Abstract
Due to their durability, mechanical prostheses are frequently used for aortic valve replacement (AVR) in young adults. However, these valves are thrombogenic and require lifelong anticoagulation. Over the last few decades, efforts have been made towards the lowering of INR targets in an effort to reduce bleeding events without influencing the thromboembolic risk. The Prospective Randomized On-X Valve Anticoagulation Clinical Trial (PROACT) was designed to compare standard versus low anticoagulation targets in high-risk patients undergoing mechanical AVR with the ON-X prosthesis.
Highlights
The ideal aortic valve substitute for young adults remains elusive
Improvements in mechanical prosthesis engineering have led to a substantial reduction in the thrombogenicity of these devices and subsequently a decrease in the incidence of valverelated complications[7]
The investigators concluded that, with the On-X prosthesis, a target INR between 1.5 and 2 translates into a lower incidence of bleeding events without a significant increase in TE events. This is consistent with recently published studies demonstrating the safety of a lower anticoagulation regimen in patients with mechanical AVR9–11
Summary
While bioprostheses avoid long-term anticoagulation, durability is a major concern in young adults because of early structural valve degeneration[1,2]. Mechanical prostheses are more frequently used in young adults These valves are thrombogenic, requiring lifelong anticoagulation which is mostly responsible for valve-related morbidity and mortality following mechanical AVR2–4. This partially explains the increased observed mortality in young adults undergoing mechanical AVR in comparison with an age- and gender-matched general population[2]. The Prospective Randomized On-X Valve Anticoagulation Clinical Trial (PROACT) aimed to evaluate the safety of lower anticoagulation (target INR 1.5–2.0) after implantation of the ON-X prosthesis (Figure 1) in patients at high risk of thromboembolic events[8].
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