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The Annals of Thoracic Surgery, Vol 44, 430-445, Copyright © 1987 by The Society of Thoracic Surgeons
LH Edmunds Jr
A review of articles published since 1979 indicates that thrombotic and
bleeding complications account for about 50% of valve-related complications
in patients with bioprosthetic aortic and mitral valves and for
approximately 75% of the complications in patients with mechanical valves.
Although compromised by lack of standard definitions and by variability in
reporting and follow-up, the data suggest that the linearized rate of both
thrombotic and bleeding complications in patients with aortic bioprostheses
is approximately half that for aortic mechanical prostheses (2% versus 4%),
but is approximately equal for both bioprostheses and mechanical valves in
the mitral position (approximately 4%), and for mechanical and
bioprosthetic aortic and mitral valves in combination. However, linearized
rates for fatal thrombotic and bleeding events are two to four times higher
in patients with mechanical prostheses. The adequacy of warfarin
anticoagulation is the most important factor affecting thrombotic and
bleeding complications in patients with mechanical valves and over shadows
the dubious importance of other phenomena such as atrial fibrillation and
left atrial thrombus. Short-term warfarin anticoagulation or the use of
long-term platelet inhibitors, or both, do not appear to reduce the
incidence of thrombotic complications in patients with aortic bioprostheses
but increase bleeding. For mitral bioprostheses, the postoperative use of
warfarin for three months or aspirin indefinitely is as effective in
preventing thromboembolism as long-term warfarin. Acute prosthetic valve
endocarditis is associated with a 13 to 40% incidence of thrombotic
complications. Likewise, the recurrence rate of cerebral emboli is high
(20-30%) in patients with prosthetic valves who are not anticoagulated.
Bioprostheses are strongly preferred for women who wish to bear children;
fetal wastage occurs in 25 to 30% of pregnant women with mechanical heart
valves who receive either warfarin or heparin, or a combination of the two.
Heparin, however, greatly increases the risk of maternal bleeding. In
children, the efficacy of platelet inhibitors without warfarin
anticoagulation is unproven; nearly all serious strokes occur when warfarin
is omitted; and permanent disability from warfarin-related bleeding is
rare. All prosthetic cardiac valves initiate coagulation and affect the
dynamic equilibrium between activated procoagulants and endogenous
anticoagulants. Warfarin is the only available oral exogenous
anticoagulant.(ABSTRACT TRUNCATED AT 400 WORDS)
ARTICLES
Thrombotic and bleeding complications of prosthetic heart valves
Department of Surgery, University of Pennsylvania, Philadelphia 19104.
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