TY - JOUR
T1 - High risk of thromboemboli early after bioprosthetic cardiac valve replacement
AU - Heras, Magda
AU - Chesebro, James H.
AU - Fuster, Valentin
AU - Penny, William J.
AU - Grill, Diane E.
AU - Bailey, Kent R.
AU - Danielson, Gordon K.
AU - Orszulak, Thomas A.
AU - Pluth, James R.
AU - Puga, Francisco J.
AU - Schaff, Hartzell V.
AU - Larsonkeller, Jeffrey J.
N1 - Funding Information:
From the \]Divisions of Cardiovascular Disease and Internal Medicine and Cardiovascular Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota; :~Cardiovascular Institute, Mount Sinai Medical Center, New York, New York; and §Department of Cardiology, University. of Wales College of Medicine, Cardiff, Wales, United Kingdom. Dr. Heras is the recipient of a research grant from CIR1T-Generalitat de Catalunya, Barcelona, Spain. Dr. Penny is the recipient of a British-American Research fellowship from the American Heart Association, Dallas, Texas and the British Heart Association, London, England, United Kingdom. Manuscript received October 21, 1993; revised manuscript received November 7, 1994, accepted December 12, 1994. *Present address: Hospital Clinic Villaroel, 170, 08036 Barcelona, Spain. Address for correspondence: Dr. James H. Chesebro, Cardiovascular Institute, Mount Sinai Medical Center, Box 1030, One Gustave L. Levy Place, New York, New York 10029-6574.
PY - 1995/4
Y1 - 1995/4
N2 - Objectives.: We studied the rate of thromboembolism in patients undergoing bioprosthetic replacement of the aortic or mitral valve, or both, at serial intervals after operation and the effects of anticoagulant or antiplatelet treatment and risk factors. Background.: Thromboembolism appears to occur early after operation, but the incidence, timing and risk factors for thromboembolism and the role, timing, adequacy, effectiveness, duration and risk of anticoagulation and antiplatelet agents are uncertain. Methods.: The rate of thromboembolism was studied at three time intervals after operation (1 to 10, 11 to 90 and >90 days) in 816 patients who underwent bioprosthetic replacement of the aortic or mitral valve, or both, at the Mayo Clinic from January 1975 to December 1982. The effect of antithrombotic therapy (warfarin, aspirin or dipyridamole, alone or in combination) was evaluated. Results.: Median follow-up of surviving patients was 8.6 years. The rate of thromboembolism (%/year) decreased significantly (p < 0.01) at each time interval after operation (1 to 10, 11 to 90 and >90 days) for mitral valve replacement (55%, 10% and 2.4%/year, respectively) and over the first time interval for aortic valve replacement (41%,3.6% and 1.9%/year, respectively). During the first 10 days, 52% to 70% of prothrombin time ratios were low (<1.5 × control). Patients with mitral valve replacement who received anticoagulation had a lower rate of thromboembolism for the entire follow-up period (2.5%/year with vs. 3.9%/year without anticoagulation, p = 0.05). Of 112 patients with a first thromboembolic episode, permanent disability occurred in 38% and death in 4%. Risk factors for emboli were lack of anticoagulation, mitral valve location, history of thromboembolism and increasing age. Only 10% of aortic, 44% of mitral and 17% of double valve recipients had anticoagulation at the time of an event. Patients with bleeding episodes (2.3%/year) were older and usually underwent anticoagulation. Blood transfusions were required in 60 of 111 patients (1.2%/year), and 13 patients (0.3%/year) died. Conclusions.: Thromboembolic risk was especially high for aortic and mitral valve replacement for 90 days after operation, and overall was increased with lack of anticoagulation, mitral valve location, previous thromboembolism and increasing age. Anticoagulation reduced thromboemboli and appears to be indicated in all patients as early as possible for 3 months and thereafter in those with risk factors, but needs prospective testing.
AB - Objectives.: We studied the rate of thromboembolism in patients undergoing bioprosthetic replacement of the aortic or mitral valve, or both, at serial intervals after operation and the effects of anticoagulant or antiplatelet treatment and risk factors. Background.: Thromboembolism appears to occur early after operation, but the incidence, timing and risk factors for thromboembolism and the role, timing, adequacy, effectiveness, duration and risk of anticoagulation and antiplatelet agents are uncertain. Methods.: The rate of thromboembolism was studied at three time intervals after operation (1 to 10, 11 to 90 and >90 days) in 816 patients who underwent bioprosthetic replacement of the aortic or mitral valve, or both, at the Mayo Clinic from January 1975 to December 1982. The effect of antithrombotic therapy (warfarin, aspirin or dipyridamole, alone or in combination) was evaluated. Results.: Median follow-up of surviving patients was 8.6 years. The rate of thromboembolism (%/year) decreased significantly (p < 0.01) at each time interval after operation (1 to 10, 11 to 90 and >90 days) for mitral valve replacement (55%, 10% and 2.4%/year, respectively) and over the first time interval for aortic valve replacement (41%,3.6% and 1.9%/year, respectively). During the first 10 days, 52% to 70% of prothrombin time ratios were low (<1.5 × control). Patients with mitral valve replacement who received anticoagulation had a lower rate of thromboembolism for the entire follow-up period (2.5%/year with vs. 3.9%/year without anticoagulation, p = 0.05). Of 112 patients with a first thromboembolic episode, permanent disability occurred in 38% and death in 4%. Risk factors for emboli were lack of anticoagulation, mitral valve location, history of thromboembolism and increasing age. Only 10% of aortic, 44% of mitral and 17% of double valve recipients had anticoagulation at the time of an event. Patients with bleeding episodes (2.3%/year) were older and usually underwent anticoagulation. Blood transfusions were required in 60 of 111 patients (1.2%/year), and 13 patients (0.3%/year) died. Conclusions.: Thromboembolic risk was especially high for aortic and mitral valve replacement for 90 days after operation, and overall was increased with lack of anticoagulation, mitral valve location, previous thromboembolism and increasing age. Anticoagulation reduced thromboemboli and appears to be indicated in all patients as early as possible for 3 months and thereafter in those with risk factors, but needs prospective testing.
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U2 - 10.1016/0735-1097(94)00563-6
DO - 10.1016/0735-1097(94)00563-6
M3 - Article
C2 - 7897124
AN - SCOPUS:0028911051
SN - 0735-1097
VL - 25
SP - 1111
EP - 1119
JO - Journal of the American College of Cardiology
JF - Journal of the American College of Cardiology
IS - 5
ER -