Target Audience:

Who should attend:

• Clinical faculty from the University of Pittsburgh School of Pharmacy
• Clinical staff pharmacists employed by the University of Pittsburgh Medical Center and deployed throughout the hospital campus in unit based roles and centrally in the department of pharmacy's main pharmacy
• Student pharmacy interns currently working within the department of pharmacy
• Certified Pharmacy Technicians

Abstract
Transcatheter aortic-valve replacement (TAVR) is a procedure, in which a bioprosthetic valve is inserted through a catheter and implanted within the stenotic native aortic valve. Although outcomes from TAVR continue to improve, patients remain at risk for both thromboembolic events and bleeding events following the procedure, raising the question regarding the optimal antiplatelet and anticoagulation strategies. Extrapolating from experience with intra-coronary stents, the early TAVR trial protocols used 3-6 months of dual antiplatelet therapy (DAPT) with aspirin and clopidogrel followed by daily low-dose aspirin.
There are three possible scenarios which clinicians may encounter:

1. patients undergoing TAVR with no recent percutaneous coronary intervention (PCI) and no indication for anticoagulation
2. patients undergoing TAVR with recent PCI and no indication for anticoagulation, and
3. patients undergoing TAVR with an indication for anticoagulation.

Current guidelines recommend low-dose aspirin monotherapy (Class IIa) or DAPT for 3-6 months (Class IIb) post-TAVR where anticoagulation is not indicated.1 There remains debate about the use of DAPT or single antiplatelet therapy (SAPT) is, and regarding anticoagulation. Evidence from the GALILEO trial5 suggests routine anticoagulation should not be used in all TAVR patients; yet, questions remain regarding the best strategy in TAVR patients who have an indication for oral anticoagulation. This presentation seeks to evaluate current evidence and recommendations for the use of DAPT and SAPT as well as with direct acting anticoagulants with warfarin.

Educational Objectives:

Upon successful completion of this continuing pharmacy education program, the participant should be able to:

• Recognize barriers to selecting appropriate antithrombotic therapies following transcatheter aortic valve replacement (TAVR).
• Discuss the evidence surrounding of the use of antiplatelet and anticoagulant therapy following TAVR.
• Identify an appropriate adjunctive antithrombotic therapy for patients with aortic stenosis undergoing TAVR.

Pharmacy Continuing Education Credits In support of improving patient care, the University of Pittsburgh is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. The assigned universal program number(s) is JA4008223-0000-23-100-H01-P This knowledge-based activity provides 1  contact hours of continuing pharmacy education credit.

Suggested Additional Reading & Joint Accreditation Statement - Note: This Accreditation Statement Supersedes All Other Statements:

References

1. Otto CM, Nishimura RA, Bonow RO. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021;143(5):e72. Epub 2020 Dec 17.
2. Leon MB, Smith CR, Mack M, et al. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med 2010;363:1597-607.
3. Smith CR, Leon MB, Mack M, et al. Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med 2011;364:2187-98.
4. Popma JJ, Adams DH, Reardon MJ, et al. Transcatheter aortic valve replacement using a self-expanding bioprosthesis in patients with severe aortic stenosis at extreme risk for surgery. J Am Coll Cardiol 2014;63:1972-81
5. Dangas GD, Tijssen JGP, Wöhrle J, et al. A Controlled Trial of Rivaroxaban after Transcatheter Aortic-Valve Replacement. N Engl J Med 2020;382:120-9
6. Kuno T, Takagi H, Sugiyama T, et al. Antithrombotic strategies after transcatheter aortic valve implantation: Insights from a network meta-analysis. Catheter Cardiovasc Interv 2020; 96:E177.
7. Baumgartner H, Falk V, Bax JJ, et al. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J 2017; 38:2739.
8. Saito Y, Nazif T, Baumbach A, et al. Adjunctive Antithrombotic Therapy for Patients With Aortic Stenosis Undergoing Transcatheter Aortic Valve Replacement. JAMA Cardiol 2020; 5:92.
9. Ranasinghe MP, Peter K, McFadyen JD. Thromboembolic and Bleeding Complications in Transcatheter Aortic Valve Implantation: Insights on Mechanisms, Prophylaxis and Therapy. J Clin Med 2019; 8.
10. Didier R, Lhermusier T, Auffret V, et al. TAVR Patients Requiring Anticoagulation: Direct Oral Anticoagulant or Vitamin K Antagonist? JACC Cardiovasc Interv 2021.
11. Whitlock RP, Sun JC, Fremes SE, Rubens FD, Teoh KH, American College of Chest P. Antithrombotic and thrombolytic therapy for valvular disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141(2 Suppl):e576S-600S.
12. Holmes DR, Jr., Mack MJ, Kaul S, et al. 2012 ACCF/AATS/SCAI/STS expert consensus document on transcatheter aortic valve replacement. J Am Coll Cardiol 2012;59:1200-1254.
13. Joint Task Force on the Management of Valvular Heart Disease of the European Society of C, European Association for Cardio-Thoracic S, Vahanian A, et al. Guidelines on the management of valvular heart disease (version 2012). Eur Heart J 2012;33:2451-2496.
14. American College of Cardiology/American Heart Association Task Force on Practice G, Society of Cardiovascular A, Society for Cardiovascular A, et al. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease... Circulation 2006;114:e84-231

Joint Accreditation Statement - this statement supersedes any other statement on this page
In support of improving patient care, the University of Pittsburgh is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Pharmacy (CPE) - This knowledge-based activity provides 1.0 contact hours of continuing pharmacy education credit.

Other Healthcare Professionals: Other health care professionals will receive a certificate of attendance confirming the number of contact hours commensurate with the extent of participation in this activity.