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Mangner N, Brinkert M, Keller LS, Moriyama N, Hagemeyer D, Haussig S, Crusius L, Kobza R, Abdel-Wahab M, Laine M, Stortecky S, Pilgrim T, Nietlispach F, Ruschitzka F, Thiele H, Toggweiler S, Linke A. Continued non-vitamin K antagonist oral anticoagulants versus vitamin K antagonists during transcatheter aortic valve implantation. EUROINTERVENTION 2023; 18:e1066-e1076. [PMID: 36440479 PMCID: PMC9909456 DOI: 10.4244/eij-d-22-00521] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 09/27/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND One-third of patients undergoing transcatheter aortic valve implantation (TAVI) have an indication for long-term oral anticoagulation (OAC). AIMS We aimed to investigate whether continued non-vitamin K antagonist oral anticoagulant (NOAC) therapy compared with continued vitamin K antagonist (VKA) therapy during TAVI is equally safe and effective. Methods: Consecutive patients on OAC with either NOAC or VKA undergoing transfemoral TAVI at five European centres were enrolled. The primary outcome measure was a composite of major/life-threatening bleeding, stroke, and all-cause mortality at 30 days. RESULTS In total, 584 patients underwent TAVI under continued OAC with 294 (50.3%) patients receiving VKA and 290 (49.7%) patients receiving NOAC. At 30 days, the composite primary outcome had occurred in 51 (17.3%) versus 36 (12.4%) patients with continued VKA and with continued NOAC, respectively (odds ratio [OR] 0.68, 95% confidence interval [CI]: 0.43-1.07; p=0.092). Rates of major/life-threatening bleeding (OR 0.87, 95% CI: 0.52-1.47; p=0.606) and stroke (OR 1.02, 95% CI: 0.29-3.59; p=0.974) were not different between groups. In a multivariate Cox regression analysis, continued NOAC, compared with continued VKA, was associated with a lower risk for all-cause 1-year mortality (hazard ratio [HR] 0.61, 95% CI: 0.37-0.98; p=0.043). The analysis of the propensity score-matched cohort revealed similar results. CONCLUSIONS Continued NOAC compared with continued VKA during TAVI led to comparable outcomes with regard to the composite outcome measure indicating that continued OAC with both drugs is feasible. These hypothesis-generating results need to be confirmed by a dedicated randomised controlled trial.
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Affiliation(s)
- Norman Mangner
- Department of Internal Medicine and Cardiology, Heart Center Dresden, Technische Universität Dresden, Dresden, Germany
| | - Miriam Brinkert
- Division of Cardiology, Medical University Department, Kantonsspital Aarau, Aarau, Switzerland
| | - Lukas S Keller
- Quebec Heart and Lung Institute, Laval University, Quebec, QC, Canada
| | - Noriaki Moriyama
- Division of Cardiology, Helsinki University Central Hospital, Helsinki, Finland
- Division of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Daniel Hagemeyer
- Department of Cardiology, University Hospital Bern, Bern, Switzerland
| | - Stephan Haussig
- Department of Internal Medicine and Cardiology, Heart Center Dresden, Technische Universität Dresden, Dresden, Germany
| | - Lisa Crusius
- Department of Internal Medicine and Cardiology, Heart Center Dresden, Technische Universität Dresden, Dresden, Germany
| | - Richard Kobza
- Heart Center Lucerne, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Mohamed Abdel-Wahab
- Department of Internal Medicine/Cardiology, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | - Mika Laine
- Division of Cardiology, Helsinki University Central Hospital, Helsinki, Finland
| | - Stefan Stortecky
- Department of Cardiology, University Hospital Bern, Bern, Switzerland
| | - Thomas Pilgrim
- Department of Cardiology, University Hospital Bern, Bern, Switzerland
| | - Fabian Nietlispach
- Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
- CardioVascular Center Zürich, Hirslanden Klinik im Park, Zürich, Switzerland
| | - Frank Ruschitzka
- Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | | | - Axel Linke
- Department of Internal Medicine and Cardiology, Heart Center Dresden, Technische Universität Dresden, Dresden, Germany
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Jimenez Diaz VA, Estevez Loureiro R, Baz Alonso JA, Juan Salvadores P, Bastos Fernandez G, Caneiro Queija B, Veiga Garcia C, Iñiguez Romo A. Stroke prevention during and after transcatheter aortic valve implantation: From cerebral protection devices to antithrombotic management. Front Cardiovasc Med 2022; 9:958732. [PMID: 36324741 PMCID: PMC9618870 DOI: 10.3389/fcvm.2022.958732] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 09/12/2022] [Indexed: 07/29/2023] Open
Abstract
Since its conception, transcatheter aortic valve implantation (TAVI) has undergone important improvements both in the implantation technique and in transcatheter devices, allowing an enthusiastic adoption of this therapeutic approach in a wide population of patients previously without a surgical option and managed conservatively. Nowadays, patients with severe symptomatic aortic stenosis are typically managed with TAVI, regardless of their risk to surgery, improving the prognosis of patients and thus achieving an exponential global expansion of its use. However, thromboembolic and hemorrhagic complications remain a latent concern in TAVI recipients. Both complications can appear simultaneously in the periprocedural period or during the follow-up, and when minor, they resolved without apparent sequelae, but in a relevant percentage of cases, they are devastating, overshadowing the benefit achieved with TAVI. Our review outlines the etiology and incidence of thromboembolic complications associated with TAVI, the main current strategies for their prevention, and the implications of its pharmacological management at the follow-up in a TAVI population, mostly frail and predisposed to bleeding complications.
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Affiliation(s)
- Victor Alfonso Jimenez Diaz
- Department of Cardiology, Hospital Álvaro Cunqueiro, University Hospital of Vigo, Vigo, Spain
- Cardiovascular Research Group, Galicia Sur Health Research Institute (IIS Galicia Sur), Vigo, Spain
| | - Rodrigo Estevez Loureiro
- Department of Cardiology, Hospital Álvaro Cunqueiro, University Hospital of Vigo, Vigo, Spain
- Cardiovascular Research Group, Galicia Sur Health Research Institute (IIS Galicia Sur), Vigo, Spain
| | - Jose Antonio Baz Alonso
- Department of Cardiology, Hospital Álvaro Cunqueiro, University Hospital of Vigo, Vigo, Spain
- Cardiovascular Research Group, Galicia Sur Health Research Institute (IIS Galicia Sur), Vigo, Spain
| | - Pablo Juan Salvadores
- Department of Cardiology, Hospital Álvaro Cunqueiro, University Hospital of Vigo, Vigo, Spain
- Cardiovascular Research Group, Galicia Sur Health Research Institute (IIS Galicia Sur), Vigo, Spain
| | - Guillermo Bastos Fernandez
- Department of Cardiology, Hospital Álvaro Cunqueiro, University Hospital of Vigo, Vigo, Spain
- Cardiovascular Research Group, Galicia Sur Health Research Institute (IIS Galicia Sur), Vigo, Spain
| | - Berenice Caneiro Queija
- Department of Cardiology, Hospital Álvaro Cunqueiro, University Hospital of Vigo, Vigo, Spain
- Cardiovascular Research Group, Galicia Sur Health Research Institute (IIS Galicia Sur), Vigo, Spain
| | - Cesar Veiga Garcia
- Cardiovascular Research Group, Galicia Sur Health Research Institute (IIS Galicia Sur), Vigo, Spain
| | - Andres Iñiguez Romo
- Department of Cardiology, Hospital Álvaro Cunqueiro, University Hospital of Vigo, Vigo, Spain
- Cardiovascular Research Group, Galicia Sur Health Research Institute (IIS Galicia Sur), Vigo, Spain
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Antithrombotic Therapy Following Transcatheter Aortic Valve Replacement. J Clin Med 2022; 11:jcm11082190. [PMID: 35456283 PMCID: PMC9031701 DOI: 10.3390/jcm11082190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 03/31/2022] [Accepted: 04/07/2022] [Indexed: 11/22/2022] Open
Abstract
Due to a large technical improvement in the past decade, transcatheter aortic valve replacement (TAVR) has expanded to lower-surgical-risk patients with symptomatic and severe aortic stenosis. While mortality rates related to TAVR are decreasing, the prognosis of patients is still impacted by ischemic and bleeding complications, and defining the optimal antithrombotic regimen remains a priority. Recent randomized control trials reported lower bleeding rates with an equivalent risk in ischemic outcomes with single antiplatelet therapy (SAPT) when compared to dual antiplatelet therapy (DAPT) in patients without an underlying indication for anticoagulation. In patients requiring lifelong oral anticoagulation (OAC), the association of OAC plus antiplatelet therapy leads to a higher risk of bleeding events with no advantages on mortality or ischemic outcomes. Considering these data, guidelines have recently been updated and now recommend SAPT and OAC alone for TAVR patients without and with a long-term indication for anticoagulation. Whether a direct oral anticoagulant or vitamin K antagonist provides better outcomes in patients in need of anticoagulation remains uncertain, as recent trials showed a similar impact on ischemic and bleeding outcomes with apixaban but higher gastrointestinal bleeding with edoxaban. This review aims to summarize the most recently published data in the field, as well as describe unresolved issues.
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Zahid S, Ullah W, Khan MU, Abbas S, Ud Din MT, Uddin MF, Inayat A, Ubaid A, Salman F, Thakkar S, Salama A, Khan MZ. Trends, predictors, and outcomes of major bleeding after transcatheter aortic valve implantation, from national inpatient sample (2011-2018). Expert Rev Cardiovasc Ther 2021; 19:557-563. [PMID: 33926363 DOI: 10.1080/14779072.2021.1924678] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Major bleeding remains one of the most frequent complications seen in transcatheter aortic valve implantation (TAVI). The purpose of this study was to evaluate outcomes, trends, and predictors of major bleeding in patients undergoing TAVI. METHODS We utilized the National Inpatient Sample (NIS) data from the year 2011 to 2018. Baseline characteristics were compared using a Pearsonχ2 test for categorical variables and Mann-Whitney U-Test for continuous variables. A multivariable logistic regression model was used to evaluate predictors of major bleeding. Propensity Matching was done for adjusted analysis to compare outcomes in TAVI with and without major bleeding. RESULTS A total of 215,938 weighted hospitalizations for TAVI were included in the analysis. Of the patient undergoing the procedure, 20,102 (9.3%) had major bleeding and 195,836 (90.7%) patients did not have in-hospital bleeding events. Patients in the major bleeding cohort were older and had greater female gender representation. At baseline patients with thrombocytopenia (Odds Ratio [OR], 1.47[confidence interval (CI), 1.36-1.59]), colon cancer (OR, 1.70[CI, 1.27-2.28]), coagulopathy (OR, 1.17[CI, 1.08-1.27]), liver disease (OR, 1.31[CI, 1.21-1.41]), chronic obstructive pulmonary disease (OR, 1.29[CI, 1.25-1.33]), congestive heart failure (OR, 1.12[CI, 1.08-1.16]), and end-stage renal disease (ESRD) (OR, 1.47[CI, 1.38-1.57]) had higher adjusted rates of major bleeding. The percentage of adjusted in-hospital mortality (14.4% vs. 4.2%, P < 0.01) was significantly higher in the major bleeding group Patients with major bleeding had higher median cost of stay ($235,274 vs. $177,920) and length of stay (7 vs 3 days). CONCLUSION In conclusion, we report that mortality is higher in patients with major bleeding and that baseline comorbidities like ESRD, liver disease, coagulopathy and colonic malignancy are important predictors of this adverse event.
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Affiliation(s)
- Salman Zahid
- Department of Medicine, Rochester General Hospital, Rochester,NY,USA
| | - Waqas Ullah
- Department of Medicine, Abington Jefferson Health, PA, USA
| | - Muhammad Usman Khan
- Department of Cardiology, Division of Cardiovascular Medicine, West Virginia University Heart & Vascular Institute, Morgantown, WV, USA
| | - Sakina Abbas
- Department of Medicine, Dow Medical College, Karachi, PK
| | | | | | - Arslan Inayat
- Department of Medicine, Internal Medicine, University at Buffalo, Catholic Health System, Buffalo, NY, USA
| | - Aamer Ubaid
- Department of Medicine, Internal Medicine, University of Missouri- Kansas City, Kansas City, MO
| | - Fnu Salman
- Department of Medicine, Mercy Health St. Vincent Medical Center, Toledo, USA
| | | | - Amr Salama
- Department of Medicine, Rochester General Hospital, Rochester,NY,USA
| | - Muhammad Zia Khan
- Department of Medicine, West Virginia University, Medicine, Morgantown, WV, USA
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