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
- Bloodworks Northwest
- 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
- 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.
- 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.
- 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.
- Torn M, van der Meer FJ, Rosendaal FR. Lowering the intensity of oral anticoagulant therapy: effects on the risk of hemorrhage and thromboembolism. Arch Intern Med 2004; 164:668.
- 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; 7:CD003464.
- Little SH, Massel DR. Antiplatelet and anticoagulation for patients with prosthetic heart valves. Cochrane Database Syst Rev 2003; :CD003464.
- 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.
- 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.
- 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.
- Yun KL, Miller DC, Moore KA, et al. Durability of the Hancock MO bioprosthesis compared with standard aortic valve bioprostheses. Ann Thorac Surg 1995; 60:S221.
- Levine MN, Raskob G, Hirsh J. Hemorrhagic complications of long-term anticoagulant therapy. Chest 1989; 95:26S.
- Beyth RJ, Quinn LM, Landefeld CS. Prospective evaluation of an index for predicting the risk of major bleeding in outpatients treated with warfarin. Am J Med 1998; 105:91.
- Masters RG, Semelhago LC, Pipe AL, Keon WJ. Are older patients with mechanical heart valves at increased risk? Ann Thorac Surg 1999; 68:2169.
- Palareti G, Leali N, Coccheri S, et al. Bleeding complications of oral anticoagulant treatment: an inception-cohort, prospective collaborative study (ISCOAT). Italian Study on Complications of Oral Anticoagulant Therapy. Lancet 1996; 348:423.
- Yiu KH, Siu CW, Jim MH, et al. Comparison of the efficacy and safety profiles of intravenous vitamin K and fresh frozen plasma as treatment of warfarin-related over-anticoagulation in patients with mechanical heart valves. Am J Cardiol 2006; 97:409.
- Levi M, Levy JH, Andersen HF, Truloff D. Safety of recombinant activated factor VII in randomized clinical trials. N Engl J Med 2010; 363:1791.
- Skolnick BE, Mathews DR, Khutoryansky NM, et al. Exploratory study on the reversal of warfarin with rFVIIa in healthy subjects. Blood 2010; 116:693.
- Katholi RE, Nolan SP, McGuire LB. Living with prosthetic heart valves. Subsequent noncardiac operations and the risk of thromboembolism or hemorrhage. Am Heart J 1976; 92:162.
- Tinker JH, Tarhan S. Discontinuing anticoagulant therapy in surgical patients with cardiac valve prostheses. Observations in 180 operations. JAMA 1978; 239:738.
- Deviri E, Sareli P, Wisenbaugh T, Cronje SL. Obstruction of mechanical heart valve prostheses: clinical aspects and surgical management. J Am Coll Cardiol 1991; 17:646.
- Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e326S.
- Woods K, Douketis JD, Kathirgamanathan K, et al. Low-dose oral vitamin K to normalize the international normalized ratio prior to surgery in patients who require temporary interruption of warfarin. J Thromb Thrombolysis 2007; 24:93.
- Katholi RE, Nolan SP, McGuire LB. The management of anticoagulation during noncardiac operations in patients with prosthetic heart valves. A prospective study. Am Heart J 1978; 96:163.
- Salem DN, O'Gara PT, Madias C, et al. Valvular and structural heart disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133:593S.
- Amorosi SL, Tsilimingras K, Thompson D, et al. Cost analysis of "bridging therapy" with low-molecular-weight heparin versus unfractionated heparin during temporary interruption of chronic anticoagulation. Am J Cardiol 2004; 93:509.
- Spyropoulos AC, Frost FJ, Hurley JS, Roberts M. Costs and clinical outcomes associated with low-molecular-weight heparin vs unfractionated heparin for perioperative bridging in patients receiving long-term oral anticoagulant therapy. Chest 2004; 125:1642.
- Kovacs MJ, Kearon C, Rodger M, et al. Single-arm study of bridging therapy with low-molecular-weight heparin for patients at risk of arterial embolism who require temporary interruption of warfarin. Circulation 2004; 110:1658.
- Douketis JD, Berger PB, Dunn AS, et al. The perioperative management of antithrombotic therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133:299S.
- Birnie DH, Healey JS, Wells GA, et al. Pacemaker or defibrillator surgery without interruption of anticoagulation. N Engl J Med 2013; 368:2084.
- 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