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Mortality and Early Valve Dysfunction Based on Anticoagulation Use
Study Questions:
How do outcomes following transcatheter aortic valve replacement (TAVR) differ based on the use of dual antiplatelet therapy (DAPT) or single antiplatelet therapy plus oral anticoagulation (OAC)?
Methods:
The authors explored the FRANCE-TAVI prospective multicenter registry of TAVR patients. They assessed long-term all-cause mortality and early bioprosthetic valve dysfunction based on the use of DAPT versus single antiplatelet plus OAC. Valve dysfunction was defined as a valve gradient increase of 10+ mm Hg or a new gradient of 20+ mm Hg.
Results:
Among 12,804 patients who underwent TAVR between January 2013 and December 2015, 11,469 were alive at discharge and 2,555 had at least two echocardiographic follow-ups for analysis. Mean follow-up was 495 days. Neither the use of aspirin nor clopidogrel was independently associated with mortality. Male gender (adjusted hazard ratio [aHR], 1.63; 95% confidence interval [CI], 1.44-1.84), a history of atrial fibrillation (aHR, 1.41; 95% CI, 1.23-1.62), and chronic renal failure (aHR, 1.37; 95% CI, 1.23-1.53) were each associated with all-cause mortality. Anticoagulation use at discharge was associated with a mild increased risk of all-cause mortality (aHR, 1.18; 95% CI, 1.04-1.35). The use of anticoagulation at hospital discharge (adjusted odds ratio [aOR], 0.54; 95% CI, 0.35-0.82) and a nonfemoral approach (aOR, 0.53; 95% CI, 0.28-1.02) were independently associated with lower rates of bioprosthetic valve dysfunction. Chronic renal failure (aOR, 1.46; 95% CI, 1.03-2.08) and prosthesis size ≤23 mm (aOR, 3.43; 95% CI, 2.41-4.89) were both associated with a higher risk of bioprosthetic valve dysfunction.
Conclusions:
The authors concluded that gender, renal failure, and atrial fibrillation were all associated with increased all-cause mortality, while anticoagulation use (usually for atrial fibrillation) decreased the risk of valve dysfunction following TAVR.
Perspective:
There has been no large randomized trial exploring different antithrombotic strategies following TAVR. This is of particular interest for preventing early valve dysfunction. In this retrospective registry analysis, use of anticoagulation (most commonly for stroke prevention in atrial fibrillation) was associated with a nearly 50% reduction in the risk of valve dysfunction. Ongoing, prospective studies using direct OACs will shed more light onto the role of OAC use among TAVR patients, including those without atrial fibrillation. For now, most TAVR patients should continue to get DAPT, unless they have another indication for OAC use (e.g., atrial fibrillation).
Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Valvular Heart Disease, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and VHD, Interventions and Imaging, Interventions and Structural Heart Disease, Echocardiography/Ultrasound
Keywords: ESC Congress, ESC18, Anticoagulants, Arrhythmias, Cardiac, Aspirin, Atrial Fibrillation, Echocardiography, Heart Valve Diseases, Heart Valve Prosthesis, Kidney Failure, Chronic, Platelet Aggregation Inhibitors, Renal Insufficiency, Secondary Prevention, Transcatheter Aortic Valve Replacement, Vascular Diseases
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