Antithrombotic therapy - predictor of early and long-term bleeding complications after transcatheter aortic valve implantation.
BACKGROUND
Dual antiplatelet therapy (DAPT) - aspirin and clopidogrel - is recommended after transcatheter aortic valve implantation (TAVI) without an evidence base. The main aim of the study was to estimate the impact of antithrombotic therapy on early and late bleeding. Moreover, we assessed the impact of patients' characteristics on early bleeding and the influence of bleeding on prognosis.


METHODS
Between 2009 and 2011, 83 consecutive TAVI patients, age 81.1 ±7.2 years, were included. Bleeding complications were defined by the Valve Academic Research Consortium (VARC) scale. The median follow-up was 12 ±15.5 months (range: 1 to 23) and included 68 (81.9%) patients.


RESULTS
Early bleeding occurred in 51 (61.4%) patients. Vitamin K antagonists (VKA) pre-TAVI (p = 0.001) and VKA + clopidogrel early post-TAVI (p = 0.04) were the safest therapies; in comparison to the safest one, peri-procedural DAPT (p = 0.002; p = 0.05) or triple anticoagulant therapy (TAT) (p = 0.003, p = 0.05) increased the risk for early bleeding. Predictors for early bleeding were: clopidogrel pre-TAVI (OR: 4.43, 95% CI: 1.02-19.24, p = 0.04), preceding percutaneous coronary intervention (PCI) (10.08, OR: 95% CI: 1.12-90.56, p = 0.04), anemia (OR: 4.00, 95% CI: 1.32-12.15, p = 0.01), age > 85 years (OR: 5.96, 95% CI: 1.47-24.13, p = 0.01), body mass index (BMI) (OR: 0.86, 95% CI: 0.74-0.99, p = 0.04). Late bleeding occurred in 35 patients (51.4%) on combined therapy, and none on VKA or clopidogrel monotherapy (p = 0.04). Bleeding complications did not worsen the survival.


CONCLUSIONS
This study seems to suggest that advanced age, BMI, and a history of anemia increased the risk for early bleeding after TAVI. Clopidogrel pre-TAVI should be avoided; therefore, time of preceding PCI should take into account discontinuation of clopidogrel in the pre-TAVI period. Vitamin K antagonists with clopidogrel seems to be the safest therapy in the early post-TAVI period, similarly as VKA/clopidogrel monotherapy in long-term prophylaxis.
Department of Acquired Valvular Disease, Institute of Cardiology, Warsaw, Poland.
Katarzyna
K
Czerwińska-Jelonkiewicz
Department of Interventional Cardiology and Angiology, Institute of Cardiology, Warsaw, Poland.
Adam
A
Witkowski
Department of Interventional Cardiology and Angiology, Institute of Cardiology, Warsaw, Poland.
Maciej
M
Dąbrowski
Department of Intensive Cardiac Care, Institute of Cardiology, Warsaw, Poland.
Marek
M
Banaszewski
Department of Interventional Cardiology and Angiology, Institute of Cardiology, Warsaw, Poland.
Ewa
E
Księżycka-Majczyńska
Department of Interventional Cardiology and Angiology, Institute of Cardiology, Warsaw, Poland.
Zbigniew
Z
Chmielak
Department of Cardiac Surgery and Transplantology, Institute of Cardiology, Warsaw, Poland.
Krzysztof
K
Kuśmierski
Department of Acquired Valvular Disease, Institute of Cardiology, Warsaw, Poland.
Tomasz
T
Hryniewiecki
Department of Coronary Artery Disease and Structural Heart Disease, Institute of Cardiology, Warsaw, Poland.
Marcin
M
Demkow
Department of Acquired Valvular Disease, Institute of Cardiology, Warsaw, Poland.
Ewa
E
Orłowska-Baranowska
Department of Intensive Cardiac Care, Institute of Cardiology, Warsaw, Poland.
Janina
J
Stępińska
antithrombotic prophylaxis; aortic stenosis; bleeding complications; transcatheter aortic valve implantation