Anticoagulation Management After Transcatheter and Surgical Valve Replacement

Valvular heart disease is associated with high morbidity and mortality, and its prevalence is rising as the population ages. Treatment of severe valvular disease has historically required surgical correction, which carries its own risks, but there have been significant advances in valve replacement technologies and techniques, most notably the development of percutaneous options for repair and replacement. While valve replacements alleviate the hemodynamic burden of valvular disease, the synthetic material comprising part or all of the replacement valve provides nidus for clot, necessitating antithrombotic therapy. Providing the right balance between thromboembolic and bleeding risk is made more challenging by the comorbidities that often co-exist with valve disease in the elderly patient. The backbone of anticoagulation regimens has been comprised of aspirin, warfarin, or both, but newer agents are gaining popularity due to improved convenience and safety profiles. The expanding medical arsenal brings not only more options but also more complexity with the increasing number of possible combinations of anticoagulants and valve types. In general, mechanical heart valves are thought to be the most durable option with the highest thrombotic risk, requiring anticoagulation with warfarin with the addition of aspirin. Bioprosthetic valves placed surgically or percutaneously are less likely to cause thrombus and have been successfully managed with antiplatelet agents alone. However, concerns about previously undetected complications coming to light with new imaging techniques have brought uncertainty about current practice. In order to provide optimal care for our patients, careful review of the current literature, guideline recommendations, and the thrombotic and bleeding risk unique to the individual patient and valve type is necessary.