Safety and Efficacy of Different Antithrombotic Strategies after Transcatheter Aortic Valve Implantation: A Network Meta-Analysis

Abstract

Background The optimal pharmacological therapy after transcatheter aortic valve implantation (TAVI) remains uncertain. We compared efficacy and safety of various antiplatelet and anticoagulant approaches after TAVI by a network meta-analysis. Methods A total of 14 studies (both observational and randomized) were considered, with 24,119 patients included. Primary safety endpoint was the incidence of any bleeding complications during follow-up. Secondary safety endpoint was major bleeding. Efficacy endpoints were stroke, myocardial infarction, and cardiovascular mortality. A frequentist network meta-analysis was conducted with a random-effects model. The following strategies were compared: dual antiplatelet therapy (DAPT), single antiplatelet therapy (SAPT), oral anticoagulation (OAC), and OAC + SAPT. The mean follow-up was 15 months. Results In comparison to DAPT, SAPT was associated with a 44% risk reduction of any bleeding (odds ratio [OR]: 0.56 [95% confidence interval, CI: 0.39–0.80]). SAPT was ranked as the safest strategy for the prevention of any bleeding (p-score: 0.704), followed by OAC alone (p-score: 0.476) and DAPT (p-score: 0.437). Consistent results were observed for major bleeding. The incidence of cardiovascular death and secondary ischemic endpoints did not differ among the tested antithrombotic approaches. In patients with indication for long-term anticoagulation, OAC alone showed similar rates of stroke (OR: 0.92 [95% CI: 0.41–2.05], p = 0.83) and reduced occurrence of any bleeding (OR: 0.49 [95% CI: 0.37–0.66], p < 0.01) versus OAC + SAPT. Conclusion The present network meta-analysis supports after TAVI the use of SAPT in patients without indication for OAC and OAC alone in those needing long-term anticoagulation.

Antithrombotic Therapy After Transcatheter Aortic Valve Replacement: An Overview

“…Additionally, a recent meta-analysis of 4 studies including 2032 patients post-TAVR with concomitant AF has shown that major and life-threatening bleeding rates are lower in patients on an OAC regimen compared to OAC + antiplatelet regimens, while the risk of stroke and mortality do not differ between the groups. 96 Similar results were demonstrated in a meta-analysis by Navarese et al., 64 showing that OAC therapy alone reduced bleeding rates compared to OAC + SAPT regimens, without affecting stroke rates, in patients requiring long-term anticoagulation. On the contrary, another study of the PARTNER 2 trial by Kosmidou et al.…”

“…62 Other recent studies and updated meta-analyses largely agree with the findings that post-TAVR DAPT therapy increases the risk of bleeding events without reducing the rates of thromboembolism and mortality compared to SAPT. [63][64][65][66] Even though these results are in agreement, larger studies with a longer mean follow-up time are required to adequately assess these end points more effectively.…”

“…In addition, in patients with indication for OAC therapy, triple therapy with DAPT + OAC is associated with a prohibitive bleeding risk. 64 , 95 The benefit of combining antiplatelets with OAC regimens post-TAVR is not proven and may harbor safety risks. 99 Whether this is an acceptable therapy post-TAVR, especially in those with concomitant CAD, is not clear and still under investigation.…”

Access Site Bleeding Complications with NOACs versus VKAs in Patients with Atrial Fibrillation Undergoing Cardiac Implantable Device Intervention

“…In fact, among patients with mechanical heart valves, the occurrence of both bleeding and ischemic events was higher in those receiving dabigatran versus VKAs, regardless of concomitant AF [17]. Moreover, in randomized studies on patients with AF the incidence of hemorrhagic complications, also including early post-procedural events, was similar with NOACs and VKAs after percutaneous ablation procedures [18], transcatheter aortic valve intervention [19], or cardioversion [20]. Finally, in a study-level meta-analysis on AF patients undergoing non-cardiac surgery, VKAs were as effective and safe as NOACs [21].…”

Thrombosis and Haemostasis 2022 Editors' Choice Papers

“…A large-scale network meta-analysis on more than 24,000 patients from 14 studies revealed that single antiplatelet therapy lowered the risk of bleeding with no changes in stroke, myocardial infarction, or cardiovascular death when compared with dual antiplatelet therapy. 63 In addition, oral anticoagulation treatment seemed beneficial for patients with an indication for long-term anticoagulation.…”