Antiplatelet Therapy After Tricuspid Clip
After tricuspid edge-to-edge clip repair, use single antiplatelet therapy (SAPT) with aspirin 75-100 mg daily for 3-6 months, followed by discontinuation in patients without other indications for antiplatelet therapy. If the patient has atrial fibrillation or another indication for oral anticoagulation, continue the anticoagulant alone without adding antiplatelet therapy.
Evidence-Based Approach
The evidence for tricuspid clip specifically is extremely limited, so recommendations must be extrapolated from mitral TEER data and general structural heart intervention principles. The most recent and highest quality evidence from mitral TEER strongly supports a de-escalation strategy:
For Patients WITHOUT Atrial Fibrillation or OAC Indication
Use SAPT (aspirin 75-100 mg daily) for 3-6 months post-procedure, then discontinue 1, 2. The MitraSafe study demonstrated that SAPT was associated with significantly better 12-month survival compared to DAPT (94% vs 78.7%, p=0.014) and lower cardiac mortality (98.5% vs 89.4%, p=0.031) 1. A large propensity-matched analysis of 900 patients per group showed equivalent stroke protection between SAPT and DAPT at one year (2.7% vs 2.3%, HR 1.15, p=0.91) with no significant difference in GI bleeding 2.
Avoid DAPT unless there is a concurrent coronary indication (recent PCI, acute coronary syndrome). DAPT after TEER increases bleeding risk without providing additional thromboembolic protection 1, 3.
For Patients WITH Atrial Fibrillation or OAC Indication
Use oral anticoagulation alone without adding antiplatelet therapy 4, 3. A national registry analysis of 322 patients with OAC indications showed that single antithrombotic therapy (OAC alone) reduced bleeding by 45% compared to combined therapy (14% vs 24%, p=0.03) with only 3 thrombotic events total (0.9%), all in the combined therapy group 3.
If the patient has atrial fibrillation, anticoagulation provides stroke protection and adding antiplatelet therapy only increases bleeding risk 4. A subgroup analysis specifically showed benefit of anticoagulation in AF patients (HR 0.82, p=0.04) 4.
Practical Algorithm
- Immediate post-procedure (day 0-1): All patients receive aspirin 81-100 mg
- Days 1-90 to 180:
- No AF/OAC indication → Continue aspirin 75-100 mg daily
- AF or OAC indication → Stop aspirin, continue OAC alone
- After 3-6 months:
- No AF/OAC indication → Stop aspirin (unless other indication like CAD)
- AF or OAC indication → Continue OAC alone indefinitely
Critical Caveats
- Recent PCI or ACS: If the patient had coronary intervention within 12 months, follow standard post-PCI DAPT guidelines 5, which take precedence over the structural heart intervention
- High bleeding risk: Consider stopping antiplatelet therapy earlier (1 month) in patients with very high bleeding risk 1
- Triple therapy should be avoided: The combination of OAC + aspirin + clopidogrel dramatically increases bleeding without proven benefit in structural heart interventions 3, 6
Why Not DAPT?
Multiple studies consistently show DAPT after TEER increases bleeding without reducing thrombotic events. The device endothelializes within weeks, and the low-flow, low-shear environment of the tricuspid position makes thrombosis unlikely compared to arterial interventions like TAVI or coronary stents 7, 8.
Anticoagulant Selection (if indicated)
When anticoagulation is needed for AF, prefer a NOAC over warfarin 5, 9. Use standard AF dosing (not reduced doses used in some PCI trials) since there is no concurrent antiplatelet therapy 9.