title: The optimal management of anti-thrombotic therapy after valve replacement: certainties and uncertainties.
abstract: Anti-thrombotic therapy after valve replacement encompasses a number of different situations. Long-term anticoagulation of mechanical prostheses uses vitamin K antagonists with a target international normalized ratio adapted to the characteristics of the prosthesis and the patient. The association of low-dose aspirin is systematic in the American guidelines and more restrictive in the European guidelines. Early heparin therapy is frequently used early after mechanical valve replacement, although there are no precise recommendations regarding timing, type, and dose of drug. Direct oral anticoagulants are presently contraindicated in patients with mechanical prosthesis. The main advantage of bioprostheses is the absence of long-term anticoagulant therapy. Early anticoagulation is indicated after valve replacement for mitral bioprostheses, whereas aspirin is now favoured early after bioprosthetic valve replacement in the aortic position. Early dual antiplatelet therapy is indicated after transcatheter aortic valve implantation, followed by single antiplatelet therapy. However, this relies on low levels of evidence and optimization of anti-thrombotic therapy is warranted in these high-risk patients. Although guidelines are consistent in most instances, discrepancies and the low-level of evidence of certain recommendations highlight the need for further controlled trials, in particular with regard to the combination of antiplatelet therapy with oral anticoagulant and the early post-operative anti-thrombotic therapy following the procedure.
authors.affiliation: Cardiology Department, AP-HP, Bichat Hospital, 46 rue Henri Huchard, 75018, Paris, France Paris-Diderot University, DHU Fire, Paris, France bernard.iung@bch.aphp.fr josep.rodes@criucpq.ulaval.ca.
authors.forename: Bernard
authors.initials: B
authors.lastname: Iung
authors.affiliation: Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada bernard.iung@bch.aphp.fr josep.rodes@criucpq.ulaval.ca.
authors.forename: Josep
authors.initials: J
authors.lastname: Rodés-Cabau
mesh_terms: D054058:Acute Coronary Syndrome / Q000628:therapy; D000925:Anticoagulants / Q000506:poisoning / Q000627:therapeutic use*; D001705:Bioprosthesis; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000379:methods*; D006470:Hemorrhage / Q000139:chemically induced; D006801:Humans; D019934:International Normalized Ratio; D008134:Long-Term Care / Q000379:methods; D008875:Middle Aged; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D011182:Postoperative Care / Q000379:methods; D011183:Postoperative Complications / Q000517:prevention & control; D017410:Practice Guidelines as Topic; D016032:Randomized Controlled Trials as Topic; D015607:Stents; D013923:Thromboembolism / Q000517:prevention & control; D065467:Transcatheter Aortic Valve Replacement / Q000379:methods
chemical_list: D000925:Anticoagulants; D010975:Platelet Aggregation Inhibitors
keywords: Anticoagulant therapy; Antiplatelet drugs; Bioprosthesis; Mechanical prosthesis; Transcatheter aortic valve implantation; Valve prosthesis