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Two major trials on blood thinners after heart valve replacement came to opposite conclusions. ACASA-TAVI found that 12 months of DOAC therapy significantly reduced leaflet clotting without a worrying safety trade-off, while NOTION-4 found that a shorter 3-month DOAC course offered no lasting benefit — and came with more clinical events. For now, aspirin remains the guideline-recommended default.
Two randomized trials presented at the ESC Congress 2026 in Munich tackled the same question — should patients receive blood thinners (DOACs) after a successful TAVI procedure? — and landed on strikingly different answers.
ACASA-TAVI randomized 360 patients to 12 months of DOAC monotherapy or aspirin after TAVI. The DOAC group showed significantly less subclinical leaflet clotting (HALT) on CT scans, and the safety profile was non-inferior to aspirin — with numerically fewer bleeds and deaths in the DOAC arm. NOTION-4, meanwhile, tested a shorter 3-month DOAC course followed by aspirin versus aspirin alone in 352 patients. While DOACs reduced HALT at 3 months, the benefit had disappeared by 12 months — and the DOAC group had significantly more deaths, strokes, and major bleeds.
By the Numbers:
Why it matters: With TAVI expanding into younger patients who need their valves to last decades, optimizing post-procedure antithrombotic therapy is critical. These conflicting results mean aspirin stays the guideline standard for now — but the debate over how best to protect valve longevity is far from over.
