Is it necessary to use Plavix (clopidoporin) after Transcatheter Aortic Valve Replacement (TAVR)?

From the Guidelines

The use of Plavix (clopidogrel) after Transcatheter Aortic Valve Replacement (TAVR) is generally recommended for a duration of 3-6 months, in addition to lifelong aspirin therapy, to prevent thromboembolic complications and reduce the risk of stroke. The standard antiplatelet regimen following TAVR typically includes dual antiplatelet therapy (DAPT) consisting of aspirin 75-100 mg daily indefinitely and clopidogrel 75 mg daily for 3-6 months, as suggested by the 2020 ACC/AHA guideline for the management of patients with valvular heart disease 1. This regimen helps prevent blood clots from forming on the newly implanted valve and reduces the risk of stroke and other thromboembolic complications. The duration of clopidogrel therapy may vary based on individual patient factors such as bleeding risk, but 3-6 months is the most common recommendation. Some key points to consider include:

• The rationale behind this therapy is that TAVR creates a foreign surface (the prosthetic valve) in the bloodstream that can activate platelets and the coagulation cascade, potentially leading to thrombus formation.
• Antiplatelet therapy inhibits this process, protecting against valve thrombosis and systemic embolization.
• Patients should be aware that bruising and minor bleeding may occur more easily while on dual antiplatelet therapy, and they should inform all healthcare providers about their medication regimen before any procedures.
• For patients who cannot tolerate clopidogrel due to allergies or other issues, alternative antiplatelet agents like ticagrelor might be considered.
• The selective use of VKA therapy might be considered after TAVI in patients at low bleeding risk on an individual basis, as reported by the PARTNER 2 investigators 1. It is essential to weigh the potential benefits of anticoagulation therapy against the risk of bleeding, and an individualized approach is required, taking into account the patient's risk factors and medical history.

From the Research

Antiplatelet Therapy after TAVR

• The use of dual antiplatelet therapy (DAPT) with aspirin and clopidogrel (Plavix) after Transcatheter Aortic Valve Replacement (TAVR) has been a topic of debate, with studies suggesting that single antiplatelet therapy (SAPT) may be sufficient in some cases 2, 3, 4, 5.
• A systematic review and meta-analysis found that SAPT with aspirin had lower bleeding rates without increasing stroke or death compared to DAPT 2.
• Another study found that patients discharged on DAPT had a similar adjusted risk of mortality, stroke, and MI compared to antiplatelet monotherapy, although the risk for bleeding was significantly higher 3.
• A meta-analysis of randomized clinical trials and prospective studies found that mono-antiplatelet therapy (MAPT) was associated with similar mortality and stroke rates compared to DAPT, but with significantly less risk of major bleeding 4.
• A systematic review and meta-analysis suggested that aspirin alone could decrease the risk of bleeding and was not associated with higher risk of mortality, stroke, or myocardial infarction compared to DAPT 5.

Comparison of Antiplatelet Regimens

• A meta-analysis found that DAPT was associated with lower mortality rates compared to SAPT, but with similar benefits compared to aspirin monotherapy 6.
• The same meta-analysis found that the addition of oral anticoagulation to MAPT did not provide significant benefits compared to MAPT or DAPT 6.
• The studies suggest that the choice of antiplatelet therapy after TAVR should be individualized, taking into account the patient's risk factors and medical history 2, 3, 4, 5, 6.