Antithrombotic Therapy During and After Transcatheter Aortic Valve Implantation

Abstract

Transcatheter aortic valve implantation (TAVI) has become the therapy of choice for patients with severe aortic stenosis (AS) who are deemed to be inoperable or at high/intermediate risk for conventional surgical aortic valve replacement (SAVR). Despite improving experience and techniques, ischaemic and bleeding events in the periprocedural period and months after TAVI still remain a relevant concern and impair survival in this generally old and comorbid-rich population. Empirically, dual antiplatelet therapy (DAPT) is currently recommended after TAVI with oral anticoagulation (OAC) restricted for specific indications. However, atrial fibrillation is common after the procedure and embolic material often thrombin-rich. For patients on OAC, a combination of OAC and aspirin or thienopyridine is generally used. Recent evidence has therefore questioned this approach, suggesting that DAPT may be futile compared with aspirin alone and that OAC could be a relevant alternative. Future randomised and appropriately powered trials comparing different strategies of antithrombotic therapy, including new antiplatelet and anticoagulant agents, are necessary to increase the available evidence on this topic. Temporarily, it remains rational to follow the current guidelines, with routine DAPT and recourse to OAC when specifically indicated.