The Impact of Antiplatelet and Antithrombotic Therapy on Outcome and Survival after Transcatheter Aortic Valve Implantation

Background: Thromboembolic complications and stroke are two of the main concerns of transcatheter aortic valve implantation (TAVI) when compared with surgical aortic valve replacement. Therefore the correct choice of antiplatelet or antithrombotic treatment is crucial. We compared procedural and follow-up outcomes and complications of our TAVI patients based on the preprocedural, discharge and long-term antiplatelet and antithrombotic treatment (single-antiplatelet [SAPT] vs. dual-antiplatelet [DAPT] vs. anticoagulation [OAC] vs. none [NT]).

Patients and methods: Between June 2009 and December 2016, a total of 532 patients underwent TAVI (transapical access: n = 266 [50%], female: n = 335 [63%]) in our institution. As main study endpoints for the preprocedural treatment, the VARC-2 defined bleeding and neurological complications were chosen as well as the VARC-2 composite early safety endpoint. For discharge and long-term treatment respectively, one-year and long-term survival with regard to cardio- and cerebrovascular events were evaluated. Mediator analysis was performed to adjust for confounders.

Results: Preprocedural antithrombotic or anticoagulation treatment had limited impact on VARC-2 defined postprocedural complications or 30-day mortality. There were no differences between the groups regarding the primary study endpoints bleeding (p = 0.611), stroke (p = 0.771) and composite early safety (p = 0.385), and for the secondary endpoint mortality at 30 days (p = 0.490). One-year survival differed significantly between the different postoperative regimens. While SAPT displayed significantly lower 1-year survival compared to DAPT and OAC, patients under DAPT had a significantly higher 1-year survival than patients under OAC (SAPT vs. DAPT, p < 0.001; SAPT vs. OAC, p = 0.006; DAPT vs. OAC, p = 0.003). There was a strong trend toward improved 2-year survival for patients in the OAC cohort treated with new oral anticoagulants compared to vitamin K antagonists (NOACs vs. VKA; log-rank p = 0.056). No difference was observed in long-term survival between the treatment cohorts.

Conclusions: It is evident from the results that the preprocedural treatment regimens had a limited impact on the procedural outcome. The superior survival curves for DAPT within the first year and NOACs over VKA within the first two years warrant considerable attention in further recommendations of antithrombotic and anticoagulation regimens after TAVI.