Antithrombotic therapy for prosthetic heart valves: Management of bleeding and invasive procedures
- 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 aims to relieve symptoms and prolong life but also exchanges the native disease for 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.
The anticoagulants used to prevent valve thrombosis and thromboembolic events in patients with prosthetic heart valves are vitamin K antagonists (VKA; eg, warfarin; generally for long-term therapy) and heparin (mainly unfractionated heparin or low molecular weight heparin; generally for short-term bridging therapy), with indications as described below. 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. (See "Antithrombotic therapy for prosthetic heart valves: Indications".)
This topic will review management of bleeding and invasive procedures in patients receiving antithrombotic therapy to reduce the risk of prosthetic valve thrombosis and thromboembolism. Indications for antithrombotic therapy for prosthetic valves, therapeutic use of VKA, endocarditis prophylaxis, evaluation of valve function, other complications of prosthetic valves (including valve thrombosis and thromboembolism), and management of antithrombotic therapy in pregnant patients with prosthetic heart valves are discussed separately. (See "Antithrombotic therapy for prosthetic heart valves: Indications" and "Overview of the management of patients with prosthetic heart valves" and "Antimicrobial prophylaxis for bacterial endocarditis" and "Complications of prosthetic heart valves" and "Management of pregnant women with prosthetic heart valves".)
MANAGEMENT OF OVERANTICOAGULATION AND BLEEDING
The risk of major bleeding with vitamin K antagonist (VKA; eg, warfarin) begins to rise steeply when the International Normalized Ratio (INR) increases to values ≥5 (figure 1), although some patients have bleeding at therapeutic or even subtherapeutic INR levels. However, rapid reversal of anticoagulation, leading to subtherapeutic INRs, increases the risk of valve thrombosis and thromboembolism. Given these concerns, we suggest an individualized approach based largely on expert opinion that is generally consistent with the 2014 American Heart Association/American College of Cardiology (AHA/ACC) and 2012 European Society of Cardiology guideline recommendations [1,2]:
- 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.
- 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.
- Bonow RO, Carabello BA, Chatterjee K, et al. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines 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 (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2008; 118:e523.
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- MANAGEMENT OF OVERANTICOAGULATION AND BLEEDING
- Overanticoagulation without bleeding
- MANAGEMENT OF ANTITHROMBOTIC THERAPY FOR INVASIVE PROCEDURES
- General considerations
- - Standardized protocol
- - Avoidance of surgery for three months after valve surgery
- Our approach
- - Minor surgical and other procedures
- Approach to minor procedures
- Pacemaker or ICD surgery
- Cardiac catheterization
- - Preprocedural management
- - Intraprocedural management
- - Major surgical procedures
- With no risk factors for thrombosis
- With risk factors for thrombosis
- - When to bridge
- - Choice of heparin for bridging
- - How to bridge
- - Reversal of anticoagulation for emergency procedures with significant bleeding risk
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS