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. 2019 May;107(5):1571-1581.
doi: 10.1016/j.athoracsur.2018.10.016. Epub 2018 Nov 17.

Antithrombotic Strategies After Bioprosthetic Aortic Valve Replacement: A Systematic Review

Joel N Papak  1 , Joseph C Chiovaro  2 , North Noelck  2 , Laura D Healy  3 , Michele Freeman  4 , Jacquelyn A Quin  5 , Robin Paynter  4 , Allison Low  4 , Karli Kondo  4 , Owen J T McCarty  3 , Devan Kansagara  6
Affiliations

Antithrombotic Strategies After Bioprosthetic Aortic Valve Replacement: A Systematic Review

Joel N Papak et al. Ann Thorac Surg. 2019 May.

Abstract

Background: The optimal antithrombotic regimen after bioprosthetic aortic valve replacement (bAVR) is unclear. We conducted a systematic review of various anticoagulation strategies following surgical or transcatheter bAVR (TAVR).

Methods: We searched Medline, PubMed, Embase, Evidence-Based Medicine Reviews, and gray literature through June 2017 for controlled clinical trials and cohort studies that directly compared different antithrombotic strategies in nonpregnant adults who had undergone bAVR. We assessed risk of bias and graded the strength of the evidence using established methods.

Results: Of 4,554 titles reviewed, 6 clinical trials and 13 cohort studies met inclusion criteria. We found moderate-strength evidence that mortality, thromboembolic events, and bleeding rates are similar between aspirin and warfarin after surgical bAVR. Observational data suggest lower mortality and thromboembolic events with aspirin combined with warfarin compared with aspirin alone after surgical bAVR, but the effect size is small and the combination is associated with a substantial increase in bleeding risk. We found insufficient evidence for all other treatment comparisons in surgical bAVR. In TAVR patients, we found moderate-strength evidence that mortality, stroke, and major cardiac events are similar between dual antiplatelet therapy and aspirin alone, though a nonsignificantly lower rate of bleeding occurred with aspirin alone.

Conclusions: Treatment with warfarin or aspirin leads to similar outcomes after surgical bAVR. Combining aspirin with warfarin may lead to a small decrease in thromboembolism and mortality, but is accompanied by increased bleeding. For TAVR patients, aspirin is equivalent to dual antiplatelet therapy for reducing thromboembolism and mortality, with a possible decrease in bleeding.

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Figures

Fig 1.
Fig 1.
Literature flow diagram. (bAVR = bioprosthetic aortic valve replacement; CDSR = Cochrane Database of Systematic Reviews; Cochrane CENTRAL = Cochrane Controlled Register of Trials; DARE = Database of Abstracts of Reviews of Effects; EBM Reviews = Evidence-Based Medicine Reviews; HTA = Health Technology Assessment; RCT = randomized controlled trial; TAVR = transcatheter aortic valve replacement.)
Fig 2.
Fig 2.
Mortality, thromboembolic events, and major bleeding complications at 90 days in trials that compared warfarin with acetylsalicylic acid (ASA) after surgical bioprosthetic aortic valve replacement. (CI = confidence interval; M-H = Mantel-Haenszel.)
Fig 3.
Fig 3.
Mortality, thromboembolic events, and major bleeding complications at 30 days in trials that compared acetylsalicylic acid (ASA) versus dual antiplatelet therapy (DAPT) after transcatheter aortic valve replacement. (CI = confidence interval; M-H = Mantel-Haenszel.)
Fig 4.
Fig 4.
Mortality, thromboembolic events, and major bleeding complications at 3 to 6 months in trials that compared acetylsalicylic acid (ASA) versus dual antiplatelet therapy (DAPT) after transcatheter aortic valve replacement. (CI = confidence interval; M-H = Mantel-Haenszel.)
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Comment in

  • Invited Commentary.
    Jaffer IH, Whitlock RP. Jaffer IH, et al. Ann Thorac Surg. 2019 May;107(5):1581-1582. doi: 10.1016/j.athoracsur.2018.12.020. Epub 2019 Jan 11. Ann Thorac Surg. 2019. PMID: 30641067 No abstract available.

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