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Primary Hemostatic Disorders and Late Major Bleeding After TAVR
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.
Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and VHD, Interventions and Imaging, Interventions and Structural Heart Disease, Interventions and Vascular Medicine, Computed Tomography, Nuclear Imaging
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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