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The Prognostic Impact of Anti-thrombotic Treatment Strategies After Biological Aortic Valve Replacement

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Abstract

Purpose

Optimal antithrombotic therapy in patients who underwent surgical biological aortic valve replacement (AVR) represents an issue of ongoing discussion. Additionally, the prognostic impact of anti-thrombotic treatment strategies after biological AVR and real-life data on anticoagulation strategies (AC) of patients presenting with short-term postoperative atrial fibrillation (POAF) has not clearly been investigated so far. Therefore, this study aimed to investigate the impact of therapeutic AC after biological AVR on patient outcome and whether the presence of POAF affects decision making on anti-thrombotic management.

Methods

Within this prospective observational study, 200 individuals that underwent biological AVR surgery were enrolled. Participants were followed prospectively until the primary study endpoint was reached. Multivariate logistic regression analysis was performed to elucidate the effect of therapeutic AC on outcome.

Results

Overall, 106 individuals received therapeutic AC at the time of discharge. The fraction of patients presenting with POAF was balanced between individuals receiving AC and the non-AC subgroup (p = 0.617). After a median follow-up time of 1418 days, 31 (15.5%) individuals died, referring to 15 (13.9%) POAF-free patients and 16 (17.4%) with POAF. We observed a strong inverse association of therapeutic AC and cardiovascular mortality, which remained stable after adjustment for potential confounders showing a HR of 0.437 (95% CI 0.202–0.943; p = 0.035), while bleeding risk was comparable (p = 0.680).

Conclusion

Within this investigation, therapeutic AC showed a strong and independent inverse association with long-term mortality in patients that underwent biological AVR. Although POAF is associated with thromboembolic adverse events, the development of this arrhythmia did not affect decision-making of the anti-thrombotic management.

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Data Availability

The datasets underlying this article are available upon reasonable request through the corresponding author.

References

  1. d’Arcy JL, Prendergast BD, Chambers JB, Ray SG, Bridgewater B. Valvular heart disease: the next cardiac epidemic. Heart. 2011;97(2):91–3.

    Article  PubMed  Google Scholar 

  2. Iung B, Rodes-Cabau J. The optimal management of anti-thrombotic therapy after valve replacement: certainties and uncertainties. Eur Heart J. 2014;35(42):2942–9.

    Article  CAS  PubMed  Google Scholar 

  3. Baumgartner H, Falk V, Bax JJ, De Bonis M, Hamm C, Holm PJ, Iung B, Lancellotti P, Lansac E, Rodriguez Munoz D, Rosenhek R, Sjogren J, Tornos Mas P, Vahanian A, Walther T, Wendler O, Windecker S, Zamorano JL, Group ESCSD. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 2017;38(36):2739–91.

    Article  PubMed  Google Scholar 

  4. Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Fleisher LA, Jneid H, Mack MJ, McLeod CJ, O’Gara PT, Rigolin VH, Sundt TM, Thompson A. 2017 AHA/ACC focused update of the 2014 AHA/ACC Guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2017;135(25):e1159–95.

    Article  PubMed  Google Scholar 

  5. Whitlock RP, Sun JC, Fremes SE, Rubens FD, Teoh KH. Antithrombotic and thrombolytic therapy for valvular disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e576S-e600S.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. Steinberg BA, Zhao Y, He X, Hernandez AF, Fullerton DA, Thomas KL, Mills R, Klaskala W, Peterson ED, Piccini JP. Management of postoperative atrial fibrillation and subsequent outcomes in contemporary patients undergoing cardiac surgery: insights from the Society of Thoracic Surgeons CAPS-Care Atrial Fibrillation Registry. Clin Cardiol. 2014;37(1):7–13.

    Article  PubMed  Google Scholar 

  7. Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, La Meir M, Lane DA, Lebeau JP, Lettino M, Lip GYH, Pinto FJ, Thomas GN, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL; ESC Scientific Document Group. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2021;42(5):373–498.

  8. Russo A, Grigioni F, Avierinos JF, Freeman WK, Suri R, Michelena H, Brown R, Sundt TM, Enriquez-Sarano M. Thromboembolic complications after surgical correction of mitral regurgitation incidence, predictors, and clinical implications. J Am Coll Cardiol. 2008;51(12):1203–11.

    Article  PubMed  Google Scholar 

  9. Aramendi JI, Mestres CA, Martinez-Leon J, Campos V, Munoz G, Navas C. Triflusal versus oral anticoagulation for primary prevention of thromboembolism after bioprosthetic valve replacement (trac): prospective, randomized, co-operative trial. Eur J Cardiothorac Surg. 2005;27(5):854–60.

    Article  PubMed  Google Scholar 

  10. Merie C, Kober L, Skov Olsen P, Andersson C, Gislason G, Skov Jensen J, Torp-Pedersen C. Association of warfarin therapy duration after bioprosthetic aortic valve replacement with risk of mortality, thromboembolic complications, and bleeding. JAMA. 2012;308(20):2118–25.

    Article  CAS  PubMed  Google Scholar 

  11. Brennan JM, Edwards FH, Zhao Y, O’Brien S, Booth ME, Dokholyan RS, Douglas PS, Peterson ED. Early anticoagulation of bioprosthetic aortic valves in older patients: results from the Society of Thoracic Surgeons Adult Cardiac Surgery National Database. J Am Coll Cardiol. 2012;60(11):971–7.

    Article  PubMed  Google Scholar 

  12. Eikelboom JW, Connolly SJ, Brueckmann M, Granger CB, Kappetein AP, Mack MJ, Blatchford J, Devenny K, Friedman J, Guiver K, Harper R, Khder Y, Lobmeyer MT, Maas H, Voigt JU, Simoons ML, Van de Werf F. Dabigatran versus warfarin in patients with mechanical heart valves. N Engl J Med. 2013;369(13):1206–14.

    Article  CAS  PubMed  Google Scholar 

  13. Carnicelli AP, Caterina RD, Halperin JL, Renda G, Ruff CT, Trevisan M, Nordio F, Mercuri MF, Antman E, Giugliano RP. Edoxaban for the prevention of thromboembolism in patients with atrial fibrillation and bioprosthetic valves. Circulation. 2017;135(13):1273–5.

    Article  PubMed  Google Scholar 

  14. Guimarães PO, Pokorney SD, Lopes RD, Wojdyla DM, Gersh BJ, Giczewska A, Carnicelli A, Lewis BS, Hanna M, Wallentin L, Vinereanu D, Alexander JH, Granger CB. Efficacy and safety of apixaban vs warfarin in patients with atrial fibrillation and prior bioprosthetic valve replacement or valve repair: Insights from the ARISTOTLE trial. Clin Cardiol. 2019;42(5):568–71.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Dangas GD, Tijssen JGP, Wöhrle J, Søndergaard L, Gilard M, Möllmann H, Makkar RR, Herrmann HC, Giustino G, Baldus S, De Backer O, Guimarães AHC, Gullestad L, Kini A, von Lewinski D, Mack M, Moreno R, Schäfer U, Seeger J, Tchétché D, Thomitzek K, Valgimigli M, Vranckx P, Welsh RC, Wildgoose P, Volkl AA, Zazula A, van Amsterdam RGM, Mehran R, Windecker S. A controlled trial of rivaroxaban after transcatheter aortic-valve replacement. N Engl J Med. 2019;382(2):120–9.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria

    Andreas Hammer, Felix Hofer, Niema Kazem, Lorenz Koller, Sebastian Schnaubelt, Johann Wojta, Christian Hengstenberg, Alexander Niessner & Patrick Sulzgruber

  2. Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria

    Günther Laufer

  3. Department of Anaesthesiology, Medical University of Vienna, Vienna, Austria

    Barbara Steinlechner

Authors
  1. Andreas Hammer
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  2. Felix Hofer
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  3. Niema Kazem
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  4. Lorenz Koller
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  5. Sebastian Schnaubelt
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  6. Günther Laufer
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  7. Barbara Steinlechner
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  8. Johann Wojta
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  9. Christian Hengstenberg
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  10. Alexander Niessner
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  11. Patrick Sulzgruber
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Contributions

Study concept: AN, and PS in discussion with JW, CH, GL, and BS. Study coordination: JW, CH, GL, and BS. Data assessment: AH, FH, NK, LK, and SS. Statistical analysis: AH, PS. Manuscript writing: AH, PS with input of all other authors.

Corresponding author

Correspondence to Alexander Niessner.

Ethics declarations

Ethics Approval

This study was conducted in accordance with the Declaration of Helsinki and successfully approved by the ethics committee of the Medical University of Vienna (EK No.: 1110/2013).

Consent to Participate

All participants gave written consent at the time of study inclusion.

Consent for Publication

All participants were informed and gave consent that their data may be published in an anonymous form.

Conflict of Interest

Patrick Sulzgruber reports grants from Daiichi Sankyo and grants from Boehringer-Ingelheim outside the submitted work; Alexander Niessner reports personal fees from Bayer, personal fees from BMS, grants and personal fees from Boehringer Ingelheim, grants and personal fees from Daiichi Sankyo, and personal fees from Pfizer outside the submitted work.

The other authors have no relevant financial or non-financial interests to disclose.

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Hammer, A., Hofer, F., Kazem, N. et al. The Prognostic Impact of Anti-thrombotic Treatment Strategies After Biological Aortic Valve Replacement. Cardiovasc Drugs Ther 36, 1137–1145 (2022). https://doi.org/10.1007/s10557-021-07247-2

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  • DOI: https://doi.org/10.1007/s10557-021-07247-2

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