Refining Bleeding Risk Stratification After TAVR: Added Value of CT-ADP Beyond High Bleeding Risk Criteria.

BACKGROUND

Acquired von Willebrand factor deficiency is a key contributor to bleeding after transcatheter aortic valve replacement (TAVR).

OBJECTIVES

The aim of this study was to evaluate whether assessing primary hemostatic disorder using closure time of adenosine diphosphate (CT-ADP), a marker of von Willebrand factor dysfunction, enhances bleeding risk stratification in TAVR patients at high bleeding risk (HBR).

METHODS

A total of 884 patients from a prospective TAVR registry were analyzed. The primary endpoint was 2-year major bleeding. HBR was defined using the Valve Academic Research Consortium for High Bleeding Risk (VARC-HBR) criteria. Primary hemostatic disorder was defined as CT-ADP >180 seconds, measured before and 24 hours post-TAVR.

RESULTS

VARC-HBR criteria were met in 614 patients (69%). CT-ADP significantly decreased from pre-TAVR to 24 hours postprocedure (170 seconds [124-300 seconds] vs 125 seconds [97-180 seconds]; P < 0.0001). Postprocedural CT-ADP >180 seconds was observed in 220 patients (25%). Patients meeting the VARC-HBR criteria had a higher incidence of 2-year major bleeding than those without (21.7% vs 10.5%; log-rank P < 0.0001). Among patients meeting VARC-HBR criteria, those with postprocedural CT-ADP >180 seconds had a higher 2-year bleeding rate (37.0% vs 16.4%; log-rank P < 0.0001). Adding postprocedural CT-ADP >180 seconds to VARC-HBR score significantly improved predictive accuracy for 2-year bleeding (from 0.65 to 0.69; P = 0.00012). Landmark analysis showed that although meeting the VARC-HBR criteria predicted periprocedural bleeding, it did not predict late bleeding. However, postprocedural CT-ADP >180 seconds identified patients at increased risk for late bleeding among those meeting VARC-HBR criteria (11.4% vs 2.4%; log-rank P < 0.0001).

CONCLUSIONS

Postprocedural CT-ADP assessment enhances bleeding risk stratification beyond VARC-HBR criteria and may support individualized management strategies in high-risk TAVR patients.