Comparison of Warfarin to Dual Antiplatelet Therapy Following Transcatheter Aortic Valve Replacement

Dual antiplatelet therapy (DAPT) was the initial antithrombotic regimen of choice following transcatheter aortic valve replacement (TAVR). Subsequent identification of subclinical valve thrombosis in high-risk patients has questioned whether warfarin should be used as an alternative to DAPT for some patients.

The aim of this study was to compare thromboembolic events, bleeding, and all-cause mortality between DAPT and warfarin following TAVR.

This was a single-center, retrospective review of TAVR patients who received DAPT or warfarin following TAVR between 2008 and 2018. The primary endpoint was occurrence of thromboembolic events during the hospital stay and 1-year follow-up, while secondary endpoints included bleeding and all-cause mortality.

Of the included 764 patients, 193 received DAPT and 571 received warfarin. The median Society of Thoracic Surgeons (STS) Predicted Risk of Mortality (PROM) scores were 8.3% for the DAPT group and 6.5% for the warfarin group. The primary endpoint occurred 30 times (3.9%) during the study timeframe. No differences in thromboembolic events between the DAPT and warfarin groups were found (4.14% vs. 3.85%; p = 0.857), and there was no difference in bleeding (6.22% vs. 5.08%; p = 0.544) or risk of mortality (hazard ratio 0.59, 95% confidence interval 0.33-1.06; p = 0.076).

In this study, warfarin had similar effectiveness and safety, compared with DAPT, for antithrombotic management post-TAVR. For patients whom the provider deemed anticoagulation is indicated, our data suggest warfarin is a well-tolerated option following TAVR in intermediate- and high-risk STS score patients.