Peri-procedural anticoagulation management of mechanical prosthetic heart valve patients.
BACKGROUND
To estimate the three-month cumulative incidence of thromboembolism and bleeding among mechanical heart valve (MHV) patients receiving peri-procedural anticoagulation management, consecutive MHV patients referred to the Mayo Clinic Thrombophilia Center for peri-procedural anticoagulation management over the seven-year period, 1997-2003, were followed for three months for thromboembolism, bleeding and vital status.


METHODS
Warfarin was stopped 4-5 days prior to the procedure, and re-started after the procedure as soon as hemostasis was assured. The decision to provide bridging therapy with low molecular weight (LMWH) or unfractionated (UFH) heparin was individualized and based on the estimated risks of TE and bleeding.


RESULTS
556 MHV patients (372 aortic only, 136 mitral only, 48 with multiple valves) underwent 580 procedures. The three-month cumulative incidence of thromboembolism was 0.9% which included: cerebral ischemia (n=3), unstable angina (n=1), acute myocardial infarction (n=1). None were fatal. The cumulative incidence of major bleeding was 3.6% and fatal in 0.2%. The incidence of major bleeding events did not differ by postoperative anticoagulant strategy whether LMWH (3.7%), UFH (6.1%), or no heparin (2.4%) was used (p=0.26).


CONCLUSIONS
The three-month cumulative incidence of thromboembolism among MHV patients in whom anticoagulation is temporarily interrupted for an invasive procedure is low. Whereas bleeding exceeds thromboembolic complications, our current practice is to restart warfarin as soon as possible post-procedure. Post-procedural heparin use is reserved for patients with the highest thromboembolic risk (mitral MHV, multiple MHVs, MHV with prior stroke or atrial fibrillation) waiting at least 48 hours before initiating.
Daniels
Paul R
PR
Mayo Clinic Thrombophilia Center, Gonda Vascular Center, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA.
McBane
Robert D
RD
Litin
Scott C
SC
Ward
Sue A
SA
Hodge
David O
DO
Dowling
Nicole F
NF
Heit
John A
JA
D000368:Aged; D000925:Anticoagulants / Q000008:administration & dosage*; D015897:Comorbidity; D005260:Female; D019918:Heart Valve Prosthesis Implantation / Q000706:statistics & numerical data*; D006801:Humans; D015994:Incidence; D008297:Male; D008910:Minnesota; D019990:Perioperative Care / Q000379:methods; D019106:Postoperative Hemorrhage / Q000453:epidemiology*; D011292:Premedication / Q000379:methods*; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013923:Thromboembolism / Q000453:epidemiology* / Q000517:prevention & control*; D016896:Treatment Outcome
D000925:Anticoagulants