open access

Vol 27, No 5 (2020)
Original articles — Clinical cardiology
Published online: 2018-11-26
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Low molecular weight heparin in surgical valve procedures: When and how much for an optimal prophylaxis?

Katarzyna Czerwińska-Jelonkiewicz, Marek Cisowski, Andrzej Bochenek, Piotr Buszman, Krzysztof Milewski, Piotr Kunik, Magdalena Mularska, Krzysztof Kocot, Piotr Politowski, Jakub Brączkowski, Agata Trznadel, Michael S. Aboodi, Paweł Buszman
DOI: 10.5603/CJ.a2018.0146
·
Pubmed: 30484265
·
Cardiol J 2020;27(5):548-557.

open access

Vol 27, No 5 (2020)
Original articles — Clinical cardiology
Published online: 2018-11-26

Abstract

Background: Periprocedural antithrombotic prophylaxis in patients undergoing surgical valve procedures (SVP) is insufficiently investigated. Low molecular weight heparin (LMWH) has been considered as an alternative to unfractionated heparin (UFH). However, safety and efficacy of this prophylaxis strategy is unknown. This study aimed to investigate safety and efficacy of periprocedural LMWH prophylaxis and determine optimal dosage and timing for periprocedural cessation and initiation.

Methods:
The present study is a retrospective, single-center observational analysis of 388 patients who underwent SVP (valve replacement or valvuloplasty) between 2015 and 2016. In-hospital endpoints were bleeding, transfusions, reoperation due to bleeding, and thromboembolic events. Results: Giving the first dose of LMWH on the day of SVP was a risk factor for bleeding (OR 1.07; 95% CI 1.04–1.10; p < 0.001), transfusions (OR 1.04; 95% CI 1.01–1.07; p = 0.008) and reoperation due to bleeding (OR 1.20; 95% CI 1.12–1.28; p < 0.001), with > 40 mg/day as a predictor. A higher dosage of LMWH premedication was an independent risk factor for bleeding (OR 1.02; 95% CI 1.00–1.04; p = 0.03) and transfusion (OR 1.03; 95% CI 1.01–1.05; p = 0.01), with > 60 mg/day as a predictor for these events. LMWH dosed within 24 h prior to SVP increased the risk of transfusion (AUC 0.636; 95% CI 0.496–0.762; p = 0.04).

Conclusions:
Bleeding is an important early concern after surgical valve procedures. Safety and efficacy of periprocedural prophylaxis with LMWH depends on dosage and the timing of its administration. The most optimal periprocedural prophylaxis in the SVP population appears to be LMWH in dosage of 40–60 mg/day, which is recommended for deep vein thrombosis prophylaxis, ceased at least one day before SVP

Abstract

Background: Periprocedural antithrombotic prophylaxis in patients undergoing surgical valve procedures (SVP) is insufficiently investigated. Low molecular weight heparin (LMWH) has been considered as an alternative to unfractionated heparin (UFH). However, safety and efficacy of this prophylaxis strategy is unknown. This study aimed to investigate safety and efficacy of periprocedural LMWH prophylaxis and determine optimal dosage and timing for periprocedural cessation and initiation.

Methods:
The present study is a retrospective, single-center observational analysis of 388 patients who underwent SVP (valve replacement or valvuloplasty) between 2015 and 2016. In-hospital endpoints were bleeding, transfusions, reoperation due to bleeding, and thromboembolic events. Results: Giving the first dose of LMWH on the day of SVP was a risk factor for bleeding (OR 1.07; 95% CI 1.04–1.10; p < 0.001), transfusions (OR 1.04; 95% CI 1.01–1.07; p = 0.008) and reoperation due to bleeding (OR 1.20; 95% CI 1.12–1.28; p < 0.001), with > 40 mg/day as a predictor. A higher dosage of LMWH premedication was an independent risk factor for bleeding (OR 1.02; 95% CI 1.00–1.04; p = 0.03) and transfusion (OR 1.03; 95% CI 1.01–1.05; p = 0.01), with > 60 mg/day as a predictor for these events. LMWH dosed within 24 h prior to SVP increased the risk of transfusion (AUC 0.636; 95% CI 0.496–0.762; p = 0.04).

Conclusions:
Bleeding is an important early concern after surgical valve procedures. Safety and efficacy of periprocedural prophylaxis with LMWH depends on dosage and the timing of its administration. The most optimal periprocedural prophylaxis in the SVP population appears to be LMWH in dosage of 40–60 mg/day, which is recommended for deep vein thrombosis prophylaxis, ceased at least one day before SVP

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Keywords

surgical valve procedure, bleeding complications, antithrombotic prophylaxis

Supplementary Files (2)
Supplementary Table 1. Procedure-related characteristics and in-hospital outcomes.
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Supplementary Table 2. Impact of clinical characteristics and type of procedures on study endpoints.
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About this article
Title

Low molecular weight heparin in surgical valve procedures: When and how much for an optimal prophylaxis?

Journal

Cardiology Journal

Issue

Vol 27, No 5 (2020)

Pages

548-557

Published online

2018-11-26

DOI

10.5603/CJ.a2018.0146

Pubmed

30484265

Bibliographic record

Cardiol J 2020;27(5):548-557.

Keywords

surgical valve procedure
bleeding complications
antithrombotic prophylaxis

Authors

Katarzyna Czerwińska-Jelonkiewicz
Marek Cisowski
Andrzej Bochenek
Piotr Buszman
Krzysztof Milewski
Piotr Kunik
Magdalena Mularska
Krzysztof Kocot
Piotr Politowski
Jakub Brączkowski
Agata Trznadel
Michael S. Aboodi
Paweł Buszman

References (30)
  1. Kulik A, Rubens FD, Wells PS, et al. Early postoperative anticoagulation after mechanical valve replacement: a systematic review. Ann Thorac Surg. 2006; 81(2): 770–781.
  2. Passaglia LG, de Barros GM, de Sousa MR. Early postoperative bridging anticoagulation after mechanical heart valve replacement: a systematic review and meta-analysis. J Thromb Haemost. 2015; 13(9): 1557–1567.
  3. Russo A, Grigioni F, Avierinos JF, et al. Thromboembolic complications after surgical correction of mitral regurgitation incidence, predictors, and clinical implications. J Am Coll Cardiol. 2008; 51(12): 1203–1211.
  4. Allou N, Piednoir P, Berroëta C, et al. Incidence and risk factors of early thromboembolic events after mechanical heart valve replacement in patients treated with intravenous unfractionated heparin. Heart. 2009; 95(20): 1694–1700.
  5. Laplace G, Lafitte S, Labèque JN, et al. Clinical significance of early thrombosis after prosthetic mitral valve replacement: a postoperative monocentric study of 680 patients. J Am Coll Cardiol. 2004; 43(7): 1283–1290.
  6. Mok CK, Boey J, Wang R, et al. Warfarin versus dipyridamole-aspirin and pentoxifylline-aspirin for the prevention of prosthetic heart valve thromboembolism: a prospective randomized clinical trial. Circulation. 1985; 72(5): 1059–1063.
  7. Cannegieter SC, Rosendaal FR, Briët E. Thromboembolic and bleeding complications in patients with mechanical heart valve prostheses. Circulation. 1994; 89(2): 635–641.
  8. Nishimura RA, Otto CM, Bonow RO, et al. 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. J Am Coll Cardiol. 2017; 70: 252–289.
  9. Guglielmetti LC, Sorabella R, Chiuzan C, et al. Bridging Anticoagulation After Mechanical Aortic Heart Valve Replacement: A Questionable Routine. Ann Thorac Surg. 2016; 102(1): 48–54.
  10. Kindo M, Gerelli S, Hoang Minh T, et al. Exclusive low-molecular-weight heparin as bridging anticoagulant after mechanical valve replacement. Ann Thorac Surg. 2014; 97(3): 789–795.
  11. Mathew JG, Spyropoulos AC, Yusuf A, et al. Efficacy and safety of early parenteral anticoagulation as a bridge to warfarin after mechanical valve replacement. Thromb Haemost. 2014; 112(6): 1120–1128.
  12. Douketis JD. Anticoagulation therapy: Perioperative anticoagulation-are we at 'a bridge too far'? Nat Rev Cardiol. 2015; 12(3): 133–134.
  13. Keenan JE, Wang H, Gulack BC, et al. Does moderate hypothermia really carry less bleeding risk than deep hypothermia for circulatory arrest? A propensity-matched comparison in hemiarch replacement. J Thorac Cardiovasc Surg. 2016; 152(6): 1559–1569.e2.
  14. Meesters MI, Veerhoek D, de Lange F, et al. Effect of high or low protamine dosing on postoperative bleeding following heparin anticoagulation in cardiac surgery. A randomised clinical trial. Thromb Haemost. 2016; 116(2): 251–261.
  15. Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012; 141(2 Suppl): e326S–e350S.
  16. Baumgartner H, Falk V, Bax JJ, et al. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. The Task Force for the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2017; 38: 2739–2786.
  17. Kristensen SD, Knuuti J, Saraste A, et al. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management: The Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur Heart J. 2014; 35(35): 2383–2431.
  18. Whitlock RP, Sun JC, Fremes SE, et al. 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.
  19. Dunning J, Versteegh M, Fabbri A, et al. Guideline on antiplatelet and anticoagulation management in cardiac surgery. Eur J Cardio-Thorac Surg. 2008; 34(1): 73–92.
  20. Akins C, Miller D, Turina M, et al. Guidelines for Reporting Mortality and Morbidity After Cardiac Valve Interventions. Ann Thorac Surg. 2008; 85(4): 1490–1495.
  21. Dyke C, Aronson S, Dietrich W, et al. Universal definition of perioperative bleeding in adult cardiac surgery. J Thorac Cardiovasc Surg. 2014; 147(5): 1458–1463.e1.
  22. van der Voort PH, Zandstra DF. Pathogenesis, risk factors, and incidence of upper gastrointestinal bleeding after cardiac surgery: is specific prophylaxis in routine bypass procedures needed? J Cardiothorac Vasc Anesth. 2000; 14(3): 293–299.
  23. Unsworth-White MJ, Herriot A, Valencia O, et al. Resternotomy for bleeding after cardiac operation: a marker for increased morbidity and mortality. Ann Thorac Surg. 1995; 59(3): 664–667.
  24. Meurin P, Weber H, Renaud N, et al. Evolution of the postoperative pericardial effusion after day 15: the problem of the late tamponade. Chest. 2004; 125(6): 2182–2187.
  25. Bucci C, Geerts WH, Sinclair A, et al. Comparison of the effectiveness and safety of low-molecular weight heparin versus unfractionated heparin anticoagulation after heart valve surgery. Am J Cardiol. 2011; 107(4): 591–594.
  26. Fanikos J, Tsilimingras K, Kucher N, et al. Comparison of efficacy, safety, and cost of low-molecular-weight heparin with continuous-infusion unfractionated heparin for initiation of anticoagulation after mechanical prosthetic valve implantation. Am J Cardiol. 2004; 93(2): 247–250.
  27. Rivas-Gándara N, Ferreira-González I, Tornos P, et al. Enoxaparin as bridging anticoagulant treatment in cardiac surgery. Heart. 2008; 94(2): 205–210.
  28. Ageno W, Turpie AG, Steidl L, et al. Comparison of a daily fixed 2.5-mg warfarin dose with a 5-mg, international normalized ratio adjusted, warfarin dose initially following heart valve replacement. Am J Cardiol. 2001; 88(1): 40–44.
  29. Iung B, Rodés-Cabau J. The optimal management of anti-thrombotic therapy after valve replacement: certainties and uncertainties. Eur Heart J. 2014; 35(42): 2942–2949.
  30. Falck-Ytter Y, Francis C, Johanson N, et al. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012; 141(2): 278–325.

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