Antithrombotic treatment in transcatheter aortic valve implantation: Insights for cerebrovascular and bleeding events

Josep Rodés-Cabau, Harold L. Dauerman, Mauricio G. Cohen, Roxana Mehran, Eric M. Small, Susan S. Smyth, Marco A. Costa, Jessica L. Mega, Michelle L. O'Donoghue, E. Magnus Ohman, Richard C. Becker

Research output: Contribution to journalReview articlepeer-review

136 Scopus citations

Abstract

Transcatheter aortic valve implantation (TAVI) has emerged as a therapeutic alternative for patients with symptomatic aortic stenosis at high or prohibitive surgical risk. However, patients undergoing TAVI are also at high risk for both bleeding and stroke complications, and specific mechanical aspects of the procedure itself can increase the risk of these complications. The mechanisms of periprocedural bleeding complications seem to relate mainly to vascular/access site complications (related to the use of large catheters in a very old and frail elderly population), whereas the pathophysiology of cerebrovascular events remains largely unknown. Further, although mechanical complications, especially the interaction between the valve prosthesis and the native aortic valve, may play a major role in events that occur during TAVI, post-procedural events might also be related to a prothrombotic environment or state generated by the implanted valve, the occurrence of atrial arrhythmias, and associated comorbidities. Antithrombotic therapy in the setting of TAVI has been empirically determined, and unfractionated heparin during the procedure followed by dual antiplatelet therapy with aspirin (indefinitely) and clopidogrel (1 to 6 months) is the most commonly recommended treatment. However, bleeding and cerebrovascular events are common; these may be modifiable with optimization of periprocedural and post-procedural pharmacology. Further, as the field of antiplatelet and anticoagulant therapy evolves, potential drug combinations will multiply, introducing variability in treatment. Randomized trials are the best path forward to determine the balance between the efficacy and risks of antithrombotic treatment in this high risk-population.

Original languageEnglish
Pages (from-to)2349-2359
Number of pages11
JournalJournal of the American College of Cardiology
Volume62
Issue number25
DOIs
StatePublished - Dec 24 2013

Bibliographical note

Funding Information:
The 2012 Platelet Colloquium was supported by grants from AstraZeneca, Wilmington, Delaware; Daiichi/Eli Lilly Partnership, Parsippany, New Jersey and Indianapolis, Indiana; Merck & Co., Inc., Whitehouse Station, New Jersey; Regado Biosciences, Inc., Durham, North Carolina; St. Jude Medical, Inc., St. Paul, Minnesota; and The Medicines Company, Parsippany, New Jersey. Dr. Rodés-Cabau is a proctor for Edwards Lifesciences. Dr. Dauerman has consulted for Medtronic and The Medicines Company. Dr. Cohen has received grant support from Regado Biosciences and The Medicines Company ; honoraria from AstraZeneca; has been an investigator for Edwards Lifesciences; and has consulted for Edwards Lifesciences, Medtronic, and St. Jude. Dr. Mehran has received grant support from Bristol-Myers Squibb/sanofi and The Medicines Company ; has consulted for AstraZeneca and Regado Biosciences; and has been an advisory board member for Ortho-McNeil-Janssen. Dr. Small has patent-licensing arrangements with miRagen Therapeutics. Dr. Smyth has received grant support from AstraZeneca, Boehringer Ingelheim , and The Medicines Company . Dr. Costa has received honoraria from Abbott Vascular; has consulted for Abbott Vascular, Cordis, Daiichi/Eli Lilly, Medtronic, and St. Jude Medical; and has served on the speaker’s bureau for Daiichi-Sankyo. Dr. Mega has received grant support from Bayer Healthcare, Bristol-Myers Squibb, Daiichi/Eli Lilly, Johnson & Johnson , and sanofi-aventis ; and has consulted for Boehringer-Ingelheim and Janssen. Dr. O’Donoghue has received grant support from AstraZeneca and Eisai . Dr. Ohman has received research grants from Daiichi/Eli Lilly and Maquet ; has consulted for Abiomed, AstraZeneca, Biotie, Bristol-Myers Squibb, Gilead Sciences, Ikaria, Janssen Pharmaceuticals, Liposcience, Merck, Pozen, sanofi-aventis, The Medicines Company, and WebMD; and has received honoraria from Gilead Sciences, Janssen Pharmaceuticals, and The Medicines Company. Dr. Becker has received research grants from AstraZeneca, Bayer Pharmaceuticals, Bristol-Myers Squibb, Johnson & Johnson, Regado Biosciences, and The Medicines Company ; has been an investigator for AstraZeneca, Bayer Pharmaceuticals, Regado Biosciences, and The Medicines Company; has been an advisory board member for Daiichi and Merck; has received (modest) honoraria from Daiichi and Merck; and has received laboratory research services from Bristol-Myers Squibb and Johnson & Johnson.

Keywords

  • antiplatelet agents
  • bleeding
  • platelets
  • stroke
  • transcatheter aortic valve implantation

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

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