Dietrich Laurent, Kibler Marion, Matsushita Kensuke, Marchandot Benjamin, Trimaille Antonin, Reydel Antje, Diop Bamba, Truong Phi Dinh, Trung Anh Mai, Trinh Annie, Carmona Adrien, Hess Sébastien, Jesel Laurence, Ohlmann Patrick, Morel Olivier
Centre Hospitalier Universitaire, Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Université de Strasbourg, 67000 Strasbourg, France.
Institut National de la Santé et de la Recherche Médicale (INSERM), Nano Médecine Régénérative, Unité Mixte de Recherche 1260, Faculté de Pharmacie, Université de Strasbourg, 67400 Illkirch, France.
J Clin Med. 2021 Dec 31;11(1):212. doi: 10.3390/jcm11010212.
Bleeding events are among the striking complications following transcatheter aortic valve replacement (TAVR), and bleeding prediction models are crucially warranted. Several studies have highlighted that primary hemostasis disorders secondary to persistent loss of high-molecular-weight (HMW) multimers of the von Willebrand factor (vWF) and assessed by adenosine diphosphate closure time (CT-ADP) may be a strong predictor of late major/life-threatening bleeding complications (MLBCs). Pre-existing atrial fibrillation (AF) is a frequent comorbidity in TAVR patients and potentially associated with increased bleeding events after the procedure.
This study evaluated the impact of ongoing primary hemostasis disorders, as assessed by post-procedural CT-ADP > 180 s, on clinical events after TAVR among anticoagulated AF patients.
An ongoing primary hemostasis disorder was defined by post-procedure CT-ADP > 180 s. Bleeding complications were assessed according to the Valve Academic Research Consortium-2 (VARC-2) criteria. The primary endpoint was the occurrence of late MLBCs at one-year follow-up. The secondary endpoint was a composite of mortality, stroke, myocardial infarction, and rehospitalization for heart failure.
In total, 384 TAVR patients were included in the analysis. Of these patients, 57 patients (14.8%) had a prolongated CT-ADP > 180 s. Increased MLBCs were observed in patients with CT-ADP > 180 s (35.1% versus 1.2%; < 0.0001). Conversely, the occurrence of the composite endpoint did not differ between the groups. Multivariate analysis identified CT-ADP > 180 s (HR 28.93; 95% CI 9.74-85.95; < 0.0001), bleeding history, paradoxical aortic stenosis (AS), and major vascular complications following TAVR as independent predictors of late MLBCs.
Among patients with anticoagulated AF, a post-procedural CT-ADP > 180 s was identified as a strong independent predictor of late MLBCs. These findings suggest that persistent primary hemostasis disorders contribute to a higher risk of late bleeding events and should be considered for a tailored, risk-adjusted antithrombotic therapy after TAVR.
出血事件是经导管主动脉瓣置换术（TAVR）后显著的并发症之一，因此出血预测模型至关重要。多项研究强调，继发于血管性血友病因子（vWF）高分子量（HMW）多聚体持续丢失且通过二磷酸腺苷封闭时间（CT-ADP）评估的原发性止血障碍，可能是晚期严重/危及生命的出血并发症（MLBC）的有力预测指标。既往存在的心房颤动（AF）是TAVR患者常见的合并症，且可能与术后出血事件增加相关。
本研究评估了术后CT-ADP>180秒所评估的持续性原发性止血障碍对接受抗凝治疗的AF患者TAVR术后临床事件的影响。
术后CT-ADP>180秒定义为持续性原发性止血障碍。根据瓣膜学术研究联盟-2（VARC-2）标准评估出血并发症。主要终点是1年随访时晚期MLBC的发生情况。次要终点是死亡、中风、心肌梗死和因心力衰竭再次住院的复合终点。
总共384例TAVR患者纳入分析。其中，57例患者（14.8%）CT-ADP延长>180秒。CT-ADP>180秒的患者中观察到MLBC增加（35.1%对1.2%；<0.0001）。相反，两组间复合终点的发生率无差异。多因素分析确定CT-ADP>180秒（HR 28.93；95%CI 9.74-85.95；<0.0001）、出血史、矛盾性主动脉狭窄（AS）以及TAVR术后的主要血管并发症是晚期MLBC的独立预测因素。
在接受抗凝治疗的AF患者中，术后CT-ADP>180秒被确定为晚期MLBC的有力独立预测因素。这些发现表明，持续性原发性止血障碍会导致晚期出血事件风险升高，TAVR术后应考虑进行针对性的、风险调整的抗栓治疗。
