Some of the many ongoing randomized studies including patients with atrial fibrillation (AF) might finally answer the question on the best antithrombotic scheme post TAVR.
According to this registry, in patients undergoing transcatheter aortic valve replacement, independent predictors of death at 3 years are being a man, having moderate to severe kidney failure, and having atrial fibrillation. Anticoagulation was mainly indicated in the context of AF, and was also independently associated to long term mortality.
Paradoxically, the use of oral anticoagulants was also associated to a minor hemodynamic risk of prosthesis deterioration. However, the clinical impact of this echocardiographic finding remains unknown.
Since this is a registry, it has its limitations. Basically, whether increased mortality risk with anticoagulants is associated to AF or is really an independent predictor. Multiple statistic adjustments were done in trying to answer this question, but only one randomized study provided an answer.
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Fortunately, there are several ongoing randomized studies trying to answer this question (GALILEO, ATLANTIS, ENVISAGE, POPULAR, AVATAR and AUREA).
For now, the current clinical guidelines recommend dual APT from 3 to 6 months after TAVR and there are no recommendations on anticoagulation in absence of AF.
The French registry included 11469 patients undergoing TAVR in 48 hospitals between 2013 and 2015. 83.3% of these patients were discharged with aspirin and 44.5% with DAPT and clopidogrel. Only 2.9% were discharged with DAPT + anticoagulation. Approximately one third was discharged with anticoagulation, and 71% of these had AF.
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It seems post TAVR antithrombotic schemes respond to patient profile rather than the device employed.
The use of small valves (23 mm or less) is associated to three times the risk of valve dysfunction at ECG.
Original title: Long-term mortality and early valve dysfunction according to anticoagulation use: the FRANCE-TAVI registry.
Reference: presented by Jean-Philippe Collet en el ESC 2018 de Munich and published simultaneously at J Am Coll Cardiol. 2018;Epub ahead of print.
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