through November 2020 to identify clinical studies that investigated single antiplatelet therapy versus DAPT use following TAVR. Studies using oral anticoagulants and antiplatelet therapy concomitantly were excluded. The DAPT group was subdivided by the duration of DAPT. We extracted the risk ratios (RRs) of major or life‐threatening bleeding, stroke, and all‐cause mortality. Four randomized controlled trials, 2 propensity‐score matched studies, and 1 observational study were identified, yielding a total of 2498 patients who underwent TAVR assigned to the single antiplatelet therapy group (n=1249), 3‐month DAPT group (n=485), or 6‐month DAPT group (n=764). Pooled analyses demonstrated that when compared with the single antiplatelet therapy group, the rates of major or life‐threatening bleeding were significantly higher in the 3‐ and 6‐month DAPT groups (RR [95% CI]=2.13 [1.33–3.40], P =0.016; RR [95% CI]=2.54 [1.49–4.33], P =0.007, respectively) with no difference between the 3‐month DAPT versus 6‐month DAPT groups. The rates of stroke and all‐cause mortality were similar among the 3 groups. Conclusions In this network meta‐analysis of antiplatelet therapy following TAVR, single antiplatelet therapy with aspirin had lower bleeding without increasing stroke or death when compared with either 3‐ or 6‐month DAPT.

Antithrombotic selection in patients undergoing transcatheter aortic valve replacement

2020 ◽  
Vol 78 (1) ◽  
pp. 22-35
Author(s):  
Jennifer K Lai ◽  
Katie L Willenborg ◽  
Theodore Berei ◽  
Anne E Rose
Keyword(s):  
Aortic Valve ◽  
Aortic Valve Replacement ◽  
Antiplatelet Therapy ◽  
Valve Replacement ◽  
Transcatheter Aortic Valve Replacement ◽  
Current Evidence ◽  
Patient Specific ◽  
Bleeding Events ◽  
Transcatheter Aortic Valve ◽  
Specific Factors

Abstract Purpose Clinical controversy regarding the most appropriate antithrombotic regimen after transcatheter aortic valve replacement remains. Current evidence, guidelines, and recommendations are discussed. Summary Antithrombotic selection following transcatheter aortic valve replacement depends on a variety of patient-specific factors. For patients without a preexisting indication for anticoagulation, initial trials employed dual antiplatelet therapy as the postprocedural therapy of choice. Newer studies in this patient population, however, suggest single antiplatelet therapy reduces bleeding events without sacrificing ischemic protection. In patients with a preexisting indication for anticoagulation, warfarin plus single antiplatelet therapy, as opposed to triple antithrombotic therapy, offered similar ischemic protection while reducing clinically significant bleeding. Warfarin monotherapy was associated with a further reduction in bleeding events. One trial demonstrated the safety and efficacy of using apixaban in patients with concomitant atrial fibrillation; however, routine use of rivaroxaban increased adverse cardiac and bleeding events, leaving the utility of direct-acting oral anticoagulants in question. Conclusion Available evidence and current guidelines point to a lack of consensus regarding antithrombotic selection after transcatheter aortic valve replacement. Patient-specific factors and comorbidities must be considered when tailoring therapy, with an emphasis on balancing thrombotic and bleeding risks.

scholarly journals Aspirin Versus Clopidogrel as Single Antithrombotic Therapy After Transcatheter Aortic Valve Replacement: Insight From the OCEAN-TAVI Registry

2021 ◽  
Vol 14 (5) ◽  
Author(s):  
Yusuke Kobari ◽  
Taku Inohara ◽  
Tetsuya Saito ◽  
Nobuhiro Yoshijima ◽  
Makoto Tanaka ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Propensity Score ◽  
Aortic Valve Replacement ◽  
Propensity Score Matching ◽  
Antiplatelet Therapy ◽  
Valve Replacement ◽  
Transcatheter Aortic Valve Replacement ◽  
Dual Antiplatelet Therapy ◽  
Bleeding Events ◽  
Transcatheter Aortic Valve

Background: Current guidelines recommend dual antiplatelet therapy for the first 1 to 6 months after transcatheter aortic valve replacement (TAVR); however, recent studies have reported better outcomes with single antiplatelet therapy than with dual antiplatelet therapy in the occurrence of bleeding events, while not increasing thrombotic events. However, no data exist about optimal single antiplatelet therapy following TAVR. Methods: Patients who underwent TAVR between October 2013 and May 2017 were enrolled from the OCEAN-TAVI Japanese multicenter registry (Optimized Transcatheter Valvular Intervention). After excluding 1759 patients, 829 who received aspirin (100 mg/d) or clopidogrel (75 mg/d) after TAVR were identified and stratified according to the presence or absence of anticoagulation. Propensity score matching was performed to adjust the baseline characteristics between the aspirin and clopidogrel groups. Outcomes of interest were all-cause and cardiovascular deaths, stroke, and life-threatening or major bleeding within 2 years following TAVR. Results: After propensity score matching, 98 and 157 pairs of patients without and with anticoagulation, respectively, were identified. Falsification end points of pneumonia, urinary tract infection, and hip fracture were evaluated, and their rates were not different between groups. All-cause deaths were not statistically different between the groups in patients with (aspirin, 17.5%; clopidogrel, 11.1%; log-rank P =0.07) and without (aspirin, 29.6%; clopidogrel, 20.1%; log-rank P =0.15) anticoagulation at 2 years post-TAVR, whereas clopidogrel was associated with a lower cardiovascular mortality at 2 years in patients with (aspirin, 8.5%; clopidogrel, 2.7%; log-rank P =0.03) and without (aspirin, 18.0%; clopidogrel, 5.2%; log-rank P =0.02) anticoagulation. Conclusions: We demonstrated that clopidogrel monotherapy was associated with a lower incidence of cardiovascular death compared with aspirin monotherapy during the 2-year follow-up after TAVR regardless of anticoagulation use. Registration: URL: https://upload.umin.ac.jp ; Unique identifier: UMIN000020423.

Abstract 15428: Network Meta-analysis of Duration of Antiplatelet Therapy Following Transcatheter Aortic Valve Replacement

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Yujiro Yokoyama ◽  
Toshiki Kuno ◽  
Alexandros BRIASOULIS ◽  
Makoto Mori ◽  
Masao Iwagami ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Aortic Valve Replacement ◽  
Antiplatelet Therapy ◽  
Valve Replacement ◽  
Transcatheter Aortic Valve Replacement ◽  
Meta Analysis ◽  
Transcatheter Aortic Valve ◽  
Increased Risk ◽  
All Cause Mortality ◽  
Life Threatening

Background: Although current guidelines recommend dual antiplatelet therapy (DAPT) for 3 to 6 months following transcatheter aortic valve replacement (TAVR), there are no studies directly comparing outcomes of different durations of DAPT following TAVR. Methods: Pubmed and EMBASE were searched through May, 2020 to identify clinical studies that investigated single antiplatelet therapy (SAPT) versus DAPT use following TAVR. Studies using oral anticoagulants and antiplatelet therapy concomitantly were excluded. The DAPT group was subdivided by the duration of DAPT. We extracted the risk ratios (RRs) of major or life-threatening bleeding, stroke, and all-cause mortality. Results: Three randomized controlled trials, two propensity-score matched studies, and one observational study were identified, yielding a total of 1,833 patients who underwent TAVR assigned to the SAPT group (n=918), 3-month DAPT group (n=151), or 6-month DAPT group (N=764). Pooled analyses demonstrated that the rates of major or life-threatening bleeding were significantly higher in the 6-month DAPT group compared with the SAPT group (RR [95% CI] =2.54 [1.49-4.33], P =0.007) while no such difference was observed between the SAPT vs. 3-month DAPT groups or the 3-month DAPT vs. 6-month DAPT groups (Figure). P-scores were 98.1% (SAPT), 32.3% (3-month DAPT), and 19.6% (6-month DAPT). The rates of stroke and all-cause mortality were similar among the groups. Conclusions: In our network meta-analysis, we observed that DAPT for 6 months following TAVR was associated with increased risk of bleeding without decreasing the risk of stroke compared with SAPT, while there was no difference between DAPT for 3 months and 6 months.

scholarly journals Impact of Incomplete Coronary Revascularization on Late Ischemic and Bleeding Events after Transcatheter Aortic Valve Replacement

2020 ◽  
Vol 9 (7) ◽  
pp. 2267
Author(s):  
Adrien Carmona ◽  
Benjamin Marchandot ◽  
François Severac ◽  
Marion Kibler ◽  
Antonin Trimaille ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Aortic Valve ◽  
Aortic Valve Replacement ◽  
Valve Replacement ◽  
Transcatheter Aortic Valve Replacement ◽  
Coronary Revascularization ◽  
Bleeding Complications ◽  
Syntax Score ◽  
Bleeding Events ◽  
Transcatheter Aortic Valve

Background: The impact of coronary artery disease (CAD) and revascularization by percutaneous coronary intervention (PCI) on prognosis in patients undergoing transcatheter aortic valve replacement (TAVR) remain debated. A dismal prognosis in patients undergoing PCI has been associated with elevated baseline SYNTAX score (bSS) and residual SYNTAX score (rSS). The objective was to investigate whether the degree of bSS and rSS impacted ischemic and bleeding events after TAVR. Methods: bSS and rSS were calculated in 311 patients admitted for TAVR. The primary outcome was the occurrence of major adverse cardiac events (MACE), a composite endpoint of myocardial infarction, stroke, cardiovascular death, or rehospitalization for heart failure. The occurrence of late major/life-threatening bleeding complications (MLBCs) and each primary endpoint individually were the secondary endpoints. Results: bSS > 22 was associated with higher occurrence of MACE (p = 0.013). rSS > 8 and bSS > 22 had no impact on overall cardiovascular mortality. rSS > 8 and bSS > 22 were associated with higher rates of myocardial infarction (p = 0.001 and p = 0.004) and late occurrence of MLBCs. Multivariate analysis showed that bSS > 22 (sHR 2.48) and rSS > 8 (sHR 2.35) remained predictors of MLBCs but not of myocardial infarction. Conclusions: Incomplete coronary revascularization and CAD burden did not impact overall and cardiac mortality but constitute predictors of late MLBCs in TAVR patients.

scholarly journals Baseline mean platelet volume is a strong predictor of major and life-threatening bleedings after transcatheter aortic valve replacement

PLoS ONE ◽  
2021 ◽  
Vol 16 (11) ◽  
pp. e0260439
Author(s):  
Antonin Trimaille ◽  
Kensuke Matsushita ◽  
Benjamin Marchandot ◽  
Adrien Carmona ◽  
Sébastien Hess ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Aortic Valve Replacement ◽  
Valve Replacement ◽  
Mean Platelet Volume ◽  
Transcatheter Aortic Valve Replacement ◽  
Bleeding Complications ◽  
Platelet Volume ◽  
Transcatheter Aortic Valve ◽  
Life Threatening ◽  
One Year

Background Bleeding following transcatheter aortic valve replacement (TAVR) has important prognostic implications. This study sought to evaluate the impact of baseline mean platelet volume (MPV) on bleeding events after TAVR. Methods and results Patients undergoing TAVR between February 2010 and May 2019 were included. Low MPV (L-MPV) was defined as MPV ≤10 fL and high MPV (H-MPV) as MPV >10 fL. The primary endpoint was the occurrence of major/life-threatening bleeding complications (MLBCs) at one-year follow-up. Among 1,111 patients, 398 (35.8%) had L-MPV and 713 (64.2%) had H-MPV. The rate of MLBCs at 1 year was higher in L-MPV patients compared with H-MPV patients (22.9% vs. 17.7% respectively, p = 0.034). L-MPV was associated with vascular access-site complications (36.2% vs. 28.9%, p = 0.012), early (<30 days) major bleeding (15.6% vs. 9.4%, p<0.01) and red blood cell transfusion >2 units (23.9% vs. 17.5%, p = 0.01). No impact of baseline MPV on overall death, cardiovascular death and ischemic events (myocardial infarction and stroke) was evidenced. Multivariate analysis using Fine and Gray model identified preprocedural hemoglobin (sHR 0.84, 95%CI [0.75–0.93], p = 0.001), preprocedural L-MPV (sHR 1.64, 95%CI [1.16–2.32], p = 0.005) and closure time adenosine diphosphate post-TAVR (sHR 2.71, 95%CI [1.87–3.95], p<0.001) as predictors of MLBCs. Conclusions Preprocedural MPV was identified as an independent predictor of MLBCs one year after TAVR, regardless of the extent of platelet inhibition and primary hemostasis disorders.

scholarly journals Surgical Repair of a Transannular Rupture During Transfemoral Transcatheter Aortic Valve Replacement

2021 ◽  
Vol 14 ◽  
pp. 117954762110381
Author(s):  
Ryaan EL-Andari ◽  
Sabin J Bozso ◽  
Jimmy JH Kang ◽  
Vinod K Manikala ◽  
Michael C Moon ◽  
...  
Keyword(s):  
Aortic Valve ◽  
Aortic Valve Replacement ◽  
Valve Replacement ◽  
Transcatheter Aortic Valve Replacement ◽  
Surgical Repair ◽  
Hybrid Operating Room ◽  
Transcatheter Aortic Valve ◽  
Acute Decompensation ◽  
Life Threatening ◽  
Midline Sternotomy

Annular rupture is a rare but life-threatening complication of transcatheter aortic valve replacement (TAVR). Mortality rates are high if immediate intervention, most often necessitating surgical repair, is not performed. Herein, we describe an 87-year-old man who, after deployment of TAVR, experienced acute decompensation and required urgent conversion to a midline sternotomy to repair an aortic annular rupture. This case demonstrates an example of a rare but severe complication of TAVR. This report provides an in-depth description of the surgical approach to repair an aortic annular rupture and demonstrates the utility of performing minimally invasive procedures inside a hybrid operating room.

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