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Haji Mohamad AZ, Kozum RM, Chakhide M, Tabbakh B, Niazi A. Surgical repair of rectus abdominis rupture with rectus sheath hematoma due to chronic cough and prolonged anticoagulant therapy in a COVID-19 patient: A case report. Int J Surg Case Rep 2024; 120:109628. [PMID: 38810295 PMCID: PMC11153896 DOI: 10.1016/j.ijscr.2024.109628] [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: 02/22/2024] [Revised: 03/31/2024] [Accepted: 04/03/2024] [Indexed: 05/31/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE Herein, we present an unexpected rectus sheath hematoma (RSH) complication due to chronic COVID-19 related cough and prolonged anticoagulation therapy. COVID-19 usually presents with respiratory symptoms, such as cough. Anticoagulants are used in severe cases of COVID-19 as well as in mechanical heart valve replacement to prevent thrombosis. However, there is a high risk of bleeding. CASE PRESENTATION We report a rare case of a 74-year-old woman who presented with a COVID-19 related cough persistent over two months, and was also undertaking warfarin daily for 10 years due to mechanical mitral valve replacement. Computed Tomography (CT) scan revealed retroperitoneal and rectus sheath hematoma (RSH) as well as rectus abdominis muscle rupture. She had hemorrhagic shock due to rapid hematoma expansion to the right and left flank as well as to the back. Thus, she required an emergency surgery in which the hematoma was excised and the rectus abdominis muscle was sutured. The patient was discharged and has completely recovered. CLINICAL DISCUSSION Many factors and mechanisms contribute to the formation of the RSH and the rupture of rectus abdominis muscle, including severe cough and anticoagulants. CONCLUSION Although the use of anticoagulants is necessary for patients who underwent mechanical valve replacement or for COVID-19 patients as a prophylaxis of thrombotic complication, RSH should be kept in mind and carefully monitored as it may require surgical intervention in severe cases.
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Affiliation(s)
| | - Reem M Kozum
- Faculty of Medicine, University of Aleppo, Aleppo, Syria
| | - Maria Chakhide
- Faculty of Medicine, University of Aleppo, Aleppo, Syria.
| | - Bashar Tabbakh
- Faculty of Medicine, University of Aleppo, Aleppo, Syria
| | - Ammar Niazi
- General Surgery Department, Faculty of Medicine, Aleppo University Hospital, Aleppo, Syria
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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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3
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Shah P, Looby M, Dimond M, Bagchi P, Shah B, Isseh I, Rollins AT, Abdul-Aziz AA, Kennedy J, Tang DG, Klein KM, Casselman S, Vermeulen C, Sheaffer W, Snipes M, Sinha SS, O'Connor CM. Evaluation of the Hemocompatibility of the Direct Oral Anticoagulant Apixaban in Left Ventricular Assist Devices: The DOAC LVAD Study. JACC. HEART FAILURE 2024:S2213-1779(24)00333-0. [PMID: 38795110 DOI: 10.1016/j.jchf.2024.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 04/03/2024] [Accepted: 04/10/2024] [Indexed: 05/27/2024]
Abstract
BACKGROUND Patients receiving left ventricular assist device (LVAD) support require long-term anticoagulation to reduce the risk of thromboembolic complications. Apixaban is a direct oral anticoagulant that has become first-line therapy; however, its safety in LVAD recipients has not been well described. OBJECTIVES This study sought to investigate whether, in patients with a fully magnetically levitated LVAD, treatment with apixaban would be feasible and comparable with respect to safety and freedom from the primary composite outcome of death or major hemocompatibility-related adverse events (HRAEs) (stroke, device thrombosis, major bleeding, aortic root thrombus, and arterial non-central nervous system thromboembolism) as compared with treatment with warfarin. METHODS The DOAC LVAD (Evaluation of the Hemocompatibility of the Direct Oral Anti-Coagulant Apixaban in Left Ventricular Assist Devices) trial was a phase 2, open label trial of LVAD recipients randomized 1:1 to either apixaban 5 mg twice daily or warfarin therapy. All patients were required to take low-dose aspirin. Patients were followed up for 24 weeks to evaluate the primary composite outcome. RESULTS A total of 30 patients were randomized: 14 patients to warfarin and 16 patients to apixaban. The median patient age was 60 years (Q1-Q3: 52-71 years), and 47% were Black patients. The median time from LVAD implantation to randomization was 115 days (Q1-Q3: 56-859 days). At 24 weeks, the primary composite outcome occurred in no patients receiving apixaban and in 2 patients (14%) receiving warfarin (P = 0.12); these 2 patients experienced major bleeding from gastrointestinal sources. CONCLUSIONS Anticoagulation with apixaban was feasible in patients with an LVAD without an excess of HRAEs or deaths. This study informs future pivotal clinical trials evaluating the safety and efficacy of apixaban in LVAD recipients. (Evaluation of the Hemocompatibility of the Direct Oral Anti-Coagulant Apixaban in Left Ventricular Assist Devices [DOAC LVAD]; NCT04865978).
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Affiliation(s)
- Palak Shah
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA.
| | - Mary Looby
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Matthew Dimond
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Pramita Bagchi
- Department of Biostatistics, George Washington University, Washington, DC, USA
| | - Bhruga Shah
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Iyad Isseh
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Allman T Rollins
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Ahmad A Abdul-Aziz
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Jamie Kennedy
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Daniel G Tang
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Katherine M Klein
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Samantha Casselman
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Christen Vermeulen
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Wendy Sheaffer
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Meredith Snipes
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - Shashank S Sinha
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, Virginia, USA
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4
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Bejjani A, Khairani CD, Assi A, Piazza G, Sadeghipour P, Talasaz AH, Fanikos J, Connors JM, Siegal DM, Barnes GD, Martin KA, Angiolillo DJ, Kleindorfer D, Monreal M, Jimenez D, Middeldorp S, Elkind MSV, Ruff CT, Goldhaber SZ, Krumholz HM, Mehran R, Cushman M, Eikelboom JW, Lip GYH, Weitz JI, Lopes RD, Bikdeli B. When Direct Oral Anticoagulants Should Not Be Standard Treatment: JACC State-of-the-Art Review. J Am Coll Cardiol 2024; 83:444-465. [PMID: 38233019 DOI: 10.1016/j.jacc.2023.10.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/16/2023] [Accepted: 10/19/2023] [Indexed: 01/19/2024]
Abstract
For most patients, direct oral anticoagulants (DOACs) are preferred over vitamin K antagonists for stroke prevention in atrial fibrillation and for venous thromboembolism treatment. However, randomized controlled trials suggest that DOACs may not be as efficacious or as safe as the current standard of care in conditions such as mechanical heart valves, thrombotic antiphospholipid syndrome, and atrial fibrillation associated with rheumatic heart disease. DOACs do not provide a net benefit in conditions such as embolic stroke of undetermined source. Their efficacy is uncertain for conditions such as left ventricular thrombus, catheter-associated deep vein thrombosis, cerebral venous sinus thrombosis, and for patients with atrial fibrillation or venous thrombosis who have end-stage renal disease. This paper provides an evidence-based review of randomized controlled trials on DOACs, detailing when they have demonstrated efficacy and safety, when DOACs should not be the standard of care, where their safety and efficacy are uncertain, and areas requiring further research.
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Affiliation(s)
- Antoine Bejjani
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Candrika D Khairani
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ali Assi
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gregory Piazza
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Parham Sadeghipour
- Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran; Clinical Trial Center, Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Azita H Talasaz
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran; Virginia Commonwealth University, Richmond, Virginia, USA
| | - John Fanikos
- Department of Pharmacy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jean M Connors
- Hematology Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Deborah M Siegal
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Geoffrey D Barnes
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Karlyn A Martin
- Division of Hematology/Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | | | - Manuel Monreal
- Cátedra de Enfermedad Tromboembólica, Universidad Católica San Antonio de Murcia, Spain
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal and Medicine Department, Universidad de Alcalá (Instituto de Ramón y Cajal de Investigación Sanitaria), Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Saskia Middeldorp
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, New York, New York, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Christian T Ruff
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Samuel Z Goldhaber
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Harlan M Krumholz
- Yale New Haven Hospital/Yale Center for Outcomes Research and Evaluation, New Haven, Connecticut, USA; Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut, USA; Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Roxana Mehran
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mary Cushman
- Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA; Department of Pathology and Laboratory Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - John W Eikelboom
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom; Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Jeffrey I Weitz
- McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA; Brazilian Clinical Research Institute, São Paulo, Brazil
| | - Behnood Bikdeli
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands; Cardiovascular Research Foundation, New York, New York, USA.
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5
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Lancellotti P, Aqil A, Musumeci L, Jacques N, Ditkowski B, Debuisson M, Thiry M, Dupont J, Gougnard A, Sandersen C, Cheramy-Bien JP, Sakalihasan N, Nchimi A, Detrembleur C, Jérôme C, Oury C. Bioactive surface coating for preventing mechanical heart valve thrombosis. J Thromb Haemost 2023; 21:2485-2498. [PMID: 37196847 DOI: 10.1016/j.jtha.2023.05.004] [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: 01/12/2023] [Revised: 04/13/2023] [Accepted: 05/04/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND Prosthetic heart valves are the only treatment for most patients with severe valvular heart disease. Mechanical valves, made of metallic components, are the most long-lasting type of replacement valves. However, they are prone to thrombosis and require permanent anticoagulation and monitoring, which leads to higher risk of bleeding and impacts the patient's quality of life. OBJECTIVES To develop a bioactive coating for mechanical valves with the aim to prevent thrombosis and improve patient outcomes. METHODS We used a catechol-based approach to produce a drug-releasing multilayer coating adherent to mechanical valves. The hemodynamic performance of coated Open Pivot valves was verified in a heart model tester, and coating durability in the long term was assessed in a durability tester producing accelerated cardiac cycles. Coating antithrombotic activity was evaluated in vitro with human plasma or whole blood under static and flow conditions and in vivo after surgical valve implantation in a pig's thoracic aorta. RESULTS We developed an antithrombotic coating consisting of ticagrelor- and minocycline-releasing cross-linked nanogels covalently linked to polyethylene glycol. We demonstrated the hydrodynamic performance, durability, and hemocompatibility of coated valves. The coating did not increase the contact phase activation of coagulation, and it prevented plasma protein adsorption, platelet adhesion, and thrombus formation. Implantation of coated valves in nonanticoagulated pigs for 1 month efficiently reduced valve thrombosis compared with noncoated valves. CONCLUSION Our coating efficiently inhibited mechanical valve thrombosis, which might solve the issues of anticoagulant use in patients and the number of revision surgeries due to valve thrombosis despite anticoagulation.
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Affiliation(s)
- Patrizio Lancellotti
- Laboratory of Cardiology, GIGA Institute, and Department of Cardiology, Centre Hospitalier Universitaire of Liège, University of Liège Hospital, Liège, Belgium
| | - Abdelhafid Aqil
- Center for Education and Research on Macromolecules, CESAM Research Unit, University of Liège, Liège, Belgium
| | - Lucia Musumeci
- Laboratory of Cardiology, GIGA Institute, and Department of Cardiology, Centre Hospitalier Universitaire of Liège, University of Liège Hospital, Liège, Belgium
| | - Nicolas Jacques
- Laboratory of Cardiology, GIGA Institute, and Department of Cardiology, Centre Hospitalier Universitaire of Liège, University of Liège Hospital, Liège, Belgium
| | - Bartosz Ditkowski
- Laboratory of Cardiology, GIGA Institute, and Department of Cardiology, Centre Hospitalier Universitaire of Liège, University of Liège Hospital, Liège, Belgium
| | - Margaux Debuisson
- Laboratory of Cardiology, GIGA Institute, and Department of Cardiology, Centre Hospitalier Universitaire of Liège, University of Liège Hospital, Liège, Belgium
| | - Marc Thiry
- Laboratory of Cellular and Tissular Biology, GIGA-Neurosciences, Cell Biology, University of Liège, Liège, Belgium
| | - Julien Dupont
- Department of Clinical Sciences, Faculty of Veterinary Medicine, University of Liège, Liège, Belgium
| | - Alexandra Gougnard
- Department of Clinical Sciences, Faculty of Veterinary Medicine, University of Liège, Liège, Belgium
| | - Charlotte Sandersen
- Department of Clinical Sciences, Faculty of Veterinary Medicine, University of Liège, Liège, Belgium
| | - Jean-Paul Cheramy-Bien
- Department of Cardiovascular and Thoracic Surgery, Centre Hospitalier Universitaire of Liège, University of Liège, Liège, Belgium; Surgical Research Center, GIGA-Cardiovascular Science Unit, University of Liège, Liège, Belgium
| | - Natzi Sakalihasan
- Department of Cardiovascular and Thoracic Surgery, Centre Hospitalier Universitaire of Liège, University of Liège, Liège, Belgium; Surgical Research Center, GIGA-Cardiovascular Science Unit, University of Liège, Liège, Belgium
| | - Alain Nchimi
- Laboratory of Cardiology, GIGA Institute, and Department of Cardiology, Centre Hospitalier Universitaire of Liège, University of Liège Hospital, Liège, Belgium
| | - Christophe Detrembleur
- Center for Education and Research on Macromolecules, CESAM Research Unit, University of Liège, Liège, Belgium
| | - Christine Jérôme
- Center for Education and Research on Macromolecules, CESAM Research Unit, University of Liège, Liège, Belgium
| | - Cécile Oury
- Laboratory of Cardiology, GIGA Institute, and Department of Cardiology, Centre Hospitalier Universitaire of Liège, University of Liège Hospital, Liège, Belgium.
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Hirsh J, de Vries TAC, Eikelboom JW, Bhagirath V, Chan NC. Clinical Studies with Anticoagulants that Have Changed Clinical Practice. Semin Thromb Hemost 2023; 49:242-254. [PMID: 36603813 DOI: 10.1055/s-0042-1760330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Anticoagulant therapy is the cornerstone of treatment and prevention of arterial and venous thromboembolism. Taking a historical perspective, starting in the 1960s, and progressing through to 2022, we discuss key clinical trials of anticoagulants that have changed clinical practice, and examine obstacles encountered in bringing these anticoagulants to the clinic. The design of some of the early studies that shaped clinical practice was poor by current standards, but their results were influential because nothing better was available. Both heparin and vitamin K antagonists had been in clinical use for several decades before well-designed trials in the 1980s optimized their dosing and enhanced their safety and efficacy. Low-molecular-weight heparin then replaced unfractionated heparin because it had a more predictable dose-response and a longer half-life, thereby allowing it to be used conveniently in out-of-hospital settings. More recently, direct oral anticoagulants became the oral anticoagulants of choice for most indications because they were shown to be at least as safe and effective as vitamin K antagonists when used in fixed doses without the need for laboratory monitoring. The design of the trials that led to the approval of the direct oral anticoagulants was excellent, but further studies are required to optimize their dosing in selected patients who were underrepresented in these trials.
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Affiliation(s)
- Jack Hirsh
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Tim A C de Vries
- Heart Center, Department of Clinical and Experimental Cardiology and Cardiothoracic Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands.,Heart Failure and Arrhythmias, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.,Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands
| | - John W Eikelboom
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Division of Hematology and Thromboembolism, Department of Medicine, Population Health Research Institute, Hamilton, Ontario, Canada.,Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Vinai Bhagirath
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Division of Hematology and Thromboembolism, Department of Medicine, Population Health Research Institute, Hamilton, Ontario, Canada.,Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Noel C Chan
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Division of Hematology and Thromboembolism, Department of Medicine, Population Health Research Institute, Hamilton, Ontario, Canada.,Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
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7
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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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8
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Rivaroxaban Versus Warfarin in Patients with Mechanical Heart Valves: Open-Label, Proof-of-Concept trial-The RIWA study. Am J Cardiovasc Drugs 2021; 21:363-371. [PMID: 33150497 DOI: 10.1007/s40256-020-00449-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/22/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND AND PURPOSE To date, vitamin K antagonists are the only available oral anticoagulants in patients with mechanical heart valves. In this way, we developed a pilot trial with rivaroxaban. METHODS The RIWA study was a proof-of-concept, open-label, randomized clinical trial and was designed to assess the incidence of thromboembolic and bleeding events of the rivaroxaban-based strategy (15 mg twice daily) in comparison to dose-adjusted warfarin. Patients were randomly assigned in a 1:1 ratio and were followed prospectively for 90 days. RESULTS A total of 72 patients were enrolled in the present study. Of these, 44 patients were randomized: 23 patients were allocated to the rivaroxaban group and 21 to the warfarin group. After 90 days of follow-up, the primary outcome occurred in one patient (4.3%) in the rivaroxaban group and three patients (14.3%) in the warfarin group (risk ratio [RR] 0.27; 95% confidence interval [CI] 0.02-2.85; P = 0.25). Minor bleeding (without discontinuation of medical therapy) occurred in six patients (26.1%) in the rivaroxaban group versus six patients (28.6%) in the warfarin group (RR 0.88; 95% CI 0.23-3.32; P = 0.85). One patient in the warfarin group died from myocardial infarction. No cases of hemorrhagic stroke, valve thrombosis, peripheral embolic events, or new intracardiac thrombus were related in both groups. CONCLUSIONS In this pilot study, rivaroxaban 15 mg twice daily had thromboembolic and bleeding events similar to warfarin in patients with mechanical heart valves. These data confirm the authors' proof-of-concept and suggest that a larger trial with a similar design is not unreasonable. CLINICALTRIAL. GOV IDENTIFIER NCT03566303.
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Abdul'ianov IV, Vagizov II, Kaipov AÉ. [Clinical results of cardiac valve repair with bicuspid full-flow mechanical prosthesis 'MedEng-ST']. ANGIOLOGII︠A︡ I SOSUDISTAI︠A︡ KHIRURGII︠A︡ = ANGIOLOGY AND VASCULAR SURGERY 2020; 26:141-148. [PMID: 33332316 DOI: 10.33529/angio2020419] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Prosthetic repair of cardiac valves with artificial mechanical prostheses is ubiquitously performed using prostheses consisting of two cusps (bicuspidal). Several years ago, new bicuspid full-flow prostheses appeared on the market. From the first use they immediately proved reliable, with stable haemodynamic characteristics. At the Interregional Clinical and Diagnostic Centre, bicuspid full-flow mechanical prostheses 'MedEng-ST' have been used since 2017. We carried out a retrospective follow up of 84 patients subjected to prosthetic repair of cardiac valves with full-flow prostheses 'MedEng-ST' in mitral and aortic positions. There were no prosthesis-associated or procedural complications during follow up. Neither were there major complications in the postoperative period. All complications were related to peculiarities of the approach to the heart. We assessed the functional parameters of the heart by standard echocardiography. The obtained findings demonstrated good haemodynamic parameters on the 'MedEng-ST' prostheses, improved intracardiac haemodynamics, which eventually had a beneficial effect on the patients' clinical picture. The transprosthetic gradients had stable parameters with a decrease in time when placing the 'MedEng-ST' prosthesis into the aortic position (p≤0.05). Proceeding from the obtained results, as well as taking into account the absence of thromboembolic events it may be stated that the proposed design of the device is universal for replacement of the aortic and mitral valves of the heart. Based on the obtained findings of the study we recommend to use the 'MedEng'ST' prostheses in clinical practice. Further studies are required for more convincing data and explicit recommendations.
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Affiliation(s)
- I V Abdul'ianov
- Department of Cardiac Surgery #2, Interregional Clinical and Diagnostic Centre, Kazan, Russia; Chair of Cardiology, Roentgenoendovascular and Cardiovascular Surgery, Kazan State Medical Academy - branch of the Russian Medical Academy of Continuous Professional Education under the RF Ministry of Public Health, Kazan, Russia
| | - I I Vagizov
- Department of Cardiac Surgery #2, Interregional Clinical and Diagnostic Centre, Kazan, Russia
| | - A É Kaipov
- Department of Cardiac Surgery #2, Interregional Clinical and Diagnostic Centre, Kazan, Russia; Chair of Cardiovascular and Endovascular Surgery, Kazan State Medical University of the RF Ministry of Public Health, Kazan, Russia
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Chew DS, Piccini JP. Postprocedural Antithrombotic Therapy Following Left Atrial Appendage Occlusion: No Longer Adrift in Uncertainty? Circ Cardiovasc Interv 2020; 13:e009534. [PMID: 32674680 DOI: 10.1161/circinterventions.120.009534] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Derek S Chew
- Duke Clinical Research Institute, Duke University, Durham, NC. Division of Cardiology, Duke University Medical Center, Durham, NC
| | - Jonathan P Piccini
- Duke Clinical Research Institute, Duke University, Durham, NC. Division of Cardiology, Duke University Medical Center, Durham, NC
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The difficult balance between thrombosis and bleeding after transcatheter aortic valve replacement: A translational review. Arch Cardiovasc Dis 2020; 113:263-275. [DOI: 10.1016/j.acvd.2019.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 11/26/2019] [Accepted: 12/02/2019] [Indexed: 01/04/2023]
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Jaffer IH, Fredenburgh JC, Stafford A, Whitlock RP, Weitz JI. Rivaroxaban and Dabigatran for Suppression of Mechanical Heart Valve-Induced Thrombin Generation. Ann Thorac Surg 2019; 110:582-590. [PMID: 31877292 DOI: 10.1016/j.athoracsur.2019.10.091] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 10/22/2019] [Accepted: 10/28/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Patients with mechanical heart valves (MHVs) require warfarin to prevent thromboembolism. Dabigatran was less effective than warfarin in patients with MHVs, which prompted a black box warning against the use of direct oral anticoagulants for this indication. However, rivaroxaban and apixaban, which inhibit factor Xa, have not been evaluated in patients with MHVs. To determine whether rivaroxaban and apixaban would be effective, we used MHV-induced thrombin generation assays to compare them with warfarin either alone or in combination with dabigatran. METHODS Thrombin generation in the absence or presence of MHV leaflets or sewing ring segments (SRSs) was quantified. Studies were done in control plasma; plasma from patients on warfarin; plasma containing varying concentrations of rivaroxaban, apixaban, or dabigatran alone; or plasma containing rivaroxaban plus dabigatran. RESULTS Mean endogenous thrombin potential (ETP) increased 1.2-fold, 1.5-fold, and 1.8-fold in the presence of leaflets, Teflon (Terumo Aortic (Sunrise, FL)) SRSs, or Dacron (Terumo Aortic (Sunrise, FL)) SRSs, respectively. Rivaroxaban and apixaban reduced ETP at concentrations above 50 ng/mL but were less effective than warfarin. When rivaroxaban and dabigatran were combined, they suppressed ETP in a more than additive manner. CONCLUSIONS Whereas warfarin suppresses MHV-induced thrombin generation, MHVs induce the generation of factor Xa in concentrations that overwhelm clinically relevant concentrations of rivaroxaban or apixaban. When used in combination, rivaroxaban and dabigatran are more effective than either agent is alone, suggesting that concomitant inhibition of factor Xa and thrombin is better than inhibition of either clotting enzyme alone.
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Affiliation(s)
- Iqbal H Jaffer
- Division of Cardiac Surgery, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - James C Fredenburgh
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Alan Stafford
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Richard P Whitlock
- Division of Cardiac Surgery, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Jeffrey I Weitz
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada; Department of Biochemistry and Biomedical Sciences, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada.
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Hirsh J, Eikelboom JW, Chan NC. Fifty years of research on antithrombotic therapy: Achievements and disappointments. Eur J Intern Med 2019; 70:1-7. [PMID: 31679885 DOI: 10.1016/j.ejim.2019.10.023] [Citation(s) in RCA: 10] [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: 10/03/2019] [Accepted: 10/17/2019] [Indexed: 11/18/2022]
Abstract
The achievements with antithrombotic therapy over the past 50 years have been monumental and the disappointments relatively few. In this review, we will discuss, chronologically, the major developments of the two recognized classes of antithrombotics - anticoagulants and antiplatelet agents.
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Affiliation(s)
- Jack Hirsh
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - John W Eikelboom
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada; Population Health Research Institute, Hamilton, Ontario, Canada
| | - Noel C Chan
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada; Population Health Research Institute, Hamilton, Ontario, Canada.
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" A Tale of Two Cities": Anticoagulation Management in Patients with Atrial Fibrillation and Prosthetic Valves in the Era of Direct Oral Anticoagulants. ACTA ACUST UNITED AC 2019; 55:medicina55080437. [PMID: 31382702 PMCID: PMC6722984 DOI: 10.3390/medicina55080437] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 07/31/2019] [Accepted: 08/01/2019] [Indexed: 01/22/2023]
Abstract
Valvular heart disease and atrial fibrillation often coexist. Oral vitamin K antagonists have represented the main anticoagulation management for antithrombotic prevention in this setting for decades. Novel direct oral anticoagulants (DOACs) are a new class of drugs and currently, due to their well-established efficacy and security, they represent the main therapeutic option in non-valvular atrial fibrillation. Some new evidences are exploring the role of DOACs in patients with valvular atrial fibrillation (mechanical and biological prosthetic valves). In this review we explore the data available in the medical literature to establish the actual role of DOACs in patients with valvular heart disease and atrial fibrillation.
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Durães AR, de Souza Lima Bitar Y, Filho JAL, Schonhofen IS, Camara EJN, Roever L, Cardoso HEDP, Akrami KM. Rivaroxaban versus Warfarin in Patients with Mechanical Heart Valve: Rationale and Design of the RIWA Study. Drugs R D 2019; 18:303-308. [PMID: 30293126 PMCID: PMC6277324 DOI: 10.1007/s40268-018-0249-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction Mechanical heart valves (MHV) are extremely durable, but they require permanent use of anticoagulation to prevent thromboembolic events. The only approved therapeutic options are vitamin K antagonists (VKAs), such as warfarin. As a drug class, clinical management is difficult, therefore new alternatives need to be evaluated. Methods RIWA is a phase II/III, prospective, open-label, randomized, pilot study designed to investigate oral rivaroxaban 15 mg twice daily compared with dose-adjusted warfarin for the prevention of stroke (ischemic or hemorrhagic) and systemic embolism in patients with MHV, from August 2018 to December 2019. Patients will undergo transesophageal echocardiography at the beginning and the end of the study (follow-up time 90 days). On an explanatory basis, all events will be analyzed, including stroke, peripheral systemic embolism, valve thrombosis, significant bleeding and death. Discussion Warfarin and similar VKAs are standard therapy for patients with an MHV. Even with the appropriate use of therapy, the incidence of thromboembolic events is high at 1–4% per year. Furthermore, bleeding risk is significant, ranging from 2 to 9% per year. The new frontier to be overcome in relation to use of the new oral anticoagulants is undoubtedly in patients with MHV. A significant portion of people with MHV worldwide will benefit if noninferiority of these new agents is confirmed. Trial Registration ClinicalTrials.gov identifier: NCT03566303. Recruitment Status: Recruiting. First Posted: 25 June 2018. Last Update Posted: 25 June 2018.
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Affiliation(s)
- André R Durães
- General Hospital Roberto Santos, Salvador, Bahia, Brazil. .,Federal University of Bahia, Medical School-UFBA/FAMEB, XV de novembro Square, s/n-Largo do Terreiro de Jesus, Salvador, BA, 40025-010, Brazil.
| | - Yasmin de Souza Lima Bitar
- Federal University of Bahia, Medical School-UFBA/FAMEB, XV de novembro Square, s/n-Largo do Terreiro de Jesus, Salvador, BA, 40025-010, Brazil
| | | | | | - Edmundo J N Camara
- Federal University of Bahia, Medical School-UFBA/FAMEB, XV de novembro Square, s/n-Largo do Terreiro de Jesus, Salvador, BA, 40025-010, Brazil
| | - Leonardo Roever
- Federal University of Uberlândia, Uberlândia, Minas Gerais, Brazil
| | | | - Kevan M Akrami
- Division of Infectious Disease, Department of Medicine, University of California, San Diego, San Diego, CA, USA
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Ranasinghe MP, Peter K, McFadyen JD. Thromboembolic and Bleeding Complications in Transcatheter Aortic Valve Implantation: Insights on Mechanisms, Prophylaxis and Therapy. J Clin Med 2019; 8:jcm8020280. [PMID: 30823621 PMCID: PMC6406714 DOI: 10.3390/jcm8020280] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Revised: 02/20/2019] [Accepted: 02/21/2019] [Indexed: 01/09/2023] Open
Abstract
Transcatheter aortic valve implantation (TAVI) has emerged as an important alternative to surgical aortic valve repair (SAVR) for patients with severe aortic stenosis. This rapidly advancing field has produced new-generation devices being delivered with small delivery sheaths, embolic protection devices and improved retrieval features. Despite efforts to reduce the rate of thrombotic complications associated with TAVI, valve thrombosis and cerebral ischaemic events post-TAVI continue to be a significant issue. However, the antithrombotic treatments utilised to prevent these dreaded complications are based on weak evidence and are associated with high rates of bleeding, which in itself is associated with adverse clinical outcomes. Recently, experimental data has shed light on the unique mechanisms, particularly the complex haemodynamic changes at sites of TAVI, that underpin the development of post-TAVI thrombosis. These new insights regarding the drivers of TAVI-associated thrombosis, coupled with the ongoing development of novel antithrombotics which do not cause bleeding, hold the potential to deliver newer, safer therapeutic paradigms to prevent post-TAVI thrombotic and bleeding complications. This review highlights the major challenge of post-TAVI thrombosis and bleeding, and the significant issues surrounding current antithrombotic approaches. Moreover, a detailed discussion regarding the mechanisms of post-TAVI thrombosis is provided, in addition to an appraisal of current antithrombotic guidelines, past and ongoing clinical trials, and how novel therapeutics offer the hope of optimizing antithrombotic strategies and ultimately improving patient outcomes.
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Affiliation(s)
- Mark P Ranasinghe
- Atherothrombosis and Vascular Biology Program, Baker Heart and Diabetes Institute, 75 Commercial Road, PO Box 6492, Melbourne, Victoria 3004, Australia.
- Department of Medicine, Monash University, Melbourne, Victoria 3800, Australia.
| | - Karlheinz Peter
- Atherothrombosis and Vascular Biology Program, Baker Heart and Diabetes Institute, 75 Commercial Road, PO Box 6492, Melbourne, Victoria 3004, Australia.
- Department of Medicine, Monash University, Melbourne, Victoria 3800, Australia.
- Heart Centre, The Alfred Hospital, 55 Commercial Road, Melbourne, Victoria 3004, Australia.
| | - James D McFadyen
- Atherothrombosis and Vascular Biology Program, Baker Heart and Diabetes Institute, 75 Commercial Road, PO Box 6492, Melbourne, Victoria 3004, Australia.
- Department of Medicine, Monash University, Melbourne, Victoria 3800, Australia.
- Department of Clinical Haematology, The Alfred Hospital, 55 Commercial Road, Melbourne, Victoria 3004, Australia.
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Durães AR, Bitar YDS, Lima MLG, Santos CC, Schonhofen IS, Filho JAL, Roever L. Usefulness and Safety of Rivaroxaban in Patients Following Isolated Mitral Valve Replacement With a Mechanical Prosthesis. Am J Cardiol 2018; 122:1047-1050. [PMID: 30098707 DOI: 10.1016/j.amjcard.2018.06.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 06/06/2018] [Accepted: 06/06/2018] [Indexed: 10/28/2022]
Abstract
Rivaroxaban has previously been tested in experimental and animal models with encouraging results. We prospectively selected seven patients between May 2017 and January 2018 who underwent isolated mitral valve replacement with a mechanical prosthesis and had unstable INR control at least 3 months after surgery. An intervention of rivaroxaban 15mg was then administered twice daily for a period of 90days. No patient presented intracardiac thrombus, reversible ischemic neurological deficit, ischemic or hemorrhagic stroke, and hospitalization or death during 3 months of follow-up. Two patients eradicated the presence of spontaneous echo contrast. Mean and peak pressure gradients, peak velocity, effective orifice area, and PHT were similar before and after the intervention. In conclusion, the use of rivaroxaban for 90days in seven patients after replacement of mitral valve with the mechanical prosthesis did not present thromboembolic or bleeding events (NCT02894307).
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