What medications are recommended for patients after Transcatheter Aortic Valve Implantation (TAVI) for aortic stenosis?

Medication Management After TAVI for Aortic Stenosis

After transcatheter aortic valve implantation (TAVI) for aortic stenosis, patients should receive dual antiplatelet therapy with aspirin 75-100 mg daily lifelong and clopidogrel 75 mg daily for 3-6 months, unless they have indications for oral anticoagulation. 1

Antithrombotic Regimen Based on Patient Profile

Standard TAVI Patient (No Anticoagulation Indication)

• First-line therapy:
  • Aspirin 75-100 mg daily (lifelong) 1
  • Clopidogrel 75 mg daily for 3-6 months 1

TAVI Patient with High Bleeding Risk

• Alternative approach:
  • Single antiplatelet therapy with aspirin 75-100 mg daily alone may be considered 1, 2
  • Recent evidence suggests single antiplatelet therapy reduces bleeding events without increasing thromboembolic risk 3

TAVI Patient with Indication for Oral Anticoagulation (e.g., Atrial Fibrillation)

• Recommended regimen:
  • Oral anticoagulation lifelong (e.g., warfarin with target INR based on indication) 1
  • No additional antiplatelet therapy unless specific indication exists 1

Important Considerations

Valve Thrombosis Prevention

• For patients at low bleeding risk without other anticoagulation indications:
  • Consider vitamin K antagonist (warfarin) with target INR of 2.5 for the first 3 months after valve implantation 1
  • This approach may help prevent early valve thrombosis 1

Medication Contraindications

• Direct oral anticoagulants (DOACs) are contraindicated for mechanical valves 1
• Low-dose rivaroxaban (10 mg) plus aspirin is contraindicated after bioprosthetic TAVI without other indications for anticoagulation 1

Follow-Up Schedule and Monitoring

Immediate Post-Procedure

• Resume preoperative medications as appropriate 1
• Ensure appropriate antithrombotic therapy is initiated before discharge 1

Long-Term Follow-Up

• TAVR team visit at 30 days 1
• Primary cardiologist at 6 months and then annually 1
• Primary care physician at 3 months and then as needed 1
• Echocardiography at 30 days and then annually to monitor valve function 1, 4
• ECG at 30 days and annually 1

Emerging Evidence

Recent studies have challenged the traditional dual antiplatelet approach:

• The POPular TAVI trial demonstrated that aspirin alone resulted in fewer bleeding events compared to dual antiplatelet therapy, without increasing thromboembolic risk 3
• Some evidence suggests clopidogrel monotherapy may be associated with lower cardiovascular mortality compared to aspirin monotherapy in the 2 years following TAVI 5

Common Pitfalls to Avoid

1. Overlooking anticoagulation needs: Failing to identify patients who require anticoagulation for other indications (e.g., atrial fibrillation)
2. Inappropriate DOAC use: Using direct oral anticoagulants when not indicated or contraindicated
3. Excessive antithrombotic therapy: Combining multiple antithrombotics without clear indication, increasing bleeding risk
4. Inadequate follow-up: Not scheduling appropriate imaging and clinical evaluations to monitor valve function

By following these medication recommendations after TAVI, clinicians can optimize outcomes by balancing thromboembolism prevention with bleeding risk management.