Medizinische Klinik III, Department Cardiology and Cardiovascular Disease, German Heart Competence Centre, University Hospital Tubingen, Otfried-Muller-Straße 10, 72076 Tubingen, Germany.
Curr Vasc Pharmacol. 2018;16(5):437-445. doi: 10.2174/1570161116666180117145015.
Transvascular Aortic Valve Replacement (TAVR) has emerged as a treatment option in patients with severe aortic stenosis who are inoperable and has recently been evaluated in patients with intermediate surgical risk. The number of procedures is increasing worldwide in parallel with the demographic changes in industrial countries. The risk for cerebral embolism is of main concern and represents a major determinant for prognosis and quality of live after TAVR. The empiric antithrombotic therapy consists of Dual Antiplatelet Therapy (DAPT); However the risk-benefit of this approach is lacking evidence from randomized, placebo-controlled trials regarding choice and duration of antithrombotic treatment. Although anticoagulation is generally not recommended in patients with aortic bioprosthesis without atrial fibrillation, there is current uncertainty whether combination of antiplatelet and anticoagulant therapy or anticoagulation alone might represent a more favorable antithrombotic regimen compared to the current empiric standard of DAPT. In addition, so far undetected atrial fibrillation is highly prevalent in the elderly population undergoing TAVR. In particular, the favorable safety profile of Non-Vitamin K Oral Anticoagulants (NOAC) offers an attractive option. A number of trials are currently underway to investigate the benefit of NOAC in patients with and without atrial fibrillation undergoing TAVR. The present article reviews the available evidence concerning stroke risk in TAVR patients and the current and future role of antithrombotic therapy during and after the procedure.
经导管主动脉瓣置换术（TAVR）已成为无法手术的严重主动脉瓣狭窄患者的一种治疗选择，最近也在中危手术风险患者中进行了评估。随着工业化国家人口结构的变化，全球范围内该手术的数量正在增加。脑栓塞的风险是主要关注点，也是 TAVR 后预后和生活质量的主要决定因素。经验性抗血栓治疗包括双联抗血小板治疗（DAPT）；然而，关于抗血栓治疗的选择和持续时间，这种方法的风险效益缺乏来自随机、安慰剂对照试验的证据。尽管对于没有心房颤动的主动脉生物瓣患者一般不建议抗凝，但目前尚不确定与当前经验性 DAPT 标准相比，抗血小板和抗凝联合治疗或单独抗凝是否可能代表更有利的抗血栓治疗方案。此外，到目前为止，在接受 TAVR 的老年人群中，未被发现的心房颤动非常普遍。特别是，新型口服抗凝剂（NOAC）的良好安全性特征提供了一个有吸引力的选择。目前有多项试验正在研究 NOAC 在接受 TAVR 的有和无心房颤动患者中的获益。本文综述了关于 TAVR 患者中风风险的现有证据，以及在该手术期间和之后抗血栓治疗的当前和未来作用。
