DAPT Treatment After Aortic Bioprosthetic Valve
For surgically implanted aortic bioprosthetic valves, aspirin alone (50-100 mg daily) is preferred over dual antiplatelet therapy for the first 3 months, followed by indefinite aspirin monotherapy. 1
Surgical Aortic Bioprosthetic Valves (SAVR)
First 3 Months Post-Implantation
Aspirin monotherapy (50-100 mg daily) is recommended over DAPT or warfarin for patients in sinus rhythm without other indications for anticoagulation. 1 The American College of Chest Physicians guidelines explicitly favor aspirin over VKA therapy during this period (Grade 2C). 1
- The ACC/AHA guidelines support indefinite low-dose aspirin for all surgically implanted biological prosthetic heart valves (Class IIa, Level B). 1
- The ESC guidelines are more conservative, considering aspirin reasonable only for the first 3 months after surgical aortic bioprosthetic valve implantation (Class IIa). 1
Warfarin (INR 2.0-3.0) may be considered for 3-6 months post-implantation, particularly in higher-risk patients. 1 The ACC/AHA provides a Class IIa recommendation for VKA therapy for up to 6 months after SAVR, while ESC offers a weaker Class IIb recommendation for only 3 months. 1 However, observational data from 25,656 patients showed combination warfarin plus aspirin reduced mortality and thromboembolic events at 3 months compared to aspirin alone, though with higher bleeding rates. 1
After 3 Months
Continue aspirin monotherapy (50-100 mg daily) indefinitely for patients in normal sinus rhythm. 1 The American College of Chest Physicians suggests aspirin therapy over no aspirin therapy after 3 months postoperatively (Grade 2C). 1
Transcatheter Aortic Valve Replacement (TAVR)
Standard Post-TAVR Regimen
Aspirin 75-100 mg daily lifelong plus clopidogrel 75 mg daily for 3-6 months is the standard regimen for patients without anticoagulation indications. 2 This DAPT regimen was used in original TAVR clinical trials. 2
- The American College of Chest Physicians suggests aspirin (50-100 mg/d) plus clopidogrel (75 mg/d) over VKA therapy and over no antiplatelet therapy in the first 3 months (Grade 2C). 1
- The ACC/AHA recommends DAPT for 3-6 months post-TAVR (Class IIa, Level C). 1
However, emerging evidence favors single antiplatelet therapy (aspirin alone) over DAPT after TAVR. 3, 4 The ARTE trial (n=222) showed that aspirin alone reduced major or life-threatening bleeding events (3.6% vs. 10.8%, p=0.038) compared to DAPT, without increasing MI or stroke risk. 4
Patients Requiring Anticoagulation
For patients with atrial fibrillation or other anticoagulation indications, use warfarin with target INR 2.0-2.5 for the first 3 months post-TAVR. 2 After 3 months, patients with long-term anticoagulation indications may transition to a direct oral anticoagulant (DOAC). 2
Avoid triple therapy (warfarin + aspirin + clopidogrel) when possible; use oral anticoagulation with low-dose aspirin instead. 3
Critical Pitfalls to Avoid
Do not use DOACs in patients with mechanical valve prostheses. 2 The GALILEO trial was terminated early due to harm with rivaroxaban compared to antiplatelet therapy after TAVR. 1
Do not assume DAPT prevents bioprosthetic valve thrombosis—only anticoagulation is effective. 3 Observational studies show antiplatelet therapy has little effect on bioprosthetic valve thrombosis, whereas anticoagulation is effective in both prevention and treatment. 3
High-risk patients benefit most from early anticoagulation: female patients, those with NYHA Class III/IV symptoms, and those receiving a 19-mm bioprosthetic aortic valve showed reduced thromboembolism with warfarin or aspirin. 5 In a study of 861 patients, the 90-day thromboembolism risk was 5% regardless of anticoagulation status overall, but these subgroups demonstrated benefit. 5
Monitoring Requirements
Perform echocardiography at 30 days post-TAVR and then annually, along with ECG at 30 days and annually. 2 Monitor closely for bleeding complications, especially with combination antithrombotic therapy. 2