Continuation of Anticoagulants for TAVR

Dec 23, 2020
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Authors:
Brinkert M, Mangner N, Moriyama N, et al.
Citation:
Safety and Efficacy of Transcatheter Aortic Valve Replacement With Continuation of Vitamin K Antagonists or Direct Oral Anticoagulants. JACC Cardiovasc Interv 2020;Dec 23:[Epub ahead of print].
Summary By:
Debabrata Mukherjee, MD, FACC

Quick Takes

  • Continuation of oral anticoagulation during TAVR was associated with a similar rate of major or life-threatening bleeding and major vascular complications compared with the commonly used strategy of interruption of anticoagulation.
  • There was a trend towards a lower periprocedural stroke rate in patients with continuation of anticoagulation.
  • These data suggest that continuation of oral anticoagulation is safe and effective and may help to simplify the periprocedural management of patients undergoing TAVR.
 

Study Questions:

What is the safety and efficacy of transcatheter aortic valve replacement (TAVR) with periprocedural continuation of oral anticoagulation versus TAVR with periprocedural interruption of anticoagulation?

Methods:

The investigators enrolled consecutive patients on oral anticoagulation who underwent transfemoral TAVR at five European centers. Oral anticoagulation was either stopped 2-4 days prior to TAVR or continued throughout the procedure. The primary safety outcome was major bleeding. Secondary efficacy endpoints included vascular complications, stroke, and mortality. Primary and secondary outcomes were evaluated by odds ratios (OR) with corresponding 95% confidence intervals (CIs) and p values, derived from logistic regression models with prespecified covariates (age, body mass index, previous stroke, peripheral arterial vascular disease, and center).

Results:

Out of 4,459 patients, 584 patients were treated with continuation of anticoagulation and 733 with interruption of anticoagulation. At 30 days, major or life-threatening bleedings occurred in 66 (11.3%) versus 105 (14.3%; OR, 0.86; 95% CI, 0.61-1.21; p = 0.39) and major vascular complications in 64 (11.0%) versus 90 (12.3%; OR, 0.89; 95% CI, 0.62-1.27; p = 0.52) patients with continuation and with interruption of anticoagulation, respectively. Transfusion of packed red blood cells was less often required in patients with continuation of anticoagulation (80 [13.7%] vs. 130 [17.7%]; OR, 0.59; 95% CI, 0.42-0.81; p = 0.001). Kaplan-Meier estimates of survival at 12 months were 85.3% in patients with continuation of anticoagulation and 84.0% in patients with interruption of anticoagulation (hazard ratio, 0.90; 95% CI, 0.73-1.12; p = 0.36).

Conclusions:

The authors concluded that continuation of oral anticoagulation throughout TAVR did not increase bleeding or vascular complication rates.

Perspective:

This study of patients on oral anticoagulation undergoing TAVR found that continuation of oral anticoagulation was associated with a similar rate of major or life-threatening bleeding and major vascular complications compared with the commonly used strategy of interruption of anticoagulation. Furthermore, there was a trend towards a lower periprocedural stroke rate in patients with continuation of anticoagulation. These data suggest that continuation of oral anticoagulation is safe and effective and may help to simplify the periprocedural management of such patients. Additional larger prospective randomized studies are indicated to confirm these findings.

Clinical Topics: Anticoagulation Management, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Prevention, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and VHD, Interventions and Structural Heart Disease

Keywords: Anticoagulants, Aortic Valve Stenosis, Cardiac Surgical Procedures, Erythrocytes, Heart Valve Diseases, Hemorrhage, Secondary Prevention, Stroke, Transcatheter Aortic Valve Replacement, Vascular Diseases, Vitamin K


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