Antithrombotic therapy in patients with prosthetic heart valves
- Gerard P Aurigemma, MD
Gerard P Aurigemma, MD
- Professor of Medicine and Radiology
- University of Massachusetts Medical School
- Barbara A Konkle, MD
Barbara A Konkle, MD
- Director, Clinical and Translational Research
- Puget Sound Blood Center
- Professor of Medicine/Hematology
- University of Washington
- 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
- 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 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.
There are five main issues the clinician must face in managing the patient with a prosthetic heart valve:
●Antithrombotic therapy to prevent valve thrombosis and thromboembolism
●Evaluation of valve function and durability
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- GENERAL CONSIDERATIONS REGARDING ANTICOAGULANTS
- Vitamin K antagonist
- - Initiation of VKA
- - Monitoring of anticoagulation
- Oral direct thrombin inhibitors and factor Xa inhibitors
- MECHANICAL VALVES
- Long-term recommendations
- Evidence for long-term therapy
- - Long-term VKA
- - VKA plus aspirin
- Bridging after mechanical valve placement
- BIOPROSTHETIC VALVES
- Bioprosthetic valve recommendations
- Evidence on bioprosthetic valves
- - Early anticoagulation after bioprosthetic valve replacement or mitral valve repair
- - Bridging after bioprosthetic valves replacement
- VALVE REPAIR
- SPECIAL CIRCUMSTANCES
- Thromboembolism despite antithrombotic therapy
- BLEEDING AND CORRECTION OF OVERANTICOAGULATION
- Overanticoagulation without bleeding
- INTERRUPTION OF WARFARIN FOR SURGICAL PROCEDURES
- General considerations
- Procedural bleeding risk
- Standardized perioperative procedure
- Role of bridging anticoagulation
- - Major guidelines
- - Choice of heparin
- Our approach
- - Determinants of high thromboembolic risk
- - Management for high thromboembolic risk
- - Patients with low thromboembolic risk
- INTERRUPTION OF WARFARIN FOR CARDIAC CATHETERIZATION/ANGIOGRAPHY
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS