Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands.
Department of Cardiology, Zuyderland Medical Centre, Heerlen, the Netherlands; Department of Cardiology, Maastricht University Medical Centre, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands.
Eur J Intern Med. 2022 Jul;101:14-20. doi: 10.1016/j.ejim.2022.05.002. Epub 2022 May 25.
Thromboembolic and bleeding complications negatively impact recovery and survival after transcatheter aortic valve implantation (TAVI). Particularly, there is a considerable risk of ischaemic stroke and vascular access related bleeding, as well as spontaneous gastro-intestinal bleeding. Therefore, benefit and harm of antithrombotic therapy should be carefully balanced. This review summarizes current evidence on peri- and post-procedural antithrombotic treatment. Indeed, in recent years, the management of antithrombotic therapy after TAVI has evolved from intensive, expert opinion-based strategies, towards a deescalated, evidence-based approach. Besides per procedural administration of unfractionated heparin, this encompasses single antiplatelet therapy in patients without a concomitant indication for oral anticoagulation (OAC); and OAC monotherapy in patients with such indication, mainly being atrial fibrillation. Combination therapy should generally be avoided to reduce bleeding risk, except after recent coronary stenting where a period of dual antiplatelet therapy (aspirin plus P2Y12-inhibitor) or P2Y12-inhibitor plus OAC (in patients with an independent indication for OAC) is recommended to prevent stent thrombosis. This new paradigm in which reduced antithrombotic intensity leads to improved patient safety, without a loss of efficacy, may be particularly suitable for elderly and fragile patients. Whether this holds in upcoming populations of younger and lower-risk patients and in specific populations as patients with subclinical valve thrombosis, is yet to be proven. Finally, whether less intensive or alternative approaches should be also applied for the periprocedural management of the antithrombotic therapy, has to be determined by ongoing and future studies.
血栓栓塞和出血并发症会对经导管主动脉瓣置换术（TAVI）后的恢复和生存产生负面影响。特别是，存在相当大的缺血性中风和血管通路相关出血风险，以及自发性胃肠道出血风险。因此，应仔细权衡抗血栓治疗的获益和危害。本综述总结了围手术期和术后抗血栓治疗的当前证据。事实上，近年来，TAVI 后抗血栓治疗的管理已从基于专家意见的强化治疗策略，发展为基于证据的降级治疗策略。除了在手术过程中给予普通肝素外，这还包括在没有口服抗凝治疗（OAC）合并指征的患者中进行单一抗血小板治疗；以及在有此类指征的患者中进行 OAC 单药治疗，主要是心房颤动。为了降低出血风险，一般应避免联合治疗，除非最近进行了冠状动脉支架置入术，在这种情况下，建议进行一段时间的双联抗血小板治疗（阿司匹林加 P2Y12 抑制剂）或 P2Y12 抑制剂加 OAC（有 OAC 独立指征的患者），以预防支架血栓形成。这种减少抗血栓强度的新范式可提高患者安全性而不降低疗效，可能特别适用于老年和脆弱的患者。这种方法是否适用于年轻和低风险患者的即将出现的人群以及亚临床瓣膜血栓形成等特定人群，还有待证实。最后，是否应在围手术期管理中应用更不强化或替代的方法来管理抗血栓治疗，这需要通过正在进行和未来的研究来确定。
