Curriculum in CardiologyThe clinical challenge of bridging anticoagulation with low-molecular-weight heparin in patients with mechanical prosthetic heart valves: An evidence-based comparative review focusing on anticoagulation options in pregnant and nonpregnant patients
Section snippets
Background and overview
Identifying safe, evidence-based, and outcome-effective approaches to managing patients who are at risk of developing arterial thromboembolism represents a formidable clinical challenge. It is likely that in no patient subgroup are the therapeutic challenges associated with anticoagulation more complex or problematic than in individuals with mechanical prosthetic heart valves (MPHVS). Low–molecular-weight heparins (LMWHs) and unfractionated heparin (UFH) have been used in these clinical
Methods
A Medline search was conducted of articles appearing in the medical literature published in English between 1992 and 2004. The search was conducted using the keywords, “bridging/heparin/prosthetic valves,” “bridging/LMWH/prosthetic valves,” “thromboembolism/prosthetic valves,” “thromboembolism/pregnancy/prosthetic valves,” “heparin/LMWH/bridging,” “bridging/prosthetic valve/guidelines,” and “thromboembolism/valves/pregnancy/warfarin.” Approximately 120 clinical trials, case reports, editorials,
Recommendations for use of LMWH in patients with mechanical prostheses
Based on currently available evidence, what recommendations can be made on the use of LMWH in patients with MPHVs? Clearly, there is a need for a definitive, large-scale, randomized, controlled trial of LMWH versus UFH to settle this issue. However, within the constraints of the available data, one approach would be to risk-stratify patients into low-risk and high-risk groups and tailor the anticoagulation regimen appropriately. Risk stratification would depend on the indications for
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Cited by (64)
Mechanical Mitral Valve Thrombosis Secondary to Tinzaparin as an Anticoagulation Bridging Strategy
2018, Annals of Thoracic SurgeryCitation Excerpt :The use of LMWH as bridge therapy for MHV patients during times of temporary warfarin interruption is endorsed by both the American Heart Association/American College of Cardiology (AHA/ACC) and European Society of Cardiology (ESC) [4, 5]. There are no comparative data between different LMWHs and dose regimens, but most of the evidence supporting their use involves twice daily regimens [6, 7]. Accordingly, twice daily dosing is recommended by the ESC for all MHV patients and for patients at highest thrombotic risk (mitral MHV or aortic MHV with other thrombotic risk factors) by the AHA/ACC [3].
Anticoagulation for Atrial Fibrillation and Prosthetic Cardiac Valves
2013, Consultative Hemostasis and Thrombosis: Third EditionChronic oral anticoagulant therapy in carotid artery stenting: The un-necessity of perioperative bridging heparin therapy
2012, Thrombosis ResearchCitation Excerpt :This gives an overall complication risk of more than 4%, which compares unfavorably with the data of unstopped OAT shown above. Some authors reported the safety of a temporary OAT interruption during less invasive procedures [25] to reduce hemorrhagic risk and maintain the anticoagulant effect, however the temporary OAT interruption with sub-therapeutic anticoagulation effect is associated with the potential increase of thrombo-embolic events [26]. The present study had an important limitation since it is a retrospective nonrandomized case cohort study, without a comparative group of patients medicated with bridging heparin therapy.
Management of antithrombotic agents for endoscopic procedures
2009, Gastrointestinal EndoscopyManagement of pregnant women with cardiac diseases at potential risk of thromboembolism - Experience and review
2009, International Journal of CardiologyCitation Excerpt :In addition, neurologic damage due to hemorrhage may occur in utero [12]. Nevertheless, the incidence of valvular thrombosis or maternal mortality remains high despite the use of UFH [13] or LMWH in cases with mechanical heart valve [5]. For thromboembolic prophylaxis, warfarin is more effective than UFH because of its longer half-life and stable serum level.