Anticoagulation after TAVI in patients with a Preexisting

Anticoagulation after TAVI in patients with: a) Pre-existing AF b) New Onset AF Kostis Raisakis ”G. Gennimatas” General Hospital of Athens

Overview: 1 AF in TAVR Patients 2 Anticoagulation in TAVR patients with AF according to Guidelines 3 4 Newer Therapeutic Considerations Ongoing Trial Involving TAVR patients and OAC.

Overview: 1 AF in TAVR Patients 2 Anticoagulation in TAVR patients with AF according to Guidelines 3 4 Newer Therapeutic Considerations Ongoing Trial Involving TAVR patients and OAC.

1. AF Types in TAVR Patients Definition Pre-existing AF: • history of AF before TAVR regardless of the duration. • the presence of AF on hospital admission • at the time of the procedure. New Onset AF: AF occurring after TAVR lasting long enough to be recorded on a 12 -lead electrocardiogram or at least 30 s on a rhythm strip. Falk et al, EHJ 2017

1. AF Types in TAVR Patients Epidemiology Tarantini et al, EHJ, 2016

1. AF Types in TAVR Patients Predictors of NOAF Amar et al, Trends Cardiovasc Med, 2020

1. AF Types in TAVR Patients Prognosis/Survival Mentias et al, JACC Cardiovasc Interv, 2019

1. AF Types in TAVR Patients Prognosis/Bleeding, Stroke Mentias et al, JACC Cardiovasc Interv, 2019

Overview: 1 AF in TAVR Patients 2 Anticoagulation in TAVR patients with AF according to Guidelines 3 4 Newer Therapeutic Considerations Ongoing Trial Involving TAVR patients and OAC.

2. Anticoagulation in TAVR patients with AF Societal Guideline Recommendations Many of the societal guidelines do not issue specific recommendations for patients requiring long-term OAC, rendering this specific subgroup a residual field of uncertainty

2. Anticoagulation in TAVR patients with AF Adherence to Guidelines Cerrato et al, Int J Cardiol, 2017

2. Anticoagulation in TAVR patients with AF Therapeutic Challenges TAVR Patients with AF No CAD/PAD VKA or DOAC? OAC+APTs? CAD/PAD OAC Alone OAC+APTs?

2. Anticoagulation in TAVR patients with AF APT on top of OAC Lugo et al, Eur Cardiol 2019 Greco et al, Interv Cardiol. 2020

Overview: 1 AF in TAVR Patients 2 Anticoagulation in TAVR patients with AF according to Guidelines 3 4 Newer Therapeutic Considerations Ongoing Trial Involving TAVR patients and OAC.

3. Newer Therapeutic Considerations VKA and Mortality (FRANCE TAVI Registry) Overtchouk et al, JACC, 2019

3. Newer Therapeutic Considerations VKA and Mortality (FRANCE TAVI Registry) CORRELATES OF BIOPROSTHETIC VALVE DYSFUNCTION Overtchouk et al, JACC, 2019

3. Newer Therapeutic Considerations Type of OAC (VKA vs NOAC) Geis et al, Clin Res Cardiol. 2018

3. Newer Therapeutic Considerations Type of OAC (VKA vs NOAC) Jockheim et al, JACC Cardiovasc Interv. 2019

3. Newer Therapeutic Considerations Abixaban vs VKA Early safety point: all-cause mortality, all stroke, life-threatening bleeding, acute kidney injury, coronary obstruction, major vascular complications, and valve dysfunction requiring re-intervention Seeger et al, JACC Cardiovasc. Interv. 2017

3. Newer Therapeutic Considerations Rivaroxaban/ASA (Galileo) Dangas et al, NEJM. 2020

3. Newer Therapeutic Considerations OAK+APT (Popular TAVI) Nijenhius et al, NEJM. 2020

Overview: 1 AF in TAVR Patients 2 Anticoagulation in TAVR patients with AF according to Guidelines 3 4 Newer Therapeutic Considerations Ongoing Trial Involving TAVR patients and OAC.

4. Ongoing Trial Involving TAVR and AF ATLANTIS

4. Ongoing Trial Involving TAVR and AF ENVISAGE

4. Ongoing Trial Involving TAVR and AF AVATAR

4. Ongoing Trial Involving TAVR and AF WATCH-TAVR

Summary ü It is reasonable to adopt a strategy of anticoagulation in all TAVR patients with AF. ü Use of VKA is the current standard of care. ü More data are needed regarding the safety of use of DOACs ü In some cases patient-specific factors favor DOACs (e. g. high bleeding risk, difficulty maintain INRs within therapeutic range with VKA) ü The use of concomitant antiplatelet therapy being reserved for patients who had undergone recent percutaneous coronary intervention

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3. Newer Therapeutic Considerations VKA and Mortality (FRANCE TAVI Registry) CORRELATES OF LONG-TERM MORTALITY Overtchouk et al, JACC, 2019

2. Anticoagulation in TAVR patients with AF Adherence to Guidelines < 30% were discharged on anticoagulant therapy Vora et al, JACC Cardiovasc Interv, 2018