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In their Heart paper, Hassell et al1 present an original analysis of four studies comparing single and dual antiplatelet therapy after transcatheter aortic valve implantation (TAVI). There was no difference in the primary endpoint of net adverse clinical and cerebral events combining 30-day rates of mortality, acute coronary syndrome, stroke and major bleeding. However, there was a strong trend, although not statistically significant, towards less major or life-threatening bleeding at 30 days in patients receiving aspirin alone as compared with those treated using the usual combination of aspirin and clopidogrel early after TAVI. These findings challenge current recommendations and may contribute to improving patient outcome after TAVI.
Guidelines consistently recommend dual antiplatelet therapy during 3–6 months after TAVI followed by single antiplatelet therapy (table 1).2–5 This relies mainly on the extrapolation of antithrombotic regimens following coronary stenting. However, despite the common presence of a metallic stent, coronary stenting and TAVI differ by a number of features which may influence thrombus formation, in particular vessel diameter, environment (atheromatous plaques or calcified aortic leaflets), presence of prosthetic leaflets and the frequency of associated atrial fibrillation.
Recommended antithrombotic regimens markedly differ between TAVI and surgical aortic valve replacement (AVR) using a bioprosthesis. Anticoagulant therapy was initially recommended during the first 3 months following bioprosthetic AVR, which corresponds to the time delay for endothelialisation of the sewing ring. However, this rationale was challenged by series suggesting that antiplatelet therapy alone may have a better risk:benefit profile.2 This led to changes in ESC/EACTS and American Heart Association/American …
Competing interests BI has received consultant fees from Abbott, Boehringer Ingelheim, Valtech and speaker fees from Edwards Lifesciences.
Provenance and peer review Commissioned; internally peer reviewed.