Variation in warfarin thromboprophylaxis after mitral valve repair

Does equipoise exist and is a randomized trial warranted?

Rakesh M. Suri, Vinod H. Thourani, Xia He, J. Matthew Brennan, Sean M. O'Brien, J. Scott Rankin, Hartzell V Schaff, James S. Gammie

Research output: Contribution to journalArticle

11 Citations (Scopus)

Abstract

Background: There are limited data available to inform decision making regarding warfarin thromboprophylaxis early after mitral valve repair. Methods: We studied 13,082 patients from The Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS ACSD) who underwent primary mitral valve repair between January 1, 2008, and June 30, 2010. Excluded were those having other major concomitant operations or with an indication/contraindication to warfarin. The predictors of warfarin administration at dismissal were evaluated. Results: In this cohort (median age 58 years; 59% male), warfarin was prescribed at hospital dismissal for 46% (5,963) of patients. Median postoperative length of stay was 5 days overall (6 days warfarin versus 5 days, p < 0.0001). Substantial surgeon and center variation existed, and multivariable analysis identified that warfarin use was more common among patients with postoperative atrial fibrillation (odds ratio [OR] 4.04, 95% confidence interval [CI]: 3.57 to 4.58), postoperative neurologic events (stroke OR 1.72, 95% CI: 1.08 to 2.71; transient ischemic attack/reversible ischemic neurologic deficit OR 6.29, 95% CI: 2.67 to 14.84), and preoperative arrhythmia (OR 2.49, 95% CI: 1.84 to 3.38). Warfarin use was less common among patients having surgery in the more recent era (OR 0.92, 95% CI: 0.89 to 0.96, per half-year increase in date of surgery), those requiring intraoperative transfusion of red blood cells (OR 0.82, 95% CI: 0.71 to 0.96), and patients with advanced heart failure (New York Heart Association functional class IV OR 0.77, 95% CI: 0.59 to 1.00). Conclusions: At present, half of patients are prescribed warfarin after isolated mitral valve repair in North American cardiac surgical practice which may impact the length of hospital stay. Although patient-level predictors of warfarin prescription exist, center- and surgeon-level variations are prominent. There is a pressing need for a randomized trial both to guide therapy and to ascertain the potential for resource conservation.

Original languageEnglish (US)
Pages (from-to)1991-1999
Number of pages9
JournalAnnals of Thoracic Surgery
Volume95
Issue number6
DOIs
StatePublished - Jun 2013

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Warfarin
Mitral Valve
Odds Ratio
Confidence Intervals
Length of Stay
boldenone undecylenate
Erythrocyte Transfusion
Transient Ischemic Attack
Neurologic Manifestations
Atrial Fibrillation
Nervous System
Thoracic Surgery
Prescriptions
Cardiac Arrhythmias
Decision Making
Heart Failure
Stroke
Databases

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Surgery
  • Pulmonary and Respiratory Medicine

Cite this

Variation in warfarin thromboprophylaxis after mitral valve repair : Does equipoise exist and is a randomized trial warranted? / Suri, Rakesh M.; Thourani, Vinod H.; He, Xia; Brennan, J. Matthew; O'Brien, Sean M.; Rankin, J. Scott; Schaff, Hartzell V; Gammie, James S.

In: Annals of Thoracic Surgery, Vol. 95, No. 6, 06.2013, p. 1991-1999.

Research output: Contribution to journalArticle

Suri, Rakesh M. ; Thourani, Vinod H. ; He, Xia ; Brennan, J. Matthew ; O'Brien, Sean M. ; Rankin, J. Scott ; Schaff, Hartzell V ; Gammie, James S. / Variation in warfarin thromboprophylaxis after mitral valve repair : Does equipoise exist and is a randomized trial warranted?. In: Annals of Thoracic Surgery. 2013 ; Vol. 95, No. 6. pp. 1991-1999.
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title = "Variation in warfarin thromboprophylaxis after mitral valve repair: Does equipoise exist and is a randomized trial warranted?",
abstract = "Background: There are limited data available to inform decision making regarding warfarin thromboprophylaxis early after mitral valve repair. Methods: We studied 13,082 patients from The Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS ACSD) who underwent primary mitral valve repair between January 1, 2008, and June 30, 2010. Excluded were those having other major concomitant operations or with an indication/contraindication to warfarin. The predictors of warfarin administration at dismissal were evaluated. Results: In this cohort (median age 58 years; 59{\%} male), warfarin was prescribed at hospital dismissal for 46{\%} (5,963) of patients. Median postoperative length of stay was 5 days overall (6 days warfarin versus 5 days, p < 0.0001). Substantial surgeon and center variation existed, and multivariable analysis identified that warfarin use was more common among patients with postoperative atrial fibrillation (odds ratio [OR] 4.04, 95{\%} confidence interval [CI]: 3.57 to 4.58), postoperative neurologic events (stroke OR 1.72, 95{\%} CI: 1.08 to 2.71; transient ischemic attack/reversible ischemic neurologic deficit OR 6.29, 95{\%} CI: 2.67 to 14.84), and preoperative arrhythmia (OR 2.49, 95{\%} CI: 1.84 to 3.38). Warfarin use was less common among patients having surgery in the more recent era (OR 0.92, 95{\%} CI: 0.89 to 0.96, per half-year increase in date of surgery), those requiring intraoperative transfusion of red blood cells (OR 0.82, 95{\%} CI: 0.71 to 0.96), and patients with advanced heart failure (New York Heart Association functional class IV OR 0.77, 95{\%} CI: 0.59 to 1.00). Conclusions: At present, half of patients are prescribed warfarin after isolated mitral valve repair in North American cardiac surgical practice which may impact the length of hospital stay. Although patient-level predictors of warfarin prescription exist, center- and surgeon-level variations are prominent. There is a pressing need for a randomized trial both to guide therapy and to ascertain the potential for resource conservation.",
author = "Suri, {Rakesh M.} and Thourani, {Vinod H.} and Xia He and Brennan, {J. Matthew} and O'Brien, {Sean M.} and Rankin, {J. Scott} and Schaff, {Hartzell V} and Gammie, {James S.}",
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T2 - Does equipoise exist and is a randomized trial warranted?

AU - Suri, Rakesh M.

AU - Thourani, Vinod H.

AU - He, Xia

AU - Brennan, J. Matthew

AU - O'Brien, Sean M.

AU - Rankin, J. Scott

AU - Schaff, Hartzell V

AU - Gammie, James S.

PY - 2013/6

Y1 - 2013/6

N2 - Background: There are limited data available to inform decision making regarding warfarin thromboprophylaxis early after mitral valve repair. Methods: We studied 13,082 patients from The Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS ACSD) who underwent primary mitral valve repair between January 1, 2008, and June 30, 2010. Excluded were those having other major concomitant operations or with an indication/contraindication to warfarin. The predictors of warfarin administration at dismissal were evaluated. Results: In this cohort (median age 58 years; 59% male), warfarin was prescribed at hospital dismissal for 46% (5,963) of patients. Median postoperative length of stay was 5 days overall (6 days warfarin versus 5 days, p < 0.0001). Substantial surgeon and center variation existed, and multivariable analysis identified that warfarin use was more common among patients with postoperative atrial fibrillation (odds ratio [OR] 4.04, 95% confidence interval [CI]: 3.57 to 4.58), postoperative neurologic events (stroke OR 1.72, 95% CI: 1.08 to 2.71; transient ischemic attack/reversible ischemic neurologic deficit OR 6.29, 95% CI: 2.67 to 14.84), and preoperative arrhythmia (OR 2.49, 95% CI: 1.84 to 3.38). Warfarin use was less common among patients having surgery in the more recent era (OR 0.92, 95% CI: 0.89 to 0.96, per half-year increase in date of surgery), those requiring intraoperative transfusion of red blood cells (OR 0.82, 95% CI: 0.71 to 0.96), and patients with advanced heart failure (New York Heart Association functional class IV OR 0.77, 95% CI: 0.59 to 1.00). Conclusions: At present, half of patients are prescribed warfarin after isolated mitral valve repair in North American cardiac surgical practice which may impact the length of hospital stay. Although patient-level predictors of warfarin prescription exist, center- and surgeon-level variations are prominent. There is a pressing need for a randomized trial both to guide therapy and to ascertain the potential for resource conservation.

AB - Background: There are limited data available to inform decision making regarding warfarin thromboprophylaxis early after mitral valve repair. Methods: We studied 13,082 patients from The Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS ACSD) who underwent primary mitral valve repair between January 1, 2008, and June 30, 2010. Excluded were those having other major concomitant operations or with an indication/contraindication to warfarin. The predictors of warfarin administration at dismissal were evaluated. Results: In this cohort (median age 58 years; 59% male), warfarin was prescribed at hospital dismissal for 46% (5,963) of patients. Median postoperative length of stay was 5 days overall (6 days warfarin versus 5 days, p < 0.0001). Substantial surgeon and center variation existed, and multivariable analysis identified that warfarin use was more common among patients with postoperative atrial fibrillation (odds ratio [OR] 4.04, 95% confidence interval [CI]: 3.57 to 4.58), postoperative neurologic events (stroke OR 1.72, 95% CI: 1.08 to 2.71; transient ischemic attack/reversible ischemic neurologic deficit OR 6.29, 95% CI: 2.67 to 14.84), and preoperative arrhythmia (OR 2.49, 95% CI: 1.84 to 3.38). Warfarin use was less common among patients having surgery in the more recent era (OR 0.92, 95% CI: 0.89 to 0.96, per half-year increase in date of surgery), those requiring intraoperative transfusion of red blood cells (OR 0.82, 95% CI: 0.71 to 0.96), and patients with advanced heart failure (New York Heart Association functional class IV OR 0.77, 95% CI: 0.59 to 1.00). Conclusions: At present, half of patients are prescribed warfarin after isolated mitral valve repair in North American cardiac surgical practice which may impact the length of hospital stay. Although patient-level predictors of warfarin prescription exist, center- and surgeon-level variations are prominent. There is a pressing need for a randomized trial both to guide therapy and to ascertain the potential for resource conservation.

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