Is early anticoagulation with warfarin necessary after bioprosthetic aortic valve replacement?

Division of Cardiovascular Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
Journal of Thoracic and Cardiovascular Surgery (Impact Factor: 4.17). 05/2005; 129(5):1024-31. DOI: 10.1016/j.jtcvs.2004.11.028
Source: PubMed


Freedom from anticoagulation is the principal advantage of bioprosthesis; however, the American Heart Association/American College of Cardiology and the American College of Chest Physicians guidelines recommend early anticoagulation with heparin, followed by warfarin for 3 months after bioprosthetic aortic valve replacement. We examined neurologic events within 90 days of bioprosthetic aortic valve replacement at our institution.
Between 1993 and 2000, 1151 patients underwent bioprosthetic aortic valve replacement with (641) or without (510) associated coronary artery bypass. By surgeon preference, 624 had early postoperative anticoagulation (AC+) and 527 did not (AC-). In the AC- group, 410 patients (78%) received antiplatelet therapy. Groups were similar with respect to gender (female, 36% AC+ vs 40% AC-, P = .21), hypertension (64% AC+ vs 61%, P = .27), and prior stroke (7.6% AC+ vs 8.5% AC-, P = .54). The AC+ group was slightly younger than the AC- group (median, 76 years vs 78 years, P = .006).
Operative mortality was 4.1% with 43 (3.7%) cerebrovascular events within 90 days. Excluding 18 deficits apparent upon emergence from anesthesia, we found that postoperative cerebrovascular accident occurred in 2.4% of AC+ and 1.9% AC- patients. By multivariable analysis, the only predictor of operative mortality was hypertension ( P < .0001). Postoperative cerebrovascular accident was unrelated to warfarin use ( P = .32). The incidence of mediastinal bleeding requiring reexploration was similar (5.0% vs 7.4%), as were other bleeding complications in the first 90 days (1.1% vs 0.8%). No variables were predictive of bleeding by multivariate analysis.
Although these data do not address the role of antiplatelet agents, early anticoagulation with warfarin after bioprosthetic aortic valve replacement did not appear to protect against neurologic events.

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Available from: Kenton J Zehr, Jul 09, 2014
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    • "They concluded that lowdose aspirin was associated with minimal bleeding complications and no increase in the incidence of TE events when started in patients in sinus rhythm following AVR with the Tissuemed porcine bioprosthesis. A more recent retrospective study by Sundt et al. [23] analysed the data from the first 90 days following bioprosthetic AVR (n = 1151), with (n = 641) or without (n = 510) associated CABG. Six hundred and twenty-four patients received anticoagulation with heparin and warfarin and 527 patients received no anticoagulation, 410 of which received antiplatelet therapy. "
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    ABSTRACT: The life expectancy of the general population is increasing. This has meant that more elderly patients are requiring aortic valve replacement (AVR). The choice of valve replacement and its durability are important. Bioprosthetic (tissue) heart valves were introduced into clinical use in the 1960s and were developed primarily to reduce the complications associated with thromboembolism (TE) and the need for lifelong oral anticoagulation, due to their low thrombogenicity compared to mechanical prostheses. This makes them suitable for use in elderly patients (aged>65 years) and in others where the risks of anticoagulation are higher or anticoagulation is contraindicated. There is thought to be a higher risk of TE for up to 90 days following bioprosthetic AVR. Guidelines for the management of patients with valvular heart disease published by the American College of Cardiology (ACC)/American Heart Association (AHA), the American College of Chest Physicians (ACCP) and the European Society of Cardiology (ESC) all recommend the use of an anticoagulation regimen for the first 3 months following bioprosthetic AVR. However, there is division of opinion and practice, despite these recommendations, and more recent studies have not supported the evidence for these guidelines. In this article, we review the literature on the use of anticoagulation in the first 90 days following bioprosthetic AVR.
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