經導管主動脈瓣植入術後抗血栓藥物的選擇

Antithrombotic Therapy After Transcatheter Aortic Valve Implantation (TAVI)

10.6168/FJCP.202401_32(1).0002

王思璇(Szu-Hsuan Wang)；蔡慈貞(Tzu-Cheng Tsai)；雷青熒(Chin-Ying Ray)

主動脈瓣狹窄 ； 經導管主動脈瓣膜植入術 ； 抗血小板藥物 ； 抗凝血藥物 ； 抗血栓藥物 ； aortic valve stenosis ； transcatheter aortic valve implantation ； antiplatelet agents ； anticoagulants ； antithrombotic agents

臺灣臨床藥學雜誌

32卷1期（2024 / 01 / 31）

10 - 20

繁體中文;英文

主動脈瓣膜狹窄（aortic stenosis, AS）會限制心臟供血的效率，嚴重狹窄則會降低其他器官的血液灌流，經導管主動脈瓣植入術（transcatheter aortic valve implantation, TAVI）是嚴重AS病人的一種治療選擇。成功進行TAVI後為預防人工瓣膜血栓形成，需給予抗血栓藥物降低缺血及栓塞的併發症，然而接受TAVI的病人可能已存在其他須使用抗血栓藥物的共病症，例如心房顫動、冠狀動脈疾病或周邊動脈疾病，使得抗血栓藥物的選擇變得複雜。依據2021年歐洲心臟學會（European Society of Cardiology, ESC）／歐洲心臟胸腔外科協會（European Association for Cardio-Thoracic Surgery, EACTS）指引及2020年美國心臟病學會（American College of Cardiology, ACC）／美國心臟學會（American Heart Association, AHA）指引，過去沒有口服抗凝血藥物適應症的病人，TAVI術後以抗血小板藥物為主，過去因適應症長期口服抗凝血藥物的病人，則繼續使用抗凝血藥物。ACC/AHA指引建議抗血小板藥物可選擇aspirin或clopidogrel，抗凝血藥物可選擇維生素K拮抗劑，然而其他抗血栓藥物是否也可用於TAVI術後預防血栓，過去尚無研究證實。近兩年來陸續有TAVI術後抗血栓藥物治療的隨機對照試驗發表，本文回顧最新治療指引並彙整文獻實證來探討不同抗血栓藥物在TAVI術後預防栓塞的有效性與安全性，希望有助於釐清TAVI術後抗血栓藥物的選擇策略。

Aortic valve stenosis poses a threat to the efficient blood supply to the heart, with severe cases potentially leading to diminished blood perfusion in other vital organs. The transcatheter aortic valve implantation (TAVI) has emerged as a pivotal treatment option for patients grappling with severe aortic valve stenosis. However, to avoid prosthetic valve thrombosis post-successful TAVI, the appropriate use of antithrombotic drugs becomes imperative to reduce ischemic and embolic complications. Patients undergoing TAVI may already have other comorbidities that necessitate the use of antithrombotic medications, such as atrial fibrillation, coronary artery disease, or peripheral arterial disease, making the selection of antithrombotic drugs more complex. According to the 2021 European Society of Cardiology (ESC)/ European Association for Cardio-Thoracic Surgery (EACTS) guidelines and the 2020 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines, patients lacking prior indications for oral anticoagulants are recommended to primarily receive antiplatelet drugs post-TAVI. Conversely, those who were on long-term oral anticoagulants should persist with anticoagulant therapy. The ACC/AHA underscores the use of aspirin or clopidogrel as antiplatelet drugs and permits the consideration of vitamin K antagonists as anticoagulant agents. However, the broader applicability of alternative antithrombotic drugs in preventing thrombosis post-TAVI awaits validation through further research. Over the past two years, there have been randomized controlled trials exploring various antithrombotic drug regimens post-TAVI. This article reviews the latest treatment guidelines and compiles evidence to evaluate the efficacy and safety profiles of diverse antithrombotic drugs in preventing embolism after TAVI. The overarching goal is to furnish clinicians with a comprehensive resource, elucidating the optimal selection strategy for antithrombotic drugs post-TAVI.