Antithrombotic Therapy After Transcatheter Aortic Valve Replacement

Abstract

The performance of transcatheter aortic valve replacement has expanded considerably during the past decade. Technological advances and refinement in implantation techniques have resulted in improved procedural outcomes, whereas indications are progressively extending toward lower-risk patients. Ischemic/embolic complications and major bleeding remain important and strongly correlate to mortality. In this regard, the optimal antithrombotic regimen after successful transcatheter aortic valve replacement remains unclear, in the absence of randomized trials. For patients without an indication for oral anticoagulation, empirical treatment with dual antiplatelet therapy (aspirin plus clopidogrel) for 3 to 6 months is currently recommended. However, dual antiplatelet therapy has been preliminarily associated with increased risk of bleeding compared with single antiplatelet therapy without significant ischemic benefit. Non–vitamin K oral anticoagulants and warfarin have also entered clinical investigation, to address the issue of preexisting or new-onset of atrial fibrillation and potentially attenuate subclinical leaflet thrombosis. Clinical trials are necessary to systematically address the risks and benefits of these approaches. In this review, we present the pathophysiological mechanisms of post-transcatheter aortic valve replacement complications and provide updated insights on the rationale behind the various antithrombotic regimens being currently evaluated in large randomized trials.