Clin Res Cardiol (2022). https://doi.org/10.1007/s00392-022-02002-5

Analysis of anticoagulant and antiplatelet therapy in a multicenter cohort of transcatheter edge-to-edge mitral valve repair patients
F. Ausbüttel1, J. Cheko1, G. Chatzis1, S. Barth2, D. Fischer3, D. Divchev1, B. Schieffer4, U. Lüsebrink1, C. Wächter1
1Klinik für Innere Medizin - Schwerpunkt Kardiologie, Universitätsklinikum Giessen und Marburg GmbH, Marburg; 2Klinik für Kardiologie I - Interventionelle Kardiologie und kardiale Bildgebung, RHÖN-KLINIKUM AG Campus Bad Neustadt, Bad Neustadt a. d. Saale; 3Medizinische Klinik II - Kardiologie, Klinikum Rheine, Rheine; 4Klinik für Kardiologie, Angiologie und internistische Intensivmedizin, Universitätsklinikum Giessen und Marburg GmbH, Marburg;
Background:
Transcatheter edge-to-edge mitral valve repair (TMVR) using the MitraClip® device has become established as a safe and efficacious therapy for severe mitral valve regurgitation (MR) in high-risk surgical patients. Despite its rapid increasing use data regarding the appropriate management of anticoagulant and antiplatelet therapy in this collective of patients are rare and still a matter of debate.

Aim:
Based on multicenter real-world data, the use of antithrombotic and antiplatelet therapy in this specific patient cohort was analyzed and correlated with outcome parameters.

Methods:
In an observational cohort study all consecutive patients who underwent successful TMVR at three German tertiary Heart Centers between October 2011 and October 2019 were enrolled and the use of anticoagulant and antiplatelet therapy under consideration of the safety and efficacy during the periprocedural phase were analyzed.

Results:
During the analysis period 506 patients were consecutively successfully treated with the MitraClip® device. The majority of these patients (370/506, 73.1%) had concomitant atrial fibrillation (AF) and thus an indication for oral anticoagulation (OAC) according to the relevant guideline. Thirty of these patients refused oral anticoagulation against medical advice or received alternative therapy in the form of interventional LAA closure. Vitamin K antagonists represented the predominantly used anticoagulant compared to DOAK (58% vs. 42%). Consequently, most patients were treated post-intervention with OAC and single antiplatelet therapy (SAPT) (204/506, 40.3%), followed by OAC mono (107/506, 21.2%) and OAC and double antiplatelet therapy (DAPT, “triple therapy”) (53/506, 10.5%). The majority of patients without an indication for OAC received DAPT (116/506, 22.9%) followed by SAPT (15/506, 2.9%). Regarding safety and efficacy, no statistically significant differences in bleeding and transfusion rates or in systemic or cerebral thromboembolism were observed depending on the anticoagulant or antiplatelet regimen during hospitalization. Furthermore, no statistically significant differences regarding 1-year survival after TMVR were observed. During the study period, there was a clear trend toward a decrease in the frequency of triple therapy without a concomitant increase in thromboembolic complications before vs. after 2018 (32/283, 11.3% vs. 23/223, 10.3%; p=0.7).

Conclusion:
Anticoagulant and antiplatelet therapy varies in clinical routine and differs widely form clinical trials and even guideline recommendations. Antithrombotic triple therapy has been largely abandoned in favor of OAC + SAPT without an increase in thromboembolic complications. Further data, preferably from prospective studies, are needed to clarify which antithrombotic regimen is favorable in this unique patient population.





Table: Survival and peri- and post-procedural major adverse cardiac and cerebrovascular event (MACCE) rates of the different antithrombotic therapies after TMVR
 Variable  SAPT (n=15)
 DAPT (n=116)
 OAC mono (n=107)
 OAC + SAPT (n=204)
OAC + DAPT (n=53)
 p-value
 1-Year Survival
 80% (12)
 79.8% (93)
 77.7% (83)
 75.2% (153)
 80.2% (43)
 0.3
MACCE
Thromboembolic event
Bleeding,requiringintervention/transfusion
In-hospital death from cardiac cause


0% (0)
0% (0)
0% (0)
0% (0)


6% (7)
0% (0)
3.4% (4)
2.6% (3)

0.9% (1)
0% (0)
0.9% (1)
0% (0)

3.4% (7)
1% (2)
2% (4)
1% (2)

1.9% (1)
0% (0)
1.9% (1)
0% (0)

0.2
0.6
0.7
0.3


https://dgk.org/kongress_programme/jt2022/aP1862.html