Indicating apixaban after transcatheter aortic valve replacement (TAVR) does not significantly reduce the risk of sub-clinical leaflet thrombosis compared with the standard of care. These data come from the computerized tomography (CT) scan sub-study from ATLANTIS, presented during the scientific sessions of the American College of Cardiology (ACC) 2021 Congress.
In patients with no prior anticoagulant indication, apixaban was able to reduce sub-clinical valvular thrombosis—assessed as motility reduction or attenuation and thickening of leaflet as detected by CT scan.
At the other end, in patients who had an indication for anticoagulation and received vitamin K inhibitors, taking apixaban did not reduce their chance of sub-clinical thrombosis.
These statements seem to suggest that what matters is using an anticoagulant agent, not the actual drug used. However, we do not know the long-term clinical implications of thrombosis and, as such, we cannot risk bleeding.
In the ATLANTIS 4D-CT trial, no association was observed between ischemic events and thrombosis three or six months after TAVR.
Read also: ACC 2021 | ATLANTIS: Apixaban After TAVR vs. Standard of Care.
The question for the future is whether decreased motility, thickening, and hypoattenuation (shown very clearly by CT scan) should remain endpoints in themselves or whether they are just observable phenomena with no clinical impact.
The main ATLANTIS study enrolled 1510 intermediate- or high-risk patients who underwent TAVR and were stratified by need for anticoagulation.
Patients were randomized to apixaban 5 mg twice a day or standard treatment (antiplatelet therapy or, if previously indicated, anticoagulation with vitamin K antagonists). Apixaban was non-superior to the standard of care in general terms.
Read also: ACC 2021 | RAPID-TnT: Usefulness of High-Sensitivity Ultra-Fast Troponin T.
In the sub-study, researchers evaluated the incidence of sub-clinical leaflet thrombosis at 3-6 months in 762 patients who underwent check-up CT scans (370 randomized to apixaban and 392 to the standard of care).
Original Title: Apixaban and valve thrombosis after transcatheter aortic valve implantation: the ATLANTIS 4D-CT substudy.
Reference: Montalescot G et al. Presentado en el congreso de la ACC 2021.
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