Intensive Cardiac Therapy Department, Institute of Cardiology, Warsaw, Poland.
Department of Cardiology and Interventional Angiology, Institute of Cardiology, Warsaw, Poland.
Arch Cardiovasc Dis. 2018 Apr;111(4):233-245. doi: 10.1016/j.acvd.2017.06.002. Epub 2017 Nov 7.
Dual antiplatelet therapy (DAPT) is recommended prophylaxis after transcatheter aortic valve implantation (TAVI). The usefulness of platelet reactivity (PLTR) tests in predicting the safety of periprocedural DAPT in the TAVI population is unknown.
To analyze the value of aspirin/clopidogrel PLTR testing in predicting the risk of in-hospital TAVI-related bleeding.
PLTR, expressed as P2Y/aspirin reaction units (PRU/ARU), was performed using optical aggregometry with the VerifyNow device, in the 24h before and on the sixth day after TAVI. Follow-up was by telephone. Bleeding was defined according to VARC-2, and comprised in-hospital, major and life-threatening events.
Overall, 100 patients undergoing TAVI were included; 30 (30%) had bleeding. Clopidogrel PLTR before TAVI (area under the curve [AUC] 0.686, 95% confidence interval [CI] 0.542-0.808; P=0.02) and after TAVI (AUC 0.970, 95% CI 0.904-0.995; P<0.001) correlated with bleeding, with PRU cut-off values of ≤204 and ≤124 as bleeding predictors, respectively. A significant periprocedural decrease in clopidogrel PLTR was noted, with a PRU drop of >78 as bleeding predictor (AUC 0.851, 95% CI 0.725-0.935; P<0.001). Only postprocedural aspirin PLTR was associated with bleeding (AUC 0.697, 95% CI 0.585-0.794; P=0.008). Follow-up (359±73 days after TAVI) included 85 patients (85%) (after exclusion for in-hospital death [n=4] and lack of contact [n=11]). Major bleeding was noted in four patients (4.7%), all on combined prophylaxis.
TAVI-related bleeding occurs mainly during the procedure or in the early postprocedural period. Testing of periprocedural clopidogrel PLTR, but not aspirin PLTR, seems useful because of its predictive value for TAVI-related bleeding. PLTR testing suggests that premedication with clopidogrel, enhanced response to clopidogrel early after TAVI and significant periprocedural drop in clopidogrel PLTR might increase the risk of TAVI-related bleeding.
经导管主动脉瓣植入术（TAVI）后推荐双联抗血小板治疗（DAPT）作为预防措施。血小板反应性（PLTR）检测在预测 TAVI 人群围术期 DAPT 安全性方面的作用尚不清楚。
分析阿司匹林/氯吡格雷 PLTR 检测在预测 TAVI 相关出血风险中的价值。
使用光学比浊法通过 VerifyNow 设备在 TAVI 前 24 小时和第 6 天检测 PLTR，以 P2Y/阿司匹林反应单位（PRU/ARU）表示。通过电话进行随访。根据 VARC-2 定义出血，包括院内、主要和危及生命的事件。
总体而言，共纳入 100 例行 TAVI 的患者；30 例（30%）发生出血。TAVI 前氯吡格雷 PLTR（曲线下面积 [AUC] 0.686，95%置信区间 [CI] 0.542-0.808；P=0.02）和 TAVI 后氯吡格雷 PLTR（AUC 0.970，95% CI 0.904-0.995；P<0.001）与出血相关，分别为≤204 和≤124 的 PRU 截断值作为出血预测因子。观察到氯吡格雷 PLTR 在围术期显著下降，PRU 下降>78 为出血预测因子（AUC 0.851，95% CI 0.725-0.935；P<0.001）。仅术后阿司匹林 PLTR 与出血相关（AUC 0.697，95% CI 0.585-0.794；P=0.008）。（TAVI 后 359±73 天）随访包括 85 例患者（85%）（排除院内死亡[n=4]和联系缺失[n=11]）。4 例（4.7%）患者发生主要出血，均为联合预防。
TAVI 相关出血主要发生在手术过程中或术后早期。检测围术期氯吡格雷 PLTR，而不是阿司匹林 PLTR，似乎具有预测 TAVI 相关出血的价值。PLTR 检测提示，TAVI 前氯吡格雷预处理、氯吡格雷早期反应增强和围术期 PLTR 显著下降可能增加 TAVI 相关出血的风险。
