Antithrombotic Therapy Following Transcatheter Aortic Valve Replacement

Due to a large technical improvement in the past decade, transcatheter aortic valve replacement (TAVR) has expanded to lower-surgical-risk patients with symptomatic and severe aortic stenosis. While mortality rates related to TAVR are decreasing, the prognosis of patients is still impacted by ischemic and bleeding complications, and defining the optimal antithrombotic regimen remains a priority. Recent randomized control trials reported lower bleeding rates with an equivalent risk in ischemic outcomes with single antiplatelet therapy (SAPT) when compared to dual antiplatelet therapy (DAPT) in patients without an underlying indication for anticoagulation. In patients requiring lifelong oral anticoagulation (OAC), the association of OAC plus antiplatelet therapy leads to a higher risk of bleeding events with no advantages on mortality or ischemic outcomes. Considering these data, guidelines have recently been updated and now recommend SAPT and OAC alone for TAVR patients without and with a long-term indication for anticoagulation. Whether a direct oral anticoagulant or vitamin K antagonist provides better outcomes in patients in need of anticoagulation remains uncertain, as recent trials showed a similar impact on ischemic and bleeding outcomes with apixaban but higher gastrointestinal bleeding with edoxaban. This review aims to summarize the most recently published data in the field, as well as describe unresolved issues.

Automated summary

Transcatheter aortic valve replacement (TAVR) has expanded to lower-risk patients with aortic stenosis, but the optimal antithrombotic regimen is still a priority. Single antiplatelet therapy (SAPT) has shown lower bleeding rates compared to dual antiplatelet therapy (DAPT) in patients without an indication for anticoagulation. Patients requiring lifelong oral anticoagulation (OAC) are at higher risk of bleeding events with OAC plus antiplatelet therapy, without any advantages on mortality or ischemic outcomes. Guidelines now recommend SAPT and OAC alone for TAVR patients without and with a long-term indication for anticoagulation.