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Commentary: Bridging anticoagulation for mechanical heart valves: Haven't we crossed this bridge before?

  • John Bozinovski
    Correspondence
    Address for reprints: John Bozinovski, MD, MSc, 106-2020 Richmond Rd, Victoria, British Columbia V8R-6R5, Canada.
    Affiliations
    Division of Cardiac Surgery, University of British Columbia and the Royal Jubilee Hospital, Victoria, British Columbia, Canada
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Open ArchivePublished:August 03, 2018DOI:https://doi.org/10.1016/j.jtcvs.2018.07.067
      The evidence for current practice regarding bridging anticoagulation of mechanical heart valves is weak but sensible.
      See Article page 200.
      In this issue of the Journal, Tan and colleagues
      • Tan C.W.
      • Wall M.
      • Rosengart T.K.
      • Ghanta R.K.
      How to bridge? Management of anticoagulation in patients with mechanical heart valves undergoing noncardiac surgical procedures.
      provide an opinion regarding anticoagulation bridging in patients with mechanical heart valves undergoing noncardiac surgical procedures. They outline the problem that operating on anticoagulated patients exposes them to risk of bleeding in excess of the risk posed were they not anticoagulated. Withholding anticoagulation to mitigate that risk, however, exposes patients to the risk of complications from thromboembolism.
      Anticoagulation aside, surgical procedures and coexisting patient characteristics carry different risks of bleeding. Recommendations by Tan and colleagues
      • Tan C.W.
      • Wall M.
      • Rosengart T.K.
      • Ghanta R.K.
      How to bridge? Management of anticoagulation in patients with mechanical heart valves undergoing noncardiac surgical procedures.
      take these varying risks into account by stratifying patients into low and high bleeding risk according to whether the surgery is a minor procedure or whether they have a low BleedMAP score. BleedMAP scores range from 0 to 4, with a point for each of the following: a history of previous bleeding, mechanical mitral valve, active cancer, and thrombocytopenia. BleedMAP was developed in a different study that assessed patients who required anticoagulation for various indications.
      • Tarfur A.J.
      • Mcbane II, R.
      • Wysokinski W.E.
      • Litin S.
      • Daniels P.
      • Slusser J.
      • et al.
      Predictors of major bleeding in peri-procedural anticoagulation management.
      Approximately a quarter of those indications were for mechanical prostheses. The value of using BleedMAP to stratify patients is thus limited but not wholly inapplicable.
      In 2014, the American College of Cardiology (ACC) and the American Heart Association (AHA) published guidelines for the management of patients with valvular heart disease, and within it are contained recommendations for bridging therapy for patients with mechanical heart valves undergoing noncardiac surgery.
      • Nishimura R.A.
      • Otto C.M.
      • Bonow R.O.
      • Carabello B.A.
      • Erwin III, J.P.
      • Guyton R.A.
      • et al.
      American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 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 practice guidelines.
      In 2017, these guidelines were updated.
      • Nishimura R.A.
      • Otto C.M.
      • Bonow R.O.
      • Carabello B.A.
      • Erwin III, J.P.
      • Fleisher L.A.
      • 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.
      The recommendations by Tan and colleagues
      • Tan C.W.
      • Wall M.
      • Rosengart T.K.
      • Ghanta R.K.
      How to bridge? Management of anticoagulation in patients with mechanical heart valves undergoing noncardiac surgical procedures.
      do not differ in any significant way from the ACC and AHA guidelines, with some exceptions. In patients at moderate to high risk (those with a mechanical mitral valve or those with a mechanical aortic valve and an additional risk factor, such as atrial fibrillation, previous thromboembolism, ejection fraction less than 35%, or a hypercoagulable state) undergoing major procedures, Tan and colleagues
      • Tan C.W.
      • Wall M.
      • Rosengart T.K.
      • Ghanta R.K.
      How to bridge? Management of anticoagulation in patients with mechanical heart valves undergoing noncardiac surgical procedures.
      recommend resuming anticoagulation 12 to 24 hours postoperatively and beginning bridging therapy on postoperative day 2, with the latter to continue until the lower range of therapeutic international normalized ratio is achieved for at least 24 hours. In comparison, the ACC and AHA guidelines recommend resuming anticoagulation 12 to 24 hours postoperatively but individually timing postoperative bridging according to risks of bleeding and thromboembolism. Tan and colleagues
      • Tan C.W.
      • Wall M.
      • Rosengart T.K.
      • Ghanta R.K.
      How to bridge? Management of anticoagulation in patients with mechanical heart valves undergoing noncardiac surgical procedures.
      provided no new evidence to support varying from the ACC and AHA guidelines. The ACC and AHA guidelines provide a more individualized approach than that suggested in the article by Tan and colleagues.
      • Tan C.W.
      • Wall M.
      • Rosengart T.K.
      • Ghanta R.K.
      How to bridge? Management of anticoagulation in patients with mechanical heart valves undergoing noncardiac surgical procedures.
      Otherwise, the recommendations are identical.
      The updated ACC and AHA guideline stating that bridging should be used for high-risk patients is class IIa (conflicting evidence or divergence of opinion regarding usefulness), however, and is not based on high level of evidence (level C). The supporting evidence for the recommendation included 2 other societal guideline publications,
      • Douketis J.D.
      • Spyropoulos A.C.
      • Spencer F.A.
      • Mayr M.
      • Jaffer A.K.
      • Eckman M.H.
      • et al.
      Perioperative management of antithrombotic therapy: antithrombotic therapy and prevention of thrombosis, 9th ed: College of Chest Physicians evidence-based clinical practice guidelines.
      • Poldermans D.
      • Bax J.J.
      • Boersma E.
      • De Hert S.
      • Eeckhout E.
      • Gowkes G.
      • et al.
      Task Force for Perioperative Cardiac Risk Assessment And Perioperative Cardiac Management In Non-cardiac Surgery of the European Society of Cardiology (ESC) and endorsed by the European Society of Anesthesiology (ESA)
      Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery.
      a randomized study of bridging in atrial fibrillation,
      • Douketis J.D.
      • Spyropoulos A.C.
      • Kaatz A.
      • Becker R.C.
      • Caprini J.A.
      • Dunn A.S.
      • et al.
      BRIDGE Investigators
      Perioperative bridging anticoagulation in patients with atrial fibrillation.
      and a nonrandomized cohort study of bridging with various indications for anticoagulation.
      • Pengo V.
      • Cucchini U.
      • Denas G.
      • Erba N.
      • Guazzaloca G.
      • La Rosa L.
      • et al.
      Italian Federation of Centers for the Diagnosis of Thrombosis and Management of Antithrombotic Therapies (FCSA). Standardized low-molecular-weight heparin bridging regimen in outpatients on oral anticoagulants undergoing invasive procedure or surgery: an inception cohort management study.
      In the latter, overall thromboembolism incidence was 0.4% with bridging, but it was 1.7% in high-risk patients and 0% in low risk patients. Major bleeding occurred in 1.2% of patients overall. That study had no comparison group of nonbridged patients, which could have provided an estimate for bleeding hazard or thromboembolism protection afforded by bridging. Further, only 190 patients (15%) had a mechanical valve as the indication for anticoagulation, again limiting the value of this study for a recommendation in that population.

      References

        • Tan C.W.
        • Wall M.
        • Rosengart T.K.
        • Ghanta R.K.
        How to bridge? Management of anticoagulation in patients with mechanical heart valves undergoing noncardiac surgical procedures.
        J Thorac Cardiovasc Surg. 2019; 158: 200-203
        • Tarfur A.J.
        • Mcbane II, R.
        • Wysokinski W.E.
        • Litin S.
        • Daniels P.
        • Slusser J.
        • et al.
        Predictors of major bleeding in peri-procedural anticoagulation management.
        J Thromb Haemost. 2012; 10: 261-267
        • Nishimura R.A.
        • Otto C.M.
        • Bonow R.O.
        • Carabello B.A.
        • Erwin III, J.P.
        • Guyton R.A.
        • et al.
        American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 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 practice guidelines.
        J Am Coll Cardiol. 2014; 63 (Erratum in: J Am Coll Cardiol. 2014;63:2489): e57-e185
        • Nishimura R.A.
        • Otto C.M.
        • Bonow R.O.
        • Carabello B.A.
        • Erwin III, J.P.
        • Fleisher L.A.
        • 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
        • Douketis J.D.
        • Spyropoulos A.C.
        • Spencer F.A.
        • Mayr M.
        • Jaffer A.K.
        • Eckman M.H.
        • et al.
        Perioperative management of antithrombotic therapy: antithrombotic therapy and prevention of thrombosis, 9th ed: College of Chest Physicians evidence-based clinical practice guidelines.
        Chest. 2012; 141: e326S-e350S
        • Poldermans D.
        • Bax J.J.
        • Boersma E.
        • De Hert S.
        • Eeckhout E.
        • Gowkes G.
        • et al.
        • Task Force for Perioperative Cardiac Risk Assessment And Perioperative Cardiac Management In Non-cardiac Surgery of the European Society of Cardiology (ESC) and endorsed by the European Society of Anesthesiology (ESA)
        Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery.
        Eur Heart J. 2009; 30: 2769-2812
        • Douketis J.D.
        • Spyropoulos A.C.
        • Kaatz A.
        • Becker R.C.
        • Caprini J.A.
        • Dunn A.S.
        • et al.
        • BRIDGE Investigators
        Perioperative bridging anticoagulation in patients with atrial fibrillation.
        N Engl J Med. 2015; 373: 823-833
        • Pengo V.
        • Cucchini U.
        • Denas G.
        • Erba N.
        • Guazzaloca G.
        • La Rosa L.
        • et al.
        Italian Federation of Centers for the Diagnosis of Thrombosis and Management of Antithrombotic Therapies (FCSA). Standardized low-molecular-weight heparin bridging regimen in outpatients on oral anticoagulants undergoing invasive procedure or surgery: an inception cohort management study.
        Circulation. 2009; 119: 2920-2927

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