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Alaour B, Ferrari E, Heg D, Tueller D, Pilgrim T, Muller O, Noble S, Jeger R, Reuthebuch O, Toggweiler S, Templin C, Wenaweser P, Nietlispach F, Taramasso M, Huber C, Roffi M, Windecker S, Stortecky S. Non-Vitamin K Antagonist Versus Vitamin K Antagonist Oral Anticoagulant Agents After Transcatheter Aortic Valve Replacement. JACC Cardiovasc Interv 2024; 17:405-418. [PMID: 38355269 DOI: 10.1016/j.jcin.2023.11.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 11/13/2023] [Accepted: 11/17/2023] [Indexed: 02/16/2024]
Abstract
BACKGROUND Studies comparing long-term outcomes between non-vitamin K antagonist (VKA) oral anticoagulant agents (direct oral anticoagulant agents [DOACs]) and VKA anticoagulant agents after transcatheter aortic valve replacement (TAVR) are scarce, with conflicting results. OBJECTIVES The aim of this study was to examine the periprocedural, short-term, and long-term safety and effectiveness of DOACs vs VKAs in patients undergoing TAVR via femoral access with concomitant indications for oral anticoagulation. METHODS Consecutive patients undergoing transfemoral TAVR in the prospective national SwissTAVI Registry between February 2011 and June 2021 were analyzed. Net clinical benefit (a composite of all-cause mortality, myocardial infarction, stroke, and life-threatening or major bleeding) and the primary safety endpoint (a composite of life-threatening and major bleeding) were compared between the VKA and DOAC groups at 30 days, 1 year, and 5 years after TAVR. RESULTS After 1:1 propensity score matching, 1,454 patients were available for analysis in each group. There was no significant difference in the rate of the net clinical benefit and the safety endpoints between the groups as assessed at 30 days and 1 and 5 years post-TAVR between VKAs and DOACs. VKAs were associated with significantly higher rates of 1- year (HR: 1.28; 95% CI: 1.01-1.62) and 5-year (HR: 1.25; 95% CI: 1.11-1.40) all-cause mortality. Long-term risk for disabling stroke was significantly lower in the VKA group after excluding periprocedural events (HR: 0.64; 95% CI: 0.46-0.90). CONCLUSIONS At 5 years after TAVR, VKAs are associated with a higher risk for all-cause mortality, a lower risk for disabling stroke, and a similar rate of life-threatening or major bleeding compared with DOACs. (SwissTAVI Registry; NCT01368250).
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Affiliation(s)
- Bashir Alaour
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Enrico Ferrari
- Department of Cardiovascular Surgery, Cardiocentro Ticino Institute-EOC, Lugano, Switzerland
| | - Dik Heg
- CTU Bern, University of Bern, Bern, Switzerland
| | - David Tueller
- Department of Cardiology, Triemli Hospital Zurich, Zurich, Switzerland
| | - Thomas Pilgrim
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Olivier Muller
- Department of Cardiology, Lausanne University Hospital-CHUV, Lausanne, Switzerland
| | - Stephane Noble
- Division of Cardiology and Cardiovascular Surgery, University Hospital, Geneva, Switzerland
| | - Raban Jeger
- Department of Cardiology, Triemli Hospital Zurich, Zurich, Switzerland; University of Basel, Basel, Switzerland
| | - Oliver Reuthebuch
- University of Basel, Basel, Switzerland; Department of Cardiovascular Surgery, Basel University Hospital, University of Basel, Basel, Switzerland
| | | | - Christian Templin
- Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - Peter Wenaweser
- Heart Clinic Hirslanden, Hirslanden Clinic Zurich, Zurich, Switzerland
| | | | | | - Christoph Huber
- Division of Cardiology and Cardiovascular Surgery, University Hospital, Geneva, Switzerland
| | - Marco Roffi
- Division of Cardiology and Cardiovascular Surgery, University Hospital, Geneva, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stefan Stortecky
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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Weber C, Blanchet X, Lip GYH. Thrombosis and Haemostasis 2022 Editors' Choice Papers. Thromb Haemost 2023; 123:123-130. [PMID: 36626900 DOI: 10.1055/s-0042-1760263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Christian Weber
- Institute for Cardiovascular Prevention (IPEK), LMU Munich, Munich, Germany.,German Centre for Cardiovascular Research (DZHK), partner site Munich Heart Alliance, Munich, Germany.,Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Xavier Blanchet
- Institute for Cardiovascular Prevention (IPEK), LMU Munich, Munich, Germany
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Hindi MN, Akodad M, Nestelberger T, Sathananthan J. Antithrombotic Therapy After Transcatheter Aortic Valve Replacement: An Overview. STRUCTURAL HEART : THE JOURNAL OF THE HEART TEAM 2022; 6:100085. [PMID: 37288058 PMCID: PMC10242582 DOI: 10.1016/j.shj.2022.100085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 07/29/2022] [Accepted: 08/04/2022] [Indexed: 06/09/2023]
Abstract
Transcatheter aortic valve replacement (TAVR) is an established procedure for the treatment of patients with severe aortic stenosis. The optimal antithrombotic regimen following TAVR, currently unknown and inconsistently applied, is impacted by thromboembolic risk, frailty, bleeding risk, and comorbidities. There is a quickly growing body of literature examining the complex issues underlying antithrombotic regimens post-TAVR. This review provides an overview of thromboembolic and bleeding events following TAVR, summarizes the evidence regarding optimal antiplatelet and anticoagulant use post-TAVR, and highlights current challenges and future directions. By understanding appropriate indications and outcomes associated with different antithrombotic regimens post-TAVR, morbidity and mortality can be minimized in a generally frail and elderly patient population.
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Affiliation(s)
- Mathew N. Hindi
- Centre for Cardiovascular and Heart Valve Innovation, St. Paul’s Hospital, University of British Columbia, Vancouver, Canada
| | - Mariama Akodad
- Centre for Cardiovascular and Heart Valve Innovation, St. Paul’s Hospital, University of British Columbia, Vancouver, Canada
| | - Thomas Nestelberger
- Centre for Cardiovascular and Heart Valve Innovation, St. Paul’s Hospital, University of British Columbia, Vancouver, Canada
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Janarthanan Sathananthan
- Centre for Cardiovascular and Heart Valve Innovation, St. Paul’s Hospital, University of British Columbia, Vancouver, Canada
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Spinoni EG, Ghiglieno C, Costantino S, Battistini E, Dell’Era G, Porcellini S, Santagostino M, De Vecchi F, Renda G, Patti G. Access Site Bleeding Complications with NOACs versus VKAs in Patients with Atrial Fibrillation Undergoing Cardiac Implantable Device Intervention. J Clin Med 2022; 11:jcm11040986. [PMID: 35207259 PMCID: PMC8876635 DOI: 10.3390/jcm11040986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 02/07/2022] [Accepted: 02/11/2022] [Indexed: 11/29/2022] Open
Abstract
There are no data on procedure-related bleeding outcome with non-vitamin K antagonist anticoagulants (NOACs) versus vitamin K antagonist anticoagulants (VKAs) in patients with atrial fibrillation (AF) undergoing cardiac implantable electronic device (CIED) intervention. Our aim was to evaluate whether NOACs have a safety benefit even in terms of fewer hemorrhagic complications at the site of CIED implant. Consecutive AF patients receiving NOACs or VKAs at the time of CIED procedure were included in this observational, retrospective, and monocentric investigation. Primary endpoint was the incidence of post-intervention pocket hematoma. A total of 311 patients were enrolled, 146 on NOACs, and 165 on VKAs. The incidence of pocket hematoma was 3.4% in the NOAC versus 13.3% in the VKA group (p = 0.002). Primary outcome-free survival at 30-days was 96.6% in patients on NOACs and 86.0% in those on VKAs (p = 0.019). Multivariate analysis, adjusted by propensity-score calculation of inverse-probability-weighting, showed a significantly lower occurrence of pocket hematoma in patients receiving NOACs versus VKAs (HR 0.35, 95% CI 0.13–0.96, p = 0.042). Such NOACs benefit was confirmed versus patients on VKAs without peri-procedural bridging with low-molecular-weight heparin (HR 0.34, 95% CI 0.11–0.99, p = 0.048). The incidence of pocket infection, surgical pocket evacuation, ischemic events, and major bleeding complications at 30 days (secondary endpoints) was similar in the two groups. In conclusion, our data suggest that, among patients with AF undergoing implantable cardiac defibrillator or pacemaker intervention, the use of NOACs versus VKAs may be associated with significant reduction of post-procedural pocket hematoma, regardless of bridging with low-molecular-weight heparin in the VKA group. These results are hypothesis generating and need to be confirmed in a specific randomized study.
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Affiliation(s)
- Enrico Guido Spinoni
- Department of Translational Medicine, University of Eastern Piedmont, 28100 Novara, Italy; (E.G.S.); (C.G.); (S.C.); (E.B.)
- Department of Thoracic, Heart and Vascular Diseases, Maggiore della Carità Hospital, 28100 Novara, Italy; (G.D.); (S.P.); (M.S.); (F.D.V.)
| | - Chiara Ghiglieno
- Department of Translational Medicine, University of Eastern Piedmont, 28100 Novara, Italy; (E.G.S.); (C.G.); (S.C.); (E.B.)
- Department of Thoracic, Heart and Vascular Diseases, Maggiore della Carità Hospital, 28100 Novara, Italy; (G.D.); (S.P.); (M.S.); (F.D.V.)
| | - Simona Costantino
- Department of Translational Medicine, University of Eastern Piedmont, 28100 Novara, Italy; (E.G.S.); (C.G.); (S.C.); (E.B.)
| | - Eleonora Battistini
- Department of Translational Medicine, University of Eastern Piedmont, 28100 Novara, Italy; (E.G.S.); (C.G.); (S.C.); (E.B.)
- Department of Thoracic, Heart and Vascular Diseases, Maggiore della Carità Hospital, 28100 Novara, Italy; (G.D.); (S.P.); (M.S.); (F.D.V.)
| | - Gabriele Dell’Era
- Department of Thoracic, Heart and Vascular Diseases, Maggiore della Carità Hospital, 28100 Novara, Italy; (G.D.); (S.P.); (M.S.); (F.D.V.)
| | - Stefano Porcellini
- Department of Thoracic, Heart and Vascular Diseases, Maggiore della Carità Hospital, 28100 Novara, Italy; (G.D.); (S.P.); (M.S.); (F.D.V.)
| | - Matteo Santagostino
- Department of Thoracic, Heart and Vascular Diseases, Maggiore della Carità Hospital, 28100 Novara, Italy; (G.D.); (S.P.); (M.S.); (F.D.V.)
| | - Federica De Vecchi
- Department of Thoracic, Heart and Vascular Diseases, Maggiore della Carità Hospital, 28100 Novara, Italy; (G.D.); (S.P.); (M.S.); (F.D.V.)
| | - Giulia Renda
- Department of Neuroscience, Imaging and Clinical Sciences, University G. D’Annunzio of Chieti-Pescara, 66100 Pescara, Italy;
| | - Giuseppe Patti
- Department of Translational Medicine, University of Eastern Piedmont, 28100 Novara, Italy; (E.G.S.); (C.G.); (S.C.); (E.B.)
- Department of Thoracic, Heart and Vascular Diseases, Maggiore della Carità Hospital, 28100 Novara, Italy; (G.D.); (S.P.); (M.S.); (F.D.V.)
- Correspondence: ; Tel.: +39-0321-373-3597
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