1
|
Gerfer S, Wahlers T, Kuhn E. Is There an Alternative Oral Anticoagulation to Vitamin-K-Antagonists for Patients with Mechanical Aortic Valve Replacement? - A Literature Review. Cardiol Ther 2024; 13:453-463. [PMID: 38753086 PMCID: PMC11333642 DOI: 10.1007/s40119-024-00371-8] [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: 03/08/2024] [Accepted: 05/01/2024] [Indexed: 08/20/2024] Open
Abstract
Current guidelines exclusively recommend vitamin-K-antagonists (VKA) as anticoagulation for patients after mechanical aortic valve replacement due to the increased postoperative risk of valve thrombosis and thrombo-embolism. Strict and regular assessments are mandatory during VKA therapy to ensure a potent anticoagulatory effect within the desired range. From the patients' perspective, VKA are associated with relevant interactions and side effects reducing the quality of life and contributing to a high number of patients not achieving the optimal therapeutic target. Direct oral anticoagulants (DOAC) have replaced VKA therapy in the past for several indications, e.g., atrial fibrillation. However, it is still unclear if DOACs could replace VKA therapy in patients after mechanical aortic valve replacement. While the PROACT-Xa study did not show a sufficient anticoagulatory effect of apixaban plus aspirin compared to VKA therapy in patients after mechanical aortic valve replacement, the direct thrombin inhibitor dabigatran and the oral factor Xa inhibitors apixaban and rivaroxaban showed promising results in comparable patient cohorts in smaller studies and case reports. Factor Xa inhibitors were able to prevent thrombosis and thrombo-embolic events in patients after mechanical aortic valve replacement. Therefore, factor Xa inhibitors or factor XI inhibitors could provide a potent alternative to VKA for patients after a mechanical aortic valve replacement.
Collapse
Affiliation(s)
- Stephen Gerfer
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Kerpener Straße 62, 50937, Cologne, Germany.
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - Elmar Kuhn
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| |
Collapse
|
2
|
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.
Collapse
Affiliation(s)
- Tom Langenaeken
- Department of Cardiac Surgery, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium (B.M.)
| | | | | | | | | | | | | |
Collapse
|
3
|
Roberts WC, Salam YM. Analysis of Mechanical Prostheses Excised from the Aortic Valve Position. Am J Cardiol 2022; 176:118-124. [PMID: 35662475 DOI: 10.1016/j.amjcard.2022.04.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 04/08/2022] [Indexed: 11/24/2022]
Abstract
Described herein are certain clinical and morphologic findings in 33 patients who had their dysfunctioning native aortic valves replaced with a mechanical prosthesis and 4 to 302 months (mean 127) later had the mechanical prosthesis explanted because of developing prosthetic stenosis or regurgitation because of thrombus forming on a metallic disc, pannus on the cloth ring with overhanging the prosthetic orifice, or because of parabasilar regurgitation. Of the 33 patients, 25 were not infected and 8 were infected. At follow-up at least 23 of the 25 patients without infection and 7 of the 8 patients with prosthetic infection survived >1 year after the prosthetic valve explantation.
Collapse
|
4
|
Nath SS, Parashar S. Perioperative management of patients with prosthetic heart valves-A narrative review. Ann Card Anaesth 2022; 25:254-263. [PMID: 35799551 PMCID: PMC9387617 DOI: 10.4103/aca.aca_109_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Worldwide, about 13% of the 200,000 annual recipients of prosthetic heart valves (PHV) present for various surgical procedures. Also, more and more females are opting for pregnancies after having PHV. All patients with PHV present unique challenges for the anesthesiologists, surgeons and obstetricians (in case of deliveries). They have to deal with the perioperative management of anticoagulation and a host of other issues involved. We reviewed the English language medical literature relevant to the different aspects of perioperative management of patients with PHV, particularly the guidelines of reputed societies that appeared in the last 20 years. Regression of cardiac pathophysiology following valve replacement is variable both in extent and timeline. The extent to which reverse remodeling occurs depends on the perioperative status of the heart. We discussed the perioperative assessment of patients with PHV, including focused history and relevant investigations with the inferences drawn. We examined the need for prophylaxis against infective endocarditis and management of anticoagulation in such patients in the perioperative period and the guidelines of reputed societies. We also reviewed the conduct of anesthesia, including general and regional anesthesia (neuraxial and peripheral nerve/plexus blocks) in such patients. Finally, we discussed the management of delivery in this group of high-risk patients. From the discussion of different aspects of perioperative management of patients with PHV, we hope to guide in formulating the comprehensive plan of management of safe anesthesia in such patients.
Collapse
Affiliation(s)
- Soumya Sankar Nath
- Department of Anesthesiology and Critical Care Medicine, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Samiksha Parashar
- Department of Anesthesiology and Critical Care Medicine, Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| |
Collapse
|
5
|
Roberts WC, Salam YM. Analysis of Dysfunctioning Mechanical Prostheses Excised from the Mitral Valve Position. Am J Cardiol 2022; 177:69-75. [PMID: 35752481 DOI: 10.1016/j.amjcard.2022.04.052] [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] [Received: 03/18/2022] [Accepted: 04/21/2022] [Indexed: 11/18/2022]
Abstract
Described herein are findings in 16 patients who had their dysfunctioning mechanical prostheses in the mitral valve position replaced. The mechanical prostheses had been in place from 2 to 157 months (mean 80). All but 1 patient had the mechanical prosthesis excised because of prosthetic stenosis or regurgitation or both secondary to prosthetic thrombus (despite warfarin therapy) on cloth-ring "pannus" overlaying the orifice or parabasilar detachment ("leak"). The dysfunction was the result of non-infected causes in 13 patients and to infective causes in 3. Three patients (19%) died in the early post-operative period; the other 13 patients survived >1 year. The prostheses were excised in a variety of methods by the explanting surgeons. The best procedure to excise the mechanical prosthesis appears to be mainly operator dependent.
Collapse
Affiliation(s)
- William C Roberts
- Baylor Scott & White Heart and Vascular Institute; Departments of Internal Medicine (Division of Cardiology); Pathology, Baylor University Medical Center, Baylor Scott & White Health, Dallas, Texas.
| | | |
Collapse
|
6
|
Aly AH, Khandelwal P, Aly AH, Kawashima T, Mori K, Saito Y, Hung J, Gorman JH, Pouch AM, Gorman RC, Yushkevich PA. Fully Automated 3D Segmentation and Diffeomorphic Medial Modeling of the Left Ventricle Mitral Valve Complex in Ischemic Mitral Regurgitation. Med Image Anal 2022; 80:102513. [PMID: 35772323 DOI: 10.1016/j.media.2022.102513] [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: 03/30/2021] [Revised: 05/30/2022] [Accepted: 06/10/2022] [Indexed: 10/18/2022]
Abstract
There is an urgent unmet need to develop a fully-automated image-based left ventricle mitral valve analysis tool to support surgical decision making for ischemic mitral regurgitation patients. This requires an automated tool for segmentation and modeling of the left ventricle and mitral valve from immediate pre-operative 3D transesophageal echocardiography. Previous works have presented methods for semi-automatically segmenting and modeling the mitral valve, but do not include the left ventricle and do not avoid self-intersection of the mitral valve leaflets during shape modeling. In this study, we develop and validate a fully automated algorithm for segmentation and shape modeling of the left ventricular mitral valve complex from pre-operative 3D transesophageal echocardiography. We performed a 3-fold nested cross validation study on two datasets from separate institutions to evaluate automated segmentations generated by nnU-net with the expert manual segmentation which yielded average overall Dice scores of 0.82±0.03 (set A), 0.87±0.08 (set B) respectively. A deformable medial template was subsequently fitted to the segmentation to generate shape models. Comparison of shape models to the manual and automatically generated segmentations resulted in an average Dice score of 0.93-0.94 and 0.75-0.81 for the left ventricle and mitral valve, respectively. This is a substantial step towards automatically analyzing the left ventricle mitral valve complex in the operating room.
Collapse
Affiliation(s)
- Ahmed H Aly
- Division of Cardiothoracic Surgery, The Ohio State University, Columbus, OH, USA; Department of Bioengineering, School of Engineering and Applied Sciences, University of Pennsylvania, Philadelphia, PA, USA; Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, USA.
| | - Pulkit Khandelwal
- Department of Bioengineering, School of Engineering and Applied Sciences, University of Pennsylvania, Philadelphia, PA, USA
| | - Abdullah H Aly
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; The Ohio State College of Medicine, Columbus, OH, USA
| | - Takayuki Kawashima
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, USA
| | - Kazuki Mori
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, USA
| | - Yoshiaki Saito
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, USA
| | - Judy Hung
- Department of Cardiology at Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Joseph H Gorman
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, USA; Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Alison M Pouch
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert C Gorman
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, USA; Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Paul A Yushkevich
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| |
Collapse
|
7
|
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.
Collapse
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
| |
Collapse
|
8
|
Gafarova ER, Grebenik EA, Lazhko AE, Frolova AA, Kuryanova AS, Kurkov AV, Bazhanov IA, Kapomba BS, Kosheleva NV, Novikov IA, Shekhter AB, Golubeva EN, Soloviova AB, Timashev PS. Evaluation of Supercritical CO 2-Assisted Protocols in a Model of Ovine Aortic Root Decellularization. Molecules 2020; 25:molecules25173923. [PMID: 32867356 PMCID: PMC7504408 DOI: 10.3390/molecules25173923] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 08/26/2020] [Accepted: 08/26/2020] [Indexed: 01/03/2023] Open
Abstract
One of the leading trends in the modern tissue engineering is the development of new effective methods of decellularization aimed at the removal of cellular components from a donor tissue, reducing its immunogenicity and the risk of rejection. Supercritical CO2 (scCO2)-assisted processing has been proposed to improve the outcome of decellularization, reduce contamination and time costs. The resulting products can serve as personalized tools for tissue-engineering therapy of various somatic pathologies. However, the decellularization of heterogeneous 3D structures, such as the aortic root, requires optimization of the parameters, including preconditioning medium composition, the type of co-solvent, values of pressure and temperature inside the scCO2 reactor, etc. In our work, using an ovine aortic root model, we performed a comparative analysis of the effectiveness of decellularization approaches based on various combinations of these parameters. The protocols were based on the combinations of treatments in alkaline, ethanol or detergent solutions with scCO2-assisted processing at different modes. Histological analysis demonstrated favorable effects of the preconditioning in a detergent solution. Following processing in scCO2 medium provided a high decellularization degree, reduced cytotoxicity, and increased ultimate tensile strength and Young’s modulus of the aortic valve leaflets, while the integrity of the extracellular matrix was preserved.
Collapse
Affiliation(s)
- Elvira R. Gafarova
- Institute for Regenerative Medicine, Sechenov First Moscow State Medical University, 119991 Moscow, Russia; (E.A.G.); (A.A.F.); (A.S.K.); (A.V.K.); (I.A.B.); (B.S.K.); (A.B.S.); (P.S.T.)
- Correspondence: ; Tel.: +7-917-372-5217
| | - Ekaterina A. Grebenik
- Institute for Regenerative Medicine, Sechenov First Moscow State Medical University, 119991 Moscow, Russia; (E.A.G.); (A.A.F.); (A.S.K.); (A.V.K.); (I.A.B.); (B.S.K.); (A.B.S.); (P.S.T.)
| | - Alexey E. Lazhko
- Kurnakov Institute of General and Inorganic Chemistry, Russian Academy of Sciences, 119991 Moscow, Russia;
| | - Anastasia A. Frolova
- Institute for Regenerative Medicine, Sechenov First Moscow State Medical University, 119991 Moscow, Russia; (E.A.G.); (A.A.F.); (A.S.K.); (A.V.K.); (I.A.B.); (B.S.K.); (A.B.S.); (P.S.T.)
| | - Anastasia S. Kuryanova
- Institute for Regenerative Medicine, Sechenov First Moscow State Medical University, 119991 Moscow, Russia; (E.A.G.); (A.A.F.); (A.S.K.); (A.V.K.); (I.A.B.); (B.S.K.); (A.B.S.); (P.S.T.)
- N. N. Semenov Federal Research Center for Chemical Physics, Russian Academy of Sciences, 117977 Moscow, Russia;
| | - Alexandr V. Kurkov
- Institute for Regenerative Medicine, Sechenov First Moscow State Medical University, 119991 Moscow, Russia; (E.A.G.); (A.A.F.); (A.S.K.); (A.V.K.); (I.A.B.); (B.S.K.); (A.B.S.); (P.S.T.)
| | - Ilya A. Bazhanov
- Institute for Regenerative Medicine, Sechenov First Moscow State Medical University, 119991 Moscow, Russia; (E.A.G.); (A.A.F.); (A.S.K.); (A.V.K.); (I.A.B.); (B.S.K.); (A.B.S.); (P.S.T.)
| | - Byron S. Kapomba
- Institute for Regenerative Medicine, Sechenov First Moscow State Medical University, 119991 Moscow, Russia; (E.A.G.); (A.A.F.); (A.S.K.); (A.V.K.); (I.A.B.); (B.S.K.); (A.B.S.); (P.S.T.)
| | - Nastasia V. Kosheleva
- FSBSI “Institute of General Pathology and Pathophysiology”, 125315 Moscow, Russia;
- Faculty of Biology, Lomonosov Moscow State University, 119234 Moscow, Russia
| | - Ivan A. Novikov
- Scientific Research Institute of Eye Diseases, 119021 Moscow, Russia;
| | - Anatoly B. Shekhter
- Institute for Regenerative Medicine, Sechenov First Moscow State Medical University, 119991 Moscow, Russia; (E.A.G.); (A.A.F.); (A.S.K.); (A.V.K.); (I.A.B.); (B.S.K.); (A.B.S.); (P.S.T.)
| | - Elena N. Golubeva
- Faculty of Chemistry, Lomonosov Moscow State University, 119991 Moscow, Russia;
| | - Anna B. Soloviova
- N. N. Semenov Federal Research Center for Chemical Physics, Russian Academy of Sciences, 117977 Moscow, Russia;
| | - Peter S. Timashev
- Institute for Regenerative Medicine, Sechenov First Moscow State Medical University, 119991 Moscow, Russia; (E.A.G.); (A.A.F.); (A.S.K.); (A.V.K.); (I.A.B.); (B.S.K.); (A.B.S.); (P.S.T.)
- N. N. Semenov Federal Research Center for Chemical Physics, Russian Academy of Sciences, 117977 Moscow, Russia;
- Faculty of Chemistry, Lomonosov Moscow State University, 119991 Moscow, Russia;
| |
Collapse
|
9
|
Khalid MO, Malyshev Y, Hashmi AT, Siddiqui S, Patel N, Shani J, Ayzenberg S. A Rare Case of Partial Aortic Mechanical Valve Thrombosis With Intact Mitral Mechanical Valve Presenting With ST-Elevation Myocardial Infarction Patients. J Investig Med High Impact Case Rep 2020; 8:2324709620963567. [PMID: 33019833 PMCID: PMC7543143 DOI: 10.1177/2324709620963567] [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] [Indexed: 11/17/2022] Open
Abstract
The incidence of mechanical valve thrombosis (MVT) is around 0.4 per 100 patient-years.
Mitral valve thrombosis has a higher incidence than aortic valve thrombosis with a nearly
5-fold increase. Various factors contribute to MVT. The most common cause of valve
thrombosis is poor adherence/disruption of anticoagulation therapy. Low cardiac output is
known to increase the risk of prosthetic valve thrombosis. Other factors such as diabetes,
hypertension, and other patient comorbidities might also play a role. Decreased flow
promotes hypercoagulability. Lower pressure in the left atrium (and higher velocities in
the left ventricle) can partially contribute to the higher incidence of mitral MVT versus
aortic MVT. The presenting symptoms usually depend on the severity of the valve
thrombosis; nonobstructive valve thrombosis patients have progressive dyspnea, signs of
heart failure, and systemic embolization with strokes being the most common complication.
In this article, we present a case of a middle-aged woman with a history of mitral and
aortic mechanical prosthesis who presented with an ST-segment elevation myocardial
infarction and pulmonary edema due to mechanical aortic valve prosthesis thrombosis. She
had an isolated mechanical aortic valve prosthesis thrombosis with intact mitral valve,
which, to the best of our knowledge, has not yet been described. We performed a literature
review by searching PubMed and Embase using the keywords “mechanical valve,” “thrombosis,”
“aortic,” and “mitral,” our search did not show similar cases.
Collapse
Affiliation(s)
| | | | | | | | | | - Jacob Shani
- Maimonides Medical Center, Brooklyn, NY, USA
| | | |
Collapse
|
10
|
Havers-Borgersen E, Butt JH, Vinding NE, Torp-Pedersen C, Gislason G, Køber L, Fosbøl EL. Time in therapeutic range and risk of thromboembolism and bleeding in patients with a mechanical heart valve prosthesis. J Thorac Cardiovasc Surg 2020; 159:74-83.e4. [PMID: 30961980 DOI: 10.1016/j.jtcvs.2019.02.061] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 01/24/2019] [Accepted: 02/12/2019] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Oral anticoagulation with vitamin K antagonists is recommended after mechanical heart valve replacement. However, data regarding the association between the quality of vitamin K antagonist treatment and the risk of complications are sparse. METHODS Patients undergoing mechanical heart valve replacement (1997-2012) with available data on international normalized ratio values were identified in Danish registries. The quality of vitamin K antagonist treatment between discharge after valve replacement and 6 months postdischarge (ie, index) was assessed as time in therapeutic range (TTR) ≥70% or <70% reflecting the percentage of time in therapeutic international normalized ratio interval. Patients were followed from index until occurrence of an outcome of interest (ie, thromboembolism and bleeding), death, or end of study (December 31, 2012), whichever came first. The risk of outcomes according to quality of vitamin K antagonist treatment was estimated with multivariable Cox regression. RESULTS In total, 659 patients undergoing mechanical heart valve replacement were included in the study. Median number of international normalized ratio measurements in the 6-month period after surgery was 13 (interquartile range, 8-19). Median TTR was 54.9% (interquartile range, 39.0%-72.9%) and 29.1% of patients had a TTR ≥70%. Median follow-up was 6.1 years. The risk of thromboembolism was significantly lower in the group with TTR ≥70% compared with TTR <70% (hazard ratio, 0.44; 95% confidence interval, 0.22-0.85), whereas no significant difference concerning risk of bleeding among groups was found (hazard ratio, 0.63; 95% confidence interval 0.36-1.08). CONCLUSIONS In patients undergoing mechanical heart valve replacement, TTR <70% in the 6-month period after surgery was associated with an increased risk of thromboembolic events but not bleeding compared with TTR ≥70%.
Collapse
Affiliation(s)
- Eva Havers-Borgersen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
| | - Jawad H Butt
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Naja E Vinding
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Gunnar Gislason
- Department of Cardiology, Herlev and Gentofte University Hospital, Hellerup, Denmark
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Emil L Fosbøl
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| |
Collapse
|
11
|
Saksena D, Mishra YK, Muralidharan S, Kanhere V, Srivastava P, Srivastava CP. Follow-up and management of valvular heart disease patients with prosthetic valve: a clinical practice guideline for Indian scenario. Indian J Thorac Cardiovasc Surg 2019; 35:3-44. [PMID: 33061064 PMCID: PMC7525528 DOI: 10.1007/s12055-019-00789-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
PURPOSE Valvular heart disease (VHD) patients after prosthetic valve implantation are at risk of thromboembolic events. Follow-up care of patients with prosthetic valve has a paramount role in reducing the morbidity and mortality. Currently, in India, there is quintessential need to stream line the follow-up care of prosthetic valve patients. This mandates the development of a consensus guideline for the antithrombotic therapy in VHD patients post prosthetic valve implantation. METHODS A national level panel was constituted comprising 13 leading cardio care experts in India who thoroughly reviewed the up to date literature, formulated the recommendations, and developed the consensus document. Later on, extensive discussions were held on this draft and the recommendations in 8 regional meetings involving 79 additional experts from the cardio care in India, to arrive at a consensus. The final consensus document is developed relying on the available evidence and/or majority consensus from all the meetings. RESULTS The panel recommended vitamin K antagonist (VKA) therapy with individualized target international normalized ratio (INR) in VHD patients after prosthetic valve implantation. The panel opined that management of prosthetic valve complications should be personalized on the basis of type of complications. In addition, the panel recommends to distinguish individuals with various co-morbidities and attend them appropriately. CONCLUSIONS Anticoagulant therapy with VKA seems to be an effective option post prosthetic valve implantation in VHD patients. However, the role for non-VKA oral therapy in prosthetic valve patients and the safety and efficacy of novel oral anticoagulants in patients with bioprosthetic valve need to be studied extensively.
Collapse
|
12
|
Flueckiger P, Singleton M, Vasu S, Zhao D. Bioprosthetic tricuspid valve thrombosis: Percutaneous PFO closure to improve hypoxia and respiratory failure. Catheter Cardiovasc Interv 2018; 92:993-997. [PMID: 29068163 DOI: 10.1002/ccd.27217] [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: 02/09/2017] [Revised: 06/08/2017] [Accepted: 06/24/2017] [Indexed: 11/11/2022]
Abstract
Prosthetic valve thrombosis (PVT) is an increasingly recognized complication of bioprosthetic valve replacement, often resulting in abnormal hemodynamic, endothelial, and hemostatic conditions. Bioprosthetic PVT may lead to significant hemodynamic and clinical effects. In hemodynamically stable patients, first-line treatment for bioprosthetic PVT is systemic anticoagulation. However, concomitant cardiovascular pathology may lead to additional clinical sequalae that requires acute therapeutic interventions. We describe two cases in which bioprosthetic PVT leads to hemodynamically significant intracardiac shunting through pre-existing patent foramen ovales requiring percutaneous closure with a Cribriform AMPLATZER occluder device. We also review the treatment for bioprosthetic PVT and discuss important clinical and hemodynamic considerations.
Collapse
Affiliation(s)
- Peter Flueckiger
- Department of Internal Medicine, Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Matthew Singleton
- Department of Internal Medicine, Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Sujethra Vasu
- Department of Internal Medicine, Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - David Zhao
- Department of Internal Medicine, Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| |
Collapse
|
13
|
Fiedler AG, Tolis G. Surgical Treatment of Valvular Heart Disease: Overview of Mechanical and Tissue Prostheses, Advantages, Disadvantages, and Implications for Clinical Use. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2018; 20:7. [DOI: 10.1007/s11936-018-0601-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
|
14
|
Review of numerical methods for simulation of mechanical heart valves and the potential for blood clotting. Med Biol Eng Comput 2017; 55:1519-1548. [DOI: 10.1007/s11517-017-1688-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 07/10/2017] [Indexed: 11/26/2022]
|
15
|
Dangas GD, Weitz JI, Giustino G, Makkar R, Mehran R. Prosthetic Heart Valve Thrombosis. J Am Coll Cardiol 2016; 68:2670-2689. [DOI: 10.1016/j.jacc.2016.09.958] [Citation(s) in RCA: 256] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 09/19/2016] [Accepted: 09/20/2016] [Indexed: 01/28/2023]
|
16
|
Wang Z, Calpe B, Zerdani J, Lee Y, Oh J, Bae H, Khademhosseini A, Kim K. High-throughput investigation of endothelial-to-mesenchymal transformation (EndMT) with combinatorial cellular microarrays. Biotechnol Bioeng 2015; 113:1403-12. [PMID: 26666585 DOI: 10.1002/bit.25905] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Revised: 12/03/2015] [Accepted: 12/07/2015] [Indexed: 01/09/2023]
Abstract
In the developing heart, a specific subset of endocardium undergoes an endothelial-to-mesenchymal transformation (EndMT) thus forming nascent valve leaflets. Extracellular matrix (ECM) proteins and growth factors (GFs) play important roles in regulating EndMT but the combinatorial effect of GFs with ECM proteins is less well understood. Here we use microscale engineering techniques to create single, binary, and tertiary component microenvironments to investigate the combinatorial effects of ECM proteins and GFs on the attachment and transformation of adult ovine mitral valve endothelial cells to a mesenchymal phenotype. With the combinatorial microenvironment microarrays, we utilized 60 different combinations of ECM proteins (Fibronectin, Collagen I, II, IV, Laminin) and GFs (TGF-β1, bFGF, VEGF) and were able to identify new microenvironmental conditions capable of modulating EndMT in MVECs. Experimental results indicated that TGF-β1 significantly upregulated the EndMT while either bFGF or VEGF downregulated EndMT process markedly. Also, ECM proteins could influence both the attachment of MVECs and the response of MVECs to GFs. In terms of attachment, fibronectin is significantly better for the adhesion of MVECs among the five tested proteins. Overall collagen IV and fibronectin appeared to play important roles in promoting EndMT process. Great consistency between macroscale and microarrayed experiments and present studies demonstrates that high-throughput cellular microarrays are a promising approach to study the regulation of EndMT in valvular endothelium. Biotechnol. Bioeng. 2016;113: 1403-1412. © 2015 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
- Zongjie Wang
- School of Engineering, University of British Columbia, Kelowna, BC, V1V1V7, Canada
| | - Blaise Calpe
- Institute of Molecular Health Sciences, ETH Zürich, Zürich, Switzerland.,Center for Biomedical Engineering, Brigham and Women's Hospital, Harvard Medical School, Cambridge, Massachusetts.,Wyss Institute for Biologically Inspired Engineering at Harvard University, Boston, Massachusetts
| | - Jalil Zerdani
- Center for Biomedical Engineering, Brigham and Women's Hospital, Harvard Medical School, Cambridge, Massachusetts.,Wyss Institute for Biologically Inspired Engineering at Harvard University, Boston, Massachusetts.,Institute of Bioengineering, École Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - Youngsang Lee
- Department of Mathematics and Statistics, University of British Columbia, Kelowna, BC, Canada
| | - Jonghyun Oh
- Center for Biomedical Engineering, Brigham and Women's Hospital, Harvard Medical School, Cambridge, Massachusetts.,Division of Mechanical Design Engineering, Chonbuk National University, Jeonjoo, Republic of Korea.,Harvard-MIT Division of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, Massachusetts, 02139
| | - Hojae Bae
- Center for Biomedical Engineering, Brigham and Women's Hospital, Harvard Medical School, Cambridge, Massachusetts.,Harvard-MIT Division of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, Massachusetts, 02139.,Department of Bioindustrial Technologies, College of Animal Bioscience and Technology, Konkuk University, Hwayang-dong, Kwangjin-gu, Seoul, Republic of Korea
| | - Ali Khademhosseini
- Center for Biomedical Engineering, Brigham and Women's Hospital, Harvard Medical School, Cambridge, Massachusetts. .,Wyss Institute for Biologically Inspired Engineering at Harvard University, Boston, Massachusetts. .,Harvard-MIT Division of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, Massachusetts, 02139. .,Department of Physics, King Abdulaziz University, Jeddah 21569, Saudi Arabia.
| | - Keekyoung Kim
- School of Engineering, University of British Columbia, Kelowna, BC, V1V1V7, Canada. .,Center for Biomedical Engineering, Brigham and Women's Hospital, Harvard Medical School, Cambridge, Massachusetts. .,Harvard-MIT Division of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, Massachusetts, 02139.
| |
Collapse
|
17
|
Han K, Yang DH, Shin SY, Kim N, Kang JW, Kim DH, Song JM, Kang DH, Song JK, Kim JB, Jung SH, Choo SJ, Chung CH, Lee JW, Lim TH. Subprosthetic Pannus after Aortic Valve Replacement Surgery: Cardiac CT Findings and Clinical Features. Radiology 2015; 276:724-31. [DOI: 10.1148/radiol.2015142400] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
18
|
Improved accuracy of anticoagulant dose prediction using a pharmacogenetic and artificial neural network-based method. Eur J Clin Pharmacol 2013; 70:265-73. [PMID: 24297344 DOI: 10.1007/s00228-013-1617-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Accepted: 11/17/2013] [Indexed: 02/05/2023]
Abstract
BACKGROUND The unpredictability of acenocoumarol dose needed to achieve target blood thinning level remains a challenge. We aimed to apply and compare a pharmacogenetic least-squares model (LSM) and artificial neural network (ANN) models for predictions of acenocoumarol dosing. METHODS LSM and ANN models were used to analyze previously collected data on 174 participants (mean age: 67.45 SD 13.49 years) on acenocoumarol maintenance therapy. The models were based on demographics, lifestyle habits, concomitant diseases, medication intake, target INR, and genotyping results for CYP2C9 and VKORC1. LSM versus ANN performance comparisons were done by two methods: by randomly splitting the data as 50 % derivation and 50 % validation cohort followed by a bootstrap of 200 iterations, and by a 10-fold leave-one-out cross-validation technique. RESULTS The ANN-based pharmacogenetic model provided higher accuracy and larger R value than all other LSM-based models. The accuracy percentage improvement ranged between 5 % and 24 % for the derivation cohort and between 12 % and 25 % for the validation cohort. The increase in R value ranged between 6 % and 31 % for the derivation cohort and between 2 % and 31 % for the validation cohort. ANN increased the percentage of accurately dosed subjects (mean absolute error ≤1 mg/week) by 14.1 %, reduced the percentage of mis-dosed subjects (mean absolute error 2-3 mg/week) by 7.04 %, and reduced the percentage of grossly mis-dosed subjects (mean absolute error ≥4 mg/week) by 24 %. CONCLUSIONS ANN-based pharmacogenetic guidance of acenocoumarol dosing reduces the error in dosing to achieve target INR. These results need to be ascertained in a prospective study.
Collapse
|
19
|
Comprehensive Evaluation of Patients With Suspected Prosthetic Heart Valve Disorders Using MDCT. AJR Am J Roentgenol 2011; 196:353-60. [DOI: 10.2214/ajr.10.4314] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
|
20
|
Singh P, Inamdar V, Hage FG, Kodali V, Karakus G, Suwanjutah T, Hsiung MC, Nanda NC. Usefulness of live/real time three-dimensional transthoracic echocardiography in evaluation of prosthetic valve function. Echocardiography 2010; 26:1236-49. [PMID: 19929870 DOI: 10.1111/j.1540-8175.2009.01079.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
We studied 31 patients with prosthetic valves (PVs) using two-dimensional and three-dimensional transthorathic echocardiography (2DTTE and 3DTTE, respectively) in order to determine whether 3DTTE provides an incremental value on top of 2DTTE in the evaluation of these patients. With 3DTTE both leaflets of the St. Jude mechanical PV can be visualized simultaneously, thereby increasing the diagnostic confidence in excluding valvular abnormalities and overcoming the well-known limitations of 2DTTE in the examination of PVs, which heavily relies on Doppler. Three-dimensional transthorathic echocardiography provides a more comprehensive evaluation of PV regurgitation than 2DTTE with its ability to more precisely quantify PV regurgitation, in determining the mechanism causing regurgitation, and in localizing the regurgitant defect. Furthermore, 3DTTE is superior in identifying, quantifying, and localizing PV thrombi and vegetations, in addition to the unique feature of providing a look inside mass lesions by serial sectioning. These preliminary results suggest the superiority of 3DTTE over 2DTTE in the evaluation of PVs and that it provides incremental knowledge to the echocardiographer.
Collapse
Affiliation(s)
- Preeti Singh
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | | | | | | | | | | | | |
Collapse
|
21
|
Correctness of multi-detector-row computed tomography for diagnosing mechanical prosthetic heart valve disorders using operative findings as a gold standard. Eur Radiol 2008; 19:857-67. [DOI: 10.1007/s00330-008-1232-2] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2008] [Revised: 09/13/2008] [Accepted: 09/21/2008] [Indexed: 10/21/2022]
|
22
|
Anscombe A, Cadet J. Follow-up of patients after heart valve surgery: Setting up a nurse-led clinic. ACTA ACUST UNITED AC 2008. [DOI: 10.12968/bjca.2008.3.7.30503] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Anna Anscombe
- Surgical unit Royal Brompton and Harefield NHS Trust, Sydney Street, London, SW3 6NP
| | - Jane Cadet
- heart valve clinic, Royal Brompton and Harefield NHS Trust, London
| |
Collapse
|
23
|
|
24
|
Worthley MI, Bayes AJ. Fluoroscopic evidence of prosthetic valve failure. Intern Med J 2006; 36:618. [PMID: 16911557 DOI: 10.1111/j.1445-5994.2006.01160.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- M I Worthley
- Department of Cardiovascular Sciences and the Libin Cardiovascular Institute, Foothills Hospital, University of Calgary, Calgary, Alberta, Canada
| | | |
Collapse
|
25
|
Badano LP, Zamorano JL, Pavoni D, Tosoratti E, Baldassi M, Zakja E, Gianfagna P, Fioretti PM, Livi U. Clinical and hemodynamic implications of supra-annular implant of biological aortic valves. J Cardiovasc Med (Hagerstown) 2006; 7:524-32. [PMID: 16801814 DOI: 10.2459/01.jcm.0000234771.96324.28] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The use of stented bioprostheses in elderly patients with degenerative aortic stenosis, despite being desirable, raises concerns about the harmful effects of residual obstruction to left ventricular outflow. To overcome this limitation new stented and stentless bioprostheses have been designed for supra-annular implant. However, the actual hemodynamic advantage of supra-annular implant over the intra-annular one remains incompletely understood. This review focuses on the geometry of biological valve prostheses designed for supra-annular implant and its implications for the echocardiographic assessment of valve hemodynamics. Available data about the hemodynamic performance of these valves implanted in the supra-annular position in comparison with the usual intra-annular implant are also reviewed. Other issues related to biological heart valve performance, such as biomaterials, tissue mechanics, durability, and clinical outcome are not addressed in this review.
Collapse
Affiliation(s)
- Luigi P Badano
- Department of Cardiopulmonary Sciences, A.O. S Maria della Misericordia, Udine, Italy.
| | | | | | | | | | | | | | | | | |
Collapse
|