Antithrombotic therapy for prosthetic heart valves: Indications
- William H Gaasch, MD
William H Gaasch, MD
- Section Editor — Valvular Disease
- Professor of Medicine
- University of Massachusetts Medical School
- Tufts University School of Medicine
- Senior Consultant in Cardiology
- Lahey Clinic
- Barbara A Konkle, MD
Barbara A Konkle, MD
- Director, Clinical and Translational Research
- Bloodworks Northwest
- Professor of Medicine/Hematology
- University of Washington
- Section Editors
- Catherine M Otto, MD
Catherine M Otto, MD
- Editor-in-Chief — Cardiovascular Medicine
- Section Editor — Cardiac Evaluation; Valvular Disease
- Professor of Medicine
- University of Washington
- Lawrence LK Leung, MD
Lawrence LK Leung, MD
- Editor-in-Chief — Hematology
- Section Editor — Disorders of Hemostasis and Coagulation
- Professor of Medicine
- Stanford University School of Medicine
Replacement of a diseased heart valve with a prosthetic valve aims to improve symptoms and prolong life but also exposes the patient to potential prosthesis-related complications. The frequency of serious complications depends upon the valve type and position, and other clinical risk factors. Complications include embolic events, bleeding, valve obstruction (due to thrombosis or pannus), infective endocarditis, structural deterioration (particularly for bioprosthetic valves), paravalvular regurgitation, hemolytic anemia, and patient-prosthesis mismatch.
Thromboembolic and anticoagulation-related problems are by far the most frequent complications of mechanical valves. The long-term risk of thromboembolism is generally lower with bioprosthetic valves, though there is an increased risk of thromboembolism for bioprosthetic as well as mechanical valves early after valve implantation.
This topic will review indications for antithrombotic therapy to reduce the risk of prosthetic valve thrombosis and thromboembolism [1-4]. Management of complications and procedures in patients receiving antithrombotic therapy for prosthetic valves, therapeutic use of warfarin, endocarditis prophylaxis, evaluation of valve function, complications of prosthetic valves (including valve obstruction), and management of antithrombotic therapy in pregnant patients with prosthetic heart valves are discussed separately. (See "Antithrombotic therapy for prosthetic heart valves: Management of bleeding and invasive procedures" and "Warfarin and other VKAs: Dosing and adverse effects" and "Antimicrobial prophylaxis for bacterial endocarditis" and "Complications of prosthetic heart valves" and "Overview of the management of patients with prosthetic heart valves" and "Management of pregnant women with prosthetic heart valves".)
●Anticoagulants – The anticoagulants used to prevent valve thrombosis and thromboembolic events in patients with prosthetic heart valves are vitamin K antagonists (VKA; generally for long-term therapy) and heparin (mainly unfractionated or low molecular weight heparin; generally for short-term bridging therapy), with indications as described below. (See 'Antithrombotic therapy according to valve type' below.)
●Antiplatelet therapy – Aspirin is recommended as an antiplatelet agent in addition to anticoagulation in patients with mechanical valve prosthesis and is suggested in patients with bioprosthetic aortic or mitral valves.
- Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 63:e57.
- Whitlock RP, Sun JC, Fremes SE, et al. Antithrombotic and thrombolytic therapy for valvular disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e576S.
- Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC), European Association for Cardio-Thoracic Surgery (EACTS), Vahanian A, et al. Guidelines on the management of valvular heart disease (version 2012). Eur Heart J 2012; 33:2451.
- Iung B, Rodés-Cabau J. The optimal management of anti-thrombotic therapy after valve replacement: certainties and uncertainties. Eur Heart J 2014; 35:2942.
- Ageno W, Turpie AG. Exaggerated initial response to warfarin following heart valve replacement. Am J Cardiol 1999; 84:905.
- Goldhaber SZ. "Bridging" and mechanical heart valves: perils, promises, and predictions. Circulation 2006; 113:470.
- Rahman M, BinEsmael TM, Payne N, Butchart EG. Increased sensitivity to warfarin after heart valve replacement. Ann Pharmacother 2006; 40:397.
- Puri D, Kumar A, Basu R, et al. Early anticoagulation after mechanical valve implantation, and related complications. J Heart Valve Dis 2008; 17:418.
- http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm332949.htm?source=govdelivery (Accessed on December 20, 2012).
- Eikelboom JW, Connolly SJ, Brueckmann M, et al. Dabigatran versus warfarin in patients with mechanical heart valves. N Engl J Med 2013; 369:1206.
- Nishimura RA, Otto CM, Bonow RO, et al. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2017.
- Meurin P, Tabet JY, Weber H, et al. Low-molecular-weight heparin as a bridging anticoagulant early after mechanical heart valve replacement. Circulation 2006; 113:564.
- Fanikos J, Tsilimingras K, Kucher N, et al. Comparison of efficacy, safety, and cost of low-molecular-weight heparin with continuous-infusion unfractionated heparin for initiation of anticoagulation after mechanical prosthetic valve implantation. Am J Cardiol 2004; 93:247.
- Allou N, Piednoir P, Berroëta C, et al. Incidence and risk factors of early thromboembolic events after mechanical heart valve replacement in patients treated with intravenous unfractionated heparin. Heart 2009; 95:1694.
- Cannegieter SC, Rosendaal FR, Briët E. Thromboembolic and bleeding complications in patients with mechanical heart valve prostheses. Circulation 1994; 89:635.
- Cannegieter SC, Rosendaal FR, Wintzen AR, et al. Optimal oral anticoagulant therapy in patients with mechanical heart valves. N Engl J Med 1995; 333:11.
- Kontozis L, Skudicky D, Hopley MJ, Sareli P. Long-term follow-up of St. Jude Medical prosthesis in a young rheumatic population using low-level warfarin anticoagulation: an analysis of the temporal distribution of causes of death. Am J Cardiol 1998; 81:736.
- Massel DR, Little SH. Antiplatelet and anticoagulation for patients with prosthetic heart valves. Cochrane Database Syst Rev 2013; :CD003464.
- Little SH, Massel DR. Antiplatelet and anticoagulation for patients with prosthetic heart valves. Cochrane Database Syst Rev 2003; :CD003464.
- Puskas J, Gerdisch M, Nichols D, et al. Reduced anticoagulation after mechanical aortic valve replacement: interim results from the prospective randomized on-X valve anticoagulation clinical trial randomized Food and Drug Administration investigational device exemption trial. J Thorac Cardiovasc Surg 2014; 147:1202.
- Heras M, Chesebro JH, Fuster V, et al. High risk of thromboemboli early after bioprosthetic cardiac valve replacement. J Am Coll Cardiol 1995; 25:1111.
- Cohn LH, Mudge GH, Pratter F, Collins JJ Jr. Five to eight-year follow-up of patients undergoing porcine heart-valve replacement. N Engl J Med 1981; 304:258.
- Aramendi JI, Mestres CA, Martinez-León J, et al. Triflusal versus oral anticoagulation for primary prevention of thromboembolism after bioprosthetic valve replacement (trac): prospective, randomized, co-operative trial. Eur J Cardiothorac Surg 2005; 27:854.
- Colli A, Mestres CA, Castella M, Gherli T. Comparing warfarin to aspirin (WoA) after aortic valve replacement with the St. Jude Medical Epic heart valve bioprosthesis: results of the WoA Epic pilot trial. J Heart Valve Dis 2007; 16:667.
- Brennan JM, Edwards FH, Zhao Y, et al. Early anticoagulation of bioprosthetic aortic valves in older patients: results from the Society of Thoracic Surgeons Adult Cardiac Surgery National Database. J Am Coll Cardiol 2012; 60:971.
- Mérie C, Køber L, Skov Olsen P, et al. Association of warfarin therapy duration after bioprosthetic aortic valve replacement with risk of mortality, thromboembolic complications, and bleeding. JAMA 2012; 308:2118.
- Aramendi JL, Agredo J, Llorente A, et al. Prevention of thromboembolism with ticlopidine shortly after valve repair or replacement with a bioprosthesis. J Heart Valve Dis 1998; 7:610.
- Duran CM, Gometza B, Kumar N, et al. From aortic cusp extension to valve replacement with stentless pericardium. Ann Thorac Surg 1995; 60:S428.
- Duran CM, Gometza B, Shahid M, Al-Halees Z. Treated bovine and autologous pericardium for aortic valve reconstruction. Ann Thorac Surg 1998; 66:S166.
- ANTITHROMBOTIC AGENTS
- Vitamin K antagonist
- - Initiation
- - Monitoring
- Direct oral anticoagulants
- - DOAC are contraindicated with a mechanical valve
- - DOAC may be used with a bioprosthetic valve
- ANTITHROMBOTIC THERAPY ACCORDING TO VALVE TYPE
- Mechanical valves
- - Mechanical valve recommendations
- - Evidence on mechanical valves
- Early bridging after mechanical valve replacement
- Continued VKA therapy
- VKA plus aspirin better than VKA alone
- Lower INR target for On-X aortic valve
- Surgical bioprosthetic valves
- - Surgical bioprosthetic valve recommendations
- - Evidence on bioprosthetic valves
- Early bridging after bioprosthetic valve replacement
- Effect of intermediate-term antithrombotic therapy
- Effect of long-term antithrombotic therapy
- Valve repair
- - Recommendations
- - Evidence
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS