A comparison of antiplatelet and oral anticoagulation strategies to prevent cerebral microembolism after transcatheter aortic valve implantation: the AUREA trial

Abstract

BACKGROUND: The effectiveness of oral anticoagulation (OAC) or dual antiplatelet therapy (DAPT) in reducing subclinical brain infarcts after transcatheter aortic valve implantation (TAVI) remains unclear. AIMS: We aimed to compare the efficacy of DAPT versus OAC in preventing cerebral microembolism during the first 3 months post-TAVI, assessed by diffusion-weighted magnetic resonance imaging (DW-MRI). METHODS: Patients with aortic stenosis and no indication for OAC were randomly assigned to receive either OAC (acenocoumarol) or DAPT (aspirin+clopidogrel) for 3 months post-TAVI. Brain DW-MRI was performed at baseline (0-3 days pre-TAVI) and at 6 and 90 days post-TAVI. The primary objective was the proportion of patients with new cerebral emboli on DW-MRI at 6 and 90 days. RESULTS: Of the 123 patients included in the study, 3.3% had new cerebral emboli on the baseline MRI prior to TAVI. At 6 days post-TAVI, new cerebral emboli were observed in 81.4% of OAC patients versus 69.8% of DAPT patients (p=0.209), and at 90 days, in 8.0% versus 8.2%, respectively (p=0.879). However, DAPT patients had a lower mean total emboli volume at 6 days (265.9 mm³ vs 303.4 mm³; p=0.019) and cumulatively at 6+90 days (266.45 mm³ vs 331.10 mm³; p=0.008). CONCLUSIONS: In patients without an indication for OAC, an OAC strategy for 3 months post-TAVI did not show any benefit over an antiplatelet strategy in preventing cerebral microembolism. Patients treated with DAPT showed a lower mean volume of brain damage on DW-MRI during the 90 days following TAVI compared to those treated with acenocoumarol.