Antithrombotic therapy after mitral valve repair: VKA or aspirin?

Abstract

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.

2021 ESC/EACTS Guidelines for the management of valvular heart disease

“…Observational data suggest comparable risk of thromboembolism with ASA or VKAs following mitral valve repair, 503 but randomized data are lacking. The high incidence of new-onset AF and its recurrence, the thrombogenic tendency of the non-endothelialized repair components, and a relatively high rate of patients who are resistant to ASA establish VKAs as a preferable option for the initial period (e.g.…”

Robotic mitral valve repair in a type B hemophiliac

“…Whether short-term anticoagulation is indicated after mitral valve repair in the general population is still a matter of controversy, but valve repair in the hemophiliac population potentially avoids the need for even short-term anticoagulation as we demonstrated in this case. 15 Our perioperative protocol differed in several ways from that used in the reported robotic CABG. We implemented intermittent bolus factor dosing whereas Chamos et al used continuous factor infusion throughout surgery and up until POD 3, at which time their patient was transitioned to bolus dosing.…”

Antithrombotic Treatment After Surgical and Transcatheter Heart Valve Repair and Replacement

“…In accordance with current guidelines, many centers worldwide systematically prescribe anticoagulants after mitral and tricuspid valve repair. However, at the University Hospitals Leuven, thromboprophylaxis with lifelong aspirin monotherapy in patients with mitral and tricuspid valve repair without OAC indication has been routine practice for more than 20 years, which is in line with several observational studies reporting a similar thromboembolic risk between VKAs and low-dose aspirin after mitral valve repair (37,38). Hence, anticoagulation is not routinely recommended, and such a strategy minimizes the risk of anticoagulation-related bleeding complications.…”

“…Guidelines are mainly based on expert opinion, but the use of an annuloplasty ring and the possible occurrence of post-operative atrial fibrillation can justify short-term antithrombotic therapy. Observational studies suggest that VKAs are not superior to low-dose aspirin regarding the thromboembolic prevention after mitral valve repair, but potentially increase the risk of bleeding (37,38). Furthermore, NOACs appear to be a potential alternative, but more data validating NOACs are needed (39).…”