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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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2
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Sachdev S, Bardia N, Nguyen L, Omar B. Bioprosthetic Valve Thrombosis. Cardiol Res 2018; 9:335-342. [PMID: 30627283 PMCID: PMC6306127 DOI: 10.14740/cr789] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Accepted: 10/25/2018] [Indexed: 11/14/2022] Open
Abstract
Degenerative valve disease is on the rise with greater than 100,000 valve operations performed in the US alone per year. The majority of those procedures employ tissue bioprostheses to avoid the attendant risk of anticoagulation, especially in the elderly. Though traditionally this approach has been considered a superior option to avoid anticoagulation, more recent analyses have demonstrated a significant incidence of previously unrecognized thrombosis associated with bioprosthetic valves, especially with the more recent advent of the transcatheter aortic valve replacement implantations. Bioprosthetic valve thrombosis is a major cause of either acute or indolent bioprosthetic valve degeneration, and often has an elusive presentation causing delayed recognition and treatment. The literature has extensively addressed the risks and benefits of anticoagulation following bioprosthetic valve replacement to prevent bioprosthetic valve thrombosis (BPVT), without conclusive evidence-based recommendations. The duration of anticoagulation following an episode of BPVT is unclear, and lifelong anticoagulation has been suggested. The increasing use of transcatheter aortic valve replacement as an alternative to surgical aortic valve replacement in various risk groups has introduced new challenges with regards to valve thrombosis, which have been poorly studied with regards to optimal treatment and prevention. The increasing use of valve-in-valve procedures is expected to bring on further uncharted challenges.
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Affiliation(s)
| | - Nikky Bardia
- University of South Alabama, Mobile, AL 36617, USA
| | | | - Bassam Omar
- University of South Alabama, Mobile, AL 36617, USA
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Lee SI, Lee KS, Kim JB, Choo SJ, Chung CH, Lee JW, Jung SH. Early Antithrombotic Therapy after Bioprosthetic Aortic Valve Replacement in Elderly Patients: A Single-Center Experience. Ann Thorac Cardiovasc Surg 2017; 23:128-134. [PMID: 28367855 DOI: 10.5761/atcs.oa.16-00297] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
PURPOSE Early antithrombotic therapy after bioprosthetic aortic valve replacement (AVR) is controversial. This study aimed to retrospectively compare between warfarin and aspirin treatment in the 3 months after bioprosthetic AVR for elderly patients more than 60 years old, and to determine the optimal antithrombotic therapy. METHODS This retrospective study included 479 patients in single center from January 1994 to June 2014. Patients were divided into two groups (Wa group, warfarin; As group, aspirin). We searched our computerized clinical database for thromboembolic or bleeding events. Propensity score analysis was conducted to adjust for selection bias. RESULTS All patients, except one patient, were followed-up in the out-patient department for 3 months after the operation. In all, 86 propensity-matched patient-pairs were derived. Early operative outcomes were similar in both the groups. There are one patient of thromboembolic event and three patients of bleeding events, but the prevalence was not significantly different (p >0.999). CONCLUSION The incidence of thromboembolic and bleeding events during early 3 months after bioprosthetic AVR were similar in Wa and As groups. If the patient does not have indications of warfarin, early antithrombotic therapy with aspirin only may be easier and more feasible for elderly patients.
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Affiliation(s)
- Seok In Lee
- Department of Thoracic and Cardiovascular Surgery, Gil Medical Center, Gachon University, Incheon, Korea
| | - Kyo Seon Lee
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, College of Medicine, Gwangju, Korea
| | - Joon Bum Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Suk Jung Choo
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Cheol Hyun Chung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Won Lee
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Ho Jung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Córdoba-Soriano JG, Puri R, Amat-Santos I, Ribeiro HB, Abdul-Jawad Altisent O, del Trigo M, Paradis JM, Dumont E, Urena M, Rodés-Cabau J. Revisión sistemática de la trombosis protésica tras implante percutáneo de válvula aórtica. Rev Esp Cardiol 2015. [DOI: 10.1016/j.recesp.2014.10.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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5
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Córdoba-Soriano JG, Puri R, Amat-Santos I, Ribeiro HB, Abdul-Jawad Altisent O, del Trigo M, Paradis JM, Dumont E, Urena M, Rodés-Cabau J. Valve thrombosis following transcatheter aortic valve implantation: a systematic review. ACTA ACUST UNITED AC 2015; 68:198-204. [PMID: 25667117 DOI: 10.1016/j.rec.2014.10.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2014] [Accepted: 10/10/2014] [Indexed: 11/28/2022]
Abstract
INTRODUCTION AND OBJECTIVES Despite the rapid global uptake of transcatheter aortic valve implantation, valve trombosis has yet to be systematically evaluated in this field. The aim of this study was to determine the clinical characteristics, diagnostic criteria, and treatment outcomes of patients diagnosed with valve thrombosis following transcatheter aortic valve implantation through a systematic review of published data. METHODS Literature published between 2002 and 2012 on valve thrombosis as a complication of transcatheter aortic valve implantation was identified through a systematic electronic search. RESULTS A total of 11 publications were identified, describing 16 patients (mean age, 80 [5] years, 65% men). All but 1 patient (94%) received a balloon-expandable valve. All patients received dual antiplatelet therapy immediately following the procedure and continued to take either mono- or dual antiplatelet therapy at the time of valve thrombosis diagnosis. Valve thrombosis was diagnosed at a median of 6 months post-procedure, with progressive dyspnea being the most common symptom. A significant increase in transvalvular gradient (from 10 [4] to 40 [12] mmHg) was the most common echocardiographic feature, in addition to leaflet thickening. Thrombus was not directly visualized with echocardiography. Three patients underwent valve explantation, and the remaining received warfarin, which effectively restored the mean transvalvular gradient to baseline within 2 months. Systemic embolism was not a feature of valve thrombosis post-transcatheter aortic valve implantation. CONCLUSIONS Although a rare, yet likely under-reported complication of post-transcatheter aortic valve implantation, progressive dyspnea coupled with an increasing transvalvular gradient on echocardiography within the months following the intervention likely signifies valve thrombosis. While direct thrombus visualization appears difficult, prompt initiation of oral anticoagulation therapy effectively restores baseline valve function.
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Affiliation(s)
| | - Rishi Puri
- Quebec Heart & Lung Institute, Quebec City, QC, Canada
| | | | | | | | | | | | - Eric Dumont
- Quebec Heart & Lung Institute, Quebec City, QC, Canada
| | - Marina Urena
- Quebec Heart & Lung Institute, Quebec City, QC, Canada
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Bekker MWA, Noyez L, van Swieten HA. Anticoagulation therapy after bioprosthetic aortic valve replacement in Dutch cardiothoracic centres: acceptance of guidelines does not lead to overall implementation. Interact Cardiovasc Thorac Surg 2014; 20:395-8. [DOI: 10.1093/icvts/ivu392] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Mohanty BD, Looser PM, Gokanapudy LR, Handa R, Mohanty S, Choi SS, Goldman ME, Fuster V, Halperin JL. Controversies regarding the new oral anticoagulants for stroke prevention in patients with atrial fibrillation. Vasc Med 2014; 19:190-204. [PMID: 24879715 DOI: 10.1177/1358863x14532869] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Increasing use of the new oral anticoagulants (NOACs) – dabigatran, rivaroxaban, and apixaban – has prompted considerable discussion in the medical community even as warfarin remains the mainstay of therapy. This article raises 10 controversial issues regarding the use of NOACs for stroke prevention in patients with atrial fibrillation, and offers a review of the latest available evidence. We provide a brief overview of the mechanism and dosing of these drugs, as well as a summary of the key clinical trials that have brought them into the spotlight. Comparative considerations relative to warfarin such as NOAC safety, efficacy, bleeding risk, reversibility, drug-transitioning and use in patients well controlled on warfarin are addressed. Use in select populations such as the elderly, those with coronary disease, renal impairment, or on multiple anti-platelet drugs is also discussed. Finally, we consider such specific issues as comparative efficacy, off-label use, cost, rebound and management during events. Ultimately, the rise of the NOACs to mainstream use will depend on further data and clinical experience amongst the medical community.
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Affiliation(s)
- Bibhu D Mohanty
- Zena and Michael A Wiener Cardiovascular Institute, Mount Sinai Heart Hospital, New York, NY, USA
| | - Patrick M Looser
- Department of Medicine, Mount Sinai School of Medicine, New York, NY, USA
| | | | - Rishi Handa
- Department of Medicine, Morristown Medical Center, Morristown, NJ, USA
| | - Sudipta Mohanty
- University of Pittsburgh, School of Medicine, Pittsburgh, PA, USA
| | - Sharon S Choi
- Department of Medicine, Mount Sinai School of Medicine, New York, NY, USA
| | - Martin E Goldman
- Zena and Michael A Wiener Cardiovascular Institute, Mount Sinai Heart Hospital, New York, NY, USA
| | - Valentin Fuster
- Zena and Michael A Wiener Cardiovascular Institute, Mount Sinai Heart Hospital, New York, NY, USA
| | - Jonathan L Halperin
- Zena and Michael A Wiener Cardiovascular Institute, Mount Sinai Heart Hospital, New York, NY, USA
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