Circulation, Vol 89, 635-641, Copyright © 1994 by American Heart Association
SC Cannegieter, FR Rosendaal and E Briet
BACKGROUND: Patients with mechanical heart valve prostheses may experience
valve thrombosis and subsequent systemic embolism for which they are
treated with oral anticoagulant therapy. It is essential to know reliable
estimates of the risks and benefits of this therapy in order to answer a
number of clinical questions rationally. We sought to obtain more precise
estimates of the risks and benefits by combining the data from individual
studies by using meta-analysis. METHODS AND RESULTS: We searched for
studies in which the incidences were reported of embolic or bleeding
complications in patients with mechanical heart valve prostheses. They were
collected from the Medline and Current Contents database and by
cross-references between 1970 and 1992. Since most studies vary greatly in
many respects, we used a number of inclusion criteria, thus selecting
comparable studies of acceptable quality only. The influence of
antithrombotic therapy, valve position, and valve type was analyzed by
univariate and by multivariate analysis with Poisson regression techniques.
Forty-six studies were found, including 13,088 patients studied for 53,647
patient-years. We found an incidence of major embolism in the absence of
antithrombotic therapy of 4 per 100 patient-years. With antiplatelet
therapy this risk was 2.2 per 100 patient-years, and with coumarin therapy
it was reduced to 1 per 100 patient-years. This risk varied with the type
and the site of the prosthesis. A prosthesis in mitral position increased
the risk almost twice as compared with the aortic position. Tilting disc
valves and bileaflet valves showed a lower incidence of major embolism than
caged ball valves. An incidence of major bleeding was found in patients
treated with coumarin derivatives of 1.4 per 100 patient-years. The
incidence of bleeding became significantly higher with the addition of
antiplatelet therapy, although this did not decrease the risk of
thromboembolism any further. CONCLUSIONS: These data provide a reference
for future studies and give adequate risk estimates for clinical decision
making.
ARTICLES
Thromboembolic and bleeding complications in patients with mechanical heart valve prostheses
Department of Hematology, University Hospital Leiden, The Netherlands.
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M. Perleth and R. Busse Health technology assessment of oral anticoagulation following heart valve replacement Eur. Heart J. Suppl., December 1, 2001; 3(suppl_Q): Q60 - Q64. [Abstract] [PDF]
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J. M. G. Paez, A. Carrera, E. J. Herrero, I. Millan, A. Rocha, A. Cordon, N. Sainz, J. Mendez, and J. L. Castillo-Olivares Influence of the Selection of the Suture Material on the Mechanical Behavior of a Biomaterial to be Employed in the Construction of Implants. Part 1: Calf Pericardium J Biomater Appl, July 1, 2001; 16(1): 47 - 67. [Abstract] [PDF]
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J. M. G. Paez, A. Carrera, E. J. Herrero, I. Millan, A. Rocha, A. Cordon, N. Sainz, J. Mendez, and J. L. Castillo-Olivares Influence of the Selection of the Suture Material on the Mechanical Behavior of a Biomaterial to be Employed in the Construction of Implants. Part 2: Porcine Pericardium J Biomater Appl, July 1, 2001; 16(1): 68 - 90. [Abstract] [PDF]
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A. Notzold, M. Huppe, C. Schmidtke, P. Blomer, T. Uhlig, and H.-H. Sievers Quality of life in aortic valve replacement: pulmonary autografts versus mechanical prostheses J. Am. Coll. Cardiol., June 1, 2001; 37(7): 1963 - 1966. [Abstract] [Full Text] [PDF]
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F. P. Casselman, M. L. Bots, W. Van Lommel, P. J. Knaepen, R. Lensen, and F. E.E. Vermeulen Repeated thromboembolic and bleeding events after mechanical aortic valve replacement Ann. Thorac. Surg., April 1, 2001; 71(4): 1172 - 1180. [Abstract] [Full Text] [PDF]
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D. Massel and S. H. Little Risks and benefits of adding anti-platelet therapy to warfarin among patients with prosthetic heart valves: a meta-analysis J. Am. Coll. Cardiol., February 1, 2001; 37(2): 569 - 578. [Abstract] [Full Text] [PDF]
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K. Ananthasubramaniam, J. N. Beattie, H. S. Rosman, V. Jayam, and S. Borzak How Safely and for How Long Can Warfarin Therapy Be Withheld in Prosthetic Heart Valve Patients Hospitalized With a Major Hemorrhage? Chest, February 1, 2001; 119(2): 478 - 484. [Abstract] [Full Text] [PDF]
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 W. Hacke The Dilemma of Reinstituting Anticoagulation for Patients With Cardioembolic Sources and Intracranial Hemorrhage: How Wide Is the Strait Between Skylla and Karybdis? Arch Neurol, December 1, 2000; 57(12): 1682 - 1684. [Full Text] [PDF]
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C. Gohlke-Bärwolf VALVE DISEASE: Anticoagulation in valvar heart disease: new aspects and management during non-cardiac surgery Heart, November 1, 2000; 84(5): 567 - 572. [Full Text]
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A. Stahle Homograft--the optimal aortic valve substitute? Eur. Heart J., October 2, 2000; 21(20): 1644 - 1647. [PDF]
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J. M. Garcia Paez, A. Carrera, A. Cordon, E. Jorge-Herrero, A. Rocha, J. Salvador, J. Mendez, J. L. Castillo-Olivares, I. Millaan, and N. Sainz Uniaxial and Biaxial Tensile Strength of Calf Pericardium Used in the Construction of Bioprostheses: Biomaterial Selection Criteria J Biomater Appl, July 1, 2000; 15(1): 47 - 64. [Abstract] [PDF]
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R. Sodian, S. P. Hoerstrup, J. S. Sperling, S. H. Daebritz, D. P. Martin, F. J. Schoen, J. P. Vacanti, and J. E. Mayer Jr Tissue engineering of heart valves: in vitro experiences Ann. Thorac. Surg., July 1, 2000; 70(1): 140 - 144. [Abstract] [Full Text] [PDF]
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G. F. Michaud, F. Pelosi Jr., M. D. Noble, B. P. Knight, F. Morady, and S. A. Strickberger A randomized trial comparing heparin initiation 6 h or 24 h after pacemaker or defibrillator implantation J. Am. Coll. Cardiol., June 1, 2000; 35(7): 1915 - 1918. [Abstract] [Full Text] [PDF]
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O. Lund, S. L. Nielsen, H. Arildsen, L. B. Ilkjaer, and H. K. Pilegaard Standard aortic St. Jude valve at 18 years: performance profile and determinants of outcome Ann. Thorac. Surg., May 1, 2000; 69(5): 1459 - 1465. [Abstract] [Full Text] [PDF]
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P. Laffort, R. Roudaut, X. Roques, S. Lafitte, C. Deville, J. Bonnet, and E. Baudet Early and long-term (one-year) effects of the association of aspirin and oral anticoagulant on thrombi and morbidity after replacement of the mitral valve with the st. jude medical prosthesis: A clinical and transesophageal echocardiographic study J. Am. Coll. Cardiol., March 1, 2000; 35(3): 739 - 746. [Abstract] [Full Text] [PDF]
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J. L. Halperin, S. J. Fry, and S. L. Houser Case 37-1999 -- A 72-Year-Old Woman with a Prosthetic Aortic Valve and Intracranial Hemorrhage N. Engl. J. Med., December 9, 1999; 341(24): 1829 - 1835. [Full Text] [PDF]
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J. D. Douketis, M. A. Crowther, S. S. Cherian, and C. B. Kearon Physician Preferences for Perioperative Anticoagulation in Patients With a Mechanical Heart Valve Who Are Undergoing Elective Noncardiac Surgery Chest, November 1, 1999; 116(5): 1240 - 1246. [Abstract] [Full Text] [PDF]
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O. Lund, H. K. Pilegaard, L. B. Ilkjaer, S. L. Nielsen, and H. Arildsen Performance profile of the Starr-Edwards aortic cloth covered valve, track valve, and silastic ball valve Eur. J. Cardiothorac. Surg., October 1, 1999; 16(4): 403 - 413. [Abstract] [Full Text] [PDF]
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S. Torregrosa, J. Gomez-Plana, F. J. Valera, J. Caffarena, J. M. Maronas, F. Garcia-Sanchez, J. Peris, R. Frias, and J. M. Caffarena Long-term clinical experience with the omnicarbon prosthetic valve Ann. Thorac. Surg., September 1, 1999; 68(3): 881 - 886. [Abstract] [Full Text] [PDF]
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A. Bader, T. Schilling, O. E. Teebken, G. Brandes, T. Herden, G. Steinhoff, and A. Haverich Tissue engineering of heart valves - human endothelial cell seeding of detergent acellularized porcine valves Eur. J. Cardiothorac. Surg., September 1, 1999; 14(3): 279 - 284. [Abstract] [Full Text] [PDF]
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R. A. North, L. Sadler, A. W. Stewart, L. M.E. McCowan, A. R. Kerr, and H. D. White Long-Term Survival and Valve-Related Complications in Young Women With Cardiac Valve Replacements Circulation, May 25, 1999; 99(20): 2669 - 2676. [Abstract] [Full Text] [PDF]
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J. M. G. Paez and E. Jorge-Herrero Assessment of Pericardium in Cardiac Bioprostheses: A Review J Biomater Appl, April 1, 1999; 13(4): 351 - 388. [Abstract] [PDF]
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J. Barbetseas, S. F. Nagueh, C. Pitsavos, P. K. Toutouzas, M. A. Quinones, and W. A. Zoghbi Differentiating thrombus from pannus formation in obstructed mechanical prosthetic valves: an evaluation of clinical, transthoracic and transesophageal echocardiographic parameters J. Am. Coll. Cardiol., November 1, 1998; 32(5): 1410 - 1417. [Abstract] [Full Text] [PDF]
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S. P. Hoerstrup, G. Zund, A. Schoeberlein, Q. Ye, P. R. Vogt, and M. I. Turina Fluorescence activated cell sorting: A reliable method in tissue engineering of a bioprosthetic heart valve Ann. Thorac. Surg., November 1, 1998; 66(5): 1653 - 1657. [Abstract] [Full Text] [PDF]
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B. K. Podesser, G. Khuenl-Brady, E. Eigenbauer, S. Roedler, A. Schmiedberger, E. Wolner, and A. Moritz Long-term results of heart valve replacement with the Edwards Duromedics bileaflet prosthesis: A prospective ten-year clinical follow-up J. Thorac. Cardiovasc. Surg., May 1, 1998; 115(5): 1121 - 1129. [Abstract] [Full Text] [PDF]
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J.-H. Jansson, K. Boman, M. Brannstrom, and T. K. Nilsson High Concentration of Thrombomodulin in Plasma Is Associated With Hemorrhage : A Prospective Study in Patients Receiving Long-term Anticoagulant Treatment Circulation, November 4, 1997; 96(9): 2938 - 2943. [Abstract] [Full Text]
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C. Kearon and J. Hirsh Management of Anticoagulation before and after Elective Surgery N. Engl. J. Med., May 22, 1997; 336(21): 1506 - 1511. [Full Text] [PDF]
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S. S. Meschengieser, C. G. Fondevila, J. Frontroth, M. T. Santarelli, and M. A. Lazzari LOW-INTENSITY ORAL ANTICOAGULATION PLUS LOW-DOSE ASPIRIN VERSUS HIGH-INTENSITY ORAL ANTICOAGULATION ALONE: A RANDOMIZED TRIAL IN PATIENTS WITH MECHANICAL PROSTHETIC HEART VALVES J. Thorac. Cardiovasc. Surg., May 1, 1997; 113(5): 910 - 916. [Abstract] [Full Text]
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