Aspirin with or without Clopidogrel after Transcatheter Aortic-Valve Implantation

Brouwer, Jorn; Nijenhuis, Vincent J.; Delewi, Ronak; Hermanides, Renicus S; Holvoet, Wouter; Dubois, Christophe; Frambach, Peter; Bruyne, Bernard De; Houwelingen, Gert K. van; Heyden, Jan A.S. Van der; Toušek, Petr; Kley, Frank van der; Buysschaert, Ian; Schotborgh, Carl E.; Ferdinande, Bert; Harst, Pim van der; Roosen, John; Peper, Joyce; Thielen, Frederick W.; Veenstra, Leo; Yin, Dean R P P Chan Pin; Swaans, Martin J.; Rensing, Benno J.; Hof, Arnoud W J van 't; Timmers, Leo; Kelder, Johannes C.; Stella, Pieter R.; Baan, Jan; Berg, Jürrien M. ten

doi:10.1056/nejmoa2017815

Cited by 282 publications

(182 citation statements)

References 29 publications

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“…17 However, recent findings suggested that an aspirin monoregime after TAVI is noninferior to dual antiplatelet therapy regarding ischemic events and even superior regarding bleeding events. 18 This is not surprising given the insufficient platelet inhibition by clopidogrel after TAVI. Furthermore, ticagrelor in addition to aspirin was shown to reduce the rate of insufficient P2Y12 inhibition in comparison to clopidogrel.…”

Section: Discussionmentioning

confidence: 99%

Impact of Transcatheter Aortic Valve Implantation on Thrombin Generation and Platelet Function

et al. 2021

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Background Transcatheter aortic valve implantation (TAVI) is an evolving treatment of severe aortic valve stenosis. However, thromboembolic events such as stroke are common, predominantly early after TAVI. Optimal periprocedural antithrombotic regime is unknown. Especially, as antithrombotic medication enhances bleeding risk, thrombin generation and platelet function are crucial in the pathogenesis of ischemic events. However, the impact of the TAVI procedure on thrombin formation and platelet reactivity is not known by now. Methods We evaluated thrombin levels using thrombin–antithrombin (TAT) complexes and prothrombin fragments (PTFs) using enzyme-linked immunosorbent assay. Furthermore, platelet reactivity was measured via light transmission aggregometry before and 2 hours after TAVI in 198 patients. Results TAT complexes and PTF F1 + 2 substantially increased during TAVI. Postprocedurally, TAT complexes and PTF were significantly higher after TAVI compared with percutaneous coronary intervention due to acute myocardial infarction, while preprocedural TAT complexes and PTF F1 + 2 did not differ. In contrast, platelet reactivity was not altered early after TAVI. Only adenosine diphosphate-induced aggregation was reduced, reflecting preprocedural loading with clopidogrel. Conclusion In this pilot study, we were able to demonstrate that thrombin generation is significantly increased early after TAVI, while platelet function is not affected. Increased thrombin concentrations may contribute to the high risk of postprocedural thromboembolic events. This leads to the hypothesis that extended peri-interventional anticoagulation early after TAVI may be an approach to reduce thromboembolic events.

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Section: Discussionmentioning

confidence: 99%

Impact of Transcatheter Aortic Valve Implantation on Thrombin Generation and Platelet Function

et al. 2021

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“…Of course, questions persist regarding the frame that is not in contact with the aortic wall and which remains uncovered and potentially thrombogenic. Single versus dual antiplatelet therapy has been compared previously in randomized controlled trials (7, 8, 20). The ARTE trial documented a trend towards increased frequency of life-threatening bleedings with dual antiplatelet therapy, with similar rates of MI and stroke in the two groups.…”

Section: Discussionmentioning

confidence: 99%

Ticagrelor vs Clopidogrel: the Impact of Platelet Inhibition on Cerebrovascular Microembolic Events during TAVR

Vavuranakis

Kalantzis²,

Voudris

et al. 2020

Preprint

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ObjectivesTo evaluate the effects of ticagrelor versus clopidogrel and of platelet inhibition on the number of cerebrovascular microembolic events, in patients undergoing transcatheter aortic valve replacement (TAVR).BackgroundThe impact of the antiplatelet regimen and the extent of associated platelet inhibition on cerebrovascular microembolic events during TAVR are unknown.MethodsPatients scheduled for TAVR were randomized prior to the procedure to either aspirin and ticagrelor or to aspirin and clopidogrel. Platelet inhibition was expressed in P2Y12 Reaction Units (PRU) and percentage of inhibition. High intensity transient signals (HITS) were assessed with transcranial Doppler (TCD). Safety outcomes were recorded according to the VARC-2 definitions.ResultsAmong 90 patients randomized, six had inadequate TCD signal. The total number of procedural HITS was lower in the ticagrelor group (416.5 [324.8, 484.2]) (42 patients) than in the clopidogrel group (723.5 [471.5, 875.0]) (42 patients), p< 0.001. After adjusting for the duration of the procedure, diabetes, extra-cardiac arteriopathy, BMI, and aortic valve calcium content, patients on ticagrelor had on average 255.9 (95% CI: [-335.4, -176.4]) fewer total procedural HITS, than did patients on clopidogrel. Platelet inhibition was greater in those randomized to ticagrelor 26 [10, 74.5] PRU than in those randomized to clopidogrel 207.5 [120-236.2] PRU, p<0.001 and correlated significantly with procedural HITS (r=0.5, p<0.05). This protective effect was not associated with an increase in complications.ConclusionsTicagrelor resulted in fewer procedural HITS, compared to clopidogrel, in patients undergoing TAVR, while achieving greater platelet inhibition, without increasing the risk for complications.Clinical Trial(ClinicalTrials.gov Identifier: NCT02989558)CONDENSED ABSTRACTWe conducted a two-center, prospective, open label, randomized, controlled clinical trial to compare the efficacy of ticagrelor vs clopidogrel in preventing cerebrovascular embolic events as assessed by transcranial Doppler during TAVR.The total number of procedural HITS was lower in the ticagrelor group (416.5 [324.8, 484.2]) than in the clopidogrel group (723.5 [471.5, 875.0]), p< 0.001. Patients on ticagrelor had on average 255.9 (95% CI: [-335.4, -176.4]) fewer total procedural HITS than those on clopidogrel. This protective effect was not associated with an increase in complications.

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“…Con estos antecedentes, el Dr. Jorn Brouwer y colaboradores diseñaron POPULAR TAVI, Cohorte A (26) , con la hipótesis de que el uso aislado de ácido acetil-salicílico (AAS) podría determinar menor incidencia de sangrado respecto a su combinación con clopidogrel por 3 meses, y podría ser no inferior con respecto al objetivo compuesto de sangrado o eventos tromboembólicos y al compuesto de eventos tromboembólicos, en pacientes que recibieran TAVI y que no tuvieran una indicación establecida de anticoagulación oral a largo plazo. Durante el Congreso, el Dr. Jurriën Ten Berg, investigador senior del estudio, indicó que no se realizó una comparación con la terapia con clopidogrel por razones logísticas, dado que usualmente la mayoría de pacientes ya reciben AAS.…”

Section: Aspirin With or Without Clopidogrel After Transcatheter Aortunclassified

Lo mejor del Congreso 2020 de la Sociedad Europea de Cardiología: la experiencia digital

Ache¹,

Guamán

Ramos³

2020

Rev Urug Cardiol.

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Aspirin with or without Clopidogrel after Transcatheter Aortic-Valve Implantation

Cited by 282 publications

References 29 publications

Impact of Transcatheter Aortic Valve Implantation on Thrombin Generation and Platelet Function

Impact of Transcatheter Aortic Valve Implantation on Thrombin Generation and Platelet Function

Ticagrelor vs Clopidogrel: the Impact of Platelet Inhibition on Cerebrovascular Microembolic Events during TAVR

Lo mejor del Congreso 2020 de la Sociedad Europea de Cardiología: la experiencia digital

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