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. 2018 Jan 26;5(1):e000748.
doi: 10.1136/openhrt-2017-000748. eCollection 2018.

Optimal antiplatelet strategy after transcatheter aortic valve implantation: a meta-analysis

Yousif Ahmad  1 , Ozan Demir  1 , Christopher Rajkumar  1 , James P Howard  1 , Matthew Shun-Shin  1 , Christopher Cook  1 , Ricardo Petraco  1 , Richard Jabbour  1 , Ahran Arnold  1 , Angela Frame  1 , Nilesh Sutaria  1 , Ben Ariff  1 , Gajen Kanaganayagam  1 , Darrel Francis  1 , Jamil Mayet  1 , Ghada Mikhail  1 , Iqbal Malik  1 , Sayan Sen  1
Affiliations

Optimal antiplatelet strategy after transcatheter aortic valve implantation: a meta-analysis

Yousif Ahmad et al. Open Heart. .

Abstract

Objective: International guidelines recommend the use of dual antiplatelet therapy (DAPT) after transcatheter aortic valve implantation (TAVI). The recommended duration of DAPT varies between guidelines. In this two-part study, we (1) performed a structured survey of 45 TAVI centres from around the world to determine if there is consensus among clinicians regarding antiplatelet therapy after TAVI; and then (2) performed a systematic review of all suitable studies (randomised controlled trials (RCTs) and registries) to determine if aspirin monotherapy can be used instead of DAPT.

Methods: A structured electronic survey regarding antiplatelet use after TAVI was completed by 45 TAVI centres across Europe, Australasia and the USA. A systematic review of TAVI RCTs and registries was then performed comparing DAPT duration and incidence of stroke, bleeding and death. A variance weighted least squared metaregression was then performed to determine the relationship of antiplatelet therapy and adverse events.

Results: 82.2% of centres routinely used DAPT after TAVI. Median duration was 3 months. 13.3% based their practice on guidelines. 11 781 patients (26 studies) were eligible for the metaregression. There was no benefit of DAPT over aspirin monotherapy for stroke (P=0.49), death (P=0.72) or bleeding (P=0.91).

Discussion: Aspirin monotherapy appears to be as safe and effective as DAPT after TAVI.

Keywords: antiplatelet treatment; aortic valve disease; percutaneous valve therapy; stroke.

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Conflict of interest statement

Competing interests: None declared.

Figures

Figure 1
Figure 1
Results of structured survey of 45 TAVI centres. Panel (A) shows the basis behind decisions made for antithrombotic treatment after TAVI; panel (B) shows antiplatelet loading regimens before TAVI; panel (C) shows longer term antiplatelet strategy after TAVI. DAPT, dual antiplatelet therapy; TAVI, transcatheter aortic valve implantation.
Figure 2
Figure 2
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart showing the search strategy for the systematic review, meta-analysis and metaregression.
Figure 3
Figure 3
Metaregression showing the relationship between mortality and antiplatelet strategy. The x-axis shows DAPT duration, including aspirin monotherapy on the far left (blue panel). The y-axis shows the incidence of mortality. Individual studies are represented by circles, with study size weighting giving varying sizes. The red line denotes the gradient (β), with there being of no benefit in terms of DAPT over aspirin for mortality. DAPT, dual antiplatelet therapy.
Figure 4
Figure 4
Metaregression showing the relationship between stroke and antiplatelet strategy. The x-axis shows DAPT duration, including aspirin monotherapy on the far left (blue panel). The y-axis shows the incidence of stroke. Individual studies are represented by circles, with study size weighting giving varying sizes. The red line denotes the gradient (β), with there being of no benefit in terms of DAPT over aspirin for stroke. DAPT, dual antiplatelet therapy.
Figure 5
Figure 5
Metaregression showing the relationship between bleeding and antiplatelet strategy. The x-axis shows DAPT duration, including aspirin monotherapy on the far left (blue panel). The y-axis shows the incidence of stroke. Individual studies are represented by circles, with study size weighting giving varying sizes. The red line denotes the gradient (β), with there being of no statistical difference between aspirin and DAPT for bleeding. DAPT, dual antiplatelet therapy.
See this image and copyright information in PMC

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