Antithrombotic Therapy, Aortic Valve Replacement, Bioprosthetic Valve Thrombosis, Rapid Deployment Valves
Conditions
Brief summary
Background: The optimal antithrombotic strategy early after aortic valve replacement surgery with a biological valve remains controversial due to lack of high-quality evidence. Either oral anticoagulants or acetylsalicylic acid should be considered for the first three months. Hypo-attenuated leaflet thickening on cardiac compute tomography has been associated with latent bioprosthetic valve thrombosis and may be prevented with anticoagulation. The investigators hypothesize that anticoagulation with apixaban is superior to single antiplatelet therapy with acetylsalicylic acid in reduction of hypo-attenuated leaflet thickening of bioprosthetic valves after aortic valve replacement. Methods: In this prospective, open-label, randomized trial patients without an indication for oral anticoagulation undergoing isolated aortic valve replacement surgery with novel rapid-deployment bioprosthetic valves will be randomized. The treatment group will receive 5 mg of apixaban twice a day for the first three months and 100 mg of acetylsalicylic acid thereafter. The control group will have 100 mg of acetylsalicylic acid once a day indefinitely. After the three-month treatment period a contrast enhanced electrocardiogram-gated cardiac computed tomography will be performed to identify hypo-attenuated leaflet thickening of the bioprosthetic valve. The primary objective of the study is to assess possible superiority of the treatment group in the prevention of hypo-attenuated leaflet thickening three months after randomization. Secondary objective is to assess possible noninferiority for safety of apixaban-based strategy when compared to acetylsalicylic acid at three months. Discussion: Antithrombotic therapy after aortic valve replacement surgery is used to prevent valve thrombosis and systemic thromboembolism. Latent bioprosthetic valve thrombosis is a precursor of clinically significant prosthetic valve dysfunction or thromboembolic event. The hallmark feature of latent bioprosthetic valve thrombosis is hypo-attenuated leaflet thickening on cardiac computed tomography. Subclinical leaflet thrombosis occurs frequently in bioprosthetic aortic valves, more commonly in transcatheter than in surgical valves. There is no evidence on the effect of direct oral anticoagulants on the incidence of hypo-attenuated leaflet thickening after surgical aortic valve replacement with rapid deployment bioprostheses.
Interventions
PROCEDUREAortic valve replacement surgery
Patients undergoing first-time isolated aortic valve replacement with a rapid deployment biological prosthesis.
DIAGNOSTIC_TESTComputed tomography
All the study patients will undergo a computed tomography imaging to assess for hypo-attenuated leaflet thickening and reduced leaflet mobility of the biological prosthesis following the three-month treatment period.
DIAGNOSTIC_TESTEchocardiography
All the study patients will undergo a transthoracic echocardiography before hospital discharge and following the three-month treatment period.
Sponsors
Clinical Hospital Centre Zagreb
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
SINGLE (Outcomes Assessor)
Eligibility
Sex/Gender
ALL
Age
65 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Men and women aged 65 or older with aortic valve stenosis undergoing successful isolated first-time aortic valve replacement with a rapid deployment bioprosthetic valve * Signed informed consent to participate in the research
Exclusion criteria
* Indication for long-term use of anticoagulant therapy * Indication for dual antiplatelet therapy * Contraindication to anticoagulation or antiplatelet therapy * Inability to start the study drug within the planned randomization period * History of atrial fibrillation * Known hemorrhagic diathesis * Presence of other significant heart pathology * Prior open-heart surgery * Presence of liver failure or other coagulopathy * Aortic valve infective endocarditis * Severe renal failure * Allergy to iodine contrast
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Proportion of patients with hypo-attenuated leaflet thickening | At the end of treatment at 3 months | Hypo-attenuated leaflet thickening is identified as increased thickness of one or more leaflets of the bioprosthetic valve on contrast-enhanced electrocardiogram gated cardiac computed tomography. Grade 3 on a 4-tier semiquantitative grading scale describes more than 50% and less than 75% of leaflet involvement. Grade 3 or higher of hypo-attenuated leaflet thickening of at least one bioprosthetic valve leaflet will be considered. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Proportion of patients with bleeding, thromboembolic event, or death | From enrolment to the end of treatment at 3 months | The safety composite outcome will be comprised of all types of VARC-3 bleeding events, thromboembolic events (myocardial infarction and stroke), and death from any cause. |
Other
| Measure | Time frame | Description |
|---|---|---|
| Proportion of patients in each NYHA functional class | At the end of treatment at 3 months | New York Heart Association functional classification of heart failure. Class I, no limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation or shortness of breath. Class II, slight limitation of physical activity. Comfortable at rest. Ordinary physical activity results in fatigue, palpitation, shortness of breath or chest pain. Class III, marked limitation of physical activity. Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, shortness of breath or chest pain. Class IV, symptoms of heart failure at rest. Any physical activity causes further discomfort. |
| Rates of bioprosthetic valve deterioration | At the end of treatment at 3 months | Stage 1 is described with morphological valve deterioration without significant hemodynamic changes. Stage 2 is characterized with moderate hemodynamic valve deterioration with an increase in mean transvalvular gradient ≥10 mmHg, and Stage 3 with severe hemodynamic valve deterioration with an increase in mean transvalvular gradient ≥20 mmHg. |
| Rate of VARC-3 bleeding events | From enrolment to the end of treatment at 3 months | A descriptive classification scheme for VARC-3 bleeding, like the Bleeding Academic Research Consortium classification has been proposed. It includes 4-type bleeding scale: Type 1 (minor), Type 2 (major), Type 3 (life-threatening), and Type 4 (leading to death) bleeding. |
| Rate of hypo-attenuated leaflet thickening | At the end of treatment at 3 months | Hypo-attenuated leaflet thickening is identified as increased thickness of one or more leaflets of the bioprosthetic valve on contrast-enhanced electrocardiogram gated cardiac computed tomography. Grade 3 on a 4-tier semiquantitative grading scale describes more than 50% and less than 75% of leaflet involvement which will be considered significant. Grade 3 or higher will be considered significant. |
| Proportion of patients with stroke | From enrolment to the end of treatment at 3 months | All stroke (ischaemic stroke, haemorrhagic stroke, or any stroke not otherwise specified) with signs and symptoms and with pathology or neuroimaging evidence of central nervous system infarction, or absence of other apparent causes. |
| Proportion of patients that died | From enrolment to the end of treatment at 3 months | All cause mortality. |
| Proportion of patients with myocardial infarction | From enrolment to the end of treatment at 3 months | Myocardial infarction with elevated biomarkers cTn values with at least symptoms of acute ischaemia, new ischaemic ECG changes, new pathologic Q-waves, imaging evidence of a new loss of viable myocardium or new wall motion abnormality, identification of a coronary thrombus by angiography or autopsy. |
| Rate of reduced leaflet mobility | At the end of treatment at 3 months | Leaflet restriction caused by hypo-attenuated leaflet thickening can be described as reduced leaflet mobility. Using computed tomography, reduced leaflet motion will be assessed on short-axis reformatted images during systole and 4D volume rendering images. The extent can be described per leaflet, using a 4-tier grading scale in systole: (1) not present, (2) \< 50% restriction in leaflet excursion, (3) ≥50% restriction in leaflet excursion and (4) immobile leaflet. Grade 3 or higher will be considered significant. |
Countries
Croatia
Contacts
Primary ContactTomislav Kopjar, MD, PhD
Outcome results
None listed