Antithrombotic Therapy After Transcatheter Aortic Valve Implantation in Patients with Long-Term Indication for Anticoagulation: Systematic Review and Meta-Analysis

Objective The aim of this study was to compare antithrombotic regimens following transcatheter aortic valve implantation (TAVI) in patients requiring long-term oral anticoagulation (OAC). Methods We systematically searched PubMed, Embase, and Cochrane databases for interventional and observational studies comparing OAC to OAC plus single antiplatelet therapy (SAPT). Results Five studies were included (four registry-based and one randomized controlled trial), comprising a total of 1318 patients. Our meta-analysis revealed lower rates of severe bleeding (pooled odds ratio [OR] 0.46 [0.31, 0.69], P<0.01, I 2 =0%) and major bleeding (pooled OR 0.46 [0.27,0.79], P<0.01, I 2 =0%) for the OAC group than for the OAC-plus-SAPT group. There was a nonsignificant trend towards reduced life-threatening bleeding events in the OAC group (pooled OR 0.54 [0.27,1.08], P=0.08, I 2 =11%). There was no difference between groups in the risks of stroke (pooled OR 1.02 [0.58,1.80], P=0.58, I 2 = 0%) or all-cause mortality (pooled OR 1.04 [0.75,1.42], P=0.83, I 2 = 0%) after TAVI. Conclusions Our pooled analysis suggests that for patients with an indication for long-term OAC after TAVI, double anti-thrombotic therapy, compared to OAC alone, increased the risk of bleeding without reducing cerebrovascular events and all-cause mortality. Key questions What is already known about this subject? Transcatheter Aortic Valve Implantation (TAVI) is a landmark techinique in interventional cardiology with growing clinical experience and continuous refinement of procedural techniques and devices. Nevertheless, the post-TAVI antithrombotic regimen guidelines are largely based on expert opinions and followed variably across the globe. What does this study add? Our pooled analysis suggests that for patients with an indication for long-term anticoagulation after TAVI, double anti-thrombotic therapy, compared to OAC alone, increased the risk of bleeding without reducing cerebrovascular events and all-cause mortality. How might this impact on clinical practice? Our finding may prove insightful for future recommendations regarding the conundrum of the best antithrombotic strategy, particularly for patients with AF.