title: Antithrombotic treatment in transcatheter aortic valve implantation: insights for cerebrovascular and bleeding events.
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.
authors.affiliation: Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada. Electronic address: josep.rodes@criucpq.ulaval.ca.
authors.forename: Josep
authors.initials: J
authors.lastname: Rodés-Cabau
authors.affiliation: Division of Cardiology, University of Vermont College of Medicine, Burlington, Vermont.
authors.forename: Harold L
authors.initials: HL
authors.lastname: Dauerman
authors.affiliation: Cardiovascular Division, University of Miami Miller School of Medicine, Miami, Florida.
authors.forename: Mauricio G
authors.initials: MG
authors.lastname: Cohen
authors.affiliation: Mt. Sinai School of Medicine, New York, New York.
authors.forename: Roxana
authors.initials: R
authors.lastname: Mehran
authors.affiliation: Aab Cardiovascular Research Institute, University of Rochester, Rochester, New York.
authors.forename: Eric M
authors.initials: EM
authors.lastname: Small
authors.affiliation: Division of Cardiovascular Medicine, Veteran's Affairs Medical Center and University of Kentucky, Lexington, Kentucky.
authors.forename: Susan S
authors.initials: SS
authors.lastname: Smyth
authors.affiliation: Heart Vascular Institute, University Hospitals Case Medical Center, Cleveland, Ohio.
authors.forename: Marco A
authors.initials: MA
authors.lastname: Costa
authors.affiliation: Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Jessica L
authors.initials: JL
authors.lastname: Mega
authors.affiliation: Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Michelle L
authors.initials: ML
authors.lastname: O'Donoghue
authors.affiliation: Division of Cardiovascular Medicine, Duke University Medical Center, Durham, North Carolina.
authors.forename: E Magnus
authors.initials: EM
authors.lastname: Ohman
authors.affiliation: Division of Cardiovascular Medicine, Duke University Medical Center, Durham, North Carolina; Divisions of Cardiology and Hematology, Duke University Medical Center, Durham, North Carolina.
authors.forename: Richard C
authors.initials: RC
authors.lastname: Becker
mesh_terms: D000818:Animals; D006328:Cardiac Catheterization / Q000009:adverse effects*; D002561:Cerebrovascular Disorders / Q000175:diagnosis / Q000453:epidemiology / Q000517:prevention & control*; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects*; D006801:Humans; D019106:Postoperative Hemorrhage / Q000175:diagnosis / Q000453:epidemiology / Q000517:prevention & control*; D012307:Risk Factors; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents
keywords: AATS; ACCF; American Association for Thoracic Surgery; American College of Cardiology Foundation; CVE; DAPT; PCI; SAVR; SCAI; STS; Society for Cardiovascular Angiography and Interventions; TAVI; The Society of Thoracic Surgeons; antiplatelet agents; bleeding; cerebrovascular event; dual antiplatelet therapy; percutaneous coronary intervention; platelets; stroke; surgical aortic valve replacement; transcatheter aortic valve implantation