Warfarin after bioprosthetic aortic valve implantation

Dabigatran is Less Effective Than Warfarin at Attenuating Mechanical Heart Valve-Induced Thrombin Generation

Background

Patients with mechanical heart valves (MHV) require warfarin to prevent thromboembolism. Although dabigatran was as effective as warfarin for stroke prevention in atrial fibrillation when compared with warfarin in patients with MHV, the study was stopped early because of more strokes and bleeding with dabigatran. To determine why dabigatran was less effective than warfarin, we compared their effects on thrombin generation induced by MHV.

Methods and Results

Thrombin generation in the absence or presence of valve leaflets or sewing ring segments (SRS) was quantified. Studies were done in control plasma, plasma depleted of factors (F) XII, XI, or VII, plasma containing varying concentrations of dabigatran, or plasma from patients on dabigatran or warfarin with varying dabigatran concentrations or international normalized ratio (INR) values. Mean endogenous thrombin potential (ETP) increased 1.2-, 1.5-, and 1.8-fold in the presence of leaflets, Teflon SRS, and Dacron SRS, respectively. Whereas ETP in FVII-depleted and control plasma was similar, ETP was reduced to background levels in FXII-depleted plasma and abrogated in FXI-depleted plasma. Dabigatran had little effect on ETP at concentrations below 400 ng/mL, whereas in plasma from warfarin-treated patients, ETP was suppressed with INR values over 1.5.

Conclusions

MHV induce thrombin generation via the intrinsic pathway and generate sufficient thrombin to overwhelm clinically relevant dabigatran concentrations. In contrast, warfarin is more effective than dabigatran at suppressing MHV-induced thrombin generation. These data explain why dabigatran failed in MHV patients and suggest that strategies targeting FXII or FXI may suppress the root cause of thrombosis in such patients.

Effect of electrical stimulus parameters on the development and propagation of action potentials in short excitable fibres

Intracellular action potentials (IAPs) produced by short fibres in response to their electrical stimulation were analysed. IAPs were calculated on the basis of the Hodgkin-Huxley (1952) model by the method described by Joyner et al. (1978). Principal differences were found in processes of activation of short (semilength L less than 5 lambda) and long fibres under near-threshold stimulation. The shorter the fibre, the lower was the threshold value (Ithr). Dependence of the latency on the stimulus strength (Ist) was substantially non-linear and was affected by the fibre length. Both fibre length and stimulus strength influenced the IAP amplitude, the instantaneous propagation velocity (IPV) and the site of the first origin of the IAP (and, consequently, excitability of the short fibre membrane). With L less than or equal to 2 lambda and Ithr less than or equal to Ist less than or equal to 1.1Ithr, IPV could reach either very high values (so that all the fibre membrane fired practically simultaneously) or even negative values. The latter corresponded to the first origin of the propagated IAP, not at the site of stimulation but at the fibre termination or at a midpoint. The characters of all the above dependencies were unchanged irrespective of the manner of approaching threshold (variation of stimulus duration or its strength). Reasons for differences in processes of activation of short and long fibres are discussed in terms of electrical load and latency. Applications of the results to explain an increased jitter, velocity recovery function and velocity-diameter relationship are also discussed.