All the controlled randomized evidence recently published called for an updated document on antithrombotic management in transcatheter aortic valve replacement (TAVR).
While thrombotic and hemorrhagic complications have diminished over time—as both the technique and the devices have been perfected—, they still remain as common adverse events in TAVR.
Recommendations in the 2017 European Guidelines were mostly based on expert opinions.
This article is only a summary of the main aspects of the document. It is paramount to understand that choosing anti-thrombotic therapy in TAVR should be based not only on the procedure, but also on patient characteristics, comorbidities, and bleeding/thrombosis risk.
When planning the procedure:
- Evaluating the risk of bleeding is mandatory.
- Patients without indications for oral anticoagulation should start taking low-dose aspirin before the procedure.
- Clopidogrel is an alternative if aspirin is contraindicated.
During the procedure:
- The decision to continue or interrupt vitamin K inhibitor or direct anticoagulant agents should be taken on a case by case basis.
- When continuing vitamin K inhibition, the international normalized ratio should be below the therapeutic range (∼2).
- Additional aspirin is not needed in the case of patients treated with oral anticoagulation.
- Unfractionated heparin with activated clotting time of 250–300 s should be used.
- Reversing the effect of unfractionated heparin with protamine is reasonable.
- Bivalirudin is a reasonable alternative if unfractionated heparin is contraindicated.
- Use of embolic protection devices is reasonable in patients at high risk of stroke.
After the procedure:
- Continuous evaluation of the risk of bleeding is mandatory.
- Low-dose aspirin is preferred for patients who do not need anticoagulation.
- If anticoagulation is indicated for any other reason, it is sufficient to continue with this regimen alone—either vitamin K inhibitors or direct anticoagulant agents.
- If, in addition to TAVR, the patient underwent coronary angioplasty, double platelet antiplatelet therapy will be necessary for one to three months (scheduled angioplasty) or for three to six months (acute coronary syndromes). This recommendation is based on the assumption that the vast majority of patients who undergo TAVR are deemed as patients at high risk of bleeding.
Original Title: Management of antithrombotic therapy in patients undergoing transcatheter aortic valve implantation: a consensus document of the ESC Working Group on Thrombosis and the European Association of Percutaneous Cardiovascular Interventions (EAPCI), in collaboration with the ESC Council on Valvular Heart Disease.
Reference: Jurrien ten Berg et al. Eur Heart J. 2021 Jun 14;42(23):2265-2269. doi: 10.1093/eurheartj/ehab196.