Journal Article

Antithrombotic Medication and Major Complications After Mechanical Aortic Valve Replacement

Björn, Rikhard, Airaksinen, K.E. Juhani, Anttila, Vesa, Lehto, Joonas, Gunn, Jarmo, Kiviniemi, Tuomas, Malmberg, Markus

2023

Overview

Patients with mechanical aortic valve replacement (AVR) require lifelong vitamin K antagonist (VKA) therapy for stroke and systemic embolism prevention. However, VKA treatment predisposes patients to various types of bleeding. In the present study, we sought to assess the success of antithrombotic therapy and the occurrence and timing of strokes and bleeding events after mechanical AVR. A total of 308 patients who underwent isolated mechanical AVR were included in the study, and follow-up data were completed for 306 patients (99.4%). The median follow-up time was 7.3 (interquartile range 4.2 to 10.9) years. The risk for major bleeding was 5-fold compared with major stroke (6.2% vs 1.3% and 20.9% vs 4.0%, respectively; events rates 3.1 vs 0.5 per 100 patient-years, respectively) at 30-day and long-term follow-up, indicating good efficacy but inadequate safety of stroke prevention. At the time of the early postoperative major bleeding, the international normalized ratio was under the therapeutic range in 73.7% of the patients. However, most patients were on triple antithrombotic treatment consisting of subcutaneous enoxaparin, VKA, and a tail effect of discontinued aspirin. During the long-term follow-up, the most common site of bleeding was gastrointestinal (41.7%), followed by genitourinary bleeding (23.3%) and intracranial hemorrhage (18.3%). Furthermore, mortality was relatively high, with a 10-year survival estimate of 78.3%. In conclusion, although ischemic stroke is a well-identified adverse event after mechanical AVR, it seems that major bleeding is a frequent clinically relevant complication during perioperative and long-term follow-up. This finding underscores the recognition and management of modifiable bleeding risk factors. The risk for major bleeding after aortic valve replacement was 5-fold compared with major stroke.Early bleeding was associated with the use of triple antithrombotic medication.During the long-term follow-up, 1/6 of the major bleeding events were intracranial hemorrhages.A total of 1/10 of the patients died within 30 days after their first major bleeding event.

• Publisher: Elsevier Inc,Elsevier Limited
• Subject: Aorta / Aortic valve / Aspirin / Bleeding / Cardiac arrhythmia / Consortia / Embolism / Heart surgery / Heart valves / Hemorrhage / Hospitals / Ischemia / ischemic stroke / Mortality / Patients / Postoperative period / Risk factors / Stroke / surgical aortic valve replacement / Thromboembolism / Vitamin K