Mono versus Dual Antiplatelet Therapy after Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis

Abstract

ABSTRACT Background: Dual antiplatelet therapy (DAPT) is routinely prescribed after transcatheter aortic valve replacement (TAVR) despite the lack of definitive data demonstrating its superiority over mono-antiplatelet therapy (MAPT). We aim to investigate the benefits of DAPT versus MAPT and at different follow-up time points post TAVR. Methods: A systematic search was conducted for studies investigating DAPT versus MAPT in patients who underwent TAVR. The primary outcome was net adverse clinical events (NACE) at longest reported follow-up, defined as a composite end-point of all-cause mortality, major stroke, myocardial infarction (MI), and combined life threatening and major bleeding. Secondary endpoints included each outcome individually. We performed subgroup analysis according to study type (randomized control trials vs. observational studies) and follow-up duration post-TAVR (≤ 30 days, between 3 and 6 months, and ≥ 1 year). Results: Twelve studies with 9,650 patients were included. Post-TAVR MAPT was associated with significantly reduced NACE (0.60 [0.45, 0.81], p < 0.001), all-cause mortality (OR 0.54 [0.33, 0.88], p = 0.01), and combined life threatening and major bleeding (0.57 [0.39, 0.84], p = 0.005) in the first 30 days after the procedure when compared to DAPT. The difference in outcomes diminishes with longer-term follow up durations (3–6 month or ≥ 6-month). No differences were seen with other secondary endpoints. Conclusion: MAPT is associated with improved outcomes compared to DAPT in the first 30 days post-TAVR with no difference in outcomes on longer-term follow up. Future prospective, adequately powered, multicenter, placebo-controlled, randomized double-blinded cohort studies are warranted to confirm our findings.