Increased bleeding risk in patients with aortic valvular stenosis: From new mechanisms to new therapies

• Type 2A von Willebrand syndrome in AS might be balanced by TF activity, increased thrombin and microparticles generation
• The enhanced thrombin generation might lead to faster formation of fibrin clots, additionally more resistant to lysis
• ​In AS, higher concentrations of thrombin may potentiate platelet activation, reducing the risk of bleeding

Aortic stenosis (AS), the most prevalent acquired valvular disease in the adults that requires invasive treatment, coexists with coagulopathy, resulting in bleeding in approximately 20% of patients. In the current review, we summarize the available knowledge on the mechanisms underlying the bleeding tendency observed in AS, and discuss potential compensatory mechanisms preventing most patients with severe AS from experiencing bleeding. We offer an update on Heyde's syndrome and other types of bleeding, and study extensively their pathobiology, providing insights into the new emerging concepts on coagulation regulation in AS. The focus is given to the impact of valvular interventions on coagulation abnormalities in AS. Both surgical valve replacement and transcatheter aortic valve implantation are discussed. Finally, we discuss current treatment recommendations in AS related bleeding.