Does a patient need to be on anticoagulation (AC) therapy after undergoing Transcatheter Aortic Valve Replacement (TAVR)?

Anticoagulation After TAVR: Evidence-Based Recommendations

Patients do NOT routinely need anticoagulation after TAVR unless they have a specific indication such as atrial fibrillation, intracardiac thrombus, or documented valve thrombosis. The standard post-TAVR antithrombotic regimen is dual antiplatelet therapy (DAPT) with clopidogrel plus aspirin, not anticoagulation.

Standard Antithrombotic Therapy (No AC Indication)

For patients without an indication for anticoagulation, the recommended regimen is:

• Clopidogrel 75 mg daily for 3-6 months (3 months for self-expanding valves, 6 months for balloon-expandable valves) 1, 2
• Aspirin 75-100 mg daily lifelong 1, 2, 3

This DAPT regimen was used in the pivotal TAVR trials and represents the current standard of care 1. The American College of Cardiology gives this a Class IIb recommendation 1.

When Anticoagulation IS Indicated

Anticoagulation after TAVR is warranted only in specific clinical scenarios:

Atrial Fibrillation

• Patients with pre-existing or new-onset atrial fibrillation should receive anticoagulation according to standard AF guidelines for patients with prosthetic valves 1, 2
• Pre-existing AF is present in approximately 25% of TAVR patients, with new-onset AF occurring in <1% to 8.6% 1
• Use warfarin or a DOAC (apixaban, rivaroxaban, edoxaban) targeting appropriate therapeutic levels 1

Intracardiac Thrombus

• If intracardiac thrombus is detected, initiate heparin followed by oral anticoagulation 1

Symptomatic Valve Thrombosis

• Anticoagulation for 3-6 months is recommended for documented bioprosthetic valve thrombosis 4, 5

Important Considerations About Routine Anticoagulation

Routine anticoagulation is NOT recommended for all TAVR patients because:

• In high-surgical-risk patients, routine anticoagulation after TAVR was associated with increased mortality and thromboembolic complications 5
• While subclinical leaflet thrombosis occurs in up to 12% of patients, it has uncertain clinical significance and does not justify routine anticoagulation in the absence of other indications 4, 6, 5
• The 2014 AHA/ACC guidelines give only a Class IIb recommendation (may be reasonable) for warfarin targeting INR 2.5 for the first 3 months after bioprosthetic AVR, acknowledging limited evidence 1

Combining Anticoagulation with Antiplatelet Therapy

When anticoagulation is required (e.g., for AF), the approach is:

• Avoid triple therapy (warfarin + aspirin + clopidogrel) whenever possible due to excessive bleeding risk 1, 3
• Preferred regimen: Anticoagulation plus low-dose aspirin (75-100 mg) 1
• If dual antithrombotic therapy is needed, use anticoagulation plus clopidogrel rather than ticagrelor due to lower bleeding risk 1, 3
• TAVR patients are elderly with multiple comorbidities and high baseline bleeding risk, making bleeding prevention critical 1

Special Situation: Recent PCI Before TAVR

For patients with recent coronary stenting:

• Use clopidogrel as the P2Y12 inhibitor when combined with anticoagulation 1, 3
• Duration of DAPT depends on stent type and whether ACS was present, but may not need significant prolongation beyond standard TAVR protocols 4
• Triple therapy should not exceed 6 months and should be minimized whenever possible 1

Direct Oral Anticoagulants (DOACs) After TAVR

DOACs can be used when anticoagulation is indicated:

• DOACs (apixaban, rivaroxaban, edoxaban, dabigatran) are acceptable alternatives to warfarin for AF or other indications 7
• Do NOT use DOACs in patients with mechanical valves (Class III: Harm recommendation) 1
• Apixaban 5 mg twice daily (or 2.5 mg twice daily with dose-reduction criteria) is commonly used 7, 8
• Retrospective data suggest DOACs are safe and well-tolerated after TAVR when indicated 7

Common Pitfalls to Avoid

• Do not routinely anticoagulate all TAVR patients based on concerns about subclinical leaflet thrombosis—this increases bleeding and mortality without clear benefit 5
• Do not use ticagrelor instead of clopidogrel in TAVR patients requiring anticoagulation due to higher bleeding risk 1, 3
• Do not extrapolate ACS data to TAVR—the thrombotic and bleeding risk profiles are different 3
• Avoid prolonged triple therapy beyond what is absolutely necessary for concurrent coronary stenting 1
• Monitor for bleeding complications given the elderly, high-comorbidity TAVR population 1

Follow-Up and Monitoring

• Baseline echocardiogram before discharge and at 30 days to assess valve function 2
• Periodic ECG monitoring to detect asymptomatic atrial fibrillation 2
• Close follow-up by the Heart Valve Team for the first 30 days, then transfer to primary cardiologist 1
• Annual follow-up with echocardiography and clinical assessment 1