(CCSP034) OPTIMAL ANTITHROMBOTIC THERAPY AFTER TRANSCATHETER AORTIC VALVE IMPLANTATION: A NETWORK META-ANALYSIS

Background: The optimal regimen of antithrombotic therapy in patients who undergo transcatheter aortic valve implantation (TAVI) is unknown due to the risk of both thrombotic and bleeding complications. We performed a systematic review and network meta-analysis of randomized controlled trials (RCTs) to compare different oral anticoagulant (OAC) and antiplatelet regimens.

METHODS AND RESULTS: We searched MEDLINE, Embase, CENTRAL, and ClinicalTrials.gov from inception to April 2023. The co-primary outcomes were all-cause death and major bleeding. Secondary outcomes included cardiovascular death, major adverse cardiovascular events, and minor bleeding based on Valve Academic Research Consortium criteria. Included were RCTs that compared any regimen of OAC and/or antiplatelet therapy and reported 1 or more outcomes of interest. No language restrictions were applied. Two reviewers independently screened articles, extracted data, and performed quality assessments using the Cochrane risk-of-bias tool 2.

We performed Bayesian network meta-analyses to compare all interventions simultaneously using the Markov-chain Monte Carlo method. We generated odds ratios with 95% credible intervals from the medians and 2.5th and 97.5th percentiles of the posterior distributions using a hierarchical Bayesian framework and random-effects model with informative priors. To rank interventions for each outcome, we calculated the mean surface under the cumulative ranking (SUCRA) curve.

From 262 citations, 11 RCTs (N=6415) were included. One RCT was unpublished. Overall risk of bias was low or with some concerns. Ten RCTs were open-label and 1 was double-blind. Three trials exclusively enrolled patients with an indication for OAC therapy. Median age was 81 years. Median follow-up was 6 months.

Compared to dual antiplatelet therapy (DAPT), a direct-acting OAC plus single antiplatelet therapy (DOAC+SAPT) had a higher risk of death, whereas there was no difference between DAPT and SAPT. DOAC+SAPT increased the risk of major bleeding compared to DAPT, while SAPT lowered the risk.

DAPT and SAPT ranked best for all-cause death (SUCRA 0.85 and 0.81, respectively). DAPT ranked best for cardiovascular death (SUCRA 0.70) and major adverse cardiovascular events (SUCRA 0.80). SAPT ranked best for major and minor bleeding (SUCRA 0.98 and 0.88, respectively). DOAC+SAPT ranked worst for all-cause death (SUCRA 0.19) and major bleeding (SUCRA 0.05). Results were nearly identical in the subgroup of trials that included patients without an indication for an OAC.

Conclusion: In post-TAVI patients, DAPT and SAPT ranked best for reducing death, whereas SAPT ranked best for bleeding. SAPT may provide the optimal balance of reducing thrombotic events while minimizing the risk of bleeding.