Bridging Anticoagulation with Mechanical Heart Valves: Current Guidelines and Clinical Decisions
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VALVULAR HEART DISEASE (TL KIEFER, SECTION EDITOR)
Bridging Anticoagulation with Mechanical Heart Valves: Current Guidelines and Clinical Decisions Mahboob Ali 1 & Richard C. Becker 1
# Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract Purpose of Review The management of patients with mechanical heart valves who require surgery or invasive procedures is a common clinical scenario in contemporary practice. The risk of thromboembolism versus the risk of bleeding is the foundation of optimal patient care. Recent Findings Randomized, controlled trials are not available; yet, there is a wealth of experience to guide best practice. Current guidelines represent a compilation of data from trials of atrial fibrillation and expert opinion. Results from the PERI-OP trial of patients with either a mechanical heart valve, atrial fibrillation, or atrial flutter requiring interruption of oral anticoagulant therapy for surgery will inform clinical practice. Summary Patient-specific factors and valve-specific factors are paramount when deciding whether a period of anticoagulant therapy interruption is safe. Similarly, the safety and efficacy of bridging anticoagulant therapy and the optimal time after surgery for restarting oral anticoagulants is vital to optimal patient care. Keywords Bridging anticoagulation . Mechanical heart valves . Perioperative management
Introduction Perioperative interruption of chronic anticoagulation and bridging with anticoagulants is associated with risk of thromboembolism (TE) and bleeding, respectively. The most common indication for long-term anticoagulation is atrial fibrillation (AF), but bridging anticoagulation is usually not required. By contrast, bridging is often required in patients with mechanical heart valves (MHV) to mitigate the risk of mechanical valve thrombosis/dysfunction, stroke, and arterial embolization. Several factors, including the type of mechanical valve, its anatomic position, prior thromboembolic events, and concomitant medical conditions associated with This article is part of the Topical Collection on Valvular Heart Disease * Richard C. Becker [email protected] Mahboob Ali [email protected] 1
Division of Cardiovascular Health and Disease, Department of Medicine, University of Cincinnati College of Medicine, 231 Albert Sabin Way ML 0542, CVC, Room 4936, Cincinnati, OH 45267-0542, USA
thrombosis (e.g., atrial fibrillation), left ventricular chamber size, ventricular performance, and time from the initial surgery, determine the risk of thrombosis. The procedure or surgery, the choice and dose of anticoagulant, and the proximity of reinitiation after surgery define the risk of bleeding. Herein, we review current practices regarding bridging anticoagulation in patients with mechanical heart valves.
Prevalence of Valvular Heart Disease Valvular heart disease (VHD) affects around 2.5% of the US population, and there is no difference in frequency of disease between men and women (p = 0.9) [1]. Its prevalence is higher among the elderly, and ~
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