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 the prevention of bacterial endocarditis" and "Complications of prosthetic heart valves" and "Overview of the management of patients with prosthetic heart valves" and "Management of antithrombotic therapy for a prosthetic heart valve during pregnancy".)
●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.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
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- 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