Primary Hemostatic Disorders and Late Major Bleeding After TAVR

Oct 22, 2018
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Authors:
Kibler M, Marchandot B, Messas N, et al.
Citation:
Primary Hemostatic Disorders and Late Major Bleeding After Transcatheter Aortic Valve Replacement. J Am Coll Cardiol 2018;72:2139-2148.
Summary By:
Geoffrey D. Barnes, MD, MSc, FACC

Study Questions:

What is the impact of ongoing primary hemostasis disorders on late major or life-threatening bleeding complications?

Methods:

Bleeding was defined using the VARC-2 (Valve Academic Research Consortium-2) criteria. Closure time of adenosine diphosphate (CT-ADP), a surrogate marker of high molecular weight von Willebrand multimers proteolysis, was assessed 24 hours after transcatheter aortic valve replacement (TAVR) procedure. Ongoing primary hemostasis disorder was defined by a CT-ADP >180 seconds.

Results:

Among 372 patients who survived at least 30 days, major or life-threatening bleeding complications occurred in 42 (11.3%) patients at a median follow-up of 383 days. Most bleeding events were gastrointestinal (42.8%) and were associated with an increased overall mortality (hazard ratio [HR], 5.66; 95% confidence interval [CI], 3.10-10.31) and cardiac mortality (HR, 11.62; 95% CI, 4.59-29.37). Multivariable analysis identified paravalvular leak (HR, 6.31; 95% CI, 3.43-11.60) and CT-ADP >180 seconds (HR, 3.08; 95% CI, 1.62-5.81) as predictors of major or life-threatening bleeding complications.

Conclusions:

The authors concluded that major or life-threatening bleeding complications are frequent and associated with increased morbidity and mortality among TAVR patients. They note that these bleeding events are associated with paravalvular leak and CT-ADP >180 seconds.

Perspective:

While TAVR represents a major advance in the treatment of severe aortic stenosis, frequent bleeding complications in both the periprocedural period and >30 days post-procedure remain concerns. Prior studies have demonstrated an association between the shear stress of aortic stenosis with a loss of the high molecular weight multimers of von Willebrand factor and gastrointestinal bleeding (Heyde’s syndrome). CT-ADP may emerge as a novel biomarker of late bleeding complications. Future prospective studies accounting for CT-ADP values and single versus dual antiplatelet therapy are needed to help personalize post-TAVR management.

Keywords: Adenosine Diphosphate, Aortic Valve Insufficiency, Aortic Valve Stenosis, Biomarkers, Heart Valve Diseases, Heart Valve Prosthesis, Hemorrhage, Hemostasis, Hemostatic Disorders, Proteolysis, Tomography, X-Ray Computed, Transcatheter Aortic Valve Replacement, Vascular Diseases, von Willebrand Diseases, von Willebrand Factor


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