We are still discussing the adequate antithrombotic scheme after transcatheter aortic valve replacement (TAVR). Additionally, we are treating a much wider array of patients ranging from low risk to inoperable. 

And there is yet one more important point: hypo-attenuated leaflet thickening diagnosed by CT. We are still unaware of the impact they have on device durability at long term, which is overly concerning in low-risk patients.  

This study recently published in Circ Cardiovasc Interv has tried to answer some of the questions above. The study openly randomized 1:1 low risk patients undergoing transfemoral TAVR to low-dose aspirin or warfarin plus low-dose aspirin for 30 days. 

It used CT or transesophageal echocardiography after one month to assess the presence of hypo-attenuated leaflet thickening, reduced leaflet motion, mean gradient ≥20 mm Hg, effective orifice area ≤1.0 cm2, moderate or severe regurgitation, stroke, or transient ischemic attack.

Read also: Medical Therapy Optimization Achieved Prior Clinical Trial.

50 patients received aspirin and 44 warfarin plus aspirin, and 30 who could not be randomized were enrolled into a registry.

The primary end point occurred in 26.5% of patients receiving aspirin vs. 7% of patient receiving aspirin and warfarin (p=0.014; OR 4.8). The difference was based on hypo-attenuated leaflet thickening rate (16.3% vs 4.8%; p=0.07).

There was no excess bleeding with warfarin during the first 30 days. 

Conclusion

In low-risk patients undergoing TAVR, anticoagulation with warfarin could prevent leaflet dysfunction at short term with no excess bleeding. 

Original Title: Randomized Trial of Aspirin Versus Warfarin After Transcatheter Aortic Valve Replacement in Low-Risk Patients.

Reference: Toby Rogers et al. Circ Cardiovasc Interv. 2021 Jan;14(1):e009983. doi: 10.1161/CIRCINTERVENTIONS.120.009983.

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