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Post-TAVR Antithrombotic Strategy
Study Questions:
What is the impact of the type of antithrombotic treatment on long-term mortality and early bioprosthetic valve dysfunction (BVD) in the FRANCE TAVI registry and the independent correlates of long-term mortality after transcatheter aortic valve replacement (TAVR)?
Methods:
The investigators used data from FRANCE TAVI, a prospective multicenter nationwide French registry. Their objectives were to identify independent correlates of long-term all-cause mortality and early BVD, defined as increased prosthetic gradient ≥10 mm Hg or new gradient ≥20 mm Hg. Variables were considered for multivariable analysis when they were related to all-cause mortality or BVD on univariate analysis with a p value < 0.20. The selected variables were included in the stepwise multivariable Cox regression for all-cause mortality and logistic regression for BVD (exit p value = 0.10) to identify independent correlates of the outcomes of interest.
Results:
Of 12,804 patients included between January 1, 2013 and December 31, 2015, 11,469 (ages 82.8 ± 0.07 years [mean ± standard error], logistic EuroSCORE 17.8 ± 0.1%, mean duration of follow-up 495 ± 3.5 days) were alive at discharge with known antithrombotic treatment and were analyzed for mortality. A total of 2,555 had ≥2 echocardiographic evaluations and were eligible for BVD assessment. One third of patients had a history of atrial fibrillation and the same proportion had oral anticoagulation at discharge (n = 3,836). Neither aspirin nor clopidogrel were independently associated with mortality. Male gender (adjusted hazard ratio [aHR], 1.63; 95% confidence interval [CI], 1.44-1.84; p < 0.001), history of atrial fibrillation (aHR, 1.41; 95% CI, 1.23-1.62; p < 0.001), and chronic renal failure (aHR, 1.37; 95% CI, 1.23-1.53; p < 0.001) were the strongest independent correlates of mortality. Anticoagulation at discharge (adjusted odds ratio [aOR], 0.54; 95% CI, 0.35-0.82; p = 0.005) and a nonfemoral approach (aOR, 0.53; 95% CI, 0.28-1.02; p = 0.049) were independently associated with lower rates of BVD, while chronic renal failure (aOR, 1.46; 95% CI, 1.03-2.08; p = 0.034) and prosthesis size ≤23 mm (aOR, 3.43; 95% CI, 2.41-4.89; p < 0.001) yielded higher risk of BVD.
Conclusions:
The authors concluded that gender, renal failure, and atrial fibrillation impacted the most mortality at 3-year follow-up, and anticoagulation (mostly given for atrial fibrillation) decreased the risk of BVD after TAVR.
Perspective:
This analysis reports that sex, renal failure, and atrial fibrillation were the most potent predictors of mortality after successful TAVR. Furthermore, post-TAVR anticoagulation given mostly for atrial fibrillation decreased the risk of bioprosthetic valve dysfunction, as opposed to antiplatelet treatment. Of note, the role of anticoagulation after TAVR is difficult to study in registries, considering all the potential confounding variables, and at this time, anticoagulation should be used only if there is an indication based on the current guidelines. Additional randomized trials are needed to clarify the clinical benefit of long-term anticoagulation after successful TAVR, particularly given the concern for increased long-term mortality despite adjustment for atrial fibrillation.
Keywords: Anticoagulants, Aspirin, Arrhythmias, Cardiac, Atrial Fibrillation, Diagnostic Imaging, Echocardiography, Geriatrics, Heart Valve Diseases, Heart Valve Prosthesis, Kidney Failure, Chronic, Primary Prevention, Prostheses and Implants, Renal Insufficiency, Chronic, Thrombosis, Transcatheter Aortic Valve Replacement
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