Fatal Association of Mechanical Valve Thrombosis With Dabigatran

Atar, Shaul; Wishniak, Alice; Shturman, Alexander; Shtiwi, Sewaed; Brezins, Marc

doi:10.1378/chest.12-2486

Cited by 11 publications

(7 citation statements)

References 9 publications

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“…Atar et al described 2 patients with bileafl et mechanical mitral valves who had been maintained on therapeutic warfarin for several years without complication. 8 After switching to dabigatran, both patients developed fatal valve thrombosis within 1 to 2 months. Three additional patients have been described, 2 with a mechanical aortic valve and 1 with a mechanical mitral valve, who experienced valve thrombosis on dabigatran.…”

Section: Efficacy In Patients With Mechanical Valvesmentioning

confidence: 98%

Dabigatran for Mechanical Valves

Howard

2014

Hosp Pharm

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Section: Efficacy In Patients With Mechanical Valvesmentioning

confidence: 98%

Dabigatran for Mechanical Valves

Howard

2014

Hosp Pharm

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“…Thus, based on this clear observation along with several case reports and editorials [48][49][50][51] surrounding this issue, dabigatran should not be used for mechanical valve anticoagulation management [50].…”

Section: Future Therapiesmentioning

confidence: 98%

Review of anticoagulation options for mechanical valve prosthesis

Toeg

Boodhwani

2015

Interventional Cardiology

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Clinical guidelines recommend lifelong oral anticoagulation (OAC) with warfarin in all patients with mechanical valves with variance in the target INR for patient associated risk factors, type of mechanical valve or implant position of the valve. Recent randomized controlled trials have demonstrated that clinicians may consider a lower OAC strategy (INR: 1.5-2.5) in low (thrombogenic) risk patients undergoing bileaflet mechanical valve replacement thereby achieving similar thromboprophylaxis yet minimizing bleeding events. Likewise, physicians may also consider a lowered OAC option in high (thrombogenic) risk patients undergoing bileaflet mechanical valve replacement yielding similar efficacy (avoidance of thromboembolic events) and improving safety (bleeding events). Finally, while advancement of novel oral anticoagulants (NOACs) has been swift in the realm of atrial fibrillation anticoagulation management, NOACs for mechanical valves are currently contraindicated due to evidence of increased thromboembolic and bleeding risk. Future studies comparing NOACs and warfarin along with newer mechanical valve construction are eagerly being awaited. a significant increased risk of major bleeding [16]. At mid-term follow-up, contemporary (2005+) incidence of thromboembolic events has been relatively low ranging from 0 to 3.6% [17,18]. With the advent of newer generation mechanical valves, there is potential for achieving even lower rates of thromboembolic and bleeding events with either less intense OAC, antiplatelet therapy alone or potentially novel OACs (NOAC). Therefore, this review is aimed at discussing current practice trends, novel strategies and future endeavors for postoperative t hromboprophylaxis for mechanical valves. Current practice for anticoagulationCurrent international guidelines generally recommend the following: low dose aspirin (74-100 mg) for all patients, OAC in mechanical aortic valves with target INR 2.0-3.0 at low-risk for thromboembolic events and OAC with target INR 2.5-3.5 in mechanical mitral valves and high-risk aortic valve patients (Table 1) [12][13][19][20]. High-risk patients are considered to be those with concomitant atrial fibrillation, previous thromboembolism, hypercoagulable state or depressed left ventricular function [21,22]. These recommendations have been partially based on older studies using more thrombogenic mechanical valves (i.e., StarrEdwards ball and cage, Bjork-Shiley tilting disc) [23][24][25] along with a landmark meta-analysis by Cannegieter and colleagues [20]. Moreover, based on Massel and Little's meta-analysis, the European guidelines advise caution with the addition of an antiplatelet medication due to the increased risk of bleeding with an odds ratio of 1.58 (95% CI: 1.14-2.18) [16,26]. Several groups have demonstrated similar effectiveness with reduced OAC therapy (compared with historically target INR of 3.0-4.5 in patients with bileaflet St. Jude Medical [St. Jude Medical, Inc., Saint Paul, MN, USA]) mechanical valves, mostly in the aortic position [21,27]...

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“…All of these cases report mechanical valve thromboembolism after a switch from warfarin to dabigatran in the setting of either mitral38, 39, 40, 41, 42 or aortic42, 43, 44, 45 heart valves. Two fatal cases of mitral valve thrombosis were reported, with neither patient surviving repeat valve replacement surgery 38. There was one report of nonfatal bioprosthetic mitral valve thrombosis leading to massive stroke after a switch from warfarin to dabigatran.…”

Section: Case Studiesmentioning

confidence: 99%

“…To date, several cases of thrombosis complicating dabigatran use in the setting of mechanical valve prosthesis have been published. All of these cases report mechanical valve thromboembolism after a switch from warfarin to dabigatran in the setting of either mitral [38][39][40][41][42] or aortic [42][43][44][45] heart valves. Two fatal cases of mitral valve thrombosis were reported, with neither patient surviving repeat valve replacement surgery.…”

Section: Case Studiesmentioning

confidence: 99%

“…Two fatal cases of mitral valve thrombosis were reported, with neither patient surviving repeat valve replacement surgery. 38 There was one report of nonfatal bioprosthetic mitral valve thrombosis leading to massive stroke after a switch from warfarin to dabigatran. Currently, there is one documented case of thrombosis in a patient with AF and coexistent valvular disease (mitral stenosis) without valve replacement during dabigatran anticoagulation.…”

Section: Case Studiesmentioning

confidence: 99%

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