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Review: Optimal Anticoagulation After Bioprosthetic Valve Replacement

Journal

Originally published on Seminars in Thoracic and Cardiovascular Surgery

Key findings

  • The optimal approach to antiplatelet and anticoagulant therapy after bioprosthetic valve replacement is still under debate
  • Guidelines vary somewhat between the American Heart Association/American College of Cardiology and the European Society of Cardiology/European Association for Cardio-Thoracic Surgery
  • Transcatheter mitral valve replacement is a new option for patients at high surgical risk who have degenerated surgical mitral valve repairs or prostheses, but there are no society guidelines yet about anticoagulation for these patients
  • On the basis of a review of recent literature, Massachusetts General Hospital surgeons present their own approach to anticoagulation and antiplatelet therapy after bioprosthetic aortic and mitral valve replacement

A continuing controversy in cardiac surgery is the optimal approach to providing antiplatelet and anticoagulant therapy after bioprosthetic valve replacement. Thromboembolic events and valve thrombosis can occur as a spectrum of complications, from subclinical leaflet thickening to valve failure.

In Seminars in Thoracic and Cardiovascular Surgery, Philicia Moonsamy, MD, surgery resident, and Serguei Melnitchouk, MD, MPH, co-director of the Heart Valve Program in the Corrigan Minehan Heart Center at Massachusetts General Hospital, and a colleague summarize the current recommendations of the American Heart Association/American College of Cardiology (AHA/ACC) and the European Society of Cardiology/European Association for Cardio-Thoracic Surgery (ESC/EACTS).

On the basis of a review of recent literature, they also present their own approach to anticoagulation and antiplatelet therapy after bioprosthetic aortic valve replacement (AVR) and mitral valve replacement (MVR).

Transcatheter AVR (TAVR)

AHA/ACC

  • Life-long aspirin 75–100 mg/day
  • For patients at low bleeding risk, a vitamin K antagonist (VKA) to achieve an international normalized ratio (INR) of 2.5 may be reasonable for at least three months
  • Clopidogrel 75 mg/day may be reasonable for six months

ESC/EACTS

  • Consider dual antiplatelet therapy (DAPT) for the first 3-6 months, followed by lifelong single antiplatelet therapy if patients don't need oral anticoagulation (OAC) for other reasons
  • For patients at high bleeding risk, consider single antiplatelet therapy
  • Lifelong OAC is recommended for patients who have other indications for anticoagulation (e.g., atrial fibrillation, venous thromboembolism, hypercoagulable state)

Surgical AVR (SAVR)

AHA/ACC

  • Aspirin 75–100 mg/day is reasonable for all patients
  • For patients at low risk of bleeding, VKA to achieve INR of 2.5 is reasonable for at least three months and as long as six months

ESC/EACTS

  • Consider aspirin 75–100 day for the first three months (also recommended after valve-sparing aortic surgery)
  • Consider OAC for the first three months
  • Lifelong OAC is recommended for patients who have other indications for anticoagulation

Conventional MVR

AHA/ACC

  • Aspirin 75–100 mg/day is reasonable for all patients
  • For patients at low risk of bleeding, VKA to achieve INR of 2.5 is reasonable for at least three months and as long as six months

ESC/EACTS

  • Consider OAC for the first three months
  • Lifelong OAC is recommended for patients who have other indications for anticoagulation

Transcatheter MVR

Transcatheter MVR is a new option for patients at high surgical risk who have degenerated surgical mitral valve repairs or prostheses. In addition, technologies are being explored for the treatment of mitral regurgitation in patients at high surgical risk. Data about anticoagulation after transcatheter MVR are still limited, so there are no society guidelines yet.

Updated Algorithm

Based on a review of the current literature, the authors have summarized the current practice and updated the algorithm around anticoagulation and antiplatelet therapy after AVR and MVR:

In General

  • Lifelong OAC is recommended for all patients who have other indications for anticoagulation (e.g., atrial fibrillation, venous thromboembolism, hypercoagulable state)

SAVR

  • Short-term: Aspirin 75–100 mg/day; addition of VKA with INR goal 2.5 may be considered
  • Long-term: Aspirin 75–100 mg/day

TAVR

  • Short-term (3-6 months): (a) DAPT or (b) VKA with INR goal 2.5 plus aspirin 75–100 mg/day
  • Long-term: Aspirin 75–100 mg/day

Conventional MVR

  • Short term: VKA with INR goal 2.5 plus aspirin 75–100 mg/day
  • Long-term: Aspirin 75–100 mg/day

Transcatheter MVR

  • Short-term: VKA with INR goal 2.5 plus aspirin 75–100 mg/day
  • Long-term: Unknown; consider lifelong DAPT or VKA with INR goal 2.5 plus aspirin 75–100 mg/day

Patient-specific risk factors must be considered when designing an ideal strategy.

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