Management of Antithrombotic Therapy in Patients Undergoing TAVI

ten Berg J, Sibbing D, Rocca B, et al.
Management of Antithrombotic Therapy in Patients Undergoing Transcatheter Aortic Valve Implantation: A Consensus Document of the ESC Working Group on Thrombosis and the European Association of Percutaneous Cardiovascular Interventions (EAPCI), in Collaboration With the ESC Council on Valvular Heart Disease. Eur Heart J 2021;Apr 5:[Epub ahead of print].

The following are key points to remember from a European consensus document on management of antithrombotic therapy in patients undergoing transcatheter aortic valve implantation (TAVI):

  1. TAVI is effective in older patients with symptomatic severe aortic stenosis, while the indication has recently broadened to younger patients at lower risk.
  2. Although thromboembolic and bleeding complications after TAVI have decreased over time, such adverse events are still common.
  3. This viewpoint document provides updated therapeutic insights in antithrombotic treatment during and after TAVI. Overall, the choice of antithrombotic therapy should be based on both TAVI procedure and patient characteristics, comorbidities, and/or co-medications that predispose to bleeding and thrombosis.
  4. For pre-TAVI:
    1. Assessment of bleeding risk is mandatory.
    2. In patients without an oral anticoagulant (OAC) indication, low-dose aspirin should be started pre-TAVI.
    3. In case of contraindication for aspirin, clopidogrel should be used.
  5. During peri-TAVI:
    1. Vitamin K anticoagulation or non-vitamin-K antagonist oral anticoagulant (NOAC) continuation or interruption should be decided on an individual basis.
    2. When a vitamin K antagonist is continued, the international normalized ratio should be at the inferior limit of the therapeutic range (∼2).
    3. Additional aspirin is not needed in OAC-treated patients.
    4. Unfractionated heparin (UFH) with activated clotting time (ACT) of 250–300 seconds is preferred.
    5. ACT-guided reversal of UFH with protamine sulphate is reasonable.
    6. Bivalirudin is an alternative if UFH is contraindicated.
    7. Use of embolic protection devices is reasonable in patients at high risk of stroke.
  6. For post-TAVI management:
    1. Periodical re-assessment of the bleeding risk is mandatory.
    2. Low-dose aspirin is preferred in the absence of OAC indication.
    3. Vitamin K anticoagulation or NOAC alone is preferred when there is an indication for OAC.
    4. After coronary stenting, if the bleeding risk is high, DAPT should be shortened to 1–3 months in case of chronic coronary syndromes (CCS) and to 3–6 months in case of acute coronary syndromes (ACS).
    5. After coronary stenting in patients on OAC, if the bleeding risk is high, clopidogrel should be shortened to 1–3 months in case of CCS and to 3–6 months in case of ACS.
    6. When coronary stenting is performed within 3 months pre-TAVI, continuing the indicated DAPT or OAC plus clopidogrel peri-TAVI should be considered.

Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Cardiac Surgery, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Prevention, Valvular Heart Disease, Anticoagulation Management and ACS, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and VHD, Interventions and ACS, Interventions and Structural Heart Disease

Keywords: Acute Coronary Syndrome, Anticoagulants, Antithrombins, Aortic Valve Stenosis, Aspirin, Embolic Protection Devices, Fibrinolytic Agents, Geriatrics, Heart Valve Diseases, Hemorrhage, Heparin, Peptide Fragments, Platelet Aggregation Inhibitors, Secondary Prevention, Stents, Stroke, Thromboembolism, Thrombosis, Transcatheter Aortic Valve Replacement, Vitamin K

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