Key result
Warfarin for suspected bioprosthetic valve thrombosis shows no benefit but is linked to higher major bleeding.
Why the study?
Anticoagulation is effective early in the prevention and treatment of bioprosthetic valve thrombosis, but long-term outcomes after bioprosthetic valve thrombosis remain unknown.
Does warfarin anticoagulation improve long-term outcomes in patients with bioprosthetic valve thrombosis compared to matched controls?
Cohort (n=249)
No
Does warfarin anticoagulation improve long-term outcomes in patients with bioprosthetic valve thrombosis compared to matched controls?
Answers are grounded in this paper and cite their sources.
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“What was quite surprising to all of us was that in the patients who had an episode of thrombosis even if you treat them well—the ones that had success with warfarin—their bioprosthesis fails earlier than controls. So, it means that something is permanently damaged, at least in a number of these patients.”
“Every center should develop a practicable algorithm with different imaging modalities and specialists to ensure the correct diagnosis of BPVT. If a patient is put under warfarin for BPVT, close monitoring might be essential to ensure the optimal therapeutic range, which seems to be the key for an effective therapy.”
Although warfarin effectively treats early bioprosthetic valve thrombosis, these patients face high long-term risks of recurrent thrombosis, major bleeding, and early prosthetic degeneration requiring re-replacement.
BACKGROUND Early in the prevention and treatment of bioprosthetic valve thrombosis (BPVT), anticoagulation is effective, but the long-term outcome after BPVT is unknown. OBJECTIVES The goal of this study was to assess the long-term outcomes of patients with BPVT treated with anticoagulation. METHODS This analysis was a matched cohort study of patients treated with warfarin for suspected BPVT at the Mayo Clinic between 1999 and 2017. RESULTS A total of 83 patients treated with warfarin for suspected BPVT (age 57 ± 18 years; 45 men [54%]) were matched to 166 control subjects; matching was performed according to age, sex, year of implantation, and prosthesis type and position. Echocardiography normalized in 62 patients (75%) within 3 months (interquartile range [IQR]: 1.5 to 6 months) of anticoagulation; 21 patients (25%) did not respond to warfarin. Median follow-up after diagnosis was 34 months (IQR: 17 to 54 months). There was no difference in the primary composite endpoint between the patients with BPVT and the matched control subjects (log-rank test, p = 0.79), but the former did have a significantly higher rate of major bleeding (12% vs. 2%; p < 0.0001). BPVT recurred (re-BPVT) in 14 (23%) responders after a median of 23 months (IQR: 11 to 39 months); all but one re-BPVT patient responded to anticoagulant therapy. Patients with BPVT had a higher probability of valve re-replacement (68% vs. 24% at 10 years' post-BPVT; log-rank test, p < 0.001). CONCLUSIONS BPVT was associated with re-BPVT and early prosthetic degeneration in a significant number of patients. Indefinite warfarin anticoagulation should be considered after a confirmed BPVT episode, but this strategy must be balanced against an increased risk of bleeding.
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Petrescu et al. (2020) conducted a cohort in Bioprosthetic valve thrombosis (BPVT) (n=249). Suspected BPVT treated with warfarin vs. Matched control subjects was evaluated on Primary composite endpoint (p=0.79). Patients with suspected bioprosthetic valve thrombosis treated with warfarin had similar primary composite outcomes to matched controls (P=0.79) but higher rates of major bleeding (12% vs 2%).
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