Sutureless Aortic Valve Replacement: A First Year Experience

Abstract

reduction of cardiovascular death and prevention of thromboembolic complications shortand long-term (stroke, myocardial infarction, peripheral vascular thromboembolic events) maintaining low incidence of haemorrhagic complications. The main question is whether antiplatelet or antithrombotic therapy is more beneficial for the patients. A number of studies of variable quality and sample sizes were conducted in this field. Due to discrepancy in their conclusions there is a remarkable difference in recommendations of guidelines on the subject of thromboprophylaxis in patients after Bioprosthetic Aortic Valve Replacement (BAVR). Aim: The aim of this review is to provide the most up-todate analysis of published clinical data and reach a conclusion on the most beneficial modality of thromboprophylaxis for the patients post BAVR. Methods:All largest andmost important studies comparing antiplatelet and antithrombotic therapy after bioprosthetic AVR are analysed. This review includes three most recent large trials published in 2012: STS Adult Cardiac Surgery Database, Danish National Patient Registry and ACTION Registry trials. This paper covers the most upto-date review of published clinical data in parallel with the evolution of major North American and European guidelines on the subject of thromboprophylaxis following BAVR. Results: Two existing randomised trials were not powered to demonstrate significant difference in incidence of TE complications in post BAVR patients treated with Aspirin or Warfarin. However, Spanish TRAC trial demonstrated significantly higher incidence of bleeding complications in patients taking vitamin K antagonists (p = 0.048). Prospective trial data (three trials with n > 1600) show that Aspirin alone is as effective in prevention of TE events as Warfarin and there is a higher morbidity in patients on Warfarin. Almost all retrospective trials favour Aspirin-only thromboprophylaxis after BAVR except high risk group. Only the STS Adult Cardiac Surgery insurance claim-based study showed survival benefit in patients over 65 years of age who took Warfarin with Aspirin for the first three months postoperatively versus Aspirin only. Conclusion: There is no demonstrated advantage in early anticoagulation following Bioprosthetic AVR in patients without high risk for thromboembolism (atrial fibrillation, past history of thromboembolism, severe LVdysfunction and hypercoagulable conditions). Aspirin-only thromboprophylaxis is a recommended management modality following BAVR. There is a possibility of some advantage of early anticoagulation in patients over 65.