Comparison of Two Antiplatelet Therapy Strategies in Patients Undergoing Transcatheter Aortic Valve Implantation

Durand, Éric; Blanchard, Didier; Chassaing, Stéphan; Gilard, Martine; Laskar, Marc; Borz, Bogdan; Lafont, Antoine; Barbey, Christophe; Godin, Matthieu; Tron, Christophe; Zegdi, Rachid; Chatel, Didier; Page, Olivier Le; Litzler, Pierre‐Yves; Bessou, Jean–Paul; Danchin, Nicolás; Cribier, Alain; Eltchaninoff, Hélène

doi:10.1016/j.amjcard.2013.09.033

Cited by 88 publications

(84 citation statements)

References 16 publications

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“…Several studies have indicated that dual antiplatelet therapy may simply increase risk of major bleeding without affecting the occurrence of cerebrovascular events. 5,[26][27][28] Further studies are needed to determine whether periprocedural dual antiplatelet therapy can reduce the risk of stroke without increasing risk of bleeding.…”

Section: Discussionmentioning

confidence: 99%

Insights Into Timing, Risk Factors, and Outcomes of Stroke and Transient Ischemic Attack After Transcatheter Aortic Valve Replacement in the PARTNER Trial (Placement of Aortic Transcatheter Valves)

Kapadia

Agarwal

Miller

et al. 2016

Circ: Cardiovascular Interventions

151

106

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T ranscatheter aortic valve replacement (TAVR) has revolutionized management of elderly patients with severe aortic stenosis, 1,2 but post-TAVR neurological events remain a concern for patients and physicians. Although occurrence of post-TAVR stroke has fallen from ≈5% in initial trials to 3% in recent reports, reducing this risk is essential for advancing this technology into lower-risk patient cohorts. See Editorial by Dangas and GiustinoUnderstanding the mechanisms of neurological events is critical for developing strategies for reducing their occurrence. Despite several attempts to identify procedure and patient characteristics that may lead to neurological events, the field remains somewhat controversial.3,4 One controversy is the timing of neurological events and its relationship to procedural embolization.5 Different reports have suggested that up to half of the events may be unrelated to procedural embolization, although small numbers of patients and events, Background-Prior studies of stroke and transient ischemic attack (TIA) after transcatheter aortic valve replacement (TAVR) are limited by reporting and follow-up variability. This is a comprehensive analysis of time-related incidence, risk factors, and outcomes of these events. Methods and Results-From 17).Stroke and TIA were associated with lower 1-year survival than expected (TF 47% after stroke versus 82%, and 64% after TIA versus 83%; TA 53% after stroke versus 80%, and 64% after TIA versus 83%). Risk factors for early stroke after TA-TAVR included more postdilatations, pure aortic stenosis without regurgitation, and possibly more pacing runs, earlier date of procedure, and no dual antiplatelet therapy; high pre-TAVR aortic peak gradient was a risk factor for stroke early after TF-TAVR. Conclusions-Risk of stroke or TIA is highest early after TAVR and is associated with increased 1-year mortality.Modifications of TAVR, emboli-prevention devices, and better intraprocedural pharmacological protection may mitigate this risk. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00530894.(Circ Cardiovasc Interv. 2016;9:e002981.

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Section: Discussionmentioning

confidence: 99%

Insights Into Timing, Risk Factors, and Outcomes of Stroke and Transient Ischemic Attack After Transcatheter Aortic Valve Replacement in the PARTNER Trial (Placement of Aortic Transcatheter Valves)

Kapadia

Agarwal

Miller

et al. 2016

Circ: Cardiovascular Interventions

151

106

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“…Two retrospective studies showed that, although mortality and thrombotic events were not different, bleeding occurred significantly less in patients receiving aspirin than in those receiving dual antiplatelet therapy. 27,28) Moreover, the number of patients receiving blood transfusions seemed higher in the dual antiplatelet group than in the aspirin group, although the studies were underpowered to show the difference in this outcome. 27) Therefore, additional clopidogrel seems to increase the risk of bleeding and should therefore be used with caution, since major and life-threatening bleeding complications after TAVI are associated with increased mortality.…”

Section: Discussionmentioning

confidence: 99%

“…27,28) Moreover, the number of patients receiving blood transfusions seemed higher in the dual antiplatelet group than in the aspirin group, although the studies were underpowered to show the difference in this outcome. 27) Therefore, additional clopidogrel seems to increase the risk of bleeding and should therefore be used with caution, since major and life-threatening bleeding complications after TAVI are associated with increased mortality. 4) Our study addressed this issue using PRU and CYP2C19 genotyping.…”

Section: Discussionmentioning

confidence: 99%

Hyper-Response to Clopidogrel in Japanese Patients Undergoing Transcatheter Aortic Valve Implantation

et al. 2016

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SummaryDual antiplatelet therapy is empirically recommended following transcatheter aortic valve implantation (TAVI). The aims of the present study were to analyze the effect of clopidogrel on platelet function and to determine the relative contribution of each CYP2C19 loss-of-function genotype undergoing TAVI.Thirty-two patients undergoing TAVI and with clopidogrel treatment were studied. All patients were treated with an Edwards SapienXT valve. Platelet reactivity was measured by the VerifyNow P2Y12 point-of-care assay at 7 days and 30 days after the procedure and a cutoff value of 95 PRU was used to identify a hyper-response of platelet reactivity. The Spartan RX TM sample-to-result point-of-care DNA testing system was used to identify CYP2C19 loss-of-function genotypes. Hyper-response of platelet reactivity was identified in 11 (34.3%) patients, although 24 (80%) were carriers of at least one CYP2C19 reduced-function allele. The PRU values did not change significantly from 7 days to 30 days after TAVI (136.7 ± 73.4 versus 150.4 ± 83.2, P = 0.13). The incidences of life-threatening bleeding, minor bleeding, and transfusion were significantly higher among the hyper-response of platelet reactivity group (27.3% versus 0%, P = 0.03, 36.4% versus 4.8%, P = 0.04, 81.8% versus 42.9%, P = 0.04, respectively).A hyper-response to clopidogrel was observed in one-third of patients undergoing TAVI and was related to bleeding events, even though 80% of the patients were carriers of the CYP2C19 reduced-function allele. (Int Heart J 2016; 57: 190-197) Key words: Platelet function tests, Antiplatelet therapy T ranscatheter aortic valve implantation (TAVI) has emerged as a viable therapeutic option for patients with severe symptomatic aortic stenosis (AS). 1,2)However, special attention should be paid to potential periprocedural and early complications, including ischemic (stroke, myocardial infarction) or bleeding (access site complication) events. 3,4) After TAVI, guidelines recommend the use of clopidogrel in addition to aspirin for a 3-to 6-month period. 5-7)While this strategy has been accepted as the usual practice following TAVI, the recommendation remains empirical and prospective controlled trials are lacking. Few data have been reported regarding the effectiveness of clopidogrel in the TAVI setting or its possible impact on adverse events.Results from previous studies in patients treated with clopidogrel have shown wide variability in platelet responsiveness, and high platelet reactivity under clopidogrel treatment has been linked to stent thrombosis and adverse cardiovascular events after coronary stenting. [8][9][10][11][12][13][14] Notably, there exists a subset of patients with a hyper-response to clopidogrel who may be at increased risk of bleeding complications. 15,16) Genetic polymorphism of the CYP2C19 allele, crucial to the metabolism of clopidogrel into its active metabolite, has been implicated as a mechanism of both hyper-and hypo-response. A loss-of-function polymorphism in CYP2C19, known as the CYP2...

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“…Nonetheless, this concept will be revisited since there are no studies to support this strategy over others [34]. Moreover, keeping in mind that many of these patients are elderly with high risk for bleeding, a more effective dual antiplatelet therapy strategy may be justified to decrease the stroke rate occurring after the procedure but it should be counterbalanced with a higher risk of bleeding in many of them.…”

mentioning

confidence: 99%

Percutaneous aortic valve replacement has come to stay

Mendiz

2015

Cardiol J

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Comparison of Two Antiplatelet Therapy Strategies in Patients Undergoing Transcatheter Aortic Valve Implantation

Cited by 88 publications

References 16 publications

Insights Into Timing, Risk Factors, and Outcomes of Stroke and Transient Ischemic Attack After Transcatheter Aortic Valve Replacement in the PARTNER Trial (Placement of Aortic Transcatheter Valves)

Insights Into Timing, Risk Factors, and Outcomes of Stroke and Transient Ischemic Attack After Transcatheter Aortic Valve Replacement in the PARTNER Trial (Placement of Aortic Transcatheter Valves)

Hyper-Response to Clopidogrel in Japanese Patients Undergoing Transcatheter Aortic Valve Implantation

Percutaneous aortic valve replacement has come to stay

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