Traditional surgical aortic valve replacement is associated with a high risk of serious complications, especially in elderly patients with other preoperative diseases and unable to undergo thoracotomy. Therefore, transcatheter aortic valve implantation (TAVI) is now the accepted standard treatment for patients with symptomatic severe aortic stenosis at elevated risk for conventional surgical valve replacement. Currently, guidelines propose the use of dual antiplatelet therapy for the prevention of thromboembolic events after TAVI in the patients without an indication for oral anticoagulation. While, this strategy is empiric and largely based on expert consensus extrapolated from the arena of percutaneous coronary intervention. Antithrombotic therapy is associated with a significant occurrence of both thrombotic and bleeding complications, thus, the balance between thrombotic and bleeding risk is critical. This review summarizes current guidelines and the evidence underpinning them and explores the rational for using antiplatelet and/or anticoagulant strategies after TAVI.
ObjectiveTo systematically evaluate the effects of non-vitamin K antagonist oral anticoagulants (NOAC) and vitamin K antagonists (VKA) on postoperative anticoagulation in patients undergoing transcatheter aortic valve implantation (TAVI) with combined high-risk atrial fibrillation (AF). MethodsAll clinical research literature on NOAC and VKA in TAVI patients with high-risk AF was collected using computer searches of PubMed, EMbase, The Cochrane Library, CNKI, VIP, and SinoMed. The retrieval schedule was from inception to January 2023. The Newcastle-Ottawa Scale (NOS) was utilized to provide an assessment of the quality of the included literature. Meta-analysis was performed by applying RevMan 5.4 software to the studies that met the quality criteria. ResultsA total of 24 592 patients were incorporated in 7 eligible papers for meta-analysis. Patients with NOAC had a significantly lower risk of all-cause mortality compared with TAVI patients with combined high-risk AF who had VKA [RR=0.74, 95%CI (0.58, 0.94), P=0.01]. During the first year of follow-up, no apparent difference in all-cause mortality was observed between the two groups [RR=0.57, 95%CI (0.17, 1.88), P=0.35]. After a year of following up on patients treated with VKA, all-cause mortality was higher in the group treated with NOAC, and the difference was statistically meaningful [RR=0.73, 95%CI (0.57, 0.95), P=0.02]. Patients in both groups had early stroke [RR=0.50, 95%CI (0.19, 1.28), P=0.15], follow-up stroke [RR=1.04, 95%CI (0.88, 1.22), P=0.64] and bleeding [RR=0.94, 95%CI (0.73, 1.21), P=0.61], severe or life-threatening hemorrhage [RR= 0.80, 95%CI (0.49, 1.31), P=0.38], and acute kidney injury [RR=0.51, 95%CI (0.16, 1.59), P=0.24] were all non-statistically significant differences. ConclusionCompared with the application of VKA, postoperative anticoagulation with NOAC in TAVI patients with combined high-risk AF may reduces all-cause mortality in patients and may yield additional benefit especially in long-term anticoagulation.