Use of DOAC’s after TAVR

Is there a benefit?

With TAVR indications becoming more and more comprehensive, the number of procedures has skyrocketed worldwide. Thus, we started to live more closely with a series of complications arising from the bioprosthesis deployment and some alternatives started to be sought to try to reduce the impact of this.

Some patients, after deployment, have pictures of subclinical thrombosis of the leaflets, just as we see in bioprostheses deployed by conventional route. Within this group, there are those who present cerebrovascular events and those who present with elevation of the gradients by the prosthesis signaling to develop a SVD (structural valve deterioration).

Current guidelines recommend the use of dual anti-aggregation with ASA and clopidogrel for a few months after implantation, but many researchers wonder whether we should try to use anticoagulants at this stage, as recommended for conventional bioprostheses.

In case of permanent AF, patients receiving TAVR could use DOAC’s, even though the evidence for such a recommendation is still scarce. In cases where there is no formal indication for anticoagulation, would the use of an anticoagulant be of benefit to these patients?

The recent publication at the AHA 2019 congress of the GALILEO trial gave a boost to this wave of expanding DOAC’s indication in cardiology. At least in the post-TAVR scenario without the formal indication as mentioned above.

With a dose lower than that commonly used in stroke prophylaxis in AF, the use of rivaroxaban 10mg day presented, when compared to the usual double antiplatelet therapy, a higher incidence of death, thromboembolic events and bleeding. Even a subanalysis showing that there was a reduction in the laboratory evidence of thickening and subclinical thrombosis of the leaflets, the result was very negative for the clinical evolution.

One of the possible explanations for these findings is that the patient receiving TAVR in general is extremely complex, with several associated comorbidities and a high risk for both thromboembolic and hemorrhagic events. Another important aspect is that the proposal bases on the treatment of subclinical changes and that in the vast majority of cases it presents a benign evolution. Perhaps the treatment restricted only to individuals who manifest events like SVD would show us a different result.

The group of patients who received TAVR and had a formal indication for anticoagulation is still being followed and in the future, we may see some different aspect in this cohort. Nevertheless, now, the dual antiplatelet therapy appears to be safer and to present better outcomes than the use of rivaroxaban at a dose of 10 mg in post-TAVR patients without AF.

Suggested literature:

1 – Dangas GD, Tijssen JGP, Wöhrle J, et al. A Controlled Trial of Rivaroxaban after Transcatheter Aortic-Valve Replacement. N Engl J Med.  2019 Nov 16.

 

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