Division of Cardiology, C.A.S.T., Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy.
Paris Sorbonne Université, ACTION Study Group, INSERM UMR_S 1166, Institut de Cardiologie, Pitié-Salpêtrière Hospital (Assistance Publique-Hôpitaux de Paris), Paris, France.
JACC Cardiovasc Interv. 2021 Aug 9;14(15):1688-1703. doi: 10.1016/j.jcin.2021.06.020.
Transcatheter aortic valve replacement (TAVR) is a treatment option for symptomatic patients with severe aortic stenosis who are candidates for a bioprosthesis across the entire spectrum of risk. However, TAVR carries a risk for thrombotic and bleeding events, underscoring the importance of defining the optimal adjuvant antithrombotic regimen. Antithrombotic considerations are convoluted by the fact that many patients undergoing TAVR are generally elderly and present with multiple comorbidities, including conditions that may require long-term oral anticoagulation (OAC) (eg, atrial fibrillation) and antiplatelet therapy (eg, coronary artery disease). After TAVR among patients without baseline indications for OAC, recent data suggest dual-antiplatelet therapy to be associated with an increased risk for bleeding events, particularly early postprocedure, compared with single-antiplatelet therapy with aspirin. Concerns surrounding the potential for thrombotic complications have raised the hypothesis of adjunctive use of OAC for patients with no baseline indications for anticoagulation. Although effective in modulating thrombus formation at the valve level, the bleeding hazard has shown to be unacceptably high, and the net benefit of combining antiplatelet and OAC therapy is unproven. For patients with indications for the use of long-term OAC, such as those with atrial fibrillation, the adjunctive use of antiplatelet therapy increases bleeding. Whether direct oral anticoagulant agents achieve better outcomes than vitamin K antagonists remains under investigation. Overall, single-antiplatelet therapy and OAC appear to be reasonable strategies in patients without and with indications for concurrent anticoagulation. The aim of the present review is to appraise the current published research and recommendations surrounding the management of antithrombotic therapy after TAVR, with perspectives on evolving paradigms and ongoing trials.
经导管主动脉瓣置换术（TAVR）是一种治疗选择，适用于有症状的严重主动脉瓣狭窄患者，这些患者在整个风险范围内都适合生物假体。然而，TAVR 存在血栓形成和出血事件的风险，这凸显了确定最佳辅助抗血栓治疗方案的重要性。抗血栓治疗的考虑因素很复杂，因为许多接受 TAVR 的患者通常年龄较大，并且患有多种合并症，包括可能需要长期口服抗凝治疗（OAC）（例如，心房颤动）和抗血小板治疗（例如，冠心病）的疾病。在没有基线 OAC 指征的 TAVR 患者中，最近的数据表明，与单一抗血小板治疗（如阿司匹林）相比，双重抗血小板治疗与出血事件风险增加相关，特别是在术后早期。对于没有基线抗凝指征的患者，对血栓形成并发症的潜在风险的担忧提出了使用 OAC 辅助治疗的假设。尽管在调节瓣膜水平的血栓形成方面有效，但出血风险被证明是不可接受的高，并且联合使用抗血小板和 OAC 治疗的净获益尚未得到证实。对于有长期 OAC 使用指征的患者，如患有心房颤动的患者，辅助使用抗血小板治疗会增加出血风险。直接口服抗凝剂是否比维生素 K 拮抗剂更能获得更好的结果仍在研究中。总体而言，在没有和有同时抗凝指征的患者中，单一抗血小板治疗和 OAC 似乎是合理的策略。本综述的目的是评估目前关于 TAVR 后抗血栓治疗管理的已发表研究和建议，并探讨不断发展的范例和正在进行的试验。
