aspirin versus aspirin + clopidogrel following transcatheter aortic valve implantation: the arte trial

Conditions: Aortic Valve Disease; Myocardial Infarction; Stroke

Summary: the purpose of this study is to compare aspirin + clopidogrel with aspirin alone as antithrombotic treatment following transcatheter aortic valve implantation (tavi) for the prevention of major ischemic events \[myocardial infarction (mi), ischemic stroke\] or death without increasing the risk of major bleeding events.

transcatheter aortic valve implantation (tavi) has emerged as an alternative to standard aortic valve replacement for the treatment of patients considered to be at very high or prohibitive surgical risk. nowadays the procedure is associated with a very high success rate (\> 95%) but major peri-procedural ischemic complications such as myocardial infarction (mi) or ischemic stroke occur in about 2% (0% to 17%) and 3% (2% to 7%) of the cases, respectively. the recently published partner trial showed a stroke rate as high as 6.5% within the 30 days following tavi, with most (77%) of these events diagnosed as major strokes. in order to avoid such ischemic complications full dose anticoagulation (usually intravenous heparin) is administered during the tavi procedure, whereas aspirin (long-term) + clopidogrel (1 to 6 months) have been the recommended antithrombotic treatment following the procedure. however, this antithrombotic regime has been recommended on an empirical basis, and no studies have as yet shown the efficacy of aspirin + clopidogrel versus aspirin alone or no antithrombotic treatment in preventing ischemic events following tavi procedures. also, patients undergoing tavi nowadays are usually octogenarians and very frequently exhibit comorbidities such as hypertension, abnormal renal function or prior cerebrovascular disease, which significantly increase the risk of major bleeding. indeed, tavi procedures can also be associated with major vascular complications which in turn can complicate with life-threatening or major bleeding. it is well know that clopidogrel on top of aspirin is associated with a higher rate of major bleeding complications, especially in elderly patients. it would therefore be of major clinical relevance to determine the risk/benefit ratio of using a dual antithrombotic therapy following tavi procedures in order to recommend the most appropriate antithrombotic treatment in this high-risk population. the arte trial is a multicenter canadian pilot trial to evaluate the efficacy and safety of aspirin versus aspirin + clopidogrel as antithrombotic treatment after tavi.

Eligibility criteria:
inclusion criteria: * patients undergoing a tavi procedure with the edwards sapien xt valve (transfemoral or transapical) exclusion criteria: * need for chronic anticoagulation treatment * major bleeding within the 3 months prior to the tavi procedure * prior intracranial bleeding * drug-eluting stent implantation within the year prior to the tavi procedure * allergy to clopidogrel and/or aspirin

Keywords: transcatheter aortic valve implantation antithrombotic treatment clopidogrel aspirin myocardial infarction ischemic stroke major bleeding