Antithrombotische Therapie während und nach kathetergestützter Implantation von Aortenklappen (TAVI)

Abstract

Transcatheter Aortic valve implantation (TAVI) is a new therapeutic option for inoperable patients or patients at high risk (logistic EURO-Score > 20 %) for conventional aortic valve replacement. The goal of antithrombotic therapy is the minimization of risk of cardioembolic complications. The risk of major stroke after TAVI varies between 1,7 and 8 %. 73 % of all strokes occur after the TAVI-procedure, while 27 % occur during the procedure. Unfractionated heparin (ACT 300 – 350 s) is the recommended peri-procedural antithrombotic therapy. After TAVI dual antiplatelet therapy with 100 mg aspirin and 75 mg clopidogrel should be maintained for 6 months. In case of indication for oral anticoagulation (atrial fibrillation/artificial heart valve), no triple therapy should be administered to these high risk bleeding patients. Antiplatelet monotherapy using clopidogrel in addition to warfarin/phenprocumon is sufficient in these patients.

• Literatur

• 1 Roques F, Nashef SA, Michel P et al. Risk factors and outcome in European cardiac surgery: analysis of the Euro-SCORE multinational database of 19.030 patients. Eur J Cardiothorac Surg 1999; 15: 816-822
• 2 Iung B, Baron G, Butchart EG et al. A prospective survey of patients with valvular heart disease in Europe: the Euro Heart Survey on Valvular Heart Disease. Eur Heart J 2003; 24: 1231-1243
• 3 Andersen HR, Knudsen LL, Hasenkam JM. Transluminal implantation of artificial heart valves: description of a new expandable aortic valve and initial results with implantation by catheter techniques in closed chest pigs. Eur Heart J 1992; 13: 704-708
• 4 Vahanian A, Alfieri O, Al-Attar N et al. Transcatheter valve implantation for patients with aortic stenosis: a position statement from the European Association of Cardio-Thoracic Surgery (EACTS) and the European Society of Cardiology (ESC), in collaboration with the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2008; 29: 1463-1470
• 5 Grube E, Laborde JC, Gerckens U et al. Percutaneous implantation of the CoreValve self-expanding valve prosthesis in high-risk patients with aortic valve disease: the Siegburg first-in-man study. Circulation 2006; 114: 1616-1624
• 6 Smith CR, Leon MB, Mach MJ et al. Transcatheter versus Surgical aortic – valve replacement in high-risk patients. N Engl J Med 2011; 64: 2187-2198
• 7 Hynes BG, Rodés-Cabau J. Transcatheter aortic valve implantation and cerebrovascular events: the current state of the art. Ann NY Acad Sci 2012; 1254: 151-163
• 8 Zahn R, Gerckens U, Grube E et al. German Transcatheter Aortic Valve Interventions-Registry Investigators. Transcatheter aortic valve implantation: first results from a multi-centre real-world registry.. Eur Heart J 2011; 32: 198-204
• 9 Thomas M, Schymik G, Walther T et al. One-Year Outcomes of Cohort 1 in the Edwards SAPIEN Aortic Bioprosthesis European Outcome (SOURCE) Registry: The European Registry of Transcatheter Aortic Valve Implantation Using the Edwards SAPIEN Valve. Circulation 2011; 124: 425-433
• 10 Leon MB, Smith CR, Mack M. PARTNER Trial Investigators et al. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery.. N Engl J Med 2010 2010; 363: 1597-1607
• 11 Nietlispach F, Wijesinghe N, Gurvitch R et al. An embolic deflection device for aortic valve interventions. JACC Cardiovasc Interv 2010; 3: 1133-1138
• 12 Dehédin B, Guinot PG, Ibrahim H et al. Anesthesia and perioperative management of patients who undergo transfemoral transcatheter aortic valve implantation: an observational study of general versus local/regional anesthesia in 125 consecutive patients. J Cardiothorac Vasc Anesth 2011; 25: 1036-1043
• 13 Bonow RO et al. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): developed in collaboration with the Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. Circulation 2006; 114: e84-e231
• 14 Müller KAL, Werner S, Sutaj B et al. Time course of platelet aggregation and platelet activation in patients under dual antiplatelet therapy undergoing percutaneous aortic valve replacement. Clin Res Cardiol 2012; abstract
• 15 Ussia GP, Scarabelli M, Mulè M et al. Dual antiplatelet therapy versus aspirin alone in patients undergoing transcatheter aortic valve implantation. Am J Cardiol 2011; 108: 1772-1776
• 16 Stabile E, Soropago E, Pucciarelli A et al. SAT-TAVI (Single Antiplatelet Therapy for TAVI) study: A Pilot Randomized Study Comparing double antiplatelet therapy for transcatheter Aortic valve implantation. J Am Coll Cardiol 2011; 58 B1 (abstract)