Orale Antikoagulation nach Klappeneingriffen – Was ist der Standard?

Zusammenfassung

Nach interventionellen Eingriffen an der Aortenklappe oder den atrioventrikulären (AV) Klappen (u. a. TAVI, M-TEER, T-TEER) wird prinzipiell eine antithrombotische Therapie empfohlen. Dabei muss differenziert werden zwischen Patienten, für die unabhängig vom Klappeneingriff eine Indikation zur oralen Antikoagulation (OAC) besteht, meist aufgrund von Vorhofflimmern (AF), und Patienten ohne OAC-Indikation. Mehrere randomisierte Studien konnten zeigen, dass bei AF-Patienten, die eine TAVI erhalten, eine Fortführung der OAC (Vitamin-K-Antagonisten oder NOAC) als Monotherapie einer dualen Therapie, bestehend aus OAC plus zusätzliche Thrombozyteninhibition, überlegen ist. Andererseits ist bei TAVI-Patienten ohne vorbestehende OAC-Indikation eine ASS-Monotherapie als postinterventionelle antithrombotische Therapie zu empfehlen. Nach segelbasierter (Edge-to-Edge) Rekonstruktion der Mitral- und Trikuspidalklappe wird bei bestehender OAC-Indikation eine Fortsetzung der Antikoagulation empfohlen, ansonsten ASS dauerhaft mit Clopidogrel für 1–3 Monate. Die optimale antithrombotische Therapie im Kontext interventioneller Eingriffe an den AV-Klappen ist jedoch bislang nicht in größeren randomisierten Studien untersucht.

Abstract

After interventional procedures of the aortic or the atrioventricular (AV) valves (e.g. TAVI, M-TEER, T-TEER), antithrombotic therapy is recommended. When choosing the optimal antithrombotic regimen, a distinction must be made between patients that have an indication for an oral anticoagulation (OAC) that exists independent of the valve intervention, mostly atrial fibrillation (AF), and patients without such an indication. Several randomized trials have shown that in AF patients receiving TAVI, continuation of OAC (vitamin K antagonists or NOAC) as monotherapy is superior to dual therapy consisting of OAC plus additional anti-platelet therapy. On the other hand, in TAVI patients without preexisting OAC indication, aspirin monotherapy is recommended as postinterventional antithrombotic therapy. After edge-to-edge repair of the mitral and tricuspid valves, continued OAC is recommended if there is a preexisting indication, otherwise aspirin should be prescribed permanently plus clopidogrel for 1–3 months. However, the optimal antithrombotic therapy after interventional repair and replacement of atrioventricular valves has not yet been investigated in larger randomized trials.

Was ist wichtig?

Bei Patienten mit Indikation zur oralen Antikoagulation sollte diese nach interventionellen Klappeneingriffen als Monotherapie fortgeführt werden.

Der Schutz vor thrombotischen klinischen Endpunkten nach perkutanen Klappeninterventionen unterscheidet sich nicht zwischen Vitamin-K-Antagonisten (VKA) und neuen oralen Antikoagulanzien (NOAC) bei bisher jedoch begrenzter Evidenz.

Schlüsselwörter

Antikoagulation - TAVI - interventionelle Klappeneingriffe - Edge-to-Edge-Rekonstruktion

Keywords

anticoagulation - TAVR - percutaneous valve interventions - edge-to-edge repair

Publikationsverlauf

Artikel online veröffentlicht:
05. Oktober 2022

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