Perioperative Anticoagulation in Patients With a Mechanical Heart Valve Who Are Undergoing Elective Noncardiac Surgery: Discussion

In: Mechanical Heart

22 Sep 2014

Perioperative Anticoagulation in Patients With a Mechanical Heart Valve Who Are Undergoing Elective Noncardiac Surgery: DiscussionFurthermore, most patients in these studies had first-generation caged-ball heart valves, which are more thrombogenic than newer bileaflet tilting-disk models. In two methodologically rigorous studies that provided quantitative estimates of the risks of TE and bleeding for patients with a mechanical heart valve who require elective surgery, the investigators questioned the use of perioperative IV heparin, except in patients at highest risk for TE (ie, previous TE, caged-ball heart valve). One of these studies concluded that in the absence of an embolic event within the previous month, the use of IV heparin was expected to markedly increase morbidity related to postoperative bleeding. Thus, although IV heparin was preferred by most respondents in this survey, the evidence to support this anticoagulation strategy is questionable. Here

Another noteworthy finding is that despite convincing evidence that subcutaneous heparin or LMWH is as effective as IV heparin for the treatment of venous TE and acute coronary syn-dromes, this anticoagulation strategy, which does not require hospitalization, was selected by only 5.3 to 23% of respondents. Thus, demonstration that outpatient perioperative anticoagulation therapy with subcutaneous heparin or LMWH is effective and safe could have a major impact on clinical practice. Further, this management approach is likely to be more cost-effective compared with the use of in-hospital IV heparin. A less aggressive anticoagulant management (ie, options ā€œcā€ or ā€œdā€), which has been advocated by some authors, was preferred in the preoperative or postoperative setting by only 3.2 to 9.4% of respondents in high-risk TE scenarios, and by 11 to 36% of respondents in low-risk TE scenarios. It is likely that before a less aggressive anticoagulant management is adopted for wider use, the effectiveness of this approach will require validation in prospective clinical trials.

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