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Antithrombotic strategy after bioprosthetic aortic valve replacement in patients in sinus rhythm: evaluation of
Sake Johannes van der Wall1, Victor A W M Umans2, Jeroen Schotten3
1Department of Thrombosis and Hemostasis, Leiden University Medical Centre Leiden, Leiden, Netherlands s.j.van_der_wall@lumc.nl.
Insights
Aspirin is safer than acenocoumarol for preventing clots after bioprosthetic aortic valve replacement. Acenocoumarol increases bleeding risk without reducing thromboembolic events, supporting aspirin use for thromboprophylaxis.
Area of Science:
- Cardiology
- Vascular Surgery
- Pharmacology
Background:
- Bioprosthetic aortic valve replacement (BAVR) carries risks of valve thrombosis and systemic thromboembolism.
- Current antithrombotic guidelines (aspirin or vitamin K antagonists) for 3 months post-procedure lack strong evidence, creating therapeutic debate.
- Optimal antithrombotic strategy post-BAVR remains unclear, necessitating further investigation into long-term outcomes.
Purpose of the Study:
- To compare the efficacy and safety of antiplatelet therapy (aspirin) versus anticoagulation (acenocoumarol) in patients 1 year after BAVR.
- To analyze thromboembolic and bleeding complications associated with different antithrombotic regimens post-BAVR.
- To identify predictors of thromboembolic and bleeding events in patients undergoing BAVR.
Main Methods:
- Retrospective analysis of 402 patients undergoing BAVR, treated with either acenocoumarol or aspirin.
- Individual antithrombotic therapy duration was recorded and correlated with thrombotic and bleeding events.
- Patients were followed for 1 year, monitoring survival, cerebral ischemia, myocardial infarction, peripheral arterial embolism, and hemorrhage.
Main Results:
- A total of 24 thromboembolic and 31 bleeding events were recorded.
- Acenocoumarol use was associated with a significantly higher risk of bleeding (RR: 8.41) but similar thromboembolic event rates compared to aspirin.
- Prior acenocoumarol use predicted thromboembolic events (RR: 3.1), while gender, dyslipidemia, prior PCI, prior acenocoumarol, and CABG predicted bleeding.
Conclusions:
- Acenocoumarol therapy post-BAVR significantly increases bleeding risk without providing additional thromboembolic protection compared to aspirin.
- Findings support the use of aspirin over vitamin K antagonists for postoperative thromboprophylaxis after BAVR.
- Identifying risk factors for bleeding and thromboembolism can help personalize antithrombotic strategies.
Objectives:
After elective aortic valve replacement, patients are at risk of developing valve thrombosis and systemic arterial thromboembolism. Current guidelines recommend antithrombotic therapy with aspirin or vitamin K antagonists (VKAs) during the first 3 months after the procedure, but have level 2 or 3 evidence. As a consequence, the most appropriate antithrombotic therapy is still a matter of debate. This retrospective study analysed all thromboembolic and bleeding complications in patients with either antiplatelet or anticoagulation therapy 1 year after bioprosthetic aortic valve replacement.
Methods:
A total of 402 patients undergoing bioprosthetic aortic valve implantation at the VU University Medical Centre and subsequently treated at three regional hospitals were included. The individual duration of either VKAs (acenocoumarol) or aspirin was determined and related to thrombotic and bleeding events. Patients were followed and censored at 1 year postoperatively for survival, cerebral ischaemia, myocardial infarction, peripheral arterial embolism, and minor and major haemorrhages.
Results:
A total of 24 thromboembolic complications and 31 bleeding episodes occurred. Multivariable analyses revealed that acenocoumarol caused more bleeding episodes (risk ratio [RR]: 8.41, 95% CI: 3.58-19.79) and a similar amount of thromboembolic events (RR: 1.2, 95% CI: 0.47-3.02) compared with aspirin. Prior use of acenocoumarol was found to be a risk factor for thromboembolic events (RR: 3.1, 95% CI: 1.31-7.19). Gender, dyslipidaemia, prior percutaneous coronary intervention, prior use of acenocoumarol and concomitant coronary artery bypass grafting were found to be predictors for bleeding events.
Conclusions:
In patients 1 year following bioprosthetic aortic valve replacement, acenocoumarol therapy was associated with a significant increased risk of bleeding events and no reduction in thromboembolic events compared with antiplatelet therapy. These findings support the recommendations of aspirin over VKAs as postoperative thromboprophylaxis.
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