Primary hemostatic disorders drive early and late major bleedings of patients with atrial fibrillation after transcatheter aortic valve replacement

Background

Patients with atrial fibrillation (AF) are likely to have multiple co-morbidities which lead to a poor prognosis including bleeding events. Closure time adenosine diphosphate (CT-ADP) is a primary hemostasis point-of-care test used as a surrogate marker of high molecular weight multimers defect of Von Willebrand factor. Our prior studies suggest that prolongation of CT-ADP (> 180 sec) after TAVR is a determinant of major/life-threatening bleeding complications (MLBCs).

Purpose

To evaluate the impact of post-procedural CT-ADP > 180 sec on bleeding events in TAVR patients with AF.

Methods

We included 878 patients from our prospective TAVR registry. Bleeding complications were assessed according to the VARC-2 criteria. Major adverse cardiac and cerebrovascular events (MACCE) was defined as a composite of all-cause death, myocardial infarction, stroke, and heart failure hospitalization after TAVR. Primary endpoint was 1-year MLBCs and the second endpoint was 1-year MACCE.

Results

Patients with AF had a higher incidence of all-cause mortality (15% vs. 8%, P = 0.002), MACCE (29% vs. 20%, P = 0.002), and MLBCs (20% vs. 12%, P = 0.001) within 1-year compared to non-AF patients. When the cohort was split into 4 subgroups according to AF and CT-ADP > 180 sec, patients with AF and CT-ADP > 180 sec had the highest risk of MLBCs (log-rank test; P < 0.001) (Fig. 1). Multivariate Cox regression analysis confirmed that the patients with AF and CT-ADP > 180 sec had 4.6-fold higher risk of MLBCs within 1 year compared to non-AF patients with CT-ADP ≤ 180 sec (hazard ratio: 4.60; 95% confidence interval: 2.18-9.68; P < 0.001) (Fig. 1).

Conclusion

Among TAVR patients, AF with post-procedural CT-ADP > 180 sec was identified as a strong predictor of MLBCs at 1-year follow-up. Our study suggest that persistent primary haemostasis disorders contribute to a higher risk of bleeding events particularly in AF patients and may be considered for a tailored and risk-adjusted antithrombotic therapy after TAVR.