Should Bioprostheses be Anticoagulated?

Transcription

1 Should Bioprostheses be Anticoagulated? Hartzell V. Schaff, MD AATS 2013 Heart Valve Summit Chicago, IL September 26-28, MFMER slide-1

2 Guidelines for AC of Bioprostheses 1. ASA - Class I indication for AVR, not MVR 2. Warfarin for 3 mo. Class I indication following MVR 3. Dual antiplatelet agents Class IIa indication following AVR 4. None of the above 5. All of the above 2012 MFMER slide-2

3 ACC/AHA Guidelines 2006 Management of Patients with Valvular Heart Disease 2012 MFMER slide-3

4 ACC/AHA Guidelines 2006 Risk Factors for AC in Patients with Bioprostheses Atrial fibrillation LV dysfunction (EF<30%) Previous thromboembolism Hypercoagulable condition Left atrial size? Echocardiographic characteristics? Management of VKA? 2012 MFMER slide-4

5 Mitral Valve Replacement STS Valve Type % 2012 MFMER slide-5

6 22 y/o Female AVCD 3 yr s/p MVR 2012 MFMER slide-6

7 77 y/o Male Ischemic MR 2.5 yr s/p MVR 2012 MFMER slide-7

8 8 patients, aged 77 yr, time to reoperation 398 days (range, days) 2012 MFMER slide-8

9 56 Yr old ER M.D., EF 21% 2 yr s/p AVR 2012 MFMER slide-9

10 What do we do? General Expectation That Most AVR Patients Without Comorbidities Need to be Treated with Warfarin 2012 MFMER slide-10

11 What do we do? Does Warfarin Use Prolong Hospital Stay Following AVR in Patients Without Comorbidities? 2012 MFMER slide-11

12 Average Days Added by Warfarin Use in AVR Patients Without Comorbidities 2012 MFMER slide-12

13 What do we do? Belief that Anti-platelet Therapy is an Acceptable Alternative to Warfarin in AVR Patients Without Comorbidities 2012 MFMER slide-13

14 Belief That Warfarin Therapy for Three Months is No Longer Standard of Care after AVR in Patients Without Comorbidities 2012 MFMER slide-14

15 Conclusions: 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 MFMER slide-15

16 Conclusions Early after bavr, the effects of these 2 antithrombotic regimens on cerebral microembolization and platelet function are equivalent. These data bring new mechanistic support to the premise that aspirin only may safely be used early after bavr in patients who have no other indication for oral anticoagulation MFMER slide-16

17 Conclusions Early anticoagulation after isolated bioprosthetic aortic valve replacement in patients in normal sinus rhythm does not seem to reduce the risk of thromboembolism except in highrisk groups. Current recommendations should be revisited, because the only patients who may benefit from anticoagulation are female, those who are highly symptomatic, and those with a small aortic prosthesis MFMER slide-17

18 2012 MFMER slide-18

19 2012 MFMER slide-19

20 Anticoagulation for Bioprostheses STS Brennan et al, JACC MFMER slide-20

21 2012 MFMER slide-21

22 Conclusions 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 MFMER slide-22

23 JAMA. 2012;308(20): MFMER slide-23

24 2012 MFMER slide-24

25 2012 MFMER slide-25

26 2012 MFMER slide-26

27 within 90 to 180 days after surgery, we found that for every 23 (95% CI, 14-54) patients not being treated with warfarin, 1 patient died from cardiovascular cause 2012 MFMER slide-27

28 within 90 to 180 days after surgery, for every 74 (95% CI, 27-95) patients being treated with warfarin, 1 patient experienced bleeding complications requiring hospital admission 2012 MFMER slide-28

29 Conclusion Discontinuation of warfarin treatment within 6 months after bioprosthetic AVR surgery was associated with increased cardiovascular death. JAMA. 2012;308(20): MFMER slide-29

30 Anticoagulation of Bioprostheses Key Points ASA for all pt Life-long warfarin for patients with risk factors Warfarin for 3 months following MVR Need data New data suggests benefit of warfarin for 6 months following AVR Trials of anticoagulation and dual antiplatelet drugs 2012 MFMER slide-30

31 Questions & Discussion 2012 MFMER slide-31

32 What do we do? Belief That Anti-platelet Therapy Alone Addresses Patient Safety While Reducing LOS and Cost 2012 MFMER slide-32