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VanderPluym C, Kobayashi R. Leveling the playing field: The role of level-based dosing in pediatric anticoagulation management. Pediatr Blood Cancer 2024; 71:e31136. [PMID: 38967607 DOI: 10.1002/pbc.31136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Accepted: 05/21/2024] [Indexed: 07/06/2024]
Affiliation(s)
- Christina VanderPluym
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Ryan Kobayashi
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
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2
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Schnegg B, Deveza R, Hayward C. Apixaban in bridge to transplant and destination LVAD - rationale and study design: the ApixiVAD trial. ESC Heart Fail 2024; 11:2387-2394. [PMID: 38650125 PMCID: PMC11287292 DOI: 10.1002/ehf2.14782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 02/19/2024] [Accepted: 03/16/2024] [Indexed: 04/25/2024] Open
Abstract
AIMS Use of novel anticoagulation in mechanical circulatory support is controversial. We report the rationale and design of the ApixiVad pilot trial, a pilot study testing the safety of apixaban as an anticoagulant in patients bridged to transplant (BTT) or for destination (DT) with Heartmate 3 (HM3) left ventricular assist device (LVAD). METHODS AND RESULTS Apixaban has been used in small non-randomized cohorts in LVAD patients and shown to be effective in ex vivo studies. The ApixiVAD study examines apixaban use in a multicentre, international, open-label, randomized, controlled trial aiming to include 50 BTT or DT HM3 patients with a 1:1 randomization ratio. This event-driven study has a maximum follow-up period of 24 months with interim analysis at 6 months. The primary outcome is death, thromboembolic events and major bleeding, including operative bleeding and immediate transplant outcomes. The secondary outcome focuses on patients' quality of life related to anticoagulation. This investigator-driven pilot study is not powered to determine the non-inferiority of apixaban. An increase in primary outcome in the apixaban group of 20% will be considered a signal of harm. CONCLUSIONS A positive outcome in the ApixiVAD study would provide the basis for future, larger, pivotal anticoagulation trials in LVAD patients.
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Affiliation(s)
- Bruno Schnegg
- Department of Cardiology, Centre for Advanced Heart Failure, InselspitalBern University HospitalBernSwitzerland
| | - Ricardo Deveza
- Heart Failure and Transplant UnitSt Vincent's HospitalSydneyNew South WalesAustralia
| | - Christopher Hayward
- Heart Failure and Transplant UnitSt Vincent's HospitalSydneyNew South WalesAustralia
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3
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Mack CA, Lau C, Girardi LN. There is still no alternative to warfarin for mechanical valves: It remains the most effective anticoagulant. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00610-X. [PMID: 39004266 DOI: 10.1016/j.jtcvs.2024.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 06/18/2024] [Accepted: 07/05/2024] [Indexed: 07/16/2024]
Affiliation(s)
- Charles A Mack
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Christopher Lau
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY.
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4
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Arminio M, Carbonaro D, Morbiducci U, Gallo D, Chiastra C. Fluid-structure interaction simulation of mechanical aortic valves: a narrative review exploring its role in total product life cycle. FRONTIERS IN MEDICAL TECHNOLOGY 2024; 6:1399729. [PMID: 39011523 PMCID: PMC11247014 DOI: 10.3389/fmedt.2024.1399729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 06/07/2024] [Indexed: 07/17/2024] Open
Abstract
Over the last years computer modelling and simulation has emerged as an effective tool to support the total product life cycle of cardiovascular devices, particularly in the device preclinical evaluation and post-market assessment. Computational modelling is particularly relevant for heart valve prostheses, which require an extensive assessment of their hydrodynamic performance and of risks of hemolysis and thromboembolic complications associated with mechanically-induced blood damage. These biomechanical aspects are typically evaluated through a fluid-structure interaction (FSI) approach, which enables valve fluid dynamics evaluation accounting for leaflets movement. In this context, the present narrative review focuses on the computational modelling of bileaflet mechanical aortic valves through FSI approach, aiming to foster and guide the use of simulations in device total product life cycle. The state of the art of FSI simulation of heart valve prostheses is reviewed to highlight the variety of modelling strategies adopted in the literature. Furthermore, the integration of FSI simulations in the total product life cycle of bileaflet aortic valves is discussed, with particular emphasis on the role of simulations in complementing and potentially replacing the experimental tests suggested by international standards. Simulations credibility assessment is also discussed in the light of recently published guidelines, thus paving the way for a broader inclusion of in silico evidence in regulatory submissions. The present narrative review highlights that FSI simulations can be successfully framed within the total product life cycle of bileaflet mechanical aortic valves, emphasizing that credible in silico models evaluating the performance of implantable devices can (at least) partially replace preclinical in vitro experimentation and support post-market biomechanical evaluation, leading to a reduction in both time and cost required for device development.
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Affiliation(s)
| | | | | | | | - Claudio Chiastra
- PoliToMed Lab, Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Turin, Italy
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5
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Kinoshita R, Watanabe T, Matsumoto R, Hirooka K. Mechanical Aortic Valve Thrombosis During Anticoagulation Using Oral Rivaroxaban: A Case Report. Cureus 2024; 16:e65007. [PMID: 39045022 PMCID: PMC11262916 DOI: 10.7759/cureus.65007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2024] [Indexed: 07/25/2024] Open
Abstract
Direct oral anticoagulants (DOACs) are widely used in cardiovascular medicine. Although rivaroxaban has potential benefits for anticoagulation in certain contexts, DOACs remain contraindicated in patients with mechanical heart valves. This case report highlights the life-threatening risks of rivaroxaban use in patients with mechanical aortic valves, underscoring the lack of proven efficacy and the necessity of adhering to established anticoagulation protocols with warfarin for this patient population. Here, we report a case of a 65-year-old man who had previously undergone aortic valve replacement and developed a thrombus in the mechanical aortic valve six months after switching from warfarin to rivaroxaban. The patient experienced a sudden loss of consciousness and chest discomfort. Echocardiography revealed a thrombus in the valve requiring urgent reoperation and replacement with a bioprosthetic valve. The postoperative recovery was uneventful.
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Affiliation(s)
- Ryoji Kinoshita
- Cardiovascular Surgery, Tsuchiura Kyodo General Hospital, Tsuchiura, JPN
| | - Taiju Watanabe
- Cardiovascular Surgery, Tsuchiura Kyodo General Hospital, Tsuchiura, JPN
| | - Ryumon Matsumoto
- Cardiovascular Surgery, Tsuchiura Kyodo General Hospital, Tsuchiura, JPN
| | - Kazunobu Hirooka
- Cardiovascular Surgery, Tsuchiura Kyodo General Hospital, Tsuchiura, JPN
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6
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Ebrahimi P, Sattartabar B, Taheri H, Soltani P, Bahiraie P, Mousavinezhad SM, Gooshvar M, Kampaktsis PN, Arsanjani R, Sahebjam M, Hosseini K, Siegel RJ. Mechanical prosthetic valve thrombosis: A literature review of treatment strategies. Curr Probl Cardiol 2024; 49:102628. [PMID: 38729276 DOI: 10.1016/j.cpcardiol.2024.102628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Accepted: 05/06/2024] [Indexed: 05/12/2024]
Abstract
Mechanical prosthetic valve thrombosis (MPVT) is a common complication of valvular implantations. This study compared the efficacy and safety of different treatments for MPVT. A systematic search of electronic databases identified studies evaluating surgical, anticoagulant, and thrombolytic therapies. Although several studies of different types have been conducted to evaluate the efficacy of these treatment strategies the lack of randomized controlled trials has resulted in the inability to make a definitive conclusion about the pros and cons of these treatments. Recent treatments, such as slow and ultraslow infusion of thrombolytics, showed comparable efficacy and lower complication rates than traditional methods. Inadequate anticoagulant use is a major risk factor for MPVT, highlighting the importance of prevention. Treatment selection should be individualized based on patient factors and available expertise. Overall, slow and ultraslow infusion of thrombolytics may be a promising treatment option for MPVT.
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Affiliation(s)
- Pouya Ebrahimi
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Babak Sattartabar
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Homa Taheri
- Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, USA
| | - Parnian Soltani
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Pegah Bahiraie
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Mehrdad Gooshvar
- School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | | | - Reza Arsanjani
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Mohammad Sahebjam
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Kaveh Hosseini
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran.
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7
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Ioannou M, Leonidou E, Chaziri I, Mouzarou A. Direct Oral Anticoagulants: Navigating Through Clinical Challenges. Cardiovasc Drugs Ther 2024; 38:637-650. [PMID: 37552381 DOI: 10.1007/s10557-023-07499-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/28/2023] [Indexed: 08/09/2023]
Abstract
PURPOSE Direct oral anticoagulants (DOACs) have been approved, for over a decade, by both European and American medicine agencies, for treatment and prevention of several cardiovascular conditions. Since then, an increasing amount of data has been added to the medical literature day by day, resulting in a dichotomy in selection of the appropriate agent, dosage, and duration of treatment for special populations with multiple comorbidities. Considering these issues, we have prepared a comprehensive review for the clinical practitioner, to optimize the DOAC utilization in clinical practice. METHODS A thorough literature search and review was conducted, concerning mainly the last decade. Our review focused on the current guidelines and the most recently published studies in PubMed, Science Direct Scopus, and Google Scholar to date. CONCLUSION The purpose of this study is to provide guidance for healthcare professionals for making proper decisions when confronted with clinical challenges. Nevertheless, further research is required to establish DOAC superiority in complicated cases, where there is clinical uncertainty.
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Affiliation(s)
- Maria Ioannou
- Department of Cardiology, General Hospital Limassol, State Health Organization Services, 4131, Limassol, Cyprus.
| | - Elena Leonidou
- Department of Cardiology, General Hospital Limassol, State Health Organization Services, 4131, Limassol, Cyprus
| | - Ioanna Chaziri
- Department of Pneumonology, Northern Älvborg County Hospital, Trollhättan, Sweden
| | - Angeliki Mouzarou
- Department of Cardiology, General Hospital Paphos, State Health Organization Services, Paphos, Cyprus
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8
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Dimond M, Looby M, Shah B, Sinha SS, Isseh I, Rollins AT, Abdul-Aziz AA, Kennedy J, Tang DG, Klein KM, Casselman S, Vermeulen C, Sheaffer W, Snipes M, O'connor CM, Shah P. Design and Rationale for the Direct Oral Anticoagulant Apixaban in Left Ventricular Assist Devices (DOAC LVAD) Study. J Card Fail 2024; 30:819-828. [PMID: 37956897 DOI: 10.1016/j.cardfail.2023.10.473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 09/28/2023] [Accepted: 10/17/2023] [Indexed: 11/21/2023]
Abstract
Implantable left ventricular assist device (LVAD) therapy is used to improve quality of life, alleviate symptoms and extend survival rates in patients with advanced heart failure. Patients with LVADs require chronic anticoagulation to reduce the risk of thromboembolic complications, and they commonly experience bleeding events. Apixaban is a direct oral anticoagulant that has become first-line therapy for patients with nonvalvular atrial fibrillation and venous thromboembolism; however, its safety in patients with LVADs has not been well characterized. The evaluation of the hemocompatibility in the DOAC LVAD (Direct Oral Anti-Coagulant apixaban in Left Ventricular Assist Devices) trial is a phase 2, open-label trial of patients with LVADs who were randomized to either apixaban or warfarin therapy. Patients randomized to apixaban will be started on a dosage of 5 mg twice daily, whereas those randomized to warfarin will be managed at an International Normalized Ratio goal of 2.0-2.5. All patients will be treated with aspirin at 81 mg daily. We plan to randomize and follow as many as 40 patients for 24 weeks to evaluate the primary outcomes of freedom from death or hemocompatibility-related adverse events (stroke, device thrombosis, bleeding, aortic root thrombus, and arterial non-CNS thromboembolism). The DOAC LVAD trial will establish the feasibility of apixaban anticoagulant therapy in patients with LVADs. Clinicaltrials.gov: NCT04865978.
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Affiliation(s)
- Matthew Dimond
- From the Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, VA
| | - Mary Looby
- From the Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, VA
| | - Bhruga Shah
- From the Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, VA
| | - Shashank S Sinha
- From the Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, VA
| | - Iyad Isseh
- From the Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, VA
| | - Allman T Rollins
- From the Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, VA
| | - Ahmad A Abdul-Aziz
- From the Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, VA
| | - Jamie Kennedy
- From the Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, VA
| | - Daniel G Tang
- From the Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, VA
| | - Katherine M Klein
- From the Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, VA
| | - Samantha Casselman
- From the Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, VA
| | - Christen Vermeulen
- From the Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, VA
| | - Wendy Sheaffer
- From the Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, VA
| | - Meredith Snipes
- From the Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, VA
| | | | - Palak Shah
- From the Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, VA.
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9
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Laskar N, Bayliss CD, Kirmani BH, Chambers JB, Maier R, Briffa NP, Cartwright N, Kendall S, Shah BN, Akowuah E. Antithrombotic therapy after heart valve surgery: contemporary practice in the UK. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2024; 38:ivae089. [PMID: 38704867 PMCID: PMC11109495 DOI: 10.1093/icvts/ivae089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Accepted: 05/02/2024] [Indexed: 05/07/2024]
Abstract
OBJECTIVES There is a lack of high-quality data informing the optimal antithrombotic drug strategy following bioprosthetic heart valve replacement or valve repair. Disparity in recommendations from international guidelines reflects this. This study aimed to document current patterns of antithrombotic prescribing after heart valve surgery in the UK. METHODS All UK consultant cardiac surgeons were e-mailed a custom-designed survey. The use of oral anticoagulant (OAC) and/or antiplatelet drugs following bioprosthetic aortic valve replacement or mitral valve replacement, or mitral valve repair (MVrep), for patients in sinus rhythm, without additional indications for antithrombotic medication, was assessed. Additionally, we evaluated anticoagulant choice following MVrep in patients with atrial fibrillation. RESULTS We identified 260 UK consultant cardiac surgeons from 36 units, of whom 103 (40%) responded, with 33 units (92%) having at least 1 respondent. The greatest consensus was for patients undergoing bioprosthetic aortic valve replacement, in which 76% of surgeons favour initial antiplatelet therapy and 53% prescribe lifelong treatment. Only 8% recommend initial OAC. After bioprosthetic mitral valve replacement, 48% of surgeons use an initial OAC strategy (versus 42% antiplatelet), with 66% subsequently prescribing lifelong antiplatelet therapy. After MVrep, recommendations were lifelong antiplatelet agent alone (34%) or following 3 months OAC (20%), no antithrombotic agent (20%), or 3 months OAC (16%). After MVrep for patients with established atrial fibrillation, surgeons recommend warfarin (38%), a direct oral anticoagulant (37%) or have no preference between the 2 (25%). CONCLUSIONS There is considerable variation in the use of antithrombotic drugs after heart valve surgery in the UK and a lack of high-quality evidence to guide practice, underscoring the need for randomized studies.
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Affiliation(s)
- Nabila Laskar
- Department of Cardiology, Barts Heart Centre, London, UK
| | - Christopher D Bayliss
- Newcastle University and the Academic Cardiovascular Unit, James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Bilal H Kirmani
- Department of Cardiac Surgery, Liverpool Heart & Chest Hospital, Liverpool, UK
| | - John B Chambers
- Department of Cardiology, Guys & St Thomas’ Hospitals, London, UK
| | - Rebecca Maier
- Newcastle University and the Academic Cardiovascular Unit, James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Norman P Briffa
- Department of Cardiac Surgery, Northern General Hospital, Sheffield, UK
| | - Neil Cartwright
- Department of Cardiac Surgery, Northern General Hospital, Sheffield, UK
| | - Simon Kendall
- Newcastle University and the Academic Cardiovascular Unit, James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Benoy Nalin Shah
- Department of Cardiology, Wessex Cardiac Centre, Southampton General Hospital, Southampton, UK
| | - Enoch Akowuah
- Newcastle University and the Academic Cardiovascular Unit, James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
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10
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Jin C, Cui C, Seplowe M, Lee KI, Vegunta R, Li B, Frishman WH, Iwai S. Anticoagulation for Atrial Fibrillation: A Review of Current Literature and Views. Cardiol Rev 2024; 32:131-139. [PMID: 36730534 DOI: 10.1097/crd.0000000000000489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Atrial fibrillation is a common supraventricular tachyarrhythmia with uncoordinated atrial activation and ineffective atrial contraction. This leads to an increased risk of atrial thrombi, most commonly in the left atrial appendage, and increased risks of embolic strokes and/or peripheral thromboembolism. It is associated with significant morbidity and mortality. To meet the concerns of thrombi and stroke, anticoagulation has been the mainstay for prevention and treatment thereof. Historically, anticoagulation involved the use of aspirin or vitamin K antagonists, mainly warfarin. Since early 2010s, direct oral anticoagulants (DOACs) including dabigatran, rivaroxaban, apixaban, and edoxaban have been introduced and approved for anticoagulation of atrial fibrillation. DOACs demonstrated a dramatic reduction in the rate of intracranial hemorrhage as compared to warfarin, and offer the advantages of absolution of monitoring therefore avoid the risk of hemorrhages in the context of narrow therapeutic window and under-treatment characteristic of warfarin, particularly in high-risk patients. One major concern and disadvantage for DOACs was lack of reversal agents, which have largely been ameliorated by the approval of Idarucizumab for dabigatran and Andexanet alfa for both apixaban and rivaroxaban, with Ciraparantag as a universal reversal agent for all DOACs undergoing Fast-Track Review from FDA. In this article, we will be providing a broad review of anticoagulation for atrial fibrillation with a focus on risk stratification schemes and anticoagulation agents (warfarin, aspirin, DOACs) including special clinical considerations.
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Affiliation(s)
- Chengyue Jin
- From the Department of Medicine, Westchester Medical Center, Valhalla, NY
| | - Can Cui
- Department of Immunobiology, School of Medicine, Yale University, New Haven, CT
| | - Matthew Seplowe
- From the Department of Medicine, Westchester Medical Center, Valhalla, NY
| | - Kyu-In Lee
- From the Department of Medicine, Westchester Medical Center, Valhalla, NY
| | | | - Bo Li
- From the Department of Medicine, Westchester Medical Center, Valhalla, NY
| | - William H Frishman
- From the Department of Medicine, Westchester Medical Center, Valhalla, NY
| | - Sei Iwai
- Department of Cardiology, Westchester Medical Center, Valhalla, NY
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11
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Franco-Moreno A, Muñoz-Rivas N, Torres-Macho J, Bustamante-Fermosel A, Ancos-Aracil CL, Madroñal-Cerezo E. Systematic review of clinical trials on antithrombotic therapy with factor XI inhibitors. Rev Clin Esp 2024; 224:167-177. [PMID: 38309621 DOI: 10.1016/j.rceng.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2024]
Abstract
INTRODUCTION AND OBJECTIVE Data from phase 2 clinical trials suggest that factor XI inhibitors may exhibit a more favorable efficacy/safety profile compared to current antithrombotic therapies. The aim of this systematic review is to analyze the available evidence derived from these studies. METHODS A literature search in the PubMed, Cochrane Library, Scopus, EMBASE databases, and clinical trial registration platforms Clinical Trials and Cochrane Central Register of Controlled was conducted. In accordance with the PRISMA statement, results were reported. RESULTS A total of 18 completed or ongoing clinical trials addressing multiple scenarios, including atrial fibrillation, stroke, myocardial infarction, and venous thromboembolism, were identified. Evidence from 8 studies with available results was analyzed. Phase 2 studies with factor XI inhibitors, overall, demonstrated an acceptable efficacy and safety profile. The benefit-risk balance, in terms of reducing venous thromboembolism in patients undergoing total knee arthroplasty, was more favorable. For this scenario, factor XI inhibitors showed a 50% reduction in the overall rate of thrombotic complications and a 60% reduction in the rate of bleeding compared to enoxaparin. Modest results in studies involving patients with atrial fibrillation, stroke, and myocardial infarction were observed. CONCLUSIONS Factor XI inhibitors offer new prospects in antithrombotic treatment and prophylaxis. Ongoing phase 3 studies will help define the most suitable drugs and indications.
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Affiliation(s)
- A Franco-Moreno
- Servicio de Medicina Interna, Unidad de Tromboembolismo Venoso, Hospital Universitario Infanta Leonor-Virgen de la Torre, Madrid, Spain.
| | - N Muñoz-Rivas
- Servicio de Medicina Interna, Unidad de Tromboembolismo Venoso, Hospital Universitario Infanta Leonor-Virgen de la Torre, Madrid, Spain
| | - J Torres-Macho
- Servicio de Medicina Interna, Hospital Universitario Infanta Leonor-Virgen de la Torre, Madrid, Spain
| | - A Bustamante-Fermosel
- Servicio de Medicina Interna, Hospital Universitario Infanta Leonor-Virgen de la Torre, Madrid, Spain
| | - C L Ancos-Aracil
- Servicio de Medicina Interna, Unidad de Tromboembolismo Venoso, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | - E Madroñal-Cerezo
- Servicio de Medicina Interna, Unidad de Tromboembolismo Venoso, Hospital Universitario de Fuenlabrada, Madrid, Spain
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12
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Olie RH, Winckers K, Rocca B, Ten Cate H. Oral Anticoagulants Beyond Warfarin. Annu Rev Pharmacol Toxicol 2024; 64:551-575. [PMID: 37758192 DOI: 10.1146/annurev-pharmtox-032823-122811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Direct oral anticoagulants (DOACs) have largely replaced vitamin K antagonists, mostly warfarin, for the main indications for oral anticoagulation, prevention and treatment of venous thromboembolism, and prevention of embolic stroke in atrial fibrillation. While DOACs offer practical, fixed-dose anticoagulation in many patients, specific restrictions or contraindications may apply. DOACs are not sufficiently effective in high-thrombotic risk conditions such as antiphospholipid syndrome and mechanical heart valves. Patients with cancer-associated thrombosis may benefit from DOACs, but the bleeding risk, particularly in those with gastrointestinal or urogenital tumors, must be carefully weighed. In patients with frailty, excess body weight, and/or moderate-to-severe chronic kidney disease, DOACs must be cautiously administered and may require laboratory monitoring. Reversal agents have been developed and approved for life-threatening bleeding. In addition, the clinical testing of potentially safer anticoagulants such as factor XI(a) inhibitors is important to further optimize anticoagulant therapy in an increasingly elderly and frail population worldwide.
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Affiliation(s)
- Renske H Olie
- Departments of Internal Medicine (Section of Vascular Medicine) and Biochemistry, Thrombosis Expertise Center, and CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands;
| | - Kristien Winckers
- Departments of Internal Medicine (Section of Vascular Medicine) and Biochemistry, Thrombosis Expertise Center, and CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands;
| | - Bianca Rocca
- Section of Pharmacology, Catholic University School of Medicine, Rome, Italy
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy
| | - Hugo Ten Cate
- Departments of Internal Medicine (Section of Vascular Medicine) and Biochemistry, Thrombosis Expertise Center, and CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands;
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
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13
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1-e156. [PMID: 38033089 PMCID: PMC11095842 DOI: 10.1161/cir.0000000000001193] [Citation(s) in RCA: 218] [Impact Index Per Article: 218.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines liaison
| | | | | | | | | | - Paul L Hess
- ACC/AHA Joint Committee on Performance Measures liaison
| | | | | | | | | | - Kazuhiko Kido
- American College of Clinical Pharmacy representative
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14
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:109-279. [PMID: 38043043 PMCID: PMC11104284 DOI: 10.1016/j.jacc.2023.08.017] [Citation(s) in RCA: 66] [Impact Index Per Article: 66.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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15
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Santarpino G, Di Mauro M, De Feo M, Menicanti L, Paparella D, Mastroroberto P, Speziale G, Pollari F, Mauro M, Torella M, Coscioni E, Barili F, Parolari A. Mechanical heart valves and oral anticoagulation: a survey of the Italian Society of Cardiac Surgery. J Cardiovasc Med (Hagerstown) 2024; 25:38-43. [PMID: 38051658 DOI: 10.2459/jcm.0000000000001525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
In the latest European guidelines for the management of valvular heart disease, mechanical valve prostheses maintain a strategic role, particularly for certain patient subsets and age groups. Despite the high number of devices implanted in clinical practice, particularly in non-European and North American regions, current scientific literature and debate seem to suggest a limited use of mechanical heart valves. The cardiac surgery community seems to be highly interested in biological and transcatheter valve prostheses but less interested in mechanical heart valves, including possible strategies for self-management of anticoagulation therapy. In this respect, the Italian Society of Cardiac Surgery (SICCH), in particular the Italian Group of Research for Outcome in Cardiac Surgery (GIROC), has promoted a survey among its members to stimulate the interest in this topic and express their opinion on this issue that, due to the prevalence of the affected population and the new treatment options for improving patients' quality of life, should be more appraised and debated in the cardiac surgery community. The recorded results, obtained on the answers to 111 questionnaires, seem to divide the specialists into 'pros' and 'contras' on a useful tool for the entire cardiac surgery community. For this reason, SICCH proposes in conclusion to declare its unified and institutional opinion on this topic.
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Affiliation(s)
- Giuseppe Santarpino
- Department of Experimental and Clinical Medicine, Magna Graecia University of Catanzaro, Catanzaro
- Department of Cardiac Surgery, Città di Lecce Hospital, GVM Care and Research, Lecce, Italy
- Department of Cardiac Surgery, Klinikum Nürnberg, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Michele Di Mauro
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
| | - Marisa De Feo
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Napoli
| | - Lorenzo Menicanti
- Department of Cardiac Surgery, IRCCS, Policlinico San Donato, San Donato Milanese
| | - Domenico Paparella
- Department of Medical and Surgical Sciences, Division of Cardiac Surgery, University of Foggia, Foggia
- Division of Cardiac Surgery, Santa Maria Hospital, GVM Care & Research, Bari
| | - Pasquale Mastroroberto
- Department of Experimental and Clinical Medicine, Magna Graecia University of Catanzaro, Catanzaro
| | - Giuseppe Speziale
- Division of Cardiac Surgery, Anthea Hospital, GVM Care & Research, Bari
| | - Francesco Pollari
- Department of Cardiac Surgery, Klinikum Nürnberg, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Marianna Mauro
- Department of Experimental and Clinical Medicine, Magna Graecia University of Catanzaro, Catanzaro
| | - Michele Torella
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Napoli
| | - Enrico Coscioni
- Division of Cardiac Surgery, AOU San Giovanni di Dio e Ruggi d'Aragona, Salerno
| | - Fabio Barili
- Department of Cardiac Surgery, Santa Croce Hospital, Cuneo
| | - Alessandro Parolari
- University Department of Cardiac Surgery, IRCCS Policlinico San Donato, Milan, Italy
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16
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Safouris A, Psychogios K, Palaiodimou L, Orosz P, Magoufis G, Kargiotis O, Theodorou A, Karapanayiotides T, Spiliopoulos S, Nardai S, Sarraj A, Nguyen TN, Yaghi S, Walter S, Sacco S, Turc G, Tsivgoulis G. Update of Anticoagulation Use in Cardioembolic Stroke With a Special Reference to Endovascular Treatment. J Stroke 2024; 26:13-25. [PMID: 38326704 PMCID: PMC10850459 DOI: 10.5853/jos.2023.01578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 11/30/2023] [Accepted: 12/04/2023] [Indexed: 02/09/2024] Open
Abstract
Cardioembolic stroke is a major cause of morbidity, with a high risk of recurrence, and anticoagulation represents the mainstay of secondary stroke prevention in most patients. The implementation of endovascular treatment in routine clinical practice complicates the decision to initiate anticoagulation, especially in patients with early hemorrhagic transformation who are considered at higher risk of hematoma expansion. Late hemorrhagic transformation in the days and weeks following stroke remains a potentially serious complication for which we still do not have any established clinical or radiological prediction tools. The optimal time to initiate therapy is challenging to define since delaying effective secondary prevention treatment exposes patients to the risk of recurrent embolism. Consequently, there is clinical equipoise to define and individualize the optimal timepoint to initiate anticoagulation combining the lowest risk of hemorrhagic transformation and ischemic recurrence in cardioembolic stroke patients. In this narrative review, we will highlight and critically outline recent observational and randomized relevant evidence in different subtypes of cardioembolic stroke with a special focus on anticoagulation initiation following endovascular treatment. We will refer mainly to the commonest cause of cardioembolism, non-valvular atrial fibrillation, and examine the possible risk and benefit of anticoagulation before, during, and shortly after the acute phase of stroke. Other indications of anticoagulation after ischemic stroke will be briefly discussed. We provide a synthesis of available data to help clinicians individualize the timing of initiation of oral anticoagulation based on the presence and extent of hemorrhagic transformation as well as stroke severity.
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Affiliation(s)
- Apostolos Safouris
- Stroke Unit, Metropolitan Hospital, Piraeus, Greece
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurointerventions, National Institute of Mental Health, Neurology and Neurosurgery, Semmelweis University, Department of Neurosurgery, Budapest, Hungary
| | | | - Lina Palaiodimou
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Peter Orosz
- Department of Neurointerventions, National Institute of Mental Health, Neurology and Neurosurgery, Semmelweis University, Department of Neurosurgery, Budapest, Hungary
| | - George Magoufis
- Interventional Neuroradiology Unit, Metropolitan Hospital, Piraeus, Greece
- Second Department of Radiology, Interventional Radiology Unit, “Attikon” University Hospital, Athens, Greece
| | | | - Aikaterini Theodorou
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Theodore Karapanayiotides
- Second Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki, School of Medicine, Thessaloniki, Greece
| | - Stavros Spiliopoulos
- Second Department of Radiology, Interventional Radiology Unit, “Attikon” University Hospital, Athens, Greece
| | - Sándor Nardai
- Department of Neurointerventions, National Institute of Mental Health, Neurology and Neurosurgery, Semmelweis University, Department of Neurosurgery, Budapest, Hungary
| | - Amrou Sarraj
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Thanh N. Nguyen
- Department of Neurology and Radiology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Shadi Yaghi
- Department of Neurology, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, RI, USA
| | - Silke Walter
- Department of Neurology, Saarland University Medical Centre, Homburg, Germany
| | - Simona Sacco
- Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, L’Aquila, Italy
| | - Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Paris, France
- INSERM U1266, Paris, France
- FHU Neurovasc, Paris, France
- Université Paris Cité, Paris, France
| | - Georgios Tsivgoulis
- Second Department of Neurology, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
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17
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Sylvester CB, Ryan CT, Frankel WC, Asokan S, Zea-Vera R, Zhang Q, Wall MJ, Coselli JS, Rosengart TK, Chatterjee S, Ghanta RK. Readmission After Bioprosthetic vs Mechanical Mitral Valve Replacement in the United States. Ann Thorac Surg 2024; 117:113-118. [PMID: 35803331 DOI: 10.1016/j.athoracsur.2022.05.064] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 05/17/2022] [Accepted: 05/25/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Choosing between a bioprosthetic and a mechanical mitral valve is an important decision for both patients and surgeons. We compared patient outcomes and readmission rates after bioprosthetic mitral valve replacement (Bio-MVR) vs mechanical mitral valve replacement (Mech-MVR). METHODS The Nationwide Readmissions Database was queried to identify 31 474 patients who underwent isolated MVR (22 998 Bio-MVR, 8476 Mech-MVR) between January 1, 2016, and December 31, 2018. Propensity score matching by age, sex, elective status, and comorbidities was used to compare outcomes between matched cohorts by prosthesis type. Freedom from readmission within the first calendar year was estimated by Kaplan-Meier analysis and compared between matched cohorts. RESULTS Bio-MVR patients were older (median age, 69 vs 57 years; P < .001) and had more comorbidities (median Elixhauser score, 14 vs 11; P < .001) compared with Mech-MVR patients. After propensity score matching (n = 15 549), Bio-MVR patients had similar operative mortality (3.5% vs 3.4%; P = .97) and costs ($50 958 vs $49 782; P = .16) but shorter lengths of stay (8 vs 9 days; P < .001) and fewer 30-day (16.0% vs 18.1%; P = .04) and 90-day (23.8% vs 26.8%; P = .01) readmissions compared with Mech-MVR patients. The difference in readmissions persisted at 1 year (P = .045). Readmission for bleeding or coagulopathy complications was less common with Bio-MVR (5.7% vs 10.1%; P < .001). CONCLUSIONS Readmission was more common after Mech-MVR than after Bio-MVR. Identifying and closely observing patients at high risk for bleeding complications may bridge the readmissions gap between Bio-MVR and Mech-MVR.
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Affiliation(s)
- Christopher B Sylvester
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Medical Scientist Training Program, Baylor College of Medicine, Houston, Texas; Department of Bioengineering, Rice University, Houston, Texas
| | - Christopher T Ryan
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - William C Frankel
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sainath Asokan
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Rodrigo Zea-Vera
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Qianzi Zhang
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Matthew J Wall
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Todd K Rosengart
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Subhasis Chatterjee
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Ravi K Ghanta
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Division of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas.
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18
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Cheng A, Malkin C, Briffa NP. Antithrombotic therapy after heart valve intervention: review of mechanisms, evidence and current guidance. Heart 2023; 110:87-93. [PMID: 37438054 DOI: 10.1136/heartjnl-2022-321387] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 06/12/2023] [Indexed: 07/14/2023] Open
Abstract
As the population ages and treatment options for heart valve disease increase, the number of patients with intracardiac valve prostheses is growing rapidly. Although all devices have the potential to cause thrombus formation, the propensity depends on the type of prosthesis as well as risk of the individual patient. Mechanical valve prostheses carry the highest (and persistent) risk of thromboembolism, and these patients require anticoagulation with vitamin K antagonists (warfarin). Required international normalised ratio levels are dependent on the location of the valve (mitral>aortic), type of valve (ball and cage vs bilealfet vs On-X bilealfet) and rhythm. The risk of tissue (biological) prosthesis is highest soon after surgery and is dependent on individual patient risk including age, valve location (mitral>aortic), history of thromboembolic events and rhythm. In patients with no other indication for anticoagulation, there is uncertainty on the benefits of anticoagulation versus antiplatelet therapy in patients with tissue prostheses or repaired native valves. Patients with an a priori indication for anticoagulation with a direct oral anticoagulant can continue taking this class of drug. Patients with transcatheter aortic valve implantation devices and no additional evidence-based indication for dual antiplatelet therapy or anticoagulation can be maintained on aspirin monotherapy. Patients undergoing transcatheter instrumentation in the mitral valve position should be anticoagulated, although there is currently no published evidence for antithrombotic management in this group of patients. Patients with thrombosed devices (commonly mitral mechanical) should preferably be treated surgically. Patients at high risk of thromboembolism (with mechanical prostheses) should undergo bridging therapy when undergoing surgery.
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Affiliation(s)
- Ann Cheng
- Infection Immunity and cardiovascular Disease, The University of Sheffield, Sheffield, UK
- Cardiothoracic Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | - Norman Paul Briffa
- Infection Immunity and cardiovascular Disease, The University of Sheffield, Sheffield, UK
- Cardiothoracic Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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19
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de Jong AJ, Santa-Ana-Tellez Y, Zuidgeest MGP, Grupstra RJ, Jami F, de Boer A, Gardarsdottir H. Direct-to-participant investigational medicinal product supply in clinical trials in Europe: Exploring the experiences of sponsors, site staff and couriers. Br J Clin Pharmacol 2023; 89:3512-3522. [PMID: 37438875 DOI: 10.1111/bcp.15850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 06/21/2023] [Accepted: 07/04/2023] [Indexed: 07/14/2023] Open
Abstract
AIMS Insights into the current practice of direct-to-participant (DtP) supply of investigational medicinal product (IMP) in the context of clinical trials conducted in Europe are needed, as regulations are unharmonized. This study is set out to explore how DtP IMP supply has been employed in Europe and what the advantages and disadvantages and barriers and facilitators of its implementation are. METHODS We conducted semi-structured interviews with representatives from sponsor companies, courier services and site study staff involved in the IMP dispensing and delivery process in Europe. Interviews were conducted between May and November 2021, and data were analysed following thematic analysis. RESULTS Sixteen respondents participated in one of the 12 interviews. Respondents had experience with different models of DtP IMP supply including shipment from the investigative site, a central pharmacy (a depot under the control of a pharmacist) and a local pharmacy-aiming to reduce trial participation burden. The respondents indicated that investigative site-to-participant shipment is not affected by regulatory barriers, but could burden site staff. Shipment from central locations was considered most efficient, but possible regulatory barriers related to maintaining participants' privacy and investigator oversight were identified. The respondents indicated that the involvement of local pharmacies to dispense IMP can be considered when the IMP is authorized. CONCLUSIONS Several DtP IMP supply models are implemented in clinical trials conducted in Europe. In this study, three main DtP IMP models were identified, which can be referenced when describing these approaches for regulatory approval.
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Affiliation(s)
- Amos J de Jong
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Yared Santa-Ana-Tellez
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Mira G P Zuidgeest
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Renske J Grupstra
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Fatemeh Jami
- Strategic Advice R&D Quality Assurance, AstraZeneca, Cambridge, UK
| | - Anthonius de Boer
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
- Dutch Medicines Evaluation Board, Utrecht, The Netherlands
| | - Helga Gardarsdottir
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
- Department of Clinical Pharmacy, Division Laboratory and Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands
- Faculty of Pharmaceutical Sciences, University of Iceland, Reykjavik, Iceland
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20
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Eikelboom JW, Weitz JI. Warfarin faring better: vitamin K antagonists beat rivaroxaban and apixaban in the INVICTUS and PROACT Xa trials. J Thromb Haemost 2023; 21:3067-3071. [PMID: 37429508 DOI: 10.1016/j.jtha.2023.06.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 06/23/2023] [Accepted: 06/27/2023] [Indexed: 07/12/2023]
Abstract
Although guidelines give preference to direct oral anticoagulants (DOACs) over vitamin K antagonists (VKAs) for stroke prevention in most patients with atrial fibrillation (AF), DOACs are not recommended in those with rheumatic heart disease or mechanical heart valves. The results of the INVICTUS trial (Investigation of Rheumatic AF Treatment Using Vitamin K Antagonists, Rivaroxaban or Aspirin Studies), which compared rivaroxaban with a VKA in patients with rheumatic heart disease-associated AF, and the PROACT Xa trial (A Trial to Determine if Participants with an On-X Aortic Valve Can be Maintained Safely on Apixaban), which compared apixaban with warfarin in patients with an On-X valve in the aortic position, support the use of VKAs for these indications. In this paper, we review the results of these trials, provide perspective on why VKAs were superior to DOACs, and discuss future directions for anticoagulation in these disorders.
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Affiliation(s)
- John W Eikelboom
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, Hamilton, Ontario, Canada
| | - Jeffrey I Weitz
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada.
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21
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Geuens L, Van Hoof L, Van De Bruaene A, Rega F, Meuris B, Verbrugghe P. Aortic valve replacement in non-elderly: the gap between reality, guidelines and evidence. Eur J Cardiothorac Surg 2023; 64:ezad318. [PMID: 37756688 DOI: 10.1093/ejcts/ezad318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 08/22/2023] [Accepted: 09/24/2023] [Indexed: 09/29/2023] Open
Abstract
OBJECTIVES There are several treatment options for non-elderly adults (18-60 years) in need of aortic valve replacement (AVR): a mechanical or biological substitute, a homograft, the Ross procedure or nowadays even transcatheter aortic valve replacement. This study evaluated the current opinions and practices of cardiac surgeons and cardiologists concerning AVR strategies in this patient group. METHODS A 43-item online survey was sent out to several scientific organizations, individual cardiac surgeons, cardiologists and residents/fellows worldwide. RESULTS Two hundred twenty-two physicians from 33 different countries answered the survey. The UK (24%), Belgium (23%) and North America (22%) are best represented. A mechanical valve is the most frequently used substitute in non-elderly. With increasing patient age, the popularity of a biological valve increases. Transcatheter aortic valve replacement and the Ross procedure are each used in <10% of this cohort. Only 12% of the cardiac surgeons has experience with the Ross surgery. In 23%, the patient seems not to be involved in the decision on the type of valve substitute. CONCLUSIONS The preferred surgical treatment for non-elderly patients in need of AVR differs widely. To enable a shared decision-making process including patient preferences, there is more need for collaboration between cardiac departments, as well as education and scientific research about patient-centred outcomes of the different AVR techniques.
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Affiliation(s)
- Lise Geuens
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Lucas Van Hoof
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | | | - Filip Rega
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Bart Meuris
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Peter Verbrugghe
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
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22
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Beaver TM, Manning E, Bavry AA. Commentary: Shades of gray: The right aortic valve for the right patient in 2022. J Thorac Cardiovasc Surg 2023; 166:738-739. [PMID: 35249751 DOI: 10.1016/j.jtcvs.2022.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 02/06/2022] [Accepted: 02/07/2022] [Indexed: 10/19/2022]
Affiliation(s)
- Thomas Mark Beaver
- Division of Cardiovascular Surgery, Department of Surgery, University of Florida College of Medicine, Gainesville, Fla.
| | - Eddie Manning
- Division of Cardiovascular Surgery, Department of Surgery, University of Florida College of Medicine, Gainesville, Fla
| | - Anthony A Bavry
- Division of Cardiology, Department of Medicine, UT Southwestern Medical Center, Dallas, Tex
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23
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Langenaeken T, Vanoppen A, Janssens F, Tanghe L, Verbrugghe P, Rega F, Meuris B. DOACs in the Anticoagulation of Mechanical Valves: A Systematic Review and Future Perspectives. J Clin Med 2023; 12:4984. [PMID: 37568386 PMCID: PMC10419922 DOI: 10.3390/jcm12154984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 07/25/2023] [Accepted: 07/26/2023] [Indexed: 08/13/2023] Open
Abstract
Valvular heart disease is a common disease often necessitating valve replacement. Mechanical heart valves (MHVs) are often used in younger patients because of their longer durability. Their main disadvantage is the need for lifelong anticoagulation. Warfarin is considered a standard treatment, but it is far from perfect. Direct oral anticoagulants (DOACs) are a new and more patient-friendly alternative to warfarin when anticoagulation is required, but have not yet been approved for the indication of mechanical valves. EVIDENCE ACQUISITION A literature search of Pubmed, Embase, Web of Science (Core Collection), and Cochrane Library (from inception to May 2023) was performed using a search string that was well defined and not modified during the study. An extensive overview of the search terms used in each database can be found in the Appendix. Only prospective clinical trials were included in this review. A total of 10 publications were included in this review. RELEVANCE TO CLINICAL PRACTICE This systematic review summarizes the different types of DOACs and their possible use in the anticoagulation of mechanical valves. We aim to propose future directions in anticoagulation research for mechanical valves. CONCLUSIONS DOAC use in MHVs has been halted due to the failure of both dabigatran and apixaban in two major clinical trials. However, rivaroxaban was successful in two small clinical trials. Ample research is still needed to explore new valve designs as well as new anticoagulation targets.
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Affiliation(s)
- Tom Langenaeken
- Department of Cardiac Surgery, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium (B.M.)
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24
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Wang TY, Svensson LG, Wen J, Vekstein A, Gerdisch M, Rao VU, Moront M, Johnston D, Lopes RD, Chavez A, Ruel M, Blackstone EH, Becker RC, Thourani V, Puskas J, Al-Khalidi HR, Cable DG, Elefteriades JA, Pochettino A, Wolfe JA, Graeve A, Sultan I, Sabe AA, Michelena HI, Alexander JH. Apixaban or Warfarin in Patients with an On-X Mechanical Aortic Valve. NEJM EVIDENCE 2023; 2:EVIDoa2300067. [PMID: 38320162 DOI: 10.1056/evidoa2300067] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND: Vitamin K antagonists are the only oral anticoagulants approved to prevent valve thrombosis and valve-related thromboembolism in patients with mechanical heart valves. Whether patients with an On-X mechanical aortic valve can be safely anticoagulated with apixaban is unknown. METHODS: Patients with an On-X aortic valve implanted at least 3 months before enrollment were randomly assigned to receive apixaban 5 mg twice daily or warfarin (target international normalized ratio 2.0 to 3.0). The primary efficacy end point was the composite of valve thrombosis or valve-related thromboembolism with coprimary analyses comparing apixaban with warfarin for noninferiority and comparing the apixaban event rate with an objective performance criterion (OPC). RESULTS: The trial was stopped after 863 participants were enrolled owing to an excess of thromboembolic events in the apixaban group. Most (94%) participants took aspirin. A total of 26 primary end-point events occurred, 20 (in 16 participants) in the apixaban group (4.2%/patient-year; 95% confidence interval [CI], 2.3 to 6.0) and 6 (in 6 participants) in the warfarin group (1.3%/patient-year; 95% CI, 0.3 to 2.3). The difference in primary end-point rates between the apixaban and warfarin groups was 2.9 (95% CI, 0.8 to 5.0); noninferiority and OPC success criteria were not met. Major bleeding rates were 3.6%/patient-year with apixaban and 4.5%/patient-year with warfarin. CONCLUSIONS: Apixaban did not demonstrate noninferiority to warfarin and is less effective than warfarin for the prevention of valve thrombosis or thromboembolism in patients with an On-X mechanical aortic valve. (Funded by Artivion; ClinicalTrials.gov number, NCT04142658.)
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Affiliation(s)
- Tracy Y Wang
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | - Jun Wen
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Andrew Vekstein
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | | | | | | | - Renato D Lopes
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Alma Chavez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Marc Ruel
- University of Ottawa Heart Institute, Ottawa, ON
| | | | | | | | | | - Hussein R Al-Khalidi
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - David G Cable
- OSF HealthCare Cardiovascular Institute, Rockford, IL
| | | | | | - J Alan Wolfe
- Northeast Georgia Medical Center, Gainesville, GA
| | - Allen Graeve
- MultiCare Institute for Research and Innovation, Tacoma, WA
| | | | - Ashraf A Sabe
- Brigham and Women's Hospital, Harvard Medical School, Boston
| | | | - John H Alexander
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
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25
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Accorsi TAD, Paixão MR, Souza Júnior JLD, Gaz MVB, Cardoso RG, Köhler KF, Lima KDA, Tarasoutchi F. Valvular Heart Disease Emergencies: A Comprehensive Review Focusing on the Initial Approach in the Emergency Department. Arq Bras Cardiol 2023; 120:e20220707. [PMID: 37341248 DOI: 10.36660/abc.20220707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 04/05/2023] [Indexed: 06/22/2023] Open
Abstract
Valvular heart disease (VHD) is an increasing health problem worldwide. Patients with VHD may experience several cardiovascular-related emergencies. The management of these patients is a challenge in the emergency department, especially when the previous heart condition is unknown. Specific recommendations for the initial management are currently poor. This integrative review proposes an evidence-based three-step approach from bedside VHD suspicion to the initial treatment of the emergencies. The first step is the suspicion of underlying valvular condition based on signs and symptoms. The second step comprises the attempt to confirm the diagnosis and assessment of VHD severity with complementary tests. Finally, the third step addresses the diagnosis and treatment options for heart failure, atrial fibrillation, valvular thrombosis, acute rheumatic fever, and infective endocarditis. In addition, several images of complementary tests and summary tables are provided for physician support.
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Affiliation(s)
- Tarso Augusto Duenhas Accorsi
- Unidade de Pronto Atendimento , Hospital Israelita Albert Einstein , São Paulo , SP - Brasil
- Instituto do Coração (InCor), Faculdade de Medicina , USP , São Paulo , SP - Brasil
| | - Milena Ribeiro Paixão
- Unidade de Pronto Atendimento , Hospital Israelita Albert Einstein , São Paulo , SP - Brasil
- Instituto do Coração (InCor), Faculdade de Medicina , USP , São Paulo , SP - Brasil
| | | | | | - Ricardo Galesso Cardoso
- Unidade de Pronto Atendimento , Hospital Israelita Albert Einstein , São Paulo , SP - Brasil
| | - Karen Francine Köhler
- Unidade de Pronto Atendimento , Hospital Israelita Albert Einstein , São Paulo , SP - Brasil
| | - Karine De Amicis Lima
- Unidade de Pronto Atendimento , Hospital Israelita Albert Einstein , São Paulo , SP - Brasil
| | - Flavio Tarasoutchi
- Instituto do Coração (InCor), Faculdade de Medicina , USP , São Paulo , SP - Brasil
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26
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Bombace S, Meucci MC, Fortuni F, Ilardi F, Manzo R, Canciello G, Esposito G, Grayburn PA, Losi MA, Sannino A. Beyond Aortic Stenosis: Addressing the Challenges of Multivalvular Disease Assessment. Diagnostics (Basel) 2023; 13:2102. [PMID: 37370999 DOI: 10.3390/diagnostics13122102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 06/12/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
Aortic stenosis (AS) can often coexist with other valvular diseases or be combined with aortic regurgitation (AR), leading to unique pathophysiological conditions. The combination of affected valves can vary widely, resulting in a lack of standardized diagnostic or therapeutic approaches. Echocardiography is crucial in assessing patients with valvular heart disease (VHD), but careful consideration of the hemodynamic interactions between combined valvular defects is necessary. This is important as it may affect the reliability of commonly used echocardiographic parameters, making the diagnosis challenging. Therefore, a multimodality imaging approach, including computed tomography or cardiac magnetic resonance, is often not just beneficial but crucial. It represents the future of diagnostics in this intricate field due to its unprecedented capacity to quantify and comprehend valvular pathology. The absence of definitive data and guidelines for the therapeutic management of AS in the context of multiple valve lesions makes this condition particularly challenging. As a result, an individualized, case-by-case approach is necessary, guided primarily by the recommendations for the predominant valve lesion. This review aims to summarize the pathophysiology of AS in the context of multiple and mixed valve disease, with a focus on the hemodynamic implications, diagnostic challenges, and therapeutic options.
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Affiliation(s)
| | - Maria Chiara Meucci
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy
| | - Federico Fortuni
- Department of Cardiology, Leiden University Medical Centre, 2333 ZA Leiden, The Netherlands
- Department of Cardiology, San Giovanni Battista Hospital, 06034 Foligno, Italy
| | - Federica Ilardi
- Department of Advanced Biomedical Sciences, Division of Cardiology, Federico II University, 80131 Naples, Italy
| | - Rachele Manzo
- Department of Advanced Biomedical Sciences, Division of Cardiology, Federico II University, 80131 Naples, Italy
| | - Grazia Canciello
- Department of Advanced Biomedical Sciences, Division of Cardiology, Federico II University, 80131 Naples, Italy
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, Division of Cardiology, Federico II University, 80131 Naples, Italy
| | - Paul A Grayburn
- Baylor Scott & White Research Institute, Plano, TX 75093, USA
| | - Maria Angela Losi
- Department of Advanced Biomedical Sciences, Division of Cardiology, Federico II University, 80131 Naples, Italy
| | - Anna Sannino
- Department of Advanced Biomedical Sciences, Division of Cardiology, Federico II University, 80131 Naples, Italy
- Baylor Scott & White Research Institute, Plano, TX 75093, USA
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27
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Soria Jiménez CE, Papolos AI, Kenigsberg BB, Ben-Dor I, Satler LF, Waksman R, Cohen JE, Rogers T. Management of Mechanical Prosthetic Heart Valve Thrombosis: JACC Review Topic of the Week. J Am Coll Cardiol 2023; 81:2115-2127. [PMID: 37225366 DOI: 10.1016/j.jacc.2023.03.412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 03/24/2023] [Accepted: 03/27/2023] [Indexed: 05/26/2023]
Abstract
Mechanical prosthetic heart valves, though more durable than bioprostheses, are more thrombogenic and require lifelong anticoagulation. Mechanical valve dysfunction can be caused by 4 main phenomena: 1) thrombosis; 2) fibrotic pannus ingrowth; 3) degeneration; and 4) endocarditis. Mechanical valve thrombosis (MVT) is a known complication with clinical presentation ranging from incidental imaging finding to cardiogenic shock. Thus, a high index of suspicion and expedited evaluation are essential. Multimodality imaging, including echocardiography, cine-fluoroscopy, and computed tomography, is commonly used to diagnose MVT and follow treatment response. Although surgery is oftentimes required for obstructive MVT, other guideline-recommended therapies include parenteral anticoagulation and thrombolysis. Transcatheter manipulation of stuck mechanical valve leaflet is another treatment option for those with contraindications to thrombolytic therapy or prohibitive surgical risk or as a bridge to surgery. The optimal strategy depends on degree of valve obstruction and the patient's comorbidities and hemodynamic status on presentation.
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Affiliation(s)
- César E Soria Jiménez
- Division of Cardiology, MedStar Washington/Georgetown University Hospital Center, Washington, DC, USA
| | - Alexander I Papolos
- Division of Cardiology, MedStar Washington/Georgetown University Hospital Center, Washington, DC, USA; Department of Critical Care Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Benjamin B Kenigsberg
- Division of Cardiology, MedStar Washington/Georgetown University Hospital Center, Washington, DC, USA; Department of Critical Care Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Itsik Ben-Dor
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Lowell F Satler
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Ron Waksman
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Jeffrey E Cohen
- Department of Cardiac Surgery, MedStar Washington Hospital Center, Washington, DC, USA
| | - Toby Rogers
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA; Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA.
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28
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Goel A, Tathireddy H, Wang SH, Vu HH, Puy C, Hinds MT, Zonies D, McCarty OJ, Shatzel JJ. Targeting the Contact Pathway of Coagulation for the Prevention and Management of Medical Device-Associated Thrombosis. Semin Thromb Hemost 2023:10.1055/s-0043-57011. [PMID: 37044117 PMCID: PMC11069398 DOI: 10.1055/s-0043-57011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
Hemorrhage remains a major complication of anticoagulants, with bleeding leading to serious and even life-threatening outcomes in rare settings. Currently available anticoagulants target either multiple coagulation factors or specifically coagulation factor (F) Xa or thrombin; however, inhibiting these pathways universally impairs hemostasis. Bleeding complications are especially salient in the medically complex population who benefit from medical devices. Extracorporeal devices-such as extracorporeal membrane oxygenation, hemodialysis, and cardiac bypass-require anticoagulation for optimal use. Nonetheless, bleeding complications are common, and with certain devices, highly morbid. Likewise, pharmacologic prophylaxis to prevent thrombosis is not commonly used with many medical devices like central venous catheters due to high rates of bleeding. The contact pathway members FXI, FXII, and prekallikrein serve as a nexus, connecting biomaterial surface-mediated thrombin generation and inflammation, and may represent safe, druggable targets to improve medical device hemocompatibility and thrombogenicity. Recent in vivo and clinical data suggest that selectively targeting the contact pathway of coagulation through the inhibition of FXI and FXII can reduce the incidence of medical device-associated thrombotic events, and potentially systemic inflammation, without impairing hemostasis. In the following review, we will outline the current in vivo and clinical data encompassing the mechanism of action of drugs targeting the contact pathway. This new class of inhibitors has the potential to herald a new era of effective and low-risk anticoagulation for the management of patients requiring the use of medical devices.
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Affiliation(s)
- Abhishek Goel
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Harsha Tathireddy
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Si-Han Wang
- Department of Biomedical Engineering, Oregon Health and Science University, Portland, Oregon
| | - Helen H. Vu
- Department of Biomedical Engineering, Oregon Health and Science University, Portland, Oregon
| | - Cristina Puy
- Department of Biomedical Engineering, Oregon Health and Science University, Portland, Oregon
| | - Monica T. Hinds
- Department of Biomedical Engineering, Oregon Health and Science University, Portland, Oregon
| | - David Zonies
- Department of Surgery, Oregon Health and Science University, Portland, Oregon
| | - Owen J.T. McCarty
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
- Department of Biomedical Engineering, Oregon Health and Science University, Portland, Oregon
| | - Joseph J. Shatzel
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
- Department of Biomedical Engineering, Oregon Health and Science University, Portland, Oregon
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29
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Go AS, Al-Khatib SM, Desvigne-Nickens P, Bansal N, Bushnell CD, Fang MC, Freeman JV, Gage BF, Hanke T, Hylek EM, Lopes RD, Noseworthy PA, Reddy VY, Singer DE, Thomas KL, Hills MT, Turakhia MP, Zieman SJ, Cooper LS, Benjamin EJ. Research Opportunities in Stroke Prevention for Atrial Fibrillation: A Report From a National Heart, Lung, and Blood Institute Virtual Workshop. Stroke 2023; 54:e75-e85. [PMID: 36848427 PMCID: PMC9995163 DOI: 10.1161/strokeaha.121.038273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 01/10/2023] [Indexed: 03/01/2023]
Abstract
Atrial fibrillation (AF) is one of the strongest risk factors for ischemic stroke, which is a leading cause of disability and death. Given the aging population, increasing prevalence of AF risk factors, and improved survival in those with cardiovascular disease, the number of individuals affected by AF will continue increasing over time. While multiple proven stroke prevention therapies exist, important questions remain about the optimal approach to stroke prevention at the population and individual patient levels. Our report summarizes the National Heart, Lung, and Blood Institute virtual workshop focused on identifying key research opportunities related to stroke prevention in AF. The workshop reviewed major knowledge gaps and identified targeted research opportunities to advance stroke prevention in AF in the following areas: (1) improving risk stratification tools for stroke and intracranial hemorrhage; (2) addressing challenges with oral anticoagulants; and (3) delineating the optimal roles of percutaneous left atrial appendage occlusion and surgical left atrial appendage closure/excision. This report aims to promote innovative, impactful research that will lead to more personalized, effective use of stroke prevention strategies in people with AF.
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Affiliation(s)
- Alan S. Go
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
- Departments of Epidemiology, Biostatistics and Medicine, University of California, San Francisco, San Francisco, CA
| | - Sana M. Al-Khatib
- Division of Cardiology and Duke Clinical Research Institute, Duke University, Durham, NC
| | - Patrice Desvigne-Nickens
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Nisha Bansal
- Division of Nephrology, University of Washington, Seattle, WA
| | | | - Margaret C. Fang
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, CA
| | - James V. Freeman
- Department of Medicine, Yale University, New Haven, CT
- Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corporation, New Haven, CT
| | - Brian F. Gage
- Department of Medicine, Washington University, St. Louis, MO
| | - Thorsten Hanke
- Department of Cardiac Surgery, Asklepios Klinikum Harburg-Hamburg, Germany
| | | | - Renato D. Lopes
- Division of Cardiology and Duke Clinical Research Institute, Duke University, Durham, NC
| | | | - Vivek Y. Reddy
- Department of Medicine, Icahn School of Medicine, New York, NY
| | - Daniel E. Singer
- Division of General Internal Medicine, Massachusetts General Hospital, and Harvard Medical School, Boston, MA
| | - Kevin L. Thomas
- Division of Cardiology and Duke Clinical Research Institute, Duke University, Durham, NC
| | | | - Mintu P. Turakhia
- Veterans Affairs Palo Alto Health Care System, Palo Alto CA
- Center for Digital Health, Stanford University, Stanford, CA
| | - Susan J. Zieman
- Division of Geriatrics and Clinical Gerontology, National Institute on Aging, National Institutes of Health, Bethesda, MD
| | - Lawton S. Cooper
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Emelia J. Benjamin
- Cardiovascular Medicine, Department of Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA
- Department of Epidemiology, Boston University School of Public Health, Boston, MA
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30
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Abstract
PURPOSE OF REVIEW Rheumatic mitral stenosis (MS) while declining in high- and middle-income countries, continues to be a major cause of death and disability in low-income countries. Although the nonvitamin-K antagonist oral anticoagulants (NOACs) have essentially supplanted vitamin K antagonists (VKA) in patients with nonvalvular atrial fibrillation (AF), their efficacy for stroke prevention in patients with rheumatic MS and AF has not been widely studied until recently. The purpose of this review is to provide a succinct synopsis of the current anticoagulation recommendations for patients with native and prosthetic heart valve disease, with a specific focus on patients with rheumatic MS. RECENT FINDINGS The INVICTUS trial was the first large randomized evaluation of a NOAC vs. VKA in approximately 4600 patients with moderate to severe rheumatic MS and AF. The primary outcome of stroke, systemic embolization, myocardial infarction, vascular and all-cause death, VKA treated patients exhibited lower event rates (including mortality) compared to rivaroxaban. We discuss and contextualize these findings as they relate to the broader use of anticoagulants in patients with valvular heart disease, with and without concomitant AF. SUMMARY VKA remains the standard of care for patients with moderate to severe rheumatic MS who have concomitant AF. Rates of stroke in anticoagulated patients with rheumatic MS and AF are lower than what is traditionally held, while nonstroke related deaths remain the most common mechanism of mortality.
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Affiliation(s)
- Raj Verma
- School of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - David A Latter
- St. Michael's Hospital, University of Toronto, Toronto, Canada
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31
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Bioprosthetic valves and atrial fibrillation: Direct anticoagulants or warfarin. J Thorac Cardiovasc Surg 2023; 165:71-75. [PMID: 34275622 DOI: 10.1016/j.jtcvs.2021.05.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/30/2021] [Accepted: 05/06/2021] [Indexed: 02/08/2023]
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32
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Baman JR, Medhekar AN, Malaisrie SC, McCarthy P, Davidson CJ, Bonow RO. Management Challenges in Patients Younger Than 65 Years With Severe Aortic Valve Disease. JAMA Cardiol 2022; 8:281-289. [PMID: 36542365 DOI: 10.1001/jamacardio.2022.4770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
ImportanceThe management of aortic valve disease, including aortic stenosis and aortic regurgitation (AR), in younger adult patients (age &lt;65 years) is complex, and the optimal strategy is often unclear, contingent on multiple anatomic and holistic factors.ObservationsTraditional surgical approaches carry significant considerations, including compulsory lifelong anticoagulation for patients who receive a mechanical aortic valve replacement (AVR) and the risk of structural valvular deterioration and need for subsequent valve intervention in those who receive a bioprosthetic AVR. These factors are magnified in young adults who are considering pregnancy, for whom issues of anticoagulation and valve longevity are heightened. The Ross procedure has emerged as a promising alternative; however, its adoption is limited to highly specialized centers. Valve repair is an option for selected patients with AR. These treatment options offer varying degrees of durability and are associated with different risks and complications, especially for younger adult patients. Patient-centered care from a multidisciplinary valve team allows for discussion of the optimal timing of intervention and the advantages and disadvantages of the various treatment options.Conclusions and RelevanceThe management of severe aortic valve disease in adults younger than 65 years is complex, and there are numerous considerations with each management decision. While mechanical AVR and bioprosthetic AVR have historically been the standards of care, other options are emerging for selected patients but are not yet generalizable beyond specialized surgical centers. A detailed discussion by members of the multidisciplinary heart team and the patient is an integral part of the shared decision-making process.
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Affiliation(s)
- Jayson R. Baman
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ankit N. Medhekar
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - S. Chris Malaisrie
- Department of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Patrick McCarthy
- Department of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Charles J. Davidson
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Robert O. Bonow
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Editor, JAMA Cardiology
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33
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Ryu R. DOACs in Valvular Heart Disease: Latest Key Updates on PROACT Xa (Apixaban) and INVICTUS (Rivaroxaban). Clin Appl Thromb Hemost 2022; 28:10760296221144044. [PMID: 36474349 PMCID: PMC9732789 DOI: 10.1177/10760296221144044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Rachel Ryu
- College of Pharmacy, Western University of Health
Sciences, Pomona, CA, USA,Rachel Ryu, College of Pharmacy, Western
University of Health Sciences, 09 East Second St, Pomona, CA 91766, USA.
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34
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Arafat AA, AlQattan H, Zahra A, Alghamdi R, Alghosoon H, AlGhamdi F, Alamro S, Albackr H, Ismail H, Adam AI, Algarni KD, Albacker TB. Using tissue mitral valves in younger patients: A word of caution. J Card Surg 2022; 37:4227-4233. [PMID: 36040616 DOI: 10.1111/jocs.16881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 07/30/2022] [Accepted: 08/17/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND The debate about the optimal mitral valve prosthesis continues. We aimed to compare the early and late outcomes, including stroke, bleeding, survival, and reoperation after isolated mitral valve replacement (MVR) using tissue versus mechanical valves. METHODS This retrospective cohort study included 291 patients who had isolated MVR from 2005 to 2015. Patients were grouped into the tissue valve group (n = 140) and the mechanical valve group (n = 151). RESULTS There were no differences in duration of mechanical ventilation, hospital stay, and hospital mortality between groups. Fifteen patients required cardiac rehospitalization, nine in the tissue valve group, and six in the mechanical valve group (p = .44). Stroke occurred in nine patients, five with tissue valves, and four with mechanical valves (p = .66). Bleeding occurred in 22 patients, seven patients with tissue valves, and 15 patients with mechanical valves (p = .09). Freedom from reoperation was 95%, 93%, 84%, 67% at 3, 5, 7, and 10 years for tissue valve and 97%, 96%, 96%, and 93% for mechanical valves, respectively (p˂ .001). The median follow-up was 84 months (Q1: Q3: 38-139). Survival at 3, 5, 7, and 10 years was 94%, 91%, 89%, 86% in tissue valves and 96%, 93%, 91%, 91% in mechanical valves, respectively (p = .49). CONCLUSIONS Tissue valve degeneration is still an issue even in the new generations of mitral tissue valves. The significant risk of reoperation in patients with mitral tissue valves should be considered when using those valves in younger patients. Mechanical valves remain a valid option for all age groups.
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Affiliation(s)
- Amr A Arafat
- Department of Adult Cardiac Surgery, Prince Sultan Cardiac Centre, Riyadh, Saudi Arabia.,Cardiothoracic Surgery Department, Tanta University, Tanta, Egypt
| | - Hussain AlQattan
- Cardiac Sciences Department, College of Medicine, King Fahad Cardiac Centre, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Ashraf Zahra
- Department of Adult Cardiac Surgery, Prince Sultan Cardiac Centre, Riyadh, Saudi Arabia.,Cardiothoracic Surgery Department, Shbeen Elkom Teaching Hospital, Shbeen Elkom, Egypt
| | - Rawan Alghamdi
- Department of Adult Cardiac Surgery, Prince Sultan Cardiac Centre, Riyadh, Saudi Arabia
| | - Haneen Alghosoon
- Cardiac Research Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Faisal AlGhamdi
- Cardiac Sciences Department, College of Medicine, King Fahad Cardiac Centre, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Sultan Alamro
- Cardiac Sciences Department, College of Medicine, King Fahad Cardiac Centre, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Hanan Albackr
- Cardiac Sciences Department, College of Medicine, King Fahad Cardiac Centre, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Huda Ismail
- Department of Adult Cardiac Surgery, Prince Sultan Cardiac Centre, Riyadh, Saudi Arabia
| | - Adam I Adam
- Department of Adult Cardiac Surgery, Prince Sultan Cardiac Centre, Riyadh, Saudi Arabia
| | - Khaled D Algarni
- Cardiac Surgery Department, Johns Hopkins Aramco Hospital, Dhahran, Saudi Arabia
| | - Turki B Albacker
- Cardiac Sciences Department, College of Medicine, King Fahad Cardiac Centre, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
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Budd AN, Wood B, Zheng W, Rong LQ. Perioperative Management of Direct Oral Anticoagulants in Cardiac Surgery: Practice Recommendations Based on Current Evidence. J Cardiothorac Vasc Anesth 2022; 36:4141-4149. [PMID: 35965231 DOI: 10.1053/j.jvca.2022.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 07/05/2022] [Accepted: 07/14/2022] [Indexed: 11/11/2022]
Abstract
An increasing number of patients on systemic oral anticoagulants present for cardiac surgery, and cardiac anesthesiologists should be well-informed on their management in the perioperative period. Direct oral anticoagulants (DOACs), including factor Xa inhibitors and direct thrombin inhibitors, are an attractive alternative to warfarin due to fewer dietary and drug interactions, less frequent monitoring requirements, and an improved patient adherence. Since the approval of DOACs by the Food and Drug Administration in 2010, the number of patients on these medications only has increased. The guidelines vary on the periprocedural management of DOACs for cardiac surgery. This review evaluated the current evidence for medication cessation before surgery, based on timing as well as plasma drug concentration. The practice recommendations of various monitoring tests and new evolving point-of-care testing are examined herein. The different reversal agents were discussed by the authors for both elective and urgent procedures. The cardiac anesthesiologist needs to be intimately familiar with the management and current best practices of DOACs for safe and appropriate patient care.
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Affiliation(s)
- Ashley N Budd
- Department of Anesthesiology, Northwestern Feinberg School of Medicine, Chicago, IL.
| | - Brendan Wood
- Department of Anesthesiology, Weill Cornell Medicine/New York Presbyterian, New York, NY
| | - William Zheng
- Department of Anesthesiology, Weill Cornell Medicine/New York Presbyterian, New York, NY
| | - Lisa Q Rong
- Department of Anesthesiology, Weill Cornell Medicine/New York Presbyterian, New York, NY
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Rapidly Progressive and Catastrophic Calciphylaxis After Mechanical Valve Replacement: An Anticoagulation Dilemma. JACC Case Rep 2022; 4:1319-1323. [PMID: 36406917 PMCID: PMC9666739 DOI: 10.1016/j.jaccas.2022.07.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 06/27/2022] [Accepted: 07/20/2022] [Indexed: 01/11/2023]
Abstract
Warfarin is the only approved anticoagulant after mechanical valve replacement, but it is a well described risk factor for calciphylaxis among patients with end-stage kidney disease. Our patient with end-stage kidney disease rapidly developed calciphylaxis after dual mechanical valve replacement in association with warfarin initiation, posing significant challenges in clinical management and a fatal outcome. (Level of Difficulty: Intermediate.).
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Derda AA, Marquardt MM, Martens A, Mirena E, Vogel-Claussen J, Kempf T, Haverich A, Bauersachs J, Napp LC. Cinefluoroscopy for assessment of mechanical heart valves with suspected dysfunction. Front Cardiovasc Med 2022; 9:952255. [PMID: 36148066 PMCID: PMC9486207 DOI: 10.3389/fcvm.2022.952255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 07/26/2022] [Indexed: 11/26/2022] Open
Abstract
Background Mechanical heart valves (MHVs) are preferred prosthesis types in many, especially younger patients who need surgical valve replacement. Although echocardiography is most frequently performed for prosthesis assessment during follow-up, ultrasound artifacts usually preclude a precise investigation of prosthesis function. Cinefluoroscopy (CF) is a simple and effective method to analyze and quantify opening and closing of prosthesis leaflets but requires careful visualization of the valve using optimal viewing angles. Here, we investigated the quality of CF studies in clinical routine and their suitability for quantitative analysis of prosthesis function. Methods and results We retrospectively identified 94 patients with 118 cinefluoroscopies performed by 31 different investigators in one tertiary center from 2012 to 2021. Of 150 MHVs (98% bi-leaflet prostheses), 87 (58%) were aortic, 53 (34%) mitral, 7 (5%) tricuspid, and 5 (3%) pulmonary valve prostheses, respectively. CF studies were categorized by their suitability to quantitatively assess opening and closing angles. Visualization of valve function was “sufficient” in 23%, “suboptimal” in 46%, and “unsuitable” in 31% of the cases. Conclusion In clinical routine, only one-fourth of CF studies allow for a complete assessment of leaflet motion of MHVs. Although this may be in part due to the varying experience of operators, the high number of unsuitable studies suggests that optimal viewing angles may not be achievable in all patients. Further research is required to investigate standard viewing angles and anatomy after MHV implantation to improve the quality of CF studies and reduce radiation exposure of patients and operators.
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Affiliation(s)
- Anselm A. Derda
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Marvin M. Marquardt
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Andreas Martens
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Elion Mirena
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Jens Vogel-Claussen
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Tibor Kempf
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - L. Christian Napp
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
- *Correspondence: L. Christian Napp,
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Right Heart Failure as an Atypical Presentation of Chronic Type A Aortic Dissection - Multimodality Imaging for Accurate Diagnosis and Treatment. A case report and mini-review of literature. J Crit Care Med (Targu Mures) 2022; 8:204-213. [PMID: 36062037 PMCID: PMC9396954 DOI: 10.2478/jccm-2022-0016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 06/12/2022] [Indexed: 11/21/2022] Open
Abstract
Background An intrapericardial organized haematoma secondary to chronic type A aortic dissection is an extremely rare cause of right heart failure. Imaging studies are essential in recognising and diagnosis of this distinctive medical condition and guiding the anticipated treatment. Case presentation A 70-year-old male patient was admitted for progressive symptoms of right heart failure. His cardiovascular history exposed an aortic valve replacement 22 years before with a Medtronic Hall 23 tilting valve with no regular follow-up. Classical signs of congestion were recognized at physical examination. Transthoracic two-dimensional echocardiography and thoraco-abdominal computed tomography angiography, as essential parts of multimodality imaging algorithm, established the underlying cause of right heart failure. Under total cardiopulmonary bypass and cardiac arrest, surgical removal of the haematoma and proximal repair of the ascending aorta with a patient-matched vascular graft were successfully performed. The patient was discharged in good condition with appropriate pharmacological treatment, guideline-directed; no imagistic signs of acute post-surgery complications were ascertained. Conclusion This paper highlights the importance of recognizing and providing a timely clinical and imagistic diagnosis of this very rare, potentially avoidable cause of right heart failure in patients with previous cardiac surgery.
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Jamieson WRE, Ely JL, Brink J, Pennel T, Bannon P, Patel J, Gupta RK, Mohan Rao PS, Agrawal D, Wiklund L, Kappetein AP, Haaverstad R, Geisner T, Doenst T, Schlensak C, Nair S, Brown C, Siepe M, Damiano RJ, Langlois Y, Cherian KM, Azar H, Chen JC, Bavaria JE, Fedoruk LM, Munfakh NA, Sridhar V, Scholz PM, Pfeffer TA, Ye J. PROSE: Prospective Randomized Trial of the On-X Mechanical Prosthesis and the St Jude Medical Mechanical Prosthesis Evaluation: Part 2: Study results-prostheses, positions, and economic development. JTCVS OPEN 2022; 12:51-70. [PMID: 36590733 PMCID: PMC9801238 DOI: 10.1016/j.xjon.2022.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 06/04/2022] [Accepted: 06/23/2022] [Indexed: 01/04/2023]
Abstract
Objectives The Prospective Randomized On-X Mechanical Prosthesis Versus St Jude Medical Mechanical Prosthesis Evaluation (PROSE) trial purpose was to investigate whether a current-generation mechanical prosthesis (On-X; On-X Life Technologies/Artivion Inc) reduced the incidence of thromboembolic-related complications compared with a previous-generation mechanical prosthesis (St Jude Medical Mechanical Prosthesis; Abbott/St Jude Medical). This second report documents the valve-related complications by individual prostheses and by Western and Developing populations. Methods The PROSE trial study was conducted in 28 worldwide centers and incorporated 855 subjects randomized between 2003 and 2016. The study enrollment was discontinued on August 31, 2016. The study protocol, and analyses of 10 demographic variables and 24 risk factors were published in detail in 2021. Results The total patient population (N = 855) included patients receiving an On-X valve (n = 462) and a St Jude Medical valve (n = 393). The overall freedom evaluation showed no differences at 5 years between the prostheses for thromboembolism or for valve thrombosis. There were also no differences in mortality. There were several differences between Developing and Western populations. The freedom relations at 5 years for mortality favored Western over Developing populations. Valve thrombosis was differentiated by position and site: aortic < mitral (P = .007) and Western < Developing (P = .005). In the mitral position there were no cases in Western populations, whereas there were 8 in Developing populations (P = .217). Conclusions The On-X valve and St Jude Medical valve performed equally well in the study with no differences found. The only differentiation occurred with valve thrombosis in the mitral position more than the aortic position and occurring in Developing more than Western populations. The occurrence of valve thrombosis was also related to a younger population possibly due to anticoagulation compliance based on record review.
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Affiliation(s)
- W. R. Eric Jamieson
- Vancouver Coastal Health Research Institute, Vancouver General Hospital and St. Paul's Hospital, University of British Columbia, Vancouver, British Colombia, Canada,Address for reprints: W. R. Eric Jamieson, MD, Vancouver Coastal Health Research Institute, University of British Columbia, 272 Waterleigh Dr, Vancouver, British Columbia V5X 4T2, Canada.
| | - John L. Ely
- Heart of the Matter Clinical Consultants, Austin, Tex
| | - Johan Brink
- Division of Cardiothoracic Surgery, University of Cape Town, Cape Town, South Africa
| | - Timothy Pennel
- Division of Cardiothoracic Surgery, University of Cape Town, Cape Town, South Africa
| | - Paul Bannon
- Department of Cardiovascular Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Jashvant Patel
- Department of Cardiac Surgery, B. D. Mehta Mahavir Heart Institute, Surat, India
| | - Rajiv Kumar Gupta
- Department of Cardiovascular and Thoracic Surgery, Dayanand Medical College, Ludhiana, India
| | - Prasanna Simha Mohan Rao
- Department of Cardiothoracic Surgery, Shri Jaya Deva Institute of Cardiovascular Sciences, Bangalore, India
| | - Damyanti Agrawal
- Department of Cardiovascular Surgery, Banaras Hindu University, Varanasi, India
| | - Lars Wiklund
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenberg, Sweden
| | | | - Rune Haaverstad
- Department of Cardiothoracic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Thomas Geisner
- Department of Cardiothoracic Surgery, Universitats Klinik Jena, Jena, Germany
| | - Torsten Doenst
- Department of Cardiovascular and Thoracic Surgery, Universitats Klinik Tuebingen, Tuebingen, Germany
| | - Christian Schlensak
- Department of Cardiothoracic Surgery, Apollo Multispecialty Hospital, Chennai, India
| | - Salgunan Nair
- Department of Cardiovascular Surgery, Horizon New Brunswick Heart Center, Saint John, New Brunswich, Canada
| | - Craig Brown
- Department of Cardiovascular Surgery, Universitats Herzzentrum, Freiburg, Germany
| | - Matthias Siepe
- Department of Surgery, Washington University School of Medicine, St Louis, Mo
| | - Ralph J. Damiano
- Division of Cardiac Surgery, Jewish General Hospital, Montreal, Québec, Canada
| | - Yves Langlois
- Department of Cardiovascular Surgery, Frontier Lifeline Hospital, Chennai, India
| | | | - Hormoz Azar
- Department of Thoracic Surgery, Kaiser-Permanente Hospital, Honolulu, Hawaii
| | - John C. Chen
- Department of Surgery, Christian Hospital Northeast, St Louis, Mo
| | - Joseph E. Bavaria
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Lynn M. Fedoruk
- Division of Cardiac Surgery, Victoria Heart Institute, Victoria, British Columbia, Canada
| | - Nabil A. Munfakh
- Department of Cardiothoracic and Vascular Surgery, Apollo Multispecialty Hospital, Madurai, India
| | - V. Sridhar
- Department of Surgery, Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Peter M. Scholz
- Department of Surgery, Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Thomas A. Pfeffer
- Department of Thoracic Surgery, Kaiser-Permanente Hospital, Los Angeles, Calif
| | - Jian Ye
- Division of Cardiovascular Surgery, St Paul's Hospital, Vancouver, British Columbia, Canada
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40
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Li S, Zhang Y. Do Oral Factor Xa Inhibitors have a Role in Patients with Mechanical Heart Valves? Am J Cardiovasc Drugs 2022; 22:595-600. [DOI: 10.1007/s40256-022-00544-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/30/2022] [Indexed: 11/01/2022]
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41
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Nguyen Q, Luc JGY, MacGillivray TE, Preventza OA. Transcatheter Versus Surgical Aortic Valve Replacement in Young, Low-risk Patients with Severe Aortic Stenosis. US CARDIOLOGY REVIEW 2022. [DOI: 10.15420/usc.2022.08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Aortic stenosis is a common form of acquired degenerative valvular disease associated with poor survival after the onset of symptoms. Treatment options for patients with aortic stenosis in addition to medical therapy include surgical aortic valve replacement (SAVR) with either tissue or mechanical valves, or transcatheter aortic valve replacement (TAVR) with either balloon-expandable or self-expanding valves via either transfemoral or alternative access routes. In this review, the authors discuss the current evidence and special considerations regarding the use of TAVR versus SAVR in the management of severe aortic stenosis in young (<65 years of age), low-risk patients, highlighting the history of aortic stenosis treatment, the current guidelines and recommendations, and important issues that remain to be addressed. Ultimately, until ongoing clinical trials with long-term follow-up data shed light on whether interventions for aortic stenosis can be broadened to a low-risk population, TAVR in young, low-risk patients should be undertaken with caution and with guidance from a multidisciplinary heart team.
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Affiliation(s)
- Quynh Nguyen
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Jessica GY Luc
- Division of Cardiovascular Surgery, Department of Surgery, University of British Columbia, Vancouver, Canada
| | - Thomas E MacGillivray
- Division of Cardiac Surgery and Thoracic Transplantation Surgery, Houston Methodist DeBakey Heart and Vascular Center, Houston, TX
| | - Ourania A Preventza
- Division of Cardiothoracic Surgery, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX
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42
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The role of mechanical valves in the aortic position in the era of bioprostheses and TAVR: Evidence-based appraisal and focus on the On-X valve. Prog Cardiovasc Dis 2022; 72:31-40. [PMID: 35738422 DOI: 10.1016/j.pcad.2022.06.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 06/05/2022] [Indexed: 11/24/2022]
Abstract
Patients who need a prosthetic aortic heart valve may decide, working with their cardiologist and cardiac surgeon, among a variety of options: surgical or transcatheter approach, bioprosthetic or mechanical valve, or a Ross procedure if suitable to their age and anatomy. This review article examines the evidence for survival benefit with mechanical aortic valves, discusses bioprosthetic structural valve degeneration and its consequences, and considers the risks of redo aortic valve surgery or subsequent valve-in-valve (ViV) transcatheter intervention. It highlights the unique characteristics of the On-X aortic valve, including the US Food and Drug Administration approved and American College of Cardiology/American Heart Association guideline supported reduced anticoagulation target INR of 1.5 to 2.0, and discusses the PROACT Xa trial comparing apixaban vs warfarin anticoagulation. The choice of prosthetic valve should be individualized, carefully considering each patient's unique circumstances. In that context, the On-X aortic valve offers a potential lifetime solution without need for a repeat operation, while minimizing the risks of long-term anticoagulation. In an era of enthusiasm for bioprosthetic and transcatheter-based approaches, the option of a second-generation bileaflet mechanical valve with optimized hemodynamics-the On-X aortic valve-may well align with patient expectations.
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43
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Antithrombotic treatment for valve protheses: Which drug, which dose, and when? Prog Cardiovasc Dis 2022; 72:4-14. [DOI: 10.1016/j.pcad.2022.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 05/29/2022] [Indexed: 11/20/2022]
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44
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Ryu R, Tran R. DOACs in Mechanical and Bioprosthetic Heart Valves: A Narrative Review of Emerging Data and Future Directions. Clin Appl Thromb Hemost 2022; 28:10760296221103578. [PMID: 35642259 PMCID: PMC9163724 DOI: 10.1177/10760296221103578] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
In the recent years, there has been significant transformation in the management of valvular heart disease (VHD), as a result of new minimally invasive technologies, such as the transcatheter aortic valve implantation (TAVI). Conventionally, mechanical heart valves require anticoagulation with warfarin to prevent thrombogenic events. Lately, there has been an uptrend in the usage of direct-acting oral anticoagulants (DOACs) in both mechanical and bioprosthetic heart valves. In clinical practice, there has shown to be notable heterogeneity in the antithrombotic regimen for patients. Recommendations from clinical guidelines and emerging data on DOAC use in these settings will be critically reviewed here. Future large, randomized-controlled trials are warranted to delineate the role of DOACs in patients receiving a bioprosthetic valve/TAVI or mechanical heart valve, with and without a baseline indication for anticoagulation or antiplatelets. Until clinical trial data from well-designed studies are available, providers must remain vigilant about DOAC use in patients with VHD, especially in patients with a bioprosthetic or mechanical heart valve.
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Affiliation(s)
- Rachel Ryu
- Western University of Health Sciences, College of Pharmacy, Department of Pharmacy, Pomona, CA, USA,Rachel Ryu, PharmD, BCPS, Western University of Health Sciences, College of Pharmacy, 309 E. Second St. Pomona, CA 91766, USA.
| | - Rebecca Tran
- Keck Graduate Institute, School of Pharmacy and Health Sciences, Department of Clinical and Administrative Sciences, Claremont, CA, USA
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Serna-Gallegos D, Sultan I. Commentary: Aortic valve repair: How much is too much? JTCVS Tech 2022; 14:73-74. [PMID: 35967215 PMCID: PMC9366510 DOI: 10.1016/j.xjtc.2022.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 04/18/2022] [Indexed: 11/22/2022] Open
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Fanaroff AC, Vora AN, Lopes RD. Non-vitamin K antagonist oral anticoagulants in patients with valvular heart disease. Eur Heart J Suppl 2022; 24:A19-A31. [PMID: 35185406 PMCID: PMC8850709 DOI: 10.1093/eurheartj/suab151] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The non-vitamin K antagonist oral anticoagulants (NOACs) dabigatran, rivaroxaban, apixaban, and edoxaban have transformed the management of atrial fibrillation (AF), but are only approved by regulatory authorities for stroke prophylaxis in patients with so-called “non-valvular AF.” This terminology has spawned confusion about which patients with valvular heart disease benefit from NOACs and which should be treated with vitamin K antagonists (VKAs) instead. Patients with valvular heart disease other than mechanical prosthetic valves or severe mitral stenosis (including those with bioprosthetic valves) were included in pivotal trials demonstrating the benefit of NOACs over VKAs, and consensus guidelines recommend NOACs over VKAs in these patients. Subsequent devoted randomized controlled trials in patients with AF and bioprosthetic valves, including transcatheter valves, have confirmed the safety of NOACs in this population. In patients with rheumatic mitral stenosis, observational studies indicate that NOACs may be safe and effective, but randomized controlled trials are ongoing. By contrast, a randomized controlled trial showed that dabigatran is harmful in patients with mechanical prosthetic mitral valves; however, these data may not extrapolate to patients with mechanical valve prostheses in other locations or to other NOACs, and randomized controlled trials are ongoing. In this review, we discuss these data in greater depth, and make recommendations for the use of NOACs in patients with valvular heart disease.
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Affiliation(s)
- Alexander C Fanaroff
- Division of Cardiovascular Medicine, Department of Medicine; Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center; and Leonard Davis Institute for Health Economics, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Amit N Vora
- UPMC Heart and Vascular Institute, Harrisburg, PA, USA
- Division of Cardiovascular Medicine, Department of Medicine, Duke University, 2400 Pratt St, Durham, NC 27710, USA
| | - Renato D Lopes
- Division of Cardiovascular Medicine, Department of Medicine, Duke University, 2400 Pratt St, Durham, NC 27710, USA
- Duke Clinical Research Institute, Duke University, PO Box 17969, Durham, NC 27715, USA
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Baumgartner H, Iung B, Messika-Zeitoun D, Otto CM. The year in cardiovascular medicine 2021: valvular heart disease. Eur Heart J 2022; 43:633-640. [PMID: 34974619 DOI: 10.1093/eurheartj/ehab885] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 10/15/2021] [Accepted: 12/23/2021] [Indexed: 12/27/2022] Open
Affiliation(s)
- Helmut Baumgartner
- Department of Cardiology III-Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Albert-Schweitzer-Campus 1, Building A1, Muenster 48149, Germany
| | - Bernard Iung
- Department of Cardiology, Bichat Hospital, APHP, Université de Paris, Paris, France
| | | | - Catherine M Otto
- Division of Cardiology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
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Van Hoof L, Truyers I, Van Hauwermeiren H, Nachtergaele B, Langenaeken T, Jacquemin M, Rega F, Verhamme P, Meuris B. OUP accepted manuscript. Interact Cardiovasc Thorac Surg 2022; 35:6543570. [PMID: 35253872 PMCID: PMC9297512 DOI: 10.1093/icvts/ivac070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 02/21/2022] [Accepted: 02/23/2022] [Indexed: 11/20/2022] Open
Affiliation(s)
- Lucas Van Hoof
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | | | | | | | - Tom Langenaeken
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Marc Jacquemin
- Department of Hemostasis in Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Filip Rega
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Peter Verhamme
- Department of Vascular Medicine and Hemostasis, University Hospitals Leuven, Leuven, Belgium
| | - Bart Meuris
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
- Corresponding author. Department of Cardiac Surgery, University Hospitals Leuven, Herestraat 49, Leuven 3000, Belgium. Tel: +32-16-344260; fax: +32-16-344616; e-mail: (B. Meuris)
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49
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Gerfer S, Grandoch M, Wahlers TCW, Kuhn EW. Factor Xa Inhibitors for Patients after Mechanical Heart Valve Replacement? Thorac Cardiovasc Surg 2021; 71:189-194. [PMID: 34894638 DOI: 10.1055/s-0041-1736242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Patients with a mechanical heart valve need a lifelong anticoagulation due to the increased risk of valve thrombosis and thrombo-embolism. Currently, vitamin K antagonists (VKA) are the only approved class of oral anticoagulants, but relevant interactions and side effects lead to a large number of patients not achieving the optimal therapeutic target international normalized ration (INR). Therefore, steady measurements of the INR are imperative to ensure potent anticoagulation within a distinctive range. Direct oral anticoagulants (DOACs) with newer agents could serve as a possible alternative to VKAs in this patient cohort. DOACs are approved for several indications, e.g., atrial fibrillation (AF). They only have a minor interaction potential, which is why monitoring is not needed. Thereby, DOACs improve the livability of patients in need of chronical anticoagulation compared with VKAs. In contrast to dual platelet inhibition using aspirin in combination with an ADP receptor antagonist and the direct thrombin inhibitor dabigatran, the oral factor Xa inhibitors apixaban and rivaroxaban show promising results according to current evidence. In small-scale studies, factor Xa inhibitors were able to prevent thrombosis and thrombo-embolic events in patients with mechanical heart valves. Finally, DOACs seem to represent a feasible treatment option in patients with mechanical heart valves, but further studies are needed to evaluate clinical safety. In addition to the ongoing PROACT Xa trial with apixaban in patients after aortic On-X valve implantation, studies in an all-comer collective with rivaroxaban could be promising.
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Affiliation(s)
- Stephen Gerfer
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Maria Grandoch
- Institute of Pharmacology and Clinical Pharmacology, Medical Faculty and University Hospital of Düsseldorf, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Thorsten C W Wahlers
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Elmar W Kuhn
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, University of Cologne, Cologne, Germany
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Rahmouni K, Naidu J, Pearce N, Chan V. Successful Explant of a Ball and Cage Mitral Valve Prosthesis 48 Years After Initial Implant. CJC Open 2021; 4:344-346. [PMID: 35386136 PMCID: PMC8978051 DOI: 10.1016/j.cjco.2021.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 11/17/2021] [Indexed: 11/26/2022] Open
Abstract
A 58-year-old female had undergone previous mechanical mitral replacement with a Starr-Edwards ball and cage valve (Edwards Lifesciences, Irvine, CA) at 11 years of age for rheumatic disease. The valve functioned well until pannus resulted in prosthetic valve stenosis with class IV dyspnea and pulmonary hypertension. She underwent reoperative mitral replacement with an On-X mechanical mitral prosthesis (Cryolife, Kennesaw, GA) 48 years after initial implantation. To our knowledge, this case represents the longest known implant period of a ball and cage mitral valve in the literature. This presentation highlights the durability of this historic prosthesis, along with the role of reoperative surgery decades after initial implantation.
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