Low-Molecular-Weight Heparin as a Bridging Anticoagulant Early After Mechanical Heart Valve Replacement

Abstract

Background-After mechanical heart valve replacement (MHVR), long-term use of unfractionated heparin is sometimes required because vitamin K antagonists (VKA) are temporarily contraindicated or because the time to reach the target international normalized ratio is long. The aim of this study was to investigate the feasibility of low-molecular-weight heparin treatment in these patients. Methods and Results-This work was conducted as a prospective study. We selected all patients (nϭ695) who underwent MHVR and were transferred to a postoperative cardiac rehabilitation center between January 2000 and January 2005. The study focused on patients who had not yet started VKA therapy or who had a below-target international normalized ratio despite VKA therapy. Unfractionated heparin was replaced by enoxaparin (100 IU/kg BID) until VKA treatment was fully effective. Two hundred fifty patients (60Ϯ11 years old) were enrolled 16Ϯ11 days after surgery (aortic valve replacement, nϭ190; mitral valve replacement, nϭ34; double valve replacement, nϭ26). Of these, 50% had permanent or transient atrial fibrillation, 40% had hypertension, 13% had diabetes, and 19% had a history of cardiac surgery. The mean duration of low-molecular-weight heparin treatment was 8.3Ϯ6.0 days. Patients were followed for 90 days, during which there were two major and three minor bleeding episodes and one transient ischemic attack. There were no cases of valve thrombosis and no deaths. Conclusions-After MHVR, one third of patients leave the cardiac surgery unit before VKA treatment is fully effective.Bridging anticoagulation therapy with enoxaparin appears to be feasible during this high-risk period for thromboembolism and could shorten the length of hospital stay. (Circulation. 2006;113:564-569.)

Endoscopy in patients on antiplatelet or anticoagulant therapy, including direct oral anticoagulants: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines

“…[21][22][23] Intravenous unfractionated heparin (UFH) is an alternative, and local cardiological advice may influence which is preferred. Bridging with UFH does, however, require a prolonged inpatient stay as warfarin is discontinued, and then restarted, to achieve satisfactory INR.…”

“Bridging” and Mechanical Heart Valves

“…In the study by Meurin et al, 8 the LMWH bridging strategy was remarkably successful. Only 3 of the 250 patients experienced adverse events: hemorrhagic pericardial tamponade, abdominal muscle hematoma, and transient ischemic attack.…”

“…Therefore, Meurin and colleagues have performed a great service by enrolling 250 patients in a well-executed case series published in this issue of Circulation. 8 Many of these patients were at high risk for stroke. Half had atrial fibrillation at baseline.…”

Bridging therapy to chronic anticoagulant treatment in patients undergoing cardiac surgery: comparison between low-molecular-weight heparin and subcutaneous unfractionated heparin. A pilot study

“…Unfractionated heparin (UFH) has for a long term been the standard bridging anticoagulant drug [2], however low-molecular-weight heparin (LMWH) may be as safe and effective without increase of bleeding risk [3]. LMWH has more predictable and rapidly reached anticoagulation due to its better Few studies have analyzed LMWH as a bridging anticoagulant after valve replacement or repair [4][5][6].…”