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Outcomes of Anticoagulation for Bioprosthetic Valve Thrombosis
Study Questions:
What are the long-term outcomes of patients with bioprosthetic valve thrombosis treated with anticoagulation?
Methods:
The authors conducted a 2:1 matched cohort study of patients with bioprosthetic valves who were treated with warfarin for suspected valve thrombosis at the Mayo Clinic between 1999 and 2017. They explored for the composite endpoint of death, stroke, or embolic events along with the rates of major bleeding. They also compared long-term need for valve replacement among patients with and without bioprosthetic valve thrombosis.
Results:
The authors identified 83 patients treated with warfarin for suspected bioprosthetic valve thrombosis and matched them with 166 control patients with bioprosthetic valve but no suspected thrombosis. Median follow-up was 34 months (interquartile range [IQR], 17-54 months). The composite endpoint of death, stroke, and embolism occurred similarly in both groups (log-rank p = 0.79). However, warfarin-treated patients more often experienced major bleeding (12% vs. 2%, p < 0.0001). Bioprosthetic valve thrombosis recurred in 14/62 (23%) initially responding patients after a median of 23 months (IQR, 11-39 months). Patients with bioprosthetic valve thrombosis had higher probability of valve re-replacement than patients without thrombosis (68% vs. 24% at 10 years, p < 0.001).
Conclusions:
The authors concluded that bioprosthetic valve thrombosis is associated with higher rates of valve re-replacement. They also concluded that indefinite warfarin anticoagulation should be considered, but an increased risk of bleeding is to be expected.
Perspective:
Most patients with suspected bioprosthetic valve thrombosis respond to a short-term course of anticoagulation. However, the long-term impact of bioprosthetic valve thrombosis and secondary prevention with warfarin anticoagulation has yet to be delineated. This study highlights the high rate of recurrent valve thrombosis (23%), the high risk of valve re-replacement following an initial thrombotic episode, and the associated long-term outcomes with long-term anticoagulation therapy. Of note, recurrent valve thrombosis is likely associated with inadequate warfarin therapy (frequent low international normalized ratio [INR] values). Additionally, the role of direct oral anticoagulants was not explored in this study, but they may offer a treatment choice with more predictable anticoagulation effect. In the meantime, clinicians should ensure high-quality warfarin therapy and consider longer courses (indefinite?) for patients with suspected bioprosthetic valve thrombosis. The length of anticoagulation therapy is likely to be influenced by a patient’s underlying bleeding risk.
Clinical Topics: Anticoagulation Management, Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, Prevention, Valvular Heart Disease, Cardiac Surgery and Arrhythmias, Cardiac Surgery and CHD and Pediatrics, Cardiac Surgery and VHD, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Quality Improvement
Keywords: Anticoagulants, Cardiology Interventions, Embolism, Hemorrhage, Heart Defects, Congenital, Heart Valve Diseases, Heart Valve Prosthesis, Secondary Prevention, Stroke, Treatment Outcome, Thrombosis, Vascular Diseases, Warfarin
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