DUAL antiplatelet therapy (DAPT) was found to be as effective as oral anticoagulation (OAC) in preventing new cerebral microemboli following transcatheter aortic valve implantation (TAVI), while also resulting in a lower mean volume of brain damage over 90 days.
Transcatheter aortic valve implantation is a widely used treatment for aortic stenosis, but the risk of subclinical cerebral embolism remains a concern, potentially impacting cognitive outcomes. The optimal post-procedural antithrombotic regimen to minimise these embolic events is still debated, particularly in patients without a clear indication for long-term anticoagulation. The AUREA trial was designed to directly compare the efficacy of DAPT and OAC in preventing cerebral microembolism in this patient group, using advanced imaging techniques.
In this randomised controlled trial, 123 patients with aortic stenosis and no existing indication for OAC were assigned to receive either DAPT (aspirin plus clopidogrel) or OAC (acenocoumarol) for three months following TAVI. Diffusion-weighted magnetic resonance imaging (DW-MRI) was performed at baseline, 6 days, and 90 days post-procedure to detect new cerebral emboli. At baseline, only 3.3% of patients had evidence of cerebral emboli. At 6 days after TAVI, new cerebral emboli were detected in 81.4% of OAC patients and 69.8% of DAPT patients, a difference that was not statistically significant (p=0.209). By 90 days, the incidence was almost identical between groups (8.0% for OAC vs 8.2% for DAPT, p=0.879). Notably, the mean total emboli volume was significantly lower in the DAPT group at 6 days (265.9 mm³ vs 303.4 mm³; p=0.019) and cumulatively at 6 and 90 days (266.45 mm³ vs 331.10 mm³; p=0.008).
These results suggest that, for patients without a specific indication for oral anticoagulation, DAPT is at least as effective as OAC in preventing new cerebral microemboli after TAVI, and may be preferable due to the reduced volume of cerebral injury observed. For clinical practice, these findings support the continued use of DAPT as a standard strategy in this population, potentially reducing the risk of cerebral damage without the added bleeding risks associated with anticoagulation. Future research should focus on long-term cognitive outcomes and the potential benefits of further individualising antithrombotic therapy after TAVI.
Reference
Diaz VAJ et al. A comparison of antiplatelet and oral anticoagulation strategies to prevent cerebral microembolism after transcatheter aortic valve implantation: the AUREA trial. Euro Intervention. 2025;DOI:10.4244/EIJ-D-24-00872.
