ESC Working Group on Thrombosis and the European Association of Percutaneous Cardiovascular Interventions (EAPCI), in collaboration with the ESC Council on Valvular Heart Disease has put forth updated guidelines on management of antithrombotic therapy in patients undergoing transcatheter aortic valve implantation. They have been published in the European Heart Journal.Transcatheter aortic...
ESC Working Group on Thrombosis and the European Association of Percutaneous Cardiovascular Interventions (EAPCI), in collaboration with the ESC Council on Valvular Heart Disease has put forth updated guidelines on management of antithrombotic therapy in patients undergoing transcatheter aortic valve implantation. They have been published in the European Heart Journal.
Transcatheter aortic valve implantation (TAVI) is effective in older patients with symptomatic severe aortic stenosis, while the indication has recently broadened to younger patients at lower risk. Although thromboembolic and bleeding complications after TAVI have decreased over time, such adverse events are still common. The recommendations of the latest 2017 ESC/EACTS Guidelines for the management of valvular heart disease on antithrombotic therapy in patients undergoing TAVI are mostly based on expert opinion. Based on recent studies and randomized controlled trials, this viewpoint document provides updated therapeutic insights in antithrombotic treatment during and after TAVI.
The choice of antithrombotic therapy should be based on both TAVI procedure and patients' characteristics, comorbidities, and/or co-medications that predispose to bleeding and thrombosis. Below are provided the consensus statements for optimal antithrombotic therapy based on the latest evidence .
Pre-transcatheter aortic valve implantation
• Assessment of bleeding risk is mandatory.
• In patients without OAC indication, low-dose aspirin should be started pre-TAVI.
• In case of contraindication for aspirin, clopidogrel should be used.
Peri-transcatheter aortic valve implantation
• Vitamin K anticoagulation or NOAC continuation or interruption should be decided on an individual basis.
• When VKA is continued, the international normalized ratio should be at the inferior limit of the therapeutic range (∼2).
• Additional aspirin is not needed in OAC-treated patients.
• Unfractionated heparin with ACT of 250–300 s is preferred.
• (ACT-guided) reversal of UFH with protamine sulphate is reasonable.
• Bivalirudin is an alternative if UFH is contraindicated.
• Use of embolic protection devices is reasonable in patients at high risk of stroke.
Post-transcatheter aortic valve implantation
• Periodical re-assessment of the bleeding risk is mandatory.
• Low-dose aspirin is preferred in the absence of OAC indication.
• Vitamin K anticoagulation or NOAC alone is preferred when there is an indication for OAC.
• After coronary stenting, if the bleeding risk is high, DAPT should be shortened to 1–3 months in case of CCS and to 3–6 months in case of ACS.
• After coronary stenting in patients on OAC, if the bleeding risk is high, clopidogrel should be shortened to 1–3 months in case of CCS and to 3–6 months in case of ACS.
• When coronary stenting is performed within 3 months pre-TAVI, continuing the indicated DAPT or OAC plus clopidogrel peri-TAVI should be considered.
Source: European Heart Journal
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