Antiplatelet versus oral anticoagulant therapy as antithrombotic prophylaxis after mitral valve repair

Paparella, Domenico; Mauro, Michele Di; Worms, Keren Bitton; Bolotin, Gil; Russo, Claudio; Trunfio, Salvatore; Scrofani, Roberto; Antona, Carlo; Dato, Guglielmo Mario Actis; Casabona, Riccardo; Colli, Andrea; Gerosa, Gino; Renzulli, Attilio; Serraino, Giuseppe Filiberto; Scrascia, Giuseppe; Zaccaria, Salvatore; Bonis, Michele De; Taramasso, Maurizio; Delgado, Luis; Tritto, Francesco Paolo; Marmo, Joseph; Parolari, Alessandro; Myaseodova, Veronika; Villa, Emmanuel; Troise, Giovanni; Nicolini, Francesco; Gherli, Tiziano; Whitlock, Richard; Conte, Manuela; Barili, Fabio; Gelsomino, Sandro; Lorusso, Roberto; Sciatti, Edoardo; Marinelli, Daniele; Giammarco, Gabriele Di; Calafiore, Antonio M.; Sheikh, Azmat A.; Alfonso, Juan J.; Glauber, Mattia; Miceli, Antonio

doi:10.1016/j.jtcvs.2015.12.036

Cited by 23 publications

(19 citation statements)

References 20 publications

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“…The observed 3-month cumulative incidence for thromboembolic events is in aligned with those reported by previous studies [ 4 , 18 ]. The observed incidence of major bleeding events was slightly higher than described in previous reports, probably due to the adjudication process of postoperative pericardial tamponade [ 19 , 20 ]. Pericardial effusion alongside signs of hemodynamic instability was adjudicated as a pericardial bleeding, whereas these events might not be considered as (major) bleedings in previous studies.…”

Section: Discussioncontrasting

confidence: 59%

“…Recommendations from international guidelines are contradictory to our results, favouring either VKA or aspirin as postoperative thromboprophylaxis 3 months after MVr [ 5 , 6 , 21 ]. Three former retrospective studies have compared antiplatelet with anticoagulation therapy in patients after MVr [ 8 , 19 , 20 , 22 ]. Two studies found no differences in stroke and bleeding rate of early VKA treatment compared with aspirin therapy, suggesting that VKA treatment might not be necessary [ 20 , 22 ].…”

Section: Discussionmentioning

confidence: 99%

“…Two studies found no differences in stroke and bleeding rate of early VKA treatment compared with aspirin therapy, suggesting that VKA treatment might not be necessary [ 20 , 22 ]. The largest study to date by Paparella et al [ 19 ] found less bleeding and comparable arterial thromboembolic events in patients treated with aspirin 6 months following MVr. However, in contrast to our study, no data on AF were reported and assigned treatment was mainly chosen by the surgeons’ preference.…”

Section: Discussionmentioning

confidence: 99%

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Antithrombotic therapy after mitral valve repair: VKA or aspirin?

Wall

Olsthoorn

Heuts

et al. 2018

J Thromb Thrombolysis

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The optimal antithrombotic therapy following mitral valve repair (MVr) is still a matter of debate. Therefore, we evaluated the rate of thromboembolic and bleeding complications of two antithrombotic prevention strategies: vitamin K antagonists (VKA) versus aspirin. Consecutive patients who underwent MVr between 2004 and 2016 at three Dutch hospitals were evaluated for thromboembolic and bleeding complications during three postoperative months. The primary endpoint was the combined incidence of thromboembolic and bleeding complications to determine the net clinical benefit of VKA strategy as compared with aspirin. Secondary objectives were to evaluate both thromboembolic and bleeding rates separately and to identify predictors for both complications. A total of 469 patients were analyzed, of whom 325 patients (69%) in the VKA group and 144 patients (31%) in the aspirin group. Three months postoperatively, the cumulative incidence of the combined end point of the study was 9.2% (95%CI 6.1–12) in the VKA group and 11% (95%CI 6.0–17) in the aspirin group [adjusted hazard ratio (HR) 1.6, 95%CI 0.83–3.1]. Moreover, no significant differences were observed in thromboembolic rates (adjusted HR 0.82, 95%CI 0.16–4.2) as well as in major bleeding rates (adjusted HR 1.89, 95%CI 0.90–3.9). VKA and aspirin therapy showed a similar event rate of 10% during 3 months after MVr in patients without prior history of AF. In both treatment groups thromboembolic event rate was low and major bleeding rates were comparable. Future prospective, randomized trials are warranted to corroborate our findings.

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Section: Discussioncontrasting

confidence: 59%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Antithrombotic therapy after mitral valve repair: VKA or aspirin?

Wall

Olsthoorn

Heuts

et al. 2018

J Thromb Thrombolysis

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“…Anticoagulation after mitral valve replacement (MVR) is intended to reduce clot formation on new prosthetic material and suture lines, and in turn reduce the risk of thromboembolism until the prosthetic material is fully endothelialized, a process that generally takes 3 months. 1,3 Mitral valve surgery has been associated with increased short-term risk of thromboembolic incidents after surgery, with an incidence of ischemic stroke within the first 30 postoperative days reported to be 4.6% ± 1.5% for MVR with a biological prosthesis, 1.5% ± 0.4% for mitral valve repair (MVr), and 1.3% ± 0.8% for a mechanical prosthesis. 4 In addition, roughly one-third of patients undergoing mitral valve surgery will experience atrial fibrillation postoperatively, which has been associated with increased risk of stroke and early death and further supports the use of anticoagulation for thromboembolic prophylaxis.…”

Section: Introductionmentioning

confidence: 99%

Anticoagulation following mitral valve repair

Watt

Murray

Brescia

et al. 2020

Journal of Cardiac Surgery

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Background and Aim: Anticoagulation after mitral valve repair is controversial and guidelines are not well-established. This study evaluated the association between postoperative warfarin use and complications after mitral valve repair, including bleeding and thromboembolic incidents, readmission, and mortality. Methods: This retrospective study investigated 1097 patients who underwent elective mitral valve repair between April 2003 and March 2017, and was naïve to atrial fibrillation or prior cardiac surgery. This cohort had no other indication for or against anticoagulation. About 775 patients were placed on warfarin with international normalized ratio goal 2.5 and 322 patients were not anticoagulated. The association between anticoagulation and complications was assessed with univariate comparisons between groups and multiple logistic regression. Results: Postoperative warfarin use was associated with a reduced composite of bleeding and thromboembolic complications (pulmonary embolism, TIA, stroke, pericardial effusion or cardiac tamponade, gastrointestinal bleeding, and reoperation for bleeding) with an odds ratio of 0.29 (95% confidence interval, 0.13-0.64, P = .003). There was no difference in 30-day or 6-month mortality or readmission rate between groups. Long-term survival estimates were superior in the warfarin group (10-year: 92% vs 85%; log-rank P < .001). Conclusions: Our analysis showed that postoperative warfarin use was associated with an overall reduced composite of bleeding and thromboembolic incidents and superior long-term survival. These findings suggest that anticoagulation with warfarin following mitral valve repair may be a safe and effective means for avoiding postoperative complications and that a large prospective randomized clinical trial is warranted.

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“…Management of patients with valve repair necessitates antithrombotic therapy for the first 3 months following surgery [ 21 ], which is a high-risk period for thromboembolism. Anticoagulation therapy has no extra advantage over antiplatelet therapy in valve repair patients, and anticoagulation therapy may lead to major bleeding complications [ 22 ]. Nonetheless, the efficacy of anticoagulants in patients with valve repair needs to be confirmed in randomized controlled trials (RCTs).…”

Section: Introductionmentioning

confidence: 99%

Follow-up and management of valvular heart disease patients with prosthetic valve: a clinical practice guideline for Indian scenario

Saksena

Mishra

Muralidharan

et al. 2019

Indian J Thorac Cardiovasc Surg

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Purpose Valvular heart disease (VHD) patients after prosthetic valve implantation are at risk of thromboembolic events. Followup care of patients with prosthetic valve has a paramount role in reducing the morbidity and mortality. Currently, in India, there is quintessential need to stream line the follow-up care of prosthetic valve patients. This mandates the development of a consensus guideline for the antithrombotic therapy in VHD patients post prosthetic valve implantation. Methods A national level panel was constituted comprising 13 leading cardio care experts in India who thoroughly reviewed the up to date literature, formulated the recommendations, and developed the consensus document. Later on, extensive discussions were held on this draft and the recommendations in 8 regional meetings involving 79 additional experts from the cardio care in India, to arrive at a consensus. The final consensus document is developed relying on the available evidence and/or majority consensus from all the meetings. Results The panel recommended vitamin K antagonist (VKA) therapy with individualized target international normalized ratio (INR) in VHD patients after prosthetic valve implantation. The panel opined that management of prosthetic valve complications should be personalized on the basis of type of complications. In addition, the panel recommends to distinguish individuals with various co-morbidities and attend them appropriately. Conclusions Anticoagulant therapy with VKA seems to be an effective option post prosthetic valve implantation in VHD patients. However, the role for non-VKA oral therapy in prosthetic valve patients and the safety and efficacy of novel oral anticoagulants in patients with bioprosthetic valve need to be studied extensively.

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Antiplatelet versus oral anticoagulant therapy as antithrombotic prophylaxis after mitral valve repair

Cited by 23 publications

References 20 publications

Antithrombotic therapy after mitral valve repair: VKA or aspirin?

Antithrombotic therapy after mitral valve repair: VKA or aspirin?

Anticoagulation following mitral valve repair

Follow-up and management of valvular heart disease patients with prosthetic valve: a clinical practice guideline for Indian scenario

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