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Early anticoagulation may reduce stroke risk after surgical AVR
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Early anticoagulation after bioprosthetic aortic valve replacement was associated with short-term reduced risk for stroke in patients who had surgical AVR but not in those who had transcatheter AVR, researchers reported.
An early anticoagulation strategy was also not associated with adverse outcomes, according to the researchers.
Tarun Chakravarty, MD, member of the Heart Valve Program Expert Team at the Smidt Heart Institute at Cedars Sinai, and colleagues analyzed 4,832 patients who underwent AVR (3,889 TAVR, 942 surgical AVR) in the PARTNER 2 randomized trials and nonrandomized registries to assess the effect of anticoagulation strategies on valve hemodynamics and clinical outcomes.
Hemodynamics similar
After the researchers adjusted for valve size, annular diameter, atrial fibrillation and ejection fraction, they found no difference between those discharged on anticoagulants and those not discharged on them in aortic valve mean gradient or area. This was consistent in the TAVR and surgical AVR cohorts.
An increase in aortic valve mean gradient of more than 10 mm Hg between 30 days and 1 year occurred more frequently in patients discharged without anticoagulation (2.3% vs. 1.1%; P = .03), Chakravarty and colleagues wrote.
In the TAVR cohort, there was no association between anticoagulation strategy and death (adjusted HR = 1.26; 95% CI, 0.92-1.74), rehospitalization (aHR = 1.21; 95% CI, 0.93-1.58) or stroke or transient ischemic attack (aHR = 1.48; 95% CI, 0.89-2.45), but in the surgical AVR cohort, discharge with anticoagulation was associated with reduced risk for stroke/TIA (aHR = 0.27; 95% CI, 0.11-0.68), though not death or rehospitalization.
Also in the TAVR cohort, minor bleeding was more common in patients discharged on anticoagulation (aHR = 1.72; 95% CI, 1.13-2.61), according to the researchers.
“Our study findings suggest that in patients with clinical indications for [anticoagulation] and acceptable bleeding risks undergoing bioprosthetic AVR, it is safe to initiate [anticoagulation] at discharge,” Chakravarty and colleagues wrote. “Longer-term follow-up will determine whether [anticoagulation] after discharge is associated with clinically meaningful differences in valve hemodynamics and/or have impact on valve durability.”
Individualized approach
In a related editorial, Phillippe Pibarot, DVM, PhD, from the Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec City, and colleagues wrote that the study and previous ones do not support systematic anticoagulation use after AVR, but that “It may be preferable to adopt an individualized approach for early and long-term anticoagulation based on the presence or absence of procedural and patient factors that increase the risk of thromboembolism, valve thrombosis, or bleeding for thromboembolisms or valve thrombosis.” – by Erik Swain
Disclosures: PARTNER 2 was funded by Edwards Lifesciences. Chakravarty reports he has been a proctor and consultant for Edwards Lifesciences and Medtronic. Pibarot reports he has received institutional funding for core lab analysis from Edwards Lifesciences and is director of the echocardiography core lab for the PARTNER 2/SAPIEN 3 nonrandomized registry sponsored by Edwards Lifesciences. Please see the study and editorial for a list of the other authors’ relevant financial disclosures.
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