The Antithrombotic Strategies For Patients With Indication For Oral Anticoagulation After Transcatheter Aortic Valve Replacement:A Meta-analysis

Background:Transcatheter aortic valve replacement(TAVR)is an effective method to treat severe aortic stenosis,and antiplatelet is routinely given to prevent thrombosis after operation.However,the strategy of antithrombotic therapy after TAVR in patients with indication for oral anticoagulation remains controversial.Compared the efficacy and safety of different antithrombotic treatments in this population,this meta-analysis was aimed to provide reliable evidence for the best antithrombotic strategy.Methods:We searched the the PubMed,Cochrane Library,Embase,China National Knowledge Internet,China Biology Medicine and Wanfang databases for the clinical studies on comparing the outcomes of oral anticoagulant(OAC)alone versus OAC+antiplatelet therapy(APT),or OAC+single antiplatelet therapy(SAPT)versus OAC+dual antiplatelet therapy(DAPT),or non-vitamin K antagonist oral anticoagulant(NOAC)versus vitamin K antagonist(VKA)in patients with indication for oral anticoagulation undergoing TAVR,up to September,2021.The main end outcomes were all-cause mortality,stroke and bleedin g event.Results:Two randomized controlled trials and 12 cohort studies were enrolled in this meta-analysis.In OAC alone group,bleeding event was significantly lower than that in OAC+antiplatelet therapy(APT)group(RR=1.40,95%CI: 1.17-1.67,P=0.0002),and there was no significant difference in all-cause mortality and stroke between the two groups(RR=1.03,95%CI: 0.73-1.44,P=0.88;RR=0.88,95%CI: 0.61-1.26,P=0.49).In additional,Compared with OAC alone,OAC+SAPT or OAC+DAPT,the incidence of bleeding event increased obviously(RR=1.63,95%CI: 1.27-2.08,P=0.0001;RR=1.95,95 % CI: 1.04-3.66,P=0.04).In OAC+SAPT,the results of all-cause mortality,stroke and bleeding event were similar with OAC+DAPT(RR=0.91,95%CI: 0.58-1.44,P=0.69;RR=0.69,95%CI: 0.28-1.69,P=0.42;RR=1.18,95%CI: 0.72-1.94,P=0.51).The all-cause mortality,stroke and bleeding event in NOAC group were consistent with VKA group(RR=0.84,95%CI: 0.63-1.11,P=0.21;RR=1.02,95%CI: 0.76-1.38,P=0.89;RR=0.92,95%CI: 0.74-1.16,P=0.49).In the short-and long-term,stroke and bleeding event of NOAC group were in accordance with VKA group(P>0.05).Besides,this was also showing no difference in the all-cause mortality at short-term between NOAC and VKA group(RR=1.06,95%CI:0.66-1.71,P=0.82).But in the long-term,NOAC performed less all-cause mortality than VKA(RR=0.72,95%CI: 0.53-0.98,P=0.04).Conclusion:OAC+APT applied to antithrombotic therapy after TAVR in patients with indication for oral anticoagulatio increased the bleeding event,but without reducing the risk of stroke and all-cause mortality.What’s more,regardless of whether NOAC or VKA was used for antithrombotic therapy,the same effect on the endpoints was shown,thus NOAC therapy was a reasonable alternative to VKA.