REVIEW  CARDIAC SECTION 

The Journal of Cardiovascular Surgery 2019 October;60(5):624-32

DOI: 10.23736/S0021-9509.19.10833-6

Copyright © 2019 EDIZIONI MINERVA MEDICA

language: English

Antiplatelet strategy after transcatheter aortic valve replacement: an updated meta-analysis

Xiaochun MA ^{1, 2} ✉, Zhenqiang XU ^{1, 2}, Jinzhang LI ^{1, 2}, Diming ZHAO ^{1, 2}, Xiangqian KONG ³, Jiwei MA ⁴, Huibo MA ⁵, Yan YUN ⁶, Liangong SUN ^{1, 2}, Yuman ZHANG ⁷, Dong WEI ^{1, 2}, Qiqi JIAO ⁸, Chengwei ZOU ^{1, 2}, Zhengjun WANG ^{1, 2}

¹ Department of Cardiovascular Surgery, Shandong Provincial Hospital affiliated to Shandong First Medical University, Jinan, China; ² Department of Cardiovascular Surgery, Shandong Provincial Hospital affiliated to Shandong University, Jinan, China; ³ Department of Vascular Surgery, Shandong Provincial Hospital affiliated to Shandong University, Jinan, China; ⁴ Department of Pathology, Shandong Provincial Hospital affiliated to Shandong University, Jinan, China; ⁵ Qingdao University Medical College, Qingdao University, Qingdao, China; ⁶ Department of Neurology, Qilu Hospital of Shandong University, Jinan, China; ⁷ Emergency Center, Shandong Provincial Hospital affiliated to Shandong University, Jinan, China; ⁸ Department of Anesthesiology, Shandong Provincial Hospital affiliated to Shandong University, Jinan, China

INTRODUCTION: Recently transcatheter aortic valve replacement (TAVR) has emerged as a feasible alternative for traditional surgical aortic valve replacement (SAVR) in patients with intermediate to high risk. There is currently no clear consensus regarding the optimal antiplatelet strategy after TAVR. The primary objective of this updated meta-analyses was to compare the outcomes of dual antiplatelet therapy (DAPT) versus single antiplatelet therapy (SAPT) following TAVR.
EVIDENCE ACQUISITION: A meta-analysis of eligible studies of patients undergoing TAVR which reported our outcomes of postoperative DAPT in comparison with SAPT, was carried out. The outcomes included the all-cause mortality, stroke, major/life-threatening bleeding, myocardial infarction and a composite endpoint of mortality, stroke, bleeding and myocardial infarction.
EVIDENCE SYNTHESIS: Three randomized controlled trials (RCTs, N.=421) and 5 observational studies (N.=6683) were included in this updated meta-analysis. All-cause mortality was comparable between the two groups (OR 1.13 [95% CI: 0.70-1.81], P=0.619). Besides, DAPT resulted in an augmented risk of major/life-threatening bleeding (OR 2.45 [95% CI: 1.08-5.59], P=0.032). No statistically significant difference was found between the two groups in the rates of stroke (OR 0.83 [95% CI: 0.62-1.10], P=0.212) and myocardial infarction (OR 1.17 [95% CI: 0.47-2.91], P=0.728). And DAPT led to an increased rate of the composite endpoint (OR 2.39 [95% CI: 1.63-3.50], P<0.0001).
CONCLUSIONSː The updated meta-analysis presents the evidence that post-TAVR DAPT increases bleeding events, with no benefit in survival and ischemic events, in comparison with SAPT. Nevertheless, it is currently difficult to evaluate by a meta-analysis the effectiveness of DAPT versus SAPT to prevent the valve thrombosis resulting in leaflet dysfunction, due to a limited number of existing publications. Additional RCTs are needed to determine the optimal antiplatelet strategy after TAVR.

KEY WORDS: Platelet aggregation inhibitors; Aspirin; Clopidogrel; Transcatheter aortic valve replacement