Is aspirin (acetylsalicylic acid) therapy necessary after Transcatheter Aortic Valve Replacement (TAVR)?

From the Guidelines

Aspirin therapy is recommended after Transcatheter Aortic Valve Replacement (TAVR) as part of the standard antiplatelet regimen, with a dose of 75-100 mg daily, in the absence of other indications for oral anticoagulants, as supported by the 2020 ACC/AHA guideline for the management of patients with valvular heart disease 1.

Key Considerations

• The recommendation for aspirin therapy is based on the 2020 ACC/AHA guideline, which suggests that aspirin 75 to 100 mg daily is reasonable in the absence of other indications for oral anticoagulants for patients with a bioprosthetic TAVI 1.
• The guideline also notes that dual-antiplatelet therapy with aspirin 75 to 100 mg and clopidogrel 75 mg may be reasonable for 3 to 6 months after valve implantation for patients with a bioprosthetic TAVI who are at low risk of bleeding 1.
• However, the decision to use aspirin therapy should be individualized based on the patient's specific clinical situation and risk factors, including bleeding risk, other medications, and overall health status.

Antiplatelet Regimen

• The antiplatelet regimen after TAVR may vary depending on the patient's specific clinical situation and risk factors.
• Aspirin is typically prescribed indefinitely following TAVR, with a dose of 75-100 mg daily.
• Clopidogrel 75 mg daily may be added for a shorter duration of 1-6 months, depending on the patient's risk factors and clinical situation.

Important Notes

• The use of anticoagulation with a vitamin K antagonist (VKA) may be considered for patients with a bioprosthetic TAVI who are at low risk of bleeding, with a target INR of 2.5 for at least 3 months and for as long as 6 months after valve implantation 1.
• However, the use of low-dose rivaroxaban (10 mg daily) plus aspirin (75-100 mg) is contraindicated in the absence of other indications for oral anticoagulants for patients with bioprosthetic TAVI 1.

From the Research

Aspirin Therapy after TAVR

• The necessity of aspirin therapy after Transcatheter Aortic Valve Replacement (TAVR) is a topic of ongoing research and debate 2, 3, 4, 5, 6.
• Current guidelines recommend dual antiplatelet therapy (DAPT) for 3 to 6 months after TAVR, but recent studies suggest that aspirin monotherapy may be sufficient and associated with a lower risk of bleeding 2, 4.
• The use of oral anticoagulants (OAC) instead of or in addition to antiplatelet therapy is also being explored, particularly in patients with atrial fibrillation or other indications for anticoagulation 3, 5.

Comparison of Antiplatelet Therapies

• A network meta-analysis found that single antiplatelet therapy with aspirin had a lower risk of bleeding compared to 3- or 6-month DAPT, without increasing the risk of stroke or death 4.
• Another study found that dual antiplatelet therapy was associated with an increased risk of bleeding events, particularly early post-procedure, compared to single antiplatelet therapy with aspirin 5.

Patient-Specific Considerations

• Patients with comorbid conditions requiring oral anticoagulation or those who develop subvalvular thromboses pose unique challenges for antithrombotic therapy after TAVR 6.
• The choice of antithrombotic therapy should be individualized based on a patient's risk of thromboembolic complications and bleeding risk 3, 5.