Perspective:

As the use of TAVR grows, including for patients with low surgical risk, an ongoing debate remains about the need for stronger antithrombotic therapy to prevent valve thrombosis and downstream complications. This large cohort study suggests that the benefit of anticoagulation therapy, if any, might be minimal. Of note, few patients in the cohort were treated with direct oral anticoagulants – most were treated with vitamin K antagonists. Additionally, this analysis only includes patients treated with the balloon-expandable Sapien valves, and therefore, cannot necessarily be extrapolated to self-expanding valves. Of note, a recent randomized trial comparing rivaroxaban to antiplatelet use following TAVR was recently halted prematurely due to an increased risk of adverse events in the rivaroxaban arm (NCT02556203). Pending larger, prospective studies, clinicians should not feel obligated to use anticoagulant therapy in patients with bioprosthetic SAVR or TAVR unless there is a comorbid condition (e.g., atrial fibrillation, venous thromboembolism).