Anticoagulation with or without antiplatelet therapy after transcatheter aortic valve replacement, when less is more: a meta-analysis

Abstract Background About 40% of patients undergoing transcatheter aortic valve replacement (TAVR) have a history of atrial fibrillation (AF) and an additional 10% develop AF after TAVR. However, there is paucity of data regarding the optimal antithrombotic regimen following TAVR in patients with a clinical indication for oral anticoagulants (OAC). Purpose To compare the prognostic impact of OAC plus at least one antiplatelet agent (APT) versus OAC therapy alone in patients undergoing TAVR. Methods We systematically searched the literature for studies evaluating the comparative efficacy and safety of OAC + APT versus OAC alone in TAVR. Random-effect meta-analysis was performed comparing clinical outcomes between the two groups. All-cause mortality and cardiovascular mortality were the efficacy outcomes. Stroke and major bleeding, defined as Bleeding Academic Research Consortium bleeding types 3 to 5, constituted the safety outcome. Results Overall, 398 titles and abstracts were identified through database searching. Four observational studies were selected, for a total of 1929 patients. After a median follow-up of 18.5 months (IQR 11.3–29.3), OAC + APT increased major bleeding events compared to OAC alone (OR=1.79; 95% CI 1.21–2.66; P=0.004) with no difference in stroke (OR 01.02; 95% CI 0.52–2.01; P=0.95), all-cause mortality (OR=1.07; 95% CI 0.78–1.47; P=0.66) and cardiovascular mortality (OR=1.08; 95% CI 0.79–1.47; P=0.62). Conclusion A combination strategy of OAC + APT provides increased risk of bleeding compared to OAC therapy alone in patients undergoing TAVR with similar outcomes in terms of stroke, all-cause mortality and cardiovascular mortality; therefore, when feasible, it should be advised not to add APT on top of OAC therapy in patients without other clinical indications for APT treatment. Funding Acknowledgement Type of funding source: None

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

Journal of the American Heart Association ◽

10.1161/jaha.120.019490 ◽

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.

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Preprocedural circulating galectin-3 and the risk of mortality after transcatheter aortic valve replacement: a systematic review and meta-analysis

Bioscience Reports ◽

10.1042/bsr20202306 ◽

2020 ◽

Vol 40 (9) ◽

Author(s):

Hong-liang Zhang ◽

Guang-yuan Song ◽

Jie Zhao ◽

Yu-bin Wang ◽

Mo-yang Wang ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Valve Replacement ◽

Valve Replacement ◽

Transcatheter Aortic Valve Replacement ◽

Meta Analysis ◽

Transcatheter Aortic Valve ◽

Increased Risk ◽

All Cause Mortality ◽

Galectin 3

Abstract Background: Galectin-3 may predict mortality for patients with aortic stenosis (AS) after transcatheter aortic valve replacement (TAVR). However, the results were inconsistent. We aimed to evaluate the association between baseline galectin and mortality after TAVR in a meta-analysis. Methods: Related follow-up studies were obtained by systematic search of PubMed, Cochrane’s Library, and Embase databases. Both the fixed- and the random-effect models were used for the meta-analysis. Subgroup analyses were performed to evaluate the influences of study characteristics on the outcome. Results: Five prospective cohort studies with 854 patients were included, with a follow-up period between 1 and 1.9 years. Patients with higher baseline circulating galectin-3 had an increased risk of all-cause mortality after TAVR (random-effects model: risk ratio [RR]: 1.63, 95% confidence interval [CI]: 1.19–2.23, P=0.002; fixed-effects model: RR: 1.62, 95% CI: 1.19–2.20, P=0.002; I2 = 4%). Adjustment of estimated glomerular filtration rate (RR: 1.73, P=0.02) or B-type natriuretic peptide (BNP) or N-terminal pro-BNP (RR: 1.83, P=0.02) did not significantly affect the result. A trend of stronger association between higher baseline circulating galectin-3 and increased risk of all-cause mortality after TAVR was observed in studies with an enzyme-linked fluorescent assay (ELFA) (RR: 3.04, P=0.003) compared with those with an enzyme-linked immunosorbent assay (ELISA) (RR: 1.42, P=0.04; P for subgroup difference =0.06). Conclusion: Higher circulating galectin-3 before the procedure may predict all-cause mortality of AS patients after TAVR.

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Low and elevated B-type natriuretic peptide levels are associated with increased mortality in patients with preserved ejection fraction undergoing transcatheter aortic valve replacement: an analysis of the PARTNER II trial and registry

European Heart Journal ◽

10.1093/eurheartj/ehz892 ◽

2019 ◽

Vol 41 (8) ◽

pp. 958-969 ◽

Cited By ~ 8

Author(s):

Shmuel Chen ◽

Bjorn Redfors ◽

Brian P O’Neill ◽

Marie-Annick Clavel ◽

Philippe Pibarot ◽

...

Keyword(s):

Aortic Valve ◽

Ejection Fraction ◽

Aortic Valve Replacement ◽

Valve Replacement ◽

Cardiovascular Mortality ◽

Transcatheter Aortic Valve Replacement ◽

Mortality Rates ◽

P Value ◽

Transcatheter Aortic Valve ◽

All Cause Mortality

Abstract Aims B-type natriuretic peptide (BNP) is a cardiac neurohormone that is secreted in response to ventricular volume expansion and pressure overload. There are conflicting data regarding the association between BNP levels and outcomes after transcatheter aortic valve replacement (TAVR). We therefore sought to assess the association between baseline BNP and adverse outcomes in patients with symptomatic, severe aortic stenosis (AS), and left ventricular ejection fraction (LVEF) ≥50%, undergoing TAVR in the PARTNER 2 Trial and Registry. Methods and results A total of 1782 patients were included in the analysis, and BNP was evaluated both as a continuous log-transformed value and by a priori categories: low (<50 pg/mL), normal (≥50 and <100 pg/mL), moderately elevated (≥100 and <400 pg/mL), or markedly elevated (≥400 pg/mL). Clinical outcomes from discharge to 2 years were compared between patients according to their baseline BNP level, using Kaplan–Meier event rates and multivariable Cox proportional hazards regression models. After adjustment, spline curves revealed a non-linear association between log-transformed BNP and all-cause and cardiovascular mortality in which both the lowest and highest values were associated with increased mortality. Two-year all-cause mortality rates for those with low (n = 86), normal (n = 202), moderately elevated (n = 885), and markedly elevated (n = 609) baseline BNP were 20.0%, 9.8%, 17.7%, and 26.1%, respectively. In adjusted models, compared to a normal baseline BNP, low [adjusted hazard ratio (HR) 2.6, 95% confidence interval (CI) 1.3–5.0, P-value 0.005], moderately elevated (adjusted HR 1.6, 95% CI 1.0–2.6, P-value 0.06), and markedly elevated (adjusted HR 2.1, 95% CI 1.3–3.5, P-value 0.003) BNP were associated with increased all-cause mortality, driven by cardiovascular mortality. Conclusions In a large cohort of patients with severe symptomatic AS and preserved LVEF undergoing TAVR, all-cause and cardiovascular mortality rates at 2 years were higher in patients with low and markedly elevated BNP levels. Clinical Trial Registration https://clinicaltrials.gov/ unique identifier #NCT01314313, #NCT02184442, #NCT03222128, and #NCT03222141.

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

Circulation ◽

10.1161/circ.142.suppl_3.15428 ◽

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.

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Pre-procedural elevated cardiac troponin predict risk of long-term all-cause mortality after transcatheter aortic valve replacement: a meta-analysis of prospective studies

Biomarkers ◽

10.1080/1354750x.2020.1714736 ◽

2020 ◽

Vol 25 (2) ◽

pp. 164-170

Author(s):

Yuehua Li ◽

Hanjun Pei ◽

Chenghui Zhou ◽

Ying Lou

Keyword(s):

Aortic Valve ◽

Aortic Valve Replacement ◽

Valve Replacement ◽

Prospective Studies ◽

Cardiac Troponin ◽

Transcatheter Aortic Valve Replacement ◽

Meta Analysis ◽

Transcatheter Aortic Valve ◽

All Cause Mortality

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One-Year Mortality in Patients Undergoing Transcatheter Aortic Valve Replacement for Stenotic Bicuspid versus Tricuspid Aortic Valves: A Meta-Analysis and Meta-Regression

Journal of Interventional Cardiology ◽

10.1155/2019/8947204 ◽

2019 ◽

Vol 2019 ◽

pp. 1-12 ◽

Cited By ~ 1

Author(s):

Raymundo A. Quintana ◽

Dominique J. Monlezun ◽

Adrian DaSilva-DeAbreu ◽

Uday G. Sandhu ◽

Derick Okwan-Duodu ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Valve Replacement ◽

Valve Replacement ◽

Transcatheter Aortic Valve Replacement ◽

Meta Analysis ◽

Transcatheter Aortic Valve ◽

All Cause Mortality ◽

Baseline Characteristics ◽

Meta Regression ◽

One Year

Objective. To assess 1-year mortality after transcatheter aortic valve replacement (TAVR) in patients with bicuspid aortic stenosis (AS). Background. Clinical trials have proven the beneficial effect of TAVR on mortality in patients with tricuspid AS. Individuals with bicuspid AS were excluded from these trials. Methods. A meta-analysis using literature search from the Cochrane, PubMed, ClinicalTrials, SCOPUS, and EMBASE databases was conducted to determine the effect of TAVR on 1-year mortality in patients with bicuspid AS. Short-term outcomes that could potentially impact one-year mortality were analyzed. Results. After evaluating 380 potential articles, 5 observational studies were selected. A total of 3890 patients treated with TAVR were included: 721 had bicuspid and 3,169 had tricuspid AS. No statistically significant difference between the baseline characteristics of the two groups of patients was seen outside of mean aortic gradient. Our primary endpoint of one-year all-cause mortality revealed 85 deaths in 719 patients (11.82%) with bicuspid AS compared to 467 deaths in 3100 patients (15.06%) with tricuspid AS, with no difference between both groups [relative risk (RR) 1.03; 95% CI 0.70-1.51]. Patients with bicuspid AS were associated with a decrease in device success (RR 0.62; 95% CI 0.45-0.84) and an increase in moderate-to-severe prosthetic valve regurgitation (RR 1.55; 95% CI 1.07-2.22) after TAVR compared to patients with tricuspid AS. The effect of meta-regression coefficients on one-year all-cause mortality was not statistically significant for any patient baseline characteristics. Conclusion. When comparing TAVR procedure in tricuspid AS versus bicuspid AS, there was no difference noted in one-year all-cause mortality.

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Epidemiology of infective endocarditis in transcatheter aortic valve replacement: systemic review and meta-analysis

Journal of Cardiovascular Medicine ◽

10.2459/jcm.0000000000001001 ◽

2020 ◽

Vol 21 (10) ◽

pp. 790-801 ◽

Cited By ~ 1

Author(s):

Narut Prasitlumkum ◽

Wasawat Vutthikraivit ◽

Sittinun Thangjui ◽

Thiratest Leesutipornchai ◽

Jakrin Kewcharoen ◽

...

Keyword(s):

Infective Endocarditis ◽

Aortic Valve ◽

Aortic Valve Replacement ◽

Valve Replacement ◽

Transcatheter Aortic Valve Replacement ◽

Meta Analysis ◽

Systemic Review ◽

Transcatheter Aortic Valve

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Faculty Opinions recommendation of Thirty-day readmissions in surgical and transcatheter aortic valve replacement: A systematic review and meta-analysis.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.733272410.793546441 ◽

2018 ◽

Author(s):

John Augoustides

Keyword(s):

Systematic Review ◽

Aortic Valve ◽

Aortic Valve Replacement ◽

Valve Replacement ◽

Transcatheter Aortic Valve Replacement ◽

Meta Analysis ◽

Transcatheter Aortic Valve

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Aortic Annular Sizing Using Novel Software in Three-Dimensional Transesophageal Echocardiography for Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis

Diagnostics ◽

10.3390/diagnostics11050751 ◽

2021 ◽

Vol 11 (5) ◽

pp. 751

Author(s):

Chanrith Mork ◽

Minjie Wei ◽

Weixi Jiang ◽

Jianli Ren ◽

Haitao Ran

Keyword(s):

Aortic Valve ◽

Aortic Valve Replacement ◽

Transesophageal Echocardiography ◽

Valve Replacement ◽

Transcatheter Aortic Valve Replacement ◽

Meta Analysis ◽

Three Dimensional ◽

Minimum Diameter ◽

Transcatheter Aortic Valve ◽

Mean Differences

(1) Background: We performed this study to evaluate the agreement between novel automated software of three-dimensional transesophageal echocardiography (3D-TEE) and multidetector computed tomography (MDCT) for aortic annular measurements of preprocedural transcatheter aortic valve replacement (TAVR); (2) Methods: PubMed, EMBASE, Web of Science, and Cochrane Library (Wiley) databases were systematically searched for studies that compared 3D-TEE and MDCT as the reference standard for aortic annular measurement of the following parameters: annular area, annular perimeter, area derived-diameter, perimeter derived-diameter, maximum and minimum diameter. Meta-analytic methods were utilized to determine the pooled correlations and mean differences between 3D-TEE and MDCT. Heterogeneity and publication bias were also assessed. Meta-regression analyses were performed based on the potential factors affecting the correlation of aortic annular area; (3) Results: A total of 889 patients from 10 studies were included in the meta-analysis. Pooled correlation coefficients between 3D-TEE and MDCT of annulus area, perimeter, area derived-diameter, perimeter derived-diameter, maximum and minimum diameter measurements were strong 0.89 (95% CI: 0.84–0.92), 0.88 (95% CI: 0.83–0.92), 0.87 (95% CI: 0.77–0.93), 0.87 (95% CI: 0.77–0.93), 0.79 (95% CI: 0.64–0.87), and 0.75 (95% CI: 0.61–0.84) (Overall p < 0.0001), respectively. Pooled mean differences between 3D-TEE and MDCT of annulus area, perimeter, area derived-diameter, perimeter derived-diameter, maximum and minimum diameter measurements were −20.01 mm2 ((95% CI: −35.37 to −0.64), p = 0.011), −2.31 mm ((95% CI: −3.31 to −1.31), p < 0.0001), −0.22 mm ((95% CI: −0.73 to 0.29), p = 0.40), −0.47 mm ((95% CI: −1.06 to 0.12), p = 0.12), −1.36 mm ((95% CI: −2.43 to −0.30), p = 0.012), and 0.31 mm ((95% CI: −0.15 to 0.77), p = 0.18), respectively. There were no statistically significant associations with the baseline patient characteristics of sex, age, left ventricular ejection fraction, mean transaortic gradient, and aortic valve area to the correlation between 3D-TEE and MDCT for aortic annular area sizing; (4) Conclusions: The present study implies that 3D-TEE using novel software tools, automatically analysis, is feasible to MDCT for annulus sizing in clinical practice.

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