Anticoagulation Plays a Controversial Role in TAVR

Men gender, kidney failure and atrial fibrillation are the factors that most affect 3-year mortality after transcatheter aortic valve replacement. On the other hand, surprisingly enough, anticoagulation (mostly indicated for atrial fibrillation) reduces mortality risk – especially the risk of valve deterioration – after TAVR.

Should anticoagulation be included in post TAVR protocols? This question remains unanswered, but just in case, we usually prescribe aspirin and clopidogrel, despite the lack of evidence as to its effectiveness. For all we know, they might work only as anxiolytics for us, interventionists, rather than holding any real benefit.

The FRANCE TAVI (French Transcatheter Aortic Valve Implantation) is a prospective multicenter registry carried out across France, aiming at identifying the independent predictors of mortality and early vascular dysfunction (≥10 mmHg increased prosthesis gradient or new ≥20 mmHg gradient).

Read also: ESC 2018 | FRANCE-TAVI: Atrial Fibrillation and Anticoagulation Associated to Mortality in TAVR.

Of the 12804 patients included in the registry between 2013 and 2015, a total 11469, discharged with a known antithrombotic scheme, provided data on mortality.

In addition, 2555 patients had at least 2 echocardiography studies at follow up and were eligible for valve deterioration.

One third of all patients had a history of atrial fibrillation and a similar proportion were discharged with oral anticoagulation. Neither aspirin nor clopidogrel could be associated to mortality (neither positively nor negatively). But male sex (HR: 1.63; CI 95%: 1.44 to 1.84; p < 0.001), a history of atrial fibrillation (HR: 1.41; CI 95%: 1.23 to 1.62; p<0.001), or kidney failure (HR: 1.37; CI 95%: 1.23 to 1.53; p<0.001) were strong correlates. The last two were the most powerful independent predictors associated to mortality.

Read also: TCT 2018 | OAC-ALONE: Anticoagulation Alone 1 Year After Stenting in Patients with Atrial Fibrillation.

On the other hand, anticoagulation at discharge (OR: 0.54; CI 95%: 0.35 to 0.82; p=0.005) and an access site other than femoral (OR: 0.53; CI 95%: 0.28 to 1.02; p=0.049) were associated to better valve performance at long term.  Small valves in patients with kidney failure deteriorated most quickly.

Conclusion

With few surprises as regards factors associated to mortality, we have started gathering information in favor of anticoagulation to prolong valve life. Antiaggregation does not seem to play an important role, at least in this registry.

Original title: Long-Term Mortality and Early Valve Dysfunction According to Anticoagulation Use. The FRANCE TAVI Registry.

Reference: Pavel Overtchouk et al. J Am Coll Cardiol 2019;73:13–21.

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