Jeffrey Berger, MD: Antithrombotic Strategy Following TAVR

TAVR has revolutionized treatment for aortic stenosis but we are still learning more about how to best manage antithrombotic strategy following this procedure.

With the onset of any practice-altering procedure, treatment, or study, a seemingly never-ending list of inquiries is prompted questioning everything from appropriate patient populations, long-term comparisons to current standards, and, often, which devices are most effective.

Transcatheter aortic valve replacement (TAVR) has endured all of these questions and then some. Now that the efficacy and safety of the procedure has been well-established, many cardiologists are looking for answers on management following the surgery.

At the same time, the community was learning more and more about this revolutionary procedure, our knowledge of antithrombotic strategy and anti-platelet therapy was growing by leaps and bounds. Naturally, these worlds began to collide and the earliest efforts and research culminated in the presentation of the GALILEO study at AHA 2019.

Even with GALILEO demonstrating rivaroxaban use was associated with an elevated risk of death and bleeding compared to anti-platelet based antithrombotic strategy, the consensus is more research and studies are needed to learn more about antithrombotic strategy following TAVR.

For more on how the onset of TAVR has impacted how cardiologists view and manage antithrombotic strategy in patients with aortic stenosis, MD Magazine® sat down with Jeffrey Berger, MD, associate professor of Medicine and Surgery and director of Center for Prevention of Cardiovascular Disease at NYU Langone, for his perspective.

MD Mag: How has the onset of TAVR impacted antithrombotic strategy?

Berger: I think TAVR has been a real revolution. In terms of taking care of patients with significant aortic stenosis. I think TAVR has really fundamentally changed How patients with severe aortic stenosis get treated. For example, in the past, most patients would undergo an open, very significant surgery And I think TAVR has really reminded us that that is not always necessary and that in fact, a non-invasive approach or a less invasive approach really seems to be desirable by the patient. But the clinical data supporting it is outstanding. So, I think it is a game-changer.

There have been some trials in terms of how do we treat patients in the long term after they have a TAVR. For example, there was a recent trial that was just presented at the American Heart Association called GALILEO where they looked at two patients who get dual antiplatelet therapy for 3 months followed by aspirin by itself versus aspirin plus an oral anticoagulant, in this case, rivaroxaban. I think people thought that the oral anticoagulant would be better, but the trial, I think, really convincingly showed us that probably the antiplatelet therapy strategy is better, is safer, and even was associated with lower all-cause mortality.

So, I think I think trials are rightfully underway to sort of help us figure out how we can combine great medicines together with procedures such as TAVR. But I think today, we're not entirely certain I think the recent study would suggest that we're that we should be using antiplatelet therapy or dual antiplatelet therapy for the first 3 months followed by single antiplatelet therapy, but I think this is an area where there is a lot of data to be ensued over the next few months and years.