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J Thorac Cardiovasc Surg 2005;130:1482-1483
© 2005 The American Association for Thoracic Surgery

Letter to the Editor

Early anticoagulation after aortic valve replacement with bioprostheses: Time to abandon it?

Francesca di Marco, MD a , Giorgio Meneghetti, MD b , Gino Gerosa, MD a

a Institute of Cardiovascular Surgery, Padua University Medical School, Padova, Italy
b Neurology Division, Padua University Medical School, Padova, Italy

To the Editor:

According to the American College of Cardiology/American Heart Association (ACC/AHA) Guidelines for Valvular Heart Disease, 1 Go a 3-month-long program of anticoagulation therapy is recommended after valve replacement with tissue valves. On the contrary, a recent study carried out by the Cardiothoracic Surgery Network (CTSNet) Valve Technology Center, "The Anticoagulation Therapy and Valve Replacement Study," 2 Go has outlined that the practice tends to diverge from the widely established guidelines. In fact, 80% of 726 participating surgeons prefer to adopt antiplatelet therapy in biologic valve recipients who do not have additional risk factors for thromboembolic events.

Sundt and associates 3 Go have demonstrated in 624 patients that anticoagulant therapy after aortic valve replacement (AVR) did not offer advantages in terms of neurologic morbidity compared with 527 patients who did not receive warfarin.

Similarly, at our institution, the policy currently adopted is to administer aspirin despite warfarin during the 3-month time interval necessary for the sewing ring to become completely endothelialized. Anticoagulants remain indicated in the presence of comorbidities that leave the patient at risk for thromboembolism, such as chronic atrial fibrillation, atriomegaly, severe impairment of left ventricular function, and ventricular aneurysms.

Nevertheless, we share the concerns raised by the CTSNet. In fact, currently there is no clear evidence that this alternative approach is free from neurologic detrimental effects. We believe that the satisfactory clinical results in terms of cerebrovascular accidents reported by Sundt and coworkers 3 Go cannot exclude the possibility of asymptomatic microembolization and that mere clinical evaluation might be limited.

At our institution, to overcome a potential underestimation related to sheer clinical observations, we decided to evaluate the occurrence of microembolic signals (MES) in patients after heart valve replacement surgery by transcranial Doppler. Our preliminary results in 58 patients (43 men and 15 women, mean age 69.8 years) undergoing tissue valve replacement (23 patients) versus mechanical valve replacement (35 patients) let us draw a correlation between the absence of clinical neurologic impairment (0% of neurologic complications) and the absence of MES in the subcohort of aortic biologic valve patients who received aspirin instead of warfarin in the early postoperative period (0% of MES at transcranial Doppler). On the basis of these preliminary results, we set out on a prospective clinical trial randomizing patients, after AVR, for antiplatelet versus anticoagulant early therapy. The postoperative evaluation pursued in the trial, which is ongoing, is both clinical and instrumental, aiming to detect potential clinically silent microembolization.

We believe that the positive clinical results encountered by Sundt and associates 3 Go and shared also by our experience need instrument-based evidence to represent a firm basis and efficacious stimulus toward reconsideration of guidelines.


   References
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 References
 

  1. Bonow RO, Carabello B, de Leon AC, Edmunds Jr LH, Fedderly BJ, Freed MD, et al. ACC/AHA Guidelines for the Management of Patients With Valvular Heart Disease. Executive Summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Valvular Heart Disease). Circulation 1998;98:1949-1984.[Free Full Text]
  2. http://www.ctsnet.org/file/AnticoagulationSurveyFinalResultsSlidesPDF.pdf..
  3. Sundt TM, Zehr KJ, Dearani A, Daly RC, Mullany CJ, McGregor CG, et al. Is early anticoagulation with warfarin necessary after bioprostheticaortic valve replacement. J Thorac Cardiovasc Surg 2005;129:1024-1031.[Abstract/Free Full Text]



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