Post-Transcatheter Aortic Valve Replacement Antithrombotic Treatment in Nonindicated Patients: Updated Systematic Review and Network Meta-Analysis

Sahand Siami; Sina Kazemian; Saba Maleki; Elham Ebrahimi; Fatemeh Jodeiri; Mandana Ebrahimzade; Mohsen Hajiqasemi; Sara Ebrahimi; Maede Mehdizadeh; Mona Aghaei; Mohammad-Mahdi Bastan; Mehrshad Fathian Sabet; Roozbeh Nazari; Pouya Ebrahimi; Jamal S Rana; Michael G Nanna; Jay Giri; Dhaval Kolte; Tor Biering-Sørensen; Mohamad Alkhouli; Kaveh Hosseini

doi:10.1016/j.jacadv.2025.101719

Post-Transcatheter Aortic Valve Replacement Antithrombotic Treatment in Nonindicated Patients: Updated Systematic Review and Network Meta-Analysis

JACC Adv. 2025 May;4(5):101719. doi: 10.1016/j.jacadv.2025.101719. Epub 2025 Mar 31.

Authors

Sahand Siami¹, Sina Kazemian², Saba Maleki², Elham Ebrahimi², Fatemeh Jodeiri¹, Mandana Ebrahimzade³, Mohsen Hajiqasemi³, Sara Ebrahimi⁴, Maede Mehdizadeh², Mona Aghaei⁵, Mohammad-Mahdi Bastan², Mehrshad Fathian Sabet⁶, Roozbeh Nazari⁷, Pouya Ebrahimi², Jamal S Rana⁸, Michael G Nanna⁹, Jay Giri¹⁰, Dhaval Kolte¹¹, Tor Biering-Sørensen¹², Mohamad Alkhouli¹³, Kaveh Hosseini¹⁴

Affiliations

¹ Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran; School of Medicine, Islamic Azad University, Tehran Medical Branch, Tehran, Iran.
² Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran.
³ School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
⁴ School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Department of Cardiology, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
⁵ School of Medicine, Islamic Azad University, Tehran Medical Branch, Tehran, Iran.
⁶ Department of Internal Medicine, McLaren Flint/Michigan State University (MSU), Flint, Michigan, USA.
⁷ Cardiovascular Research Center, Shahid Beheshti University of Medical Sciences, Modarres Hospital, Tehran, Iran.
⁸ Division of Cardiology, Kaiser Permanente Northern California, Oakland, California, USA; Division of Research, Kaiser Permanente Northern California, Oakland, California, USA.
⁹ Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA.
¹⁰ Cardiovascular Medicine Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
¹¹ Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA.
¹² Department of Cardiology, Herlev and Gentofte University Hospital, Copenhagen, Denmark.
¹³ Division of Cardiology, Mayo Clinic Hospital, Rochester, Minnesota, USA.
¹⁴ Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran. Electronic address: kaveh_hosseini130@yahoo.com.

Abstract

Background: The optimal antithrombotic strategy following transcatheter aortic valve replacement (TAVR) remains controversial.

Objectives: The authors aimed to determine the safety and efficacy of various antithrombotic regimens in patients without an indication for anticoagulation following TAVR.

Methods: We conducted a systematic search in PubMed, Embase, Scopus, and ClinicalTrials.gov until August 2024 for studies investigating antithrombotic regimens after TAVR in patients without an indication for chronic oral anticoagulation. The analysis compared single antiplatelet therapy (SAPT), dual antiplatelet therapy (DAPT), direct oral anticoagulants, and oral anticoagulant (OAC) plus SAPT. A frequentist network meta-analysis was employed to evaluate the post-TAVR risk of all-cause mortality, cardiovascular mortality, myocardial infarction, stroke, total bleeding, and life-threatening or major bleeding.

Results: Eleven studies (8 randomized controlled trials and 3 propensity score-matched cohorts) comprising 5,821 patients undergoing TAVR were included. SAPT significantly reduced the risk of life-threatening/major bleeding compared with DAPT (OR: 0.53; 95% CI: 0.35-0.80), OAC (OR: 0.52; 95% CI: 0.28-0.99), and OAC + SAPT (OR: 0.32; 95% CI: 0.13-0.76). No significant differences were observed in the risk of cardiovascular mortality, stroke, or myocardial infarction between antithrombotic regimens. Subgroup analysis indicated an increased risk of mortality with low-dose rivaroxaban+3-month SAPT compared with SAPT (OR: 0.56; 95% CI: 0.35-0.89) and DAPT (OR: 0.58; 95% CI: 0.38-0.88). Meta-regression identified chronic obstructive pulmonary disease as the only significant modifier of bleeding risk following TAVR.

Conclusions: Our findings support current guidelines recommending SAPT as the preferred antithrombotic strategy post-TAVR in patients without an indication for anticoagulation, demonstrating optimal safety without compromising efficacy.

Keywords: direct oral anticoagulant; dual antiplatelet therapy; low-dose rivaroxaban; single antiplatelet therapy; transcatheter aortic valve replacement; vitamin K antagonist.

Abstract

Grants and funding