What is the recommended anticoagulation regimen for patients undergoing Transcatheter Aortic Valve Implantation (TAVI)?

Anticoagulation for TAVI

For patients undergoing TAVI without an existing indication for oral anticoagulation, start low-dose aspirin (75-100 mg daily) before the procedure and continue lifelong as single antiplatelet therapy, avoiding dual antiplatelet therapy (DAPT) in most cases due to increased bleeding risk without proven thrombotic benefit. 1

Pre-Procedural Anticoagulation Strategy

Patients WITHOUT Pre-existing Anticoagulation Indication

• Start low-dose aspirin (75-100 mg daily) before TAVI, or use clopidogrel if aspirin is contraindicated 1
• Avoid DAPT before TAVI - the OCEAN TAVI trial demonstrated that preprocedural DAPT significantly increased bleeding risk compared to single antiplatelet therapy (SAPT) or no antiplatelet therapy, without reducing thrombotic complications including stroke 1
• The historical practice of loading with 300 mg clopidogrel followed by 3-6 months of DAPT (extrapolated from PCI trials) has been abandoned based on bleeding evidence 1

Patients WITH Pre-existing Anticoagulation Indication

• Continue vitamin K antagonist (VKA) or direct oral anticoagulant (DOAC) therapy through the TAVI procedure - this has been shown to be safe 1
• However, interruption of oral anticoagulation during TAVI may be considered based on the 2025 POPular PAUSE TAVI trial, which showed that periprocedural continuation was not noninferior to interruption, with continuation associated with significantly more bleeding (31.1% vs 21.3%, risk difference 9.8 percentage points) without reducing thromboembolic events 2

Intraprocedural Anticoagulation

• Maintain activated clotting time (ACT) of 200-300 seconds during the procedure to minimize thrombus formation risk 1
• Consider baseline ACT-guided heparin administration rather than weight-based dosing - this strategy reduced major bleeding from 33.5% to 7.5% (p<0.001) in one study of transfemoral TAVI 3

Post-Procedural Anticoagulation Strategy

Patients WITHOUT Indication for Oral Anticoagulation

The evidence strongly favors single antiplatelet therapy over DAPT:

• Continue aspirin 75-100 mg daily lifelong as monotherapy 1, 4
• For patients at low bleeding risk, DAPT with aspirin plus clopidogrel 75 mg may be considered for 3-6 months, followed by aspirin monotherapy, though this carries a Class 2b recommendation (uncertain benefit) 1, 4
• The POPular TAVI trial (2020) demonstrated that in patients receiving oral anticoagulation, adding clopidogrel increased bleeding from 21.7% to 34.6% (p=0.01) without reducing cardiovascular events 5

Patients WITH Indication for Oral Anticoagulation

• Continue oral anticoagulation alone without adding antiplatelet therapy 5
• The POPular TAVI trial showed oral anticoagulation alone was superior to oral anticoagulation plus clopidogrel, with lower bleeding (21.7% vs 34.6%, p=0.01) and fewer composite cardiovascular events (31.2% vs 45.5%) 5
• For VKA therapy, target INR of 2.5 (range 2.0-3.0) is reasonable for at least 3 months and up to 6 months 1

Critical Contraindications

• Rivaroxaban 10 mg daily plus aspirin is contraindicated after bioprosthetic TAVI in the absence of other indications for oral anticoagulants - the GALILEO study showed patients randomized to rivaroxaban experienced higher rates of death and bleeding compared to antiplatelet regimen 1, 6
• Direct oral anticoagulants (DOACs) including dabigatran are contraindicated with mechanical valve prostheses 1
• Use of rivaroxaban is not recommended in patients after TAVR based on the GALILEO study findings 6

Common Pitfalls to Avoid

• Do not routinely use DAPT - this was standard practice extrapolated from PCI trials but increases bleeding without proven benefit 1
• Do not add clopidogrel to oral anticoagulation in patients with existing anticoagulation indications - this significantly increases bleeding 5
• Do not initiate oral anticoagulation de novo after TAVI in patients without other indications - data supporting this practice are lacking 1
• Avoid protamine reversal unless emergent situations such as cardiac perforation or tamponade occur 1
• Most bleeding events occur in the first month post-TAVI and are often at the access site, emphasizing the importance of careful vascular management 5

Special Populations

High Bleeding Risk Patients

• Single antiplatelet therapy alone may be considered immediately after TAVI rather than DAPT 4
• Bleeding risk should be carefully assessed considering advanced age, prior bleeding, renal impairment, liver disease, and concomitant medications 4

Patients Requiring Triple Therapy

• If anticoagulation plus antiplatelet therapy is absolutely necessary, keep INR in the lower part of the recommended target range to reduce bleeding risk 4
• Avoid prasugrel or ticagrelor as part of triple therapy if anticoagulation is required 4