What is the post-operative treatment for Transcatheter Aortic Valve Replacement (TAVR)?

From the Guidelines

Post-operative treatment for Transcatheter Aortic Valve Replacement (TAVR) should focus on preventing complications and optimizing outcomes, with a recommended regimen of dual antiplatelet therapy with aspirin 75-100 mg daily lifelong and clopidogrel 75 mg daily for 3-6 months, as well as close monitoring for complications and management of comorbidities, as outlined in the 2017 ACC expert consensus decision pathway for TAVR 1.

Key Components of Post-TAVR Care

• Immediate post-procedure management, including waking from sedation, post-procedure monitoring, pain management, early mobilization, and discharge planning
• Long-term follow-up, including timing, antithrombotic therapy, concurrent cardiac disease management, and monitoring for post-TAVR complications
• Antithrombotic therapy, with aspirin 75-100 mg daily lifelong and clopidogrel 75 mg daily for 3-6 months, and consideration of warfarin or other oral anticoagulants for patients at risk of atrial fibrillation or venous thromboembolism
• Management of comorbidities, including coronary disease, hypertension, heart failure, and arrhythmias
• Monitoring for complications, including laboratory results, echocardiography, and electrocardiography

Rationale for Recommendations

The recommendations are based on the most recent and highest quality evidence, including the 2017 ACC expert consensus decision pathway for TAVR 1 and the 2020 ACC/AHA guideline for the management of patients with valvular heart disease 1. These guidelines emphasize the importance of dual antiplatelet therapy and close monitoring for complications in the post-TAVR period. While earlier studies, such as the 2014 AHA/ACC guideline for the management of patients with valvular heart disease 1 and the 2012 ACCF/AATS/SCAI/STS expert consensus document on transcatheter aortic valve replacement 1, provide additional context and support for these recommendations, the most recent and highest quality evidence should take precedence in guiding clinical practice.

From the Research

Post-Operative Treatment for TAVR

The post-operative treatment for Transcatheter Aortic Valve Replacement (TAVR) typically involves antithrombotic therapy to manage thromboembolic and bleeding risks.

• Current guidelines recommend single antiplatelet therapy for patients without indications for long-term anticoagulation, as dual antiplatelet therapy increases bleeding risk without improving outcomes 2.
• For patients requiring long-term anticoagulation, monotherapy with direct oral anticoagulants or vitamin K antagonists is recommended to minimize bleeding 2.
• A study comparing aspirin plus clopidogrel with aspirin alone as antithrombotic treatment following TAVR found that single-antiplatelet therapy (SAPT) tended to reduce the occurrence of major adverse events following TAVR, and reduced the risk for major or life-threatening events while not increasing the risk for MI or stroke 3.
• Another study demonstrated that clopidogrel monotherapy was associated with a lower incidence of cardiovascular death compared with aspirin monotherapy during the 2-year follow-up after TAVR, regardless of anticoagulation use 4.
• A systematic review and network meta-analysis found that single antiplatelet therapy with aspirin had lower bleeding without increasing stroke or death when compared with either 3- or 6-month dual antiplatelet therapy 5.

Antithrombotic Therapy Regimens

Different antithrombotic therapy regimens have been studied, including:

• Dual antiplatelet therapy (DAPT) for 3 to 6 months following TAVR, which is currently recommended by guidelines, but may increase bleeding risk without improving outcomes 5, 6.
• Single antiplatelet therapy (SAPT) with aspirin, which has been shown to have lower bleeding risk without increasing stroke or death 5, 3.
• Monotherapy with direct oral anticoagulants or vitamin K antagonists for patients requiring long-term anticoagulation, which is recommended to minimize bleeding 2.
• Clopidogrel monotherapy, which has been associated with a lower incidence of cardiovascular death compared with aspirin monotherapy 4.

Ongoing Research

Ongoing trials aim to clarify optimal antithrombotic regimens and strategies for preventing subclinical leaflet thrombosis, and individualized therapy based on patient risk profiles is likely needed to improve the efficacy and safety of antithrombotic treatment post-TAVR 2.