Early Anticoagulation of Bioprosthetic Aortic Valves in Older Patients

Brennan, James M.; Edwards, Fred H.; Zhao, Yue; O’Brien, Sean M.; Booth, Michael; Dokholyan, Rachel S.; Douglas, Pamela S.; Peterson, Eric D.

doi:10.1016/j.jacc.2012.05.029

Cited by 132 publications

(37 citation statements)

References 17 publications

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“…Secondary outcomes included hemorrhaging stroke (ICD-9 codes 430–432), 18 death, and a composite endpoint comprised of thromboembolism, hemorrhagic stroke, or death to 3 years. Vital status was determined by the Medicare denominator file.…”

Section: Methodsmentioning

confidence: 99%

Association Between Left Atrial Appendage Occlusion and Readmission for Thromboembolism Among Patients With Atrial Fibrillation Undergoing Concomitant Cardiac Surgery

Friedman

Piccini

Wang

et al. 2018

JAMA

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153

124

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IMPORTANCE The left atrial appendage is a key site of thrombus formation in atrial fibrillation (AF) and can be occluded or removed at the time of cardiac surgery. There is limited evidence regarding the effectiveness of surgical left atrial appendage occlusion (S-LAAO) for reducing the risk of thromboembolism. OBJECTIVE To evaluate the association of S-LAAO vs no receipt of S-LAAO with risk of thromboembolism among older patients undergoing cardiac surgery. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of a nationally representative Medicare-linked cohort from the Society of Thoracic Surgeons Adult Cardiac Surgery Database (2011–2012). Patients ≥65 years old with AF undergoing cardiac surgery (coronary artery bypass grafting [CABG], mitral valve surgery ± CABG, aortic valve surgery ± CABG) with and without concomitant S-LAAO were followed until December 31, 2014. EXPOSURE S-LAAO vs. no S-LAAO. MAIN OUTCOME MEASURES Primary outcome was readmission for thromboembolism (stroke, transient ischemic attack, or systemic embolism) at up to 3 years follow-up, as defined by Medicare claims data. Secondary endpoints included hemorrhagic stroke, all-cause mortality, and a composite endpoint (thromboembolism, hemorrhagic stroke, all-cause mortality). RESULTS Among 10,524 patients undergoing surgery (median age of 76 years; 39% female; median CHA2DS2-VASc score of 4), 3,892 (37%) underwent S-LAAO. Overall, at a mean follow-up of 2.6 years, thromboembolism occurred in 5.4%, hemorrhagic stroke in 0.9%, death in 21.5%, and the composite endpoint in 25.7%. S-LAAO, compared with no S-LAAO, was associated with lower unadjusted rates of thromboembolism (4.2% vs. 6.2%), all-cause mortality (17.3% vs. 23.9%), and the composite endpoint (20.5% vs. 28.7%), but no significance difference in rates of hemorrhagic stroke (0.9% vs. 0.9%). After inverse probability-weighted adjustment, S-LAAO was associated with a significantly lower rate of thromboembolism (subdistribution hazard ratio [HR] 0.67, confidence interval [CI] 0.56–0.81, p<0.0001), death (HR 0.88, CI 0.79–0.97, p=0.001), and the composite endpoint (HR 0.83, CI 0.76–0.91, p<0.001), but not hemorrhagic stroke (subdistribution HR 0.84, 0.53–1.32, p=0.44). S-LAAO, compared with no S-LAAO, was associated with a lower risk of thromboembolism among those discharged without anticoagulation (unadjusted rate 4.2% vs. 6.0%, adjusted subdistribution HR 0.26, CI 0.17–0.40, p<0.001), but not among those discharged with anticoagulation (unadjusted rate 4.1% vs. 6.3%, adjusted subdistribution HR 0.88, CI 0.56–1.39, p=0.59). CONCLUSIONS AND RELEVANCE Among older patients with AF undergoing concomitant cardiac surgery, S-LAAO compared with no S-LAAO, was associated with a lower risk of readmission for thromboembolism over the three years. These findings are supportive of S-LAAO, but randomized trials are necessary to provide definitive evidence.

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Section: Methodsmentioning

confidence: 99%

Association Between Left Atrial Appendage Occlusion and Readmission for Thromboembolism Among Patients With Atrial Fibrillation Undergoing Concomitant Cardiac Surgery

Friedman

Piccini

Wang

et al. 2018

JAMA

Self Cite

153

124

View full text Add to dashboard Cite

show abstract

“…More recently, Brennan et al 7 demonstrated, through a retrospective cohort study with large sample size (25,656 patients), that this is the incidence of 1%/person-year for any of the aforementioned therapies.…”

Section: Resultsmentioning

confidence: 99%

Antithrombotic Strategy in the Three First Months following Bioprosthetic Heart Valve Implantation

Durães

Correia

et al. 2013

Arquivos Brasileiros De Cardiologia

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Heart valve prosthesis unquestionably improve quality of life and survival of patients with severe valvular heart disease, but the need for antithrombotic therapy to prevent thromboembolic complications is a major challenge to clinicians and their patients. Of the articles analyzed, most were retrospective series of cases or historical cohorts obtained from the database. The few published randomized trials showed no statistical power to assess the primary outcome of death or thromboembolic event. In this article, we decided to perform a systematic literature review, in an attempt to answer the following question: what is the best antithrombotic strategy in the first three months after bioprosthetic heart valve implantation (mitral and aortic)?After two reviewers applying the extraction criteria, we found 1968 references, selecting 31 references (excluding papers truncated, which combined bioprosthesis with mechanical prosthesis, or without follow-up).Based on this literature review, there was a low level of evidence for any antithrombotic therapeutic strategy evaluated. It´s therefore interesting to use aspirin 75 to 100 mg / day as antithrombotic strategy after bioprosthesis replacement in the aortic position, regardless of etiology, for patients without other risk factors such as atrial fibrillation or previous thromboembolic event. In the mitral position, the risk of embolism, although low, is more relevant than in the aortic position, according to published series and retrospective cohorts comprised mostly of elderly non-rheumatic patients.The current evidence is limited to have a consistent and safe level of evidence regarding the best therapeutic strategy. Based on these studies, 75 to 100 mg/day of aspirin is interesting as antithrombotic strategy after implantation of aortic bioprosthesis, regardless of etiology, for patients with no other risk factors such as atrial fibrillation or previous thromboembolic event. As for mitral bioprosthesis, the risk of embolism, although low, is more relevant than in the aortic position, according to published series and retrospective cohorts - usually elderly non rheumatic patients.

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“…A 2012 document comparing 25,656 patients post-SAVR showed an individual risk of stroke or bleeding event of 1% on aspirin monotherapy at 3 months. (51) The cohort placed on aspirin plus coumadin had a lower risk of embolic stroke but had a significantly higher risk of bleeding when compared to patients on aspirin monotherapy (relative risk of bleeding: 2.80, 95% CI: 2.18 to 3.60, p<0.0001).…”

Section: Anticoagulation and Bleeding In Savr And Tavi In The Elderlymentioning

confidence: 94%

Transcatheter Aortic Valve Implantation in the Elderly: Who to Refer?

Finn¹,

Green²

2014

Progress in Cardiovascular Diseases

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In recent years, experience with transcatheter aortic valve implantation has led to improved outcomes in elderly patients with severe aortic stenosis (AS) who may not have previously been considered for intervention. These patients are often frail with significant comorbid conditions. As the prevalence of AS increases, there is a need for improved assessment parameters to determine the patients most likely to benefit from this novel procedure. This review discusses the diagnostic criteria for severe AS and the trials available to aid in the decision to refer for aortic valve procedures in the elderly.

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Early Anticoagulation of Bioprosthetic Aortic Valves in Older Patients

Abstract: Death and embolic events were relatively rare in the first 3 months after bioprosthetic aortic valve replacement. Compared with aspirin-only, aspirin plus warfarin was associated with a reduced risk of death and embolic events, but at the cost of an increased bleeding risk.

Cited by 132 publications

References 17 publications

Association Between Left Atrial Appendage Occlusion and Readmission for Thromboembolism Among Patients With Atrial Fibrillation Undergoing Concomitant Cardiac Surgery

Association Between Left Atrial Appendage Occlusion and Readmission for Thromboembolism Among Patients With Atrial Fibrillation Undergoing Concomitant Cardiac Surgery

Antithrombotic Strategy in the Three First Months following Bioprosthetic Heart Valve Implantation

Transcatheter Aortic Valve Implantation in the Elderly: Who to Refer?

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