Interpretation of 2022 version of <i>Chinese expert consensus on antithrombotic therapy after transcatheter aortic valve implantation</i>_West China Medical Journal

Authors：

BAI Lin , PENG Yong , ZHAO Zhengang ,  CHEN Mao

Department of Cardiology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P. R. China;

Corresponding author：

CHEN Mao, Email: hmaochen@vip.sina.com

Keywords：

Transcatheter aortic valve implantation; transcatheter aortic valve replacement; antithrombotic therapy; expert consensus; interpretation

DOI：

10.7507/1002-0179.202202139

Video：

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Transcatheter aortic valve replacement (TAVR) is effective in the treatment of severe symptomatic aortic stenosis and its applicable population is also gradually expanding, but it carries risk of ischemic and bleeding events, which underscores the importance of optimizing adjuvant antithrombotic regimens. The release of the 2022 version of Chinese expert consensus on antithrombotic therapy after transcatheter aortic valve implantation has promoted the standardized and safe development of antithrombotic therapy after TAVR in China. Combined with the latest progress of antithrombotic therapy after TAVR, from emphasizing ischemia and bleeding risk assessment, single-agent antiplatelet therapy for patients without anticoagulation indications, the selection of antithrombotic strategies for patients with other antithrombotic indications, antithrombotic strategy changes in postoperative valve thrombosis and bleeding events, this article interprets this consensus.

Citation： BAI Lin, PENG Yong, ZHAO Zhengang, CHEN Mao. Interpretation of 2022 version of Chinese expert consensus on antithrombotic therapy after transcatheter aortic valve implantation. West China Medical Journal, 2022, 37(4): 485-490. doi: 10.7507/1002-0179.202202139 Copy

1.	Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol, 2014, 63(22): e57-e185.
2.	Nishimura RA, Otto CM, Bonow RO, et al. 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines. J Am Coll Cardiol, 2017, 70(2): 252-289.
3.	Baumgartner H, Falk V, Bax JJ, et al. 2017 ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J, 2017, 38(36): 2739-2791.
4.	Writing Committee Members, Otto CM, Nishimura RA, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Joint Committee on clinical practice guidelines. J Am Coll Cardiol, 2021, 77(4): 450-500.
5.	Vahanian A, Beyersdorf F, Praz F, et al. 2021 ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J, 2022, 43(7): 561-632.
6.	Mangieri A, Montalto C, Poletti E, et al. Thrombotic versus bleeding risk after transcatheter aortic valve replacement: JACC review topic of the week. J Am Coll Cardiol, 2019, 74(16): 2088-2101.
7.	中华医学会心血管病学分会, 中华心血管病杂志编辑委员会. 经导管主动脉瓣植入术后抗血栓治疗中国专家共识. 中华心血管病杂志, 2022, 50(2): 117-131.
8.	Vranckx P, Windecker S, Welsh RC, et al. Thrombo-embolic prevention after transcatheter aortic valve implantation. Eur Heart J, 2017, 38(45): 3341-3350.
9.	Leon MB, Smith CR, Mack M, et al. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med, 2010, 363(17): 1597-1607.
10.	Smith CR, Leon MB, Mack MJ, et al. Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med, 2011, 364(23): 2187-2198.
11.	Adams DH, Popma JJ, Reardon MJ, et al. Transcatheter aortic-valve replacement with a self-expanding prosthesis. N Engl J Med, 2014, 370(19): 1790-1798.
12.	Leon MB, Smith CR, Mack MJ, et al. Transcatheter or surgical aortic-valve replacement in intermediate-risk patients. N Engl J Med, 2016, 374(17): 1609-1620.
13.	Reardon MJ, Van Mieghem NM, Popma JJ, et al. Surgical or transcatheter aortic-valve replacement in intermediate-risk patients. N Engl J Med, 2017, 376(14): 1321-1331.
14.	Mack MJ, Leon MB, Thourani VH, et al. Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients. N Engl J Med, 2019, 380(18): 1695-1705.
15.	Popma JJ, Deeb GM, Yakubov SJ, et al. Transcatheter aortic-valve replacement with a self-expanding valve in low-risk patients. N Engl J Med, 2019, 380(18): 1706-1715.
16.	Thyregod HG, Steinbrüchel DA, Ihlemann N, et al. Transcatheter versus surgical aortic valve replacement in patients with severe aortic valve stenosis: 1-year results from the all-comers notion randomized clinical trial. J Am Coll Cardiol, 2015, 65(20): 2184-2194.
17.	Schmidt T, Leon MB, Mehran R, et al. Debris heterogeneity across different valve types captured by a cerebral protection system during transcatheter aortic valve replacement. JACC Cardiovasc Interv, 2018, 11(13): 1262-1273.
18.	Van Mieghem NM, El Faquir N, Rahhab Z, et al. Incidence and predictors of debris embolizing to the brain during transcatheter aortic valve implantation. JACC Cardiovasc Interv, 2015, 8(5): 718-724.
19.	Ranasinghe MP, Peter K, McFadyen JD. Thromboembolic and bleeding complications in transcatheter aortic valve implantation: insights on mechanisms, prophylaxis and therapy. J Clin Med, 2019, 8(2): 280.
20.	Rodés-Cabau J, Gutiérrez M, Bagur R, et al. Incidence, predictive factors, and prognostic value of myocardial injury following uncomplicated transcatheter aortic valve implantation. J Am Coll Cardiol, 2011, 57(20): 1988-1999.
21.	Rodés-Cabau J, Masson JB, Welsh RC, et al. Aspirin versus aspirin plus clopidogrel as antithrombotic treatment following transcatheter aortic valve replacement with a balloon-expandable valve: the ARTE (aspirin versus aspirin + clopidogrel following transcatheter aortic valve implantation) randomized clinical trial. JACC Cardiovasc Interv, 2017, 10(13): 1357-1365.
22.	Stabile E, Pucciarelli A, Cota L, et al. SAT-TAVI (single antiplatelet therapy for TAVI) study: a pilot randomized study comparing double to single antiplatelet therapy for transcatheter aortic valve implantation. Int J Cardiol, 2014, 174(3): 624-627.
23.	Ussia GP, Scarabelli M, Mulè M, et al. Dual antiplatelet therapy versus aspirin alone in patients undergoing transcatheter aortic valve implantation. Am J Cardiol, 2011, 108(12): 1772-1776.
24.	Brouwer J, Nijenhuis VJ, Delewi R, et al. Aspirin with or without clopidogrel after transcatheter aortic-valve implantation. N Engl J Med, 2020, 383(15): 1447-1457.
25.	Ten Berg J, Sibbing D, Rocca B, et al. Management of antithrombotic therapy in patients undergoing transcatheter aortic valve implantation: a consensus document of the ESC Working Group on Thrombosis and the European Association of Percutaneous Cardiovascular Interventions (EAPCI), in collaboration with the ESC Council on Valvular Heart Disease. Eur Heart J, 2021, 42(23): 2265-2269.
26.	Guyatt GH, Akl EA, Crowther M, et al. Executive summary: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest, 2012, 141(Suppl 2): 7S-47S.
27.	Popma JJ, Adams DH, Reardon MJ, et al. Transcatheter aortic valve replacement using a self-expanding bioprosthesis in patients with severe aortic stenosis at extreme risk for surgery. J Am Coll Cardiol, 2014, 63(19): 1972-1981.
28.	Dangas GD, De Backer O, Windecker S. A controlled trial of rivaroxaban after transcatheter aortic-valve replacement. Reply. N Engl J Med, 2020, 383(2): e8.
29.	Overtchouk P, Guedeney P, Rouanet S, et al. Long-term mortality and early valve dysfunction according to anticoagulation use: the France TAVI registry. J Am Coll Cardiol, 2019, 73(1): 13-21.
30.	Abdul-Jawad Altisent O, Durand E, Muñoz-García AJ, et al. Warfarin and antiplatelet therapy versus warfarin alone for treating patients with atrial fibrillation undergoing transcatheter aortic valve replacement. JACC Cardiovasc Interv, 2016, 9(16): 1706-1717.
31.	Nijenhuis VJ, Brouwer J, Delewi R, et al. Anticoagulation with or without clopidogrel after transcatheter aortic-valve implantation. N Engl J Med, 2020, 382(18): 1696-1707.
32.	Valgimigli M, Bueno H, Byrne RA, et al. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS. Eur J Cardiothorac Surg, 2018, 53(1): 34-78.
33.	Cáceres-Lóriga FM, Pérez-López H, Santos-Gracia J, et al. Prosthetic heart valve thrombosis: pathogenesis, diagnosis and management. Int J Cardiol, 2006, 110(1): 1-6.
34.	Cremer PC, Rodriguez LL, Griffin BP, et al. Early bioprosthetic valve failure: mechanistic insights via correlation between echocardiographic and operative findings. J Am Soc Echocardiogr, 2015, 28(10): 1131-1148.
35.	Schoen FJ, Gotlieb AI. Heart valve health, disease, replacement, and repair: a 25-year cardiovascular pathology perspective. Cardiovasc Pathol, 2016, 25(4): 341-352.
36.	Latib A, Naganuma T, Abdel-Wahab M, et al. Treatment and clinical outcomes of transcatheter heart valve thrombosis. Circ Cardiovasc Interv, 2015, 8(4): e001779.
37.	D’Ascenzo F, Salizzoni S, Saglietto A, et al. Incidence, predictors and cerebrovascular consequences of leaflet thrombosis after transcatheter aortic valve implantation: a systematic review and meta-analysis. Eur J Cardiothorac Surg, 2019, 56(3): 488-494.
38.	Jose J, Sulimov DS, El-Mawardy M, et al. Clinical bioprosthetic heart valve thrombosis after transcatheter aortic valve replacement: incidence, characteristics, and treatment outcomes. JACC Cardiovasc Interv, 2017, 10(7): 686-697.
39.	Brown ML, Park SJ, Sundt TM, et al. Early thrombosis risk in patients with biologic valves in the aortic position. J Thorac Cardiovasc Surg, 2012, 144(1): 108-111.
40.	Egbe AC, Pislaru SV, Pellikka PA, et al. Bioprosthetic valve thrombosis versus structural failure: clinical and echocardiographic predictors. J Am Coll Cardiol, 2015, 66(21): 2285-2294.
41.	Yanagisawa R, Hayashida K, Yamada Y, et al. Incidence, predictors, and mid-term outcomes of possible leaflet thrombosis after TAVR. JACC Cardiovasc Imaging, 2016, S1936-878X(16): 30897-X.
42.	Leetmaa T, Hansson NC, Leipsic J, et al. Early aortic transcatheter heart valve thrombosis: diagnostic value of contrast-enhanced multidetector computed tomography. Circ Cardiovasc Interv, 2015, 8(4): e001596.
43.	Pache G, Schoechlin S, Blanke P, et al. Early hypo-attenuated leaflet thickening in balloon-expandable transcatheter aortic heart valves. Eur Heart J, 2016, 37(28): 2263-2271.
44.	Chakravarty T, Søndergaard L, Friedman J, et al. Subclinical leaflet thrombosis in surgical and transcatheter bioprosthetic aortic valves: an observational study. Lancet, 2017, 389(10087): 2383-2392.
45.	Chakravarty T, Abramowitz Y, Jilaihawi H, et al. Leaflet motion abnormality after TAVI: genuine threat or much ado about nothing?. EuroIntervention, 2016, 12(Y): Y28-Y32.
46.	Piccolo R, Pilgrim T, Franzone A, et al. Frequency, timing, and impact of access-site and non-access-site bleeding on mortality among patients undergoing transcatheter aortic valve replacement. JACC Cardiovasc Interv, 2017, 10(14): 1436-1446.

1. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol, 2014, 63(22): e57-e185.
2. Nishimura RA, Otto CM, Bonow RO, et al. 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines. J Am Coll Cardiol, 2017, 70(2): 252-289.
3. Baumgartner H, Falk V, Bax JJ, et al. 2017 ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J, 2017, 38(36): 2739-2791.
4. Writing Committee Members, Otto CM, Nishimura RA, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Joint Committee on clinical practice guidelines. J Am Coll Cardiol, 2021, 77(4): 450-500.
5. Vahanian A, Beyersdorf F, Praz F, et al. 2021 ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J, 2022, 43(7): 561-632.
6. Mangieri A, Montalto C, Poletti E, et al. Thrombotic versus bleeding risk after transcatheter aortic valve replacement: JACC review topic of the week. J Am Coll Cardiol, 2019, 74(16): 2088-2101.
7. 中华医学会心血管病学分会, 中华心血管病杂志编辑委员会. 经导管主动脉瓣植入术后抗血栓治疗中国专家共识. 中华心血管病杂志, 2022, 50(2): 117-131.
8. Vranckx P, Windecker S, Welsh RC, et al. Thrombo-embolic prevention after transcatheter aortic valve implantation. Eur Heart J, 2017, 38(45): 3341-3350.
9. Leon MB, Smith CR, Mack M, et al. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med, 2010, 363(17): 1597-1607.
10. Smith CR, Leon MB, Mack MJ, et al. Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med, 2011, 364(23): 2187-2198.
11. Adams DH, Popma JJ, Reardon MJ, et al. Transcatheter aortic-valve replacement with a self-expanding prosthesis. N Engl J Med, 2014, 370(19): 1790-1798.
12. Leon MB, Smith CR, Mack MJ, et al. Transcatheter or surgical aortic-valve replacement in intermediate-risk patients. N Engl J Med, 2016, 374(17): 1609-1620.
13. Reardon MJ, Van Mieghem NM, Popma JJ, et al. Surgical or transcatheter aortic-valve replacement in intermediate-risk patients. N Engl J Med, 2017, 376(14): 1321-1331.
14. Mack MJ, Leon MB, Thourani VH, et al. Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients. N Engl J Med, 2019, 380(18): 1695-1705.
15. Popma JJ, Deeb GM, Yakubov SJ, et al. Transcatheter aortic-valve replacement with a self-expanding valve in low-risk patients. N Engl J Med, 2019, 380(18): 1706-1715.
16. Thyregod HG, Steinbrüchel DA, Ihlemann N, et al. Transcatheter versus surgical aortic valve replacement in patients with severe aortic valve stenosis: 1-year results from the all-comers notion randomized clinical trial. J Am Coll Cardiol, 2015, 65(20): 2184-2194.
17. Schmidt T, Leon MB, Mehran R, et al. Debris heterogeneity across different valve types captured by a cerebral protection system during transcatheter aortic valve replacement. JACC Cardiovasc Interv, 2018, 11(13): 1262-1273.
18. Van Mieghem NM, El Faquir N, Rahhab Z, et al. Incidence and predictors of debris embolizing to the brain during transcatheter aortic valve implantation. JACC Cardiovasc Interv, 2015, 8(5): 718-724.
19. Ranasinghe MP, Peter K, McFadyen JD. Thromboembolic and bleeding complications in transcatheter aortic valve implantation: insights on mechanisms, prophylaxis and therapy. J Clin Med, 2019, 8(2): 280.
20. Rodés-Cabau J, Gutiérrez M, Bagur R, et al. Incidence, predictive factors, and prognostic value of myocardial injury following uncomplicated transcatheter aortic valve implantation. J Am Coll Cardiol, 2011, 57(20): 1988-1999.
21. Rodés-Cabau J, Masson JB, Welsh RC, et al. Aspirin versus aspirin plus clopidogrel as antithrombotic treatment following transcatheter aortic valve replacement with a balloon-expandable valve: the ARTE (aspirin versus aspirin + clopidogrel following transcatheter aortic valve implantation) randomized clinical trial. JACC Cardiovasc Interv, 2017, 10(13): 1357-1365.
22. Stabile E, Pucciarelli A, Cota L, et al. SAT-TAVI (single antiplatelet therapy for TAVI) study: a pilot randomized study comparing double to single antiplatelet therapy for transcatheter aortic valve implantation. Int J Cardiol, 2014, 174(3): 624-627.
23. Ussia GP, Scarabelli M, Mulè M, et al. Dual antiplatelet therapy versus aspirin alone in patients undergoing transcatheter aortic valve implantation. Am J Cardiol, 2011, 108(12): 1772-1776.
24. Brouwer J, Nijenhuis VJ, Delewi R, et al. Aspirin with or without clopidogrel after transcatheter aortic-valve implantation. N Engl J Med, 2020, 383(15): 1447-1457.
25. Ten Berg J, Sibbing D, Rocca B, et al. Management of antithrombotic therapy in patients undergoing transcatheter aortic valve implantation: a consensus document of the ESC Working Group on Thrombosis and the European Association of Percutaneous Cardiovascular Interventions (EAPCI), in collaboration with the ESC Council on Valvular Heart Disease. Eur Heart J, 2021, 42(23): 2265-2269.
26. Guyatt GH, Akl EA, Crowther M, et al. Executive summary: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest, 2012, 141(Suppl 2): 7S-47S.
27. Popma JJ, Adams DH, Reardon MJ, et al. Transcatheter aortic valve replacement using a self-expanding bioprosthesis in patients with severe aortic stenosis at extreme risk for surgery. J Am Coll Cardiol, 2014, 63(19): 1972-1981.
28. Dangas GD, De Backer O, Windecker S. A controlled trial of rivaroxaban after transcatheter aortic-valve replacement. Reply. N Engl J Med, 2020, 383(2): e8.
29. Overtchouk P, Guedeney P, Rouanet S, et al. Long-term mortality and early valve dysfunction according to anticoagulation use: the France TAVI registry. J Am Coll Cardiol, 2019, 73(1): 13-21.
30. Abdul-Jawad Altisent O, Durand E, Muñoz-García AJ, et al. Warfarin and antiplatelet therapy versus warfarin alone for treating patients with atrial fibrillation undergoing transcatheter aortic valve replacement. JACC Cardiovasc Interv, 2016, 9(16): 1706-1717.
31. Nijenhuis VJ, Brouwer J, Delewi R, et al. Anticoagulation with or without clopidogrel after transcatheter aortic-valve implantation. N Engl J Med, 2020, 382(18): 1696-1707.
32. Valgimigli M, Bueno H, Byrne RA, et al. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS. Eur J Cardiothorac Surg, 2018, 53(1): 34-78.
33. Cáceres-Lóriga FM, Pérez-López H, Santos-Gracia J, et al. Prosthetic heart valve thrombosis: pathogenesis, diagnosis and management. Int J Cardiol, 2006, 110(1): 1-6.
34. Cremer PC, Rodriguez LL, Griffin BP, et al. Early bioprosthetic valve failure: mechanistic insights via correlation between echocardiographic and operative findings. J Am Soc Echocardiogr, 2015, 28(10): 1131-1148.
35. Schoen FJ, Gotlieb AI. Heart valve health, disease, replacement, and repair: a 25-year cardiovascular pathology perspective. Cardiovasc Pathol, 2016, 25(4): 341-352.
36. Latib A, Naganuma T, Abdel-Wahab M, et al. Treatment and clinical outcomes of transcatheter heart valve thrombosis. Circ Cardiovasc Interv, 2015, 8(4): e001779.
37. D’Ascenzo F, Salizzoni S, Saglietto A, et al. Incidence, predictors and cerebrovascular consequences of leaflet thrombosis after transcatheter aortic valve implantation: a systematic review and meta-analysis. Eur J Cardiothorac Surg, 2019, 56(3): 488-494.
38. Jose J, Sulimov DS, El-Mawardy M, et al. Clinical bioprosthetic heart valve thrombosis after transcatheter aortic valve replacement: incidence, characteristics, and treatment outcomes. JACC Cardiovasc Interv, 2017, 10(7): 686-697.
39. Brown ML, Park SJ, Sundt TM, et al. Early thrombosis risk in patients with biologic valves in the aortic position. J Thorac Cardiovasc Surg, 2012, 144(1): 108-111.
40. Egbe AC, Pislaru SV, Pellikka PA, et al. Bioprosthetic valve thrombosis versus structural failure: clinical and echocardiographic predictors. J Am Coll Cardiol, 2015, 66(21): 2285-2294.
41. Yanagisawa R, Hayashida K, Yamada Y, et al. Incidence, predictors, and mid-term outcomes of possible leaflet thrombosis after TAVR. JACC Cardiovasc Imaging, 2016, S1936-878X(16): 30897-X.
42. Leetmaa T, Hansson NC, Leipsic J, et al. Early aortic transcatheter heart valve thrombosis: diagnostic value of contrast-enhanced multidetector computed tomography. Circ Cardiovasc Interv, 2015, 8(4): e001596.
43. Pache G, Schoechlin S, Blanke P, et al. Early hypo-attenuated leaflet thickening in balloon-expandable transcatheter aortic heart valves. Eur Heart J, 2016, 37(28): 2263-2271.
44. Chakravarty T, Søndergaard L, Friedman J, et al. Subclinical leaflet thrombosis in surgical and transcatheter bioprosthetic aortic valves: an observational study. Lancet, 2017, 389(10087): 2383-2392.
45. Chakravarty T, Abramowitz Y, Jilaihawi H, et al. Leaflet motion abnormality after TAVI: genuine threat or much ado about nothing?. EuroIntervention, 2016, 12(Y): Y28-Y32.
46. Piccolo R, Pilgrim T, Franzone A, et al. Frequency, timing, and impact of access-site and non-access-site bleeding on mortality among patients undergoing transcatheter aortic valve replacement. JACC Cardiovasc Interv, 2017, 10(14): 1436-1446.

West China Medical Journal

Interpretation of 2022 version of Chinese expert consensus on antithrombotic therapy after transcatheter aortic valve implantation

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