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Published on: June 3, 2018
Antithrombotic strategy following valve-in-valve transcatheter aortic valve replacement. A German Statutory Health
Sebastian Heyne1, Christopher Hohmann2, Sascha Macherey-Meyer2
1Clinic III for Internal Medicine, Faculty of Medicine, University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany. sebastian.heyne@uk-koeln.de.
Insights
Direct oral anticoagulants (DOACs) appear safe for patients undergoing valve-in-valve transcatheter aortic valve replacement (ViV-TAVR). Aspirin monotherapy increased stroke risk compared to dual antiplatelet therapy, highlighting the need for further research.
Area of Science:
- Cardiology
- Interventional Cardiology
- Health Outcomes Research
Background:
- Valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) is an increasingly utilized procedure.
- Optimal antithrombotic strategies post-ViV-TAVR remain undefined, necessitating investigation.
Purpose of the Study:
- To evaluate the comparative efficacy of different antithrombotic strategies following ViV-TAVR.
- To identify potential risks associated with various antithrombotic regimens.
Main Methods:
- Retrospective analysis of German Statutory Health Claims data (2005-2022).
- Stratification of 908 patients based on antithrombotic prescriptions: direct oral anticoagulants (DOACs), vitamin K antagonists (VKAs), or antiplatelet therapy (APT).
- Comparison of a composite endpoint (all-cause mortality, stroke/systemic embolism, mechanical valve complication) at 12 months using Cox regression.
Main Results:
- No significant difference in the composite endpoint between APT (20.8%), DOACs (20.3%), and VKAs (25.3%).
- Acetylsalicylic acid (ASA) monotherapy showed a higher rate of stroke/systemic embolism (SSE) compared to dual antiplatelet therapy (DAPT) (27.3% vs. 12.4%).
Conclusions:
- DOACs present a potentially safe alternative to VKAs and APT in the ViV-TAVR population.
- ASA monotherapy is associated with increased SSE risk compared to DAPT.
- Randomized controlled trials are essential to validate these findings due to the retrospective nature of the study.
Aims:
Valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) procedures are increasingly used. Specific recommendations on antithrombotic strategies following ViV-TAVR are lacking. We aimed to assess the efficacy of different antithrombotic strategies following ViV-TAVR.
Methods And Results:
We performed a retrospective analysis of German Statutory Health Claims data following ViV-TAVR stratified by antithrombotic strategies according to prescription within 90 days. Antithrombotic regimens included antiplatelet therapy (APT), direct oral anticoagulants (DOACs) or vitamin K antagonists (VKAs). The composite endpoint was all-cause mortality, stroke and/or systemic embolism (SSE) and mechanical complication of heart valve prosthesis at 12 months. Cox proportional hazard regression models were used to compare outcomes. In total, 908 patients between 2005 and 2022 were identified. Of these, 286 received DOACs, 99 received VKAs, 351 received APT exclusively and 172 had no prescription. The incidence of the composite endpoint was 20.8% in the APT group, 20.3% in the DOAC group and 25.3% in the VKA group which was not statistically significantly different. The rate of SSE in the acetylsalicylic acid (ASA) mono group was higher compared to the dual antiplatelet therapy (DAPT) group (27.3% vs. 12.4%, univariable HR 0.42, 95% CI [0.19, 0.95], p = 0.03).
Conclusion:
In this analysis of German Health Claims data, DOACs seemed to be a safe alternative to VKAs and APT. ASA monotherapy was associated with higher rates of SSE compared to DAPT. Given the high risk of bias of this retrospective analysis and the growing use of valve-in-valve procedures, randomized controlled trials are needed to confirm these findings.
