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98 Lack of Consensus on Anti-thrombotic Therapy in Patients Undergoing Tavi – an Online Survey from Uk Tavi Operators
  1. Izhar Hashmi,
  2. Andrew Wiper,
  3. Ranjit More,
  4. Franco Sogliani,
  5. Augustine Tang,
  6. David Roberts
  1. Blackpool Teaching Hospitals NHS Foundation Trust

Abstract

Introduction The incidence of cerebrovascular ischaemic events during and early after Trans-catheter Aortic Valve Implantation (TAVI) procedure remains a major concern. Peri-procedural events may be due to embolization of calcified material or atheromatous debris from aorta. Post-TAVI events may be attributed to thrombogenicity of bioprosthesis, fissured/denuded native valve and new onset atrial fibrillation. Anti-coagulation with unfractionated heparin during and dual anti-platelet therapy (DAPT) after TAVI is generally recommended but evidence for this approach is lacking. Further, there is no specific guidance on post-TAVI anti-thrombotic strategy in patients with atrial fibrillation and the duration of DAPT.

Methods An online survey to find out real life practice of anti-thrombotic therapy before, during and after the TAVI procedure was conducted.

Results Seventeen TAVI operators participated in the survey. All operators administer heparin during the procedure but only 71% measure ACT, with target ACT varying from >200 to >300 seconds. Pre-TAVI, 29% of operators give DAPT, 47% give single anti-platelet therapy (SAPT), 18% do not give anti-platelet therapy and one TAVI operator has no preference. Post-TAVI, 71% operators prescribe DAPT and 29% give SAPT. Out of those who prescribe DAPT post-TAVI, 8% give it for one month, 67% for 3 months, 8% for 6 months and 17% did not specify the duration. Only one TAVI operator tests for clopidogrel resistance and substitutes it with ticagrelor in non-responders. In patients with atrial fibrillation 35% operators prescribe post-TAVI Warfarin only, 47% combine it with SAPT and 18% did not specify whether they give any anti-platelet in addition to Warfarin. 94% start Warfarin during hospital stay following TAVI but one operator starts it 3 months later (when DAPT ceases).

Conclusion This survey highlights huge variation in the individual management of anti-thrombotic treatment before, during and after TAVI procedures. This reflects the present lack of evidence on the optimal dose of intra-procedural heparin (target ACT to be achieved) and the value of SAPT versus DAPT (dosing and duration). Early introduction/re-introduction of warfarin in patients with atrial fibrillation is recognised but approach towards anti-platelet therapy in these patients is inconsistent. Randomised trials to determine optimal anti-thrombotic strategies in the high risk TAVI population are clearly required.

  • TAVI
  • anti-thrombotic
  • anti-platelet

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