The Effect of Dual Antiplatelet Therapy on Bleeding, Transfusion, and Long-Term Outcomes After Transcatheter Aortic Valve Replacement

Background: Transcatheter aortic valve replacement (TAVR) has become an established treatment for severe aortic stenosis, offering a minimally invasive alternative to surgical aortic valve replacement. Frequently, preoperative angiogram identifies coronary artery disease requiring percutaneous coronary intervention and thus dual antiplatelet therapy. While TAVR is associated with lower rates of bleeding and transfusion compared to surgical valve replacement, bleeding complications remain a concern. The impact of antiplatelet therapy on periprocedural bleeding, transfusion requirements, and long-term survival following TAVR remains uncertain. Methods: A retrospective review was conducted on 1116 patients who underwent TAVR between 2012 and 2021. Bleeding severity and outcomes were classified using the Bleeding Academic Research Consortium (BARC) criteria. Medication regimens, including preoperative antiplatelet therapy, were documented. Statistical analysis was performed using univariate, bivariate, and survival estimates to assess the impact of bleeding and transfusion on long-term outcomes. Results: A total of 248 patients were on dual antiplatelet therapy (DAPT). Of these, 105 patients (9.4%) required a transfusion during hospitalization. Patients on preoperative ticagrelor DAPT were significantly more likely to require transfusions compared to clopidogrel DAPT, aspirin, and no antiplatelet therapy (26.3% vs. 12.8% and 7.9% and 9.2%; p = 0.01) compared to those on aspirin alone. Long-term survival was significantly worse in DAPT groups (p < 0.01). Female gender (p < 0.01), hyperlipidemia (p = 0.02), coronary artery disease (p < 0.01), and peripheral vascular disease (p < 0.01) were significantly more prevalent in patients receiving dual antiplatelet therapy compared to those on aspirin or no therapy. Conclusion: Preoperative DAPT significantly increases the risk of periprocedural bleeding and transfusion, leading to decreased survival after TAVR. Severe bleeding independently predicts poorer survival outcomes. Consideration should be given to the timing of percutaneous coronary intervention (PCI) and antiplatelet strategy prior to TAVR to optimize periprocedural safety. The impact of modifying preoperative antiplatelet strategies on medium and long-term clinical outcomes warrants further investigation.