ABSTRACT
Thromboembolic and bleeding complications negatively impact recovery and
survival after transcatheter aortic valve implantation (TAVI).
Particularly, there is a considerable risk of ischaemic stroke and
vascular access related bleeding, as well as spontaneous
gastro-intestinal bleeding. Therefore, benefit and harm of
antithrombotic therapy should be carefully balanced. This review
summarizes current evidence on peri- and post-procedural antithrombotic
treatment. Indeed, in recent years, the management of antithrombotic
therapy after TAVI has evolved from intensive, expert opinion-based
strategies, towards a deescalated, evidence-based approach. Besides per
procedural administration of unfractionated heparin, this encompasses
single antiplatelet therapy in patients without a concomitant indication
for oral anticoagulation (OAC); and OAC monotherapy in patients with
such indication, mainly being atrial fibrillation. Combination therapy
should generally be avoided to reduce bleeding risk, except after recent
coronary stenting where a period of dual antiplatelet therapy (aspirin
plus P2Y12-inhibitor) or P2Y12-inhibitor plus OAC (in patients with an
independent indication for OAC) is recommended to prevent stent
thrombosis. This new paradigm in which reduced antithrombotic intensity
leads to improved patient safety, without a loss of efficacy, may be
particularly suitable for elderly and fragile patients. Whether this
holds in upcoming populations of younger and lower-risk patients and in
specific populations as patients with subclinical valve thrombosis, is
yet to be proven. Finally, whether less intensive or alternative
approaches should be also applied for the periprocedural management of
the antithrombotic therapy, has to be determined by ongoing and future
studies.