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Transcatheter aortic valve replacement (TAVR) is an established alternative to surgery for patients with severe symptomatic aortic stenosis. Adjunctive antithrombotic therapy used to mitigate thrombotic risks in patients undergoing TAVR must be balanced against bleeding complications, since both are associated with increased mortality.
Stroke risk associated with TAVR is lower than that associated with surgical aortic valve replacement in recent trials including patients at intermediate or low risk, but it is constant beginning at the time of implant and accrues over time based on patient risk factors. Patients with aortic stenosis undergoing TAVR also have a sizable risk of life-threatening or major bleeding. Although dual antiplatelet therapy for 3 to 6 months after TAVR is the guideline-recommended regimen, this practice is not well supported by current evidence. In patients with no indication for oral anticoagulation, current registry-based evidence suggests that single antiplatelet therapy may be safer than dual antiplatelet therapy. Similarly, oral anticoagulation monotherapy appears superior to anticoagulation plus antiplatelet therapy in those where oral anticoagulant use is indicated. To date, no risk prediction models have been established to guide antithrombotic therapy.
Conclusions and Relevance
Despite the growing volume of TAVR procedures to treat patients with severe aortic stenosis, evidence for adjunctive antithrombotic therapy remains rather scarce. Ongoing clinical trials will provide better understanding to guide antithrombotic therapy.
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Accepted for Publication: September 20, 2019.
Corresponding Author: Alexandra Lansky, MD, Division of Cardiovascular Medicine, Yale School of Medicine, 135 College St, Ste 101, New Haven, CT 06510 (email@example.com).
Published Online: November 13, 2019. doi:10.1001/jamacardio.2019.4367
Author Contributions: Drs Saito and Lansky had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Saito, Nazif, Baumbach, Tchétché, Latib, Forrest, Prendergast, Lansky.
Acquisition, analysis, or interpretation of data: Saito, Tchétché, Kaple, Forrest.
Drafting of the manuscript: Saito, Latib, Forrest.
Critical revision of the manuscript for important intellectual content: Nazif, Baumbach, Tchétché, Latib, Kaple, Forrest, Prendergast, Lansky.
Administrative, technical, or material support: Latib, Forrest.
Supervision: Latib, Forrest.
Conflict of Interest Disclosures: Dr Nazif reports grants, personal fees, and nonfinancial support from Edwards Lifesciences, Medtronic, and Boston Scientific outside the submitted work. Dr Latib is on the advisory boards of Medtronic and Abbott and reported personal fees from Medtronic, Abbott, and Edwards Lifesciences outside the submitted work. Dr Forrest reports personal fees and grants from Edwards Lifesciences and Medtronic outside the submitted work. Dr Lansky reports grants from Abbott Vascular and personal fees from Venous Medical/Keystone Heart, KSH, Microport, Sinomed, and AstraZeneca outside the submitted work. Dr Saito reported grants from SENSHIN Medical Research Foundation outside the submitted work. Dr Baumbach reported grants and personal fees from Abbott and personal fees from AstraZeneca, Microport, and Sinomed outside the submitted work. No other disclosures were reported.
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