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Avvedimento M, Nuche J, Farjat-Pasos JI, Rodés-Cabau J. Bleeding Events After Transcatheter Aortic Valve Replacement: JACC State-of-the-Art Review. J Am Coll Cardiol 2023; 81:684-702. [PMID: 36792284 DOI: 10.1016/j.jacc.2022.11.050] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 11/21/2022] [Indexed: 02/15/2023]
Abstract
Transcatheter aortic valve replacement (TAVR) has gained over time a major reduction in procedural complications. Despite this, clinically relevant bleeding still occurs in a non-negligible proportion of patients and adversely affects prognosis. Patients with severe aortic stenosis are at heightened risk for spontaneous bleeding due to advanced age and a high comorbidity burden. Also, procedural factors and antithrombotic management contribute to define individual bleeding susceptibility. Bleeding prevention represents an emerging area for improving patient care. Because of the tight hemorrhagic/ischemic balance, a tailored approach based on individual bleeding-risk profile, such as a less invasive antithrombotic regimen or appropriate diagnostic preprocedural evaluation, should be pursued to avoid bleeding events. This review aims to provide an in-depth overview of bleeding events in the TAVR field, including definitions, timing and the extent of risk, and clinical impact, as well as updates on antithrombotic management and its potential influence on bleeding complications.
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Affiliation(s)
- Marisa Avvedimento
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Jorge Nuche
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | | | - Josep Rodés-Cabau
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada.
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Greco A, Spagnolo M, Capodanno D. Antithrombotic therapy after transcatheter aortic valve implantation. Expert Rev Med Devices 2022; 19:499-513. [PMID: 35881777 DOI: 10.1080/17434440.2022.2106853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Transcatheter aortic valve implantation (TAVI) is a treatment option for patients with symptomatic severe aortic stenosis across the entire spectrum of surgical risk. TAVI conveys some risk for thrombotic complications, requiring antithrombotic drugs for their prevention. Bleeding events represent the major drawback of antithrombotic therapy, which should be carefully tailored over the individual patient's risk profile. AREAS COVERED This review aimed at exploring the rationale for the adoption of a tailored antithrombotic therapy after successful TAVI, with a description and analysis of common complications and their impact on therapy selection. In addition, we aimed at reviewing and discussing current knowledge in this area, with a main focus on the high-quality evidence supporting latest guideline recommendations. Finally, ongoing studies and future directions on antithrombotic therapy after TAVI were outlined. EXPERT OPINION Initial experience with antithrombotic therapy after TAVI was derived from percutaneous coronary intervention practice. Accruing evidence in the field led to the current monotherapy paradigm, which prioritizes oral anticoagulant and single antiplatelet therapy in patients with or without an established indication for long-term anticoagulation, respectively. Future studies will investigate the role of alternative antithrombotic strategies to improve clinical outcomes of TAVI patients by minimizing both thrombotic and bleeding complications.
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Affiliation(s)
- Antonio Greco
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Marco Spagnolo
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
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Lopez-Pais J, Lopez-Otero D, Garcia-Touchard A, Izquierdo Coronel B, Antúnez Muiños PJ, Cia Mendioroz X, Pérez-Poza M, Otero Garcia Ó, Martinez Peredo CG, Arellano Flores C, Álvarez-Rodríguez L, Gomez Peña F, Juskova M, Sanmartín Pena JC, Estevez-Loureiro R, Cid Álvarez AB, Trillo Nouche R, Alonso-Martín JJ, González-Juanatey JR, Oteo JF. Impact of significant paravalvular leaks after transcatheter aortic valve implantation on anaemia and mortality. Heart 2020; 107:heartjnl-2020-316941. [PMID: 32843495 DOI: 10.1136/heartjnl-2020-316941] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 07/10/2020] [Accepted: 07/14/2020] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE The aim of this work is to assess the relationship between significant paravalvular leak (SPL) after transcatheter aortic valve implantation (TAVI) on anaemia and their impact on prognosis. METHODS Observational analytic study developed at two university hospitals, including all consecutive patients who underwent TAVI during a 10-year period (2009 to 2018). A logistic regression model was created to determine independent predictors of anaemia at 3 months. Time to event outcomes were analysed with Cox regression. Median follow-up was 21.3±21.9 months. RESULTS 788 patients were included. 5.3% had SPL. SPL was an independent predictor of anaemia 3 months after TAVI (OR: 8.31, 95% CI: 2.06 to 33.50). SPL and anaemia at 3 months were independently associated with long-term mortality (HR: 1.82, 95% CI: 1.16 to 2.85; HR: 2.07, 95% CI: 1.39 to 3.08). CONCLUSION SPL is an independent predictor of anaemia at 3 months after TAVI, a condition that doubles long-term mortality. Our findings could explain in part the worse prognosis of SPL after TAVI. Further pathophysiological studies are necessary to explain this association.
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Affiliation(s)
- Javier Lopez-Pais
- Interventional Cardiology, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain
- CIBERCV, Santiago, Spain
| | - Diego Lopez-Otero
- Interventional Cardiology, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain
- CIBERCV, Santiago, Spain
| | | | | | - Pablo José Antúnez Muiños
- Cardiology, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Xabier Cia Mendioroz
- Puerta del Hierro University Hospital of Majadahonda, Majadahonda, Madrid, Spain
| | - Marta Pérez-Poza
- Cardiology, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Óscar Otero Garcia
- Cardiology, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | | | | | - Leyre Álvarez-Rodríguez
- Cardiology, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Fernando Gomez Peña
- Hospital de Cardiología Centro Médico Nacional Siglo XXI, Mexico City, Mexico
| | - Mária Juskova
- Cardiology, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Juan Carlos Sanmartín Pena
- Interventional Cardiology, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | | | - Ana Belén Cid Álvarez
- Interventional Cardiology, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Ramiro Trillo Nouche
- Interventional Cardiology, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | | | - Jose Ramón González-Juanatey
- CIBERCV, Santiago, Spain
- Cardiology, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Juan Francisco Oteo
- Puerta del Hierro University Hospital of Majadahonda, Majadahonda, Madrid, Spain
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Greco A, Capodanno D. Anticoagulation after Transcatheter Aortic Valve Implantation: Current Status. Interv Cardiol 2020; 15:e02. [PMID: 32382318 PMCID: PMC7203879 DOI: 10.15420/icr.2019.24] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 01/27/2020] [Indexed: 02/07/2023] Open
Abstract
Transcatheter aortic valve implantation (TAVI) is the standard of care for symptomatic severe aortic stenosis. Antithrombotic therapy is required after TAVI to prevent thrombotic complications but it increases the risk of bleeding events. Current clinical guidelines are mostly driven by expert opinion and therefore yield low-grade recommendations. The optimal antithrombotic regimen following TAVI has yet to be determined and several randomised controlled trials assessing this issue are ongoing. The purpose of this article is to critically explore the impact of antithrombotic drugs, especially anticoagulants, on long-term clinical outcomes following successful TAVI.
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Affiliation(s)
- Antonio Greco
- Division of Cardiology, CAST, PO G Rodolico, Policlinico-Vittorio Emanuele University Hospital, University of Catania Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, CAST, PO G Rodolico, Policlinico-Vittorio Emanuele University Hospital, University of Catania Catania, Italy
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