Incidence, Timing, and Causes of Late Bleeding After TAVR in an Asian Cohort

Late Bleeding Following TAVR in Japan

“…As Yamamoto et al 1 note, although about 75% of the patients in the present study were prescribed dual antiplatelet therapy in the no OAC group, a recent randomized study 6 has demonstrated low rates of bleeding and similar rates of stroke events in patients prescribed single antiplatelet therapy versus dual antiplatelet therapy after TAVR. Single antiplatelet therapy has thus now become the evidence-based standard of care for post TAVR medical therapy in patients without AF or recent percutaneous coronary intervention.…”

“…The paper by Yamamoto et al 1 in this issue of JACC: Asia studies post transcatheter aortic valve replacement (TAVR) late bleeding (defined as bleeding after discharge) in a large multicenter cohort of over 2,500 patients from the Japanese OCEAN-TAVI (Optimized Transcatheter Valvular Intervention–Transcatheter Aortic Valve Implantation) registry. Importantly, 3 years after TAVR this complication was not rare, with 7.4% experiencing some form of bleeding and 5.2% experiencing major bleeding.…”

“…Yamamoto et al 1 found by far the commonest source of bleeding was the gastrointestinal (GI) tract in 40.7% of patients, followed by intracranial bleeding in 25.7%. Subgroup analysis also showed a significantly increased risk of mortality in patients with GI bleeding (HR: 3.38; 95% CI: 2.26-5.05; P < 0.001) and hemorrhagic stroke (HR: 10.5; 95% CI: 6.85-16.0; P < 0.001).…”

“…However, the rates of ischemic stroke did not differ significantly between the OAC vs no OAC groups nor between the AF vs no AF groups. Yamamoto et al 1 emphasize that the influence on mortality was much greater with bleeding than ischemic stroke; at 3 years, 7.4% with bleeding versus 3.4% with ischemic stroke. The implication is that—in the context of TAVR—one must reconsider the paradigm of OAC even in the presence of AF, or one must consider alternatives such as left atrial appendage closure, which is the subject of ongoing studies.…”

“…Yamamoto et al 1 rightly state that it is challenging to reduce the risk of late bleeding after TAVR. However, their work emphasizes a focus on avoidance of unnecessary antiplatelet or anticoagulation therapy and vigilance for susceptibility to falls, GI and intracranial pathologies; this is an important contribution which should further contribute to the amelioration of outcomes following TAVR in Asia.…”