Department of Cardiology, St Antonius Hospital, Nieuwegein, The Netherlands.
Department of Cardiology, Rigshospitalet, Copenhagen, Denmark.
Heart. 2019 May;105(10):742-748. doi: 10.1136/heartjnl-2018-314313. Epub 2019 Mar 13.
This review provides a comprehensive overview of the available data on antithrombotic therapy after transcatheter aortic valve implantation (TAVI). In the absence of large randomised clinical trials, clinical practice is leaning towards evidence reported in other populations. Due to the greater risk of major bleeding associated with oral anticoagulation using a vitamin-K antagonist (VKA), antiplatelet therapy (APT) may be considered as the first-line treatment of patients undergoing TAVI. Overall, single rather than dual APT is preferred. However, dual APT should be considered in patients with a recent acute coronary syndrome (ie, within 6 months), complex coronary stenting, large aortic arch atheromas or previous non-cardioembolic stroke. Monotherapy with VKA should be considered if concomitant atrial fibrillation or any other indication for long-term oral anticoagulation is present. APT on top of VKA seems only reasonable in patients with recent acute coronary syndrome, extensive or recent coronary stenting or large aortic arch atheromas. A direct-acting oral anticoagulant may be considered if oral anticoagulation is indicated in the absence of contraindications. Initiation of VKA is indicated in clinical valve thrombosis, for example, with high transvalvular gradient, whereas the role of VKA in the case of subclinical leaflet thrombosis is currently uncertain.
这篇综述全面概述了经导管主动脉瓣植入术（TAVI）后抗血栓治疗的现有数据。由于使用维生素 K 拮抗剂（VKA）进行口服抗凝治疗与大出血风险增加相关，因此临床实践倾向于使用其他人群中的证据。抗血小板治疗（APT）可能被视为 TAVI 患者的一线治疗。总体而言，首选单一而非双重 APT。然而，对于近期急性冠状动脉综合征（即 6 个月内）、复杂冠状动脉支架置入、大主动脉弓粥样硬化或既往非心源性脑卒中等患者，应考虑双重 APT。如果存在伴发的心房颤动或任何其他长期口服抗凝治疗的指征，则应考虑 VKA 单药治疗。如果没有禁忌证，则应考虑在需要口服抗凝治疗的情况下使用直接作用的口服抗凝剂。在临床瓣叶血栓形成的情况下，例如存在高跨瓣梯度时，应启动 VKA，而 VKA 在亚临床瓣叶血栓形成的情况下的作用目前尚不确定。
