Thrombogenicity and Antithrombotic Strategies in Structural Heart Interventions and Nonaortic Cardiac Device Therapy—Current Evidence and Practice

Abstract

As the number of, and the indications for, structural heart interventions are increasing worldwide, the optimal secondary prevention to reduce device thrombosis is becoming more important. To date, most of the recommendations are empiric. The current review discusses mechanisms behind device-related thrombosis, the available evidence with regard to antithrombotic regimen after cardiac device implantation, as well as providing an algorithm for identification of risk factors for device thrombogenicity and for management of device thrombosis after implantation of patent foramen ovale and left atrial appendage occluders, MitraClips/transcatheter mitral valve replacement, pacemaker leads, and left ventricular assist devices. Of note, the topic of antithrombotic therapy and thrombogenicity of prostheses in aortic position (transcatheter aortic valve replacement, surgical, mechanical, and bioprostheses) is not part of the present article and is discussed in detail in other contemporary focused articles.

Platelets: The Balance between Aggregation and Bleeding

“…The current evidence is given in a paper on device implantation. 9 Finally, the use of multiple antiplatelet agents may cause more bleeding than a single drug. The P2Y 12 receptor antagonists have found their way in several clinical thrombotic conditions, but they are associated with bleeding when used together with aspirin.…”

Transcatheter Mitral Valve Replacement and Thrombosis: A Review

“…PVT is a multifactorial process involving surface-, hemodynamic-, and hemostasis-related factors (4). The so-called Virchow's triad accurately describes the three main elements that may lead to endovascular/intracardiac thrombosis (5,6): blood flow alterations (stasis, turbulence), hypercoagulability (both congenital or acquired), and endothelial injury/dysfunction (7).…”

“…Following any cardiac device implantation, thrombosis may occur in two different ways: either by direct activation of coagulation cascade on the exogenous device surface or, indirectly, as a result of hemodynamic changes induced by the device itself (device-related thrombosis) (7).…”

“…Thromboembolic risk is further increased by underlying cardiac pathologies (i.e., heart failure or atrial fibrillation), leading to disturbances in endothelial function, blood flow, and blood composition (7). Furthermore, any exogenous device implanted in the mitral position is affected by higher thrombotic risk if compared with the aortic position (4), as shown by TAVR devices implanted in mitral position in the context of surgical mitral valve repair failure [Valve-in-Ring (ViR)] or surgical bioprosthesis dysfunction [Valve-in-Valve, (ViV)].…”

A Toast to the Last Decade and a Very Happy 2020 from Thrombosis and Haemostasis!

“…One theme issue focused on new therapeutic targets for atherosclerosis, [5][6][7][8][9][10][11][12][13][14][15][16][17] the other one on platelets and the balance between aggregation and bleeding. [18][19][20][21][22][23] We are looking forward to publishing a new theme issue this year on Reversal of Oral Anticoagulant Therapy. Moreover, we have published a very necessary special focus article on the Clinical Use of Biomarkers last year 24 and plan one on the hot topic of NETs and Thrombosis this year.…”