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Published on: February 26, 2013
Effects of continuation versus interruption of oral anticoagulation during transcatheter aortic valve implantation on
Dirk Jan van Ginkel1, Hendrik Stragier2, Willem L Bor1
1Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands.
Insights
Continuing oral anticoagulation (OAC) during transcatheter aortic valve implantation (TAVI) modestly reduced coagulation and fibrinolysis activation. However, it suppressed thrombin generation and increased bleeding risk without impacting thromboembolic events.
Area of Science:
- Cardiology
- Hematology
- Interventional Cardiology
Background:
- One-third of patients undergoing transcatheter aortic valve implantation (TAVI) require oral anticoagulation (OAC).
- Previous research suggested continuing OAC might mitigate post-TAVI hypercoagulation.
Purpose of the Study:
- To evaluate the impact of continuing versus interrupting OAC on hemostasis during TAVI.
- To assess periprocedural coagulation and fibrinolysis function.
Main Methods:
- Randomized controlled trial comparing OAC continuation (82 patients) versus interruption (85 patients).
- Plasma samples collected at 6 time points.
- Hemostasis assessed via thrombin/plasmin generation and coagulation/fibrinolysis/platelet/endothelial biomarkers.
Main Results:
- OAC continuation significantly reduced endogenous thrombin potential (ETP) and endogenous plasmin potential post-TAVI.
- Prothrombin fragment 1+2 levels were similar between groups.
- Markers of endothelial and platelet activation remained unaffected by OAC strategy.
Conclusions:
- Continuing OAC during TAVI moderately decreased acute coagulation and fibrinolysis activation.
- This strategy suppressed ETP and was associated with an increased bleeding risk.
- No significant differences in thromboembolic risk were observed in the main trial.
Background:
One-third of patients undergoing transcatheter aortic valve implantation (TAVI) have a concomitant indication for oral anticoagulation (OAC). Previous studies suggested that periprocedural continuation of OAC could reduce transient hypercoagulation after TAVI.
Objective:
To evaluate the effects of continuation versus interruption of OAC on periprocedural hemostasis function.
Methods:
Patients were randomized 1:1 to OAC continuation vs interruption. Plasma samples were taken at 6 time points, and hemostasis function was assessed by measuring thrombin and plasmin generation, as well as biomarkers of coagulation, fibrinolysis, platelet activation, and endothelial function.
Results:
A total of 167 patients were included: 82 were assigned to OAC continuation and 85 to OAC interruption. Pre-TAVI, a significantly lower endogenous thrombin potential (ETP) was observed in the continuation group compared with the interruption group. In both groups, ETP was reduced immediately post-TAVI, and its restoration was significantly lower in the continuation group. In contrast, levels of prothrombin fragment 1 + 2 were similar between the groups. A significantly lower endogenous plasmin potential was observed in the continuation group from pre-TAVI to 8 hours post-TAVI. In both groups, fibrin degradation products increased immediately post-TAVI, while this increase was significantly lower in the continuation group. Markers of endothelial and platelet activation were unaffected by the randomized strategy.
Conclusion:
Continuation of OAC during TAVI modestly reduced the acute activation of coagulation and fibrinolysis compared with the interruption of OAC. This did not translate into any apparent differences in thromboembolic risk in the main trial. However, continuation of OAC resulted in a marked suppression of ETP and an increased risk of bleeding.
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