Prophylactic anticoagulation for the prevention of bioprosthetic valve thrombosis: to be or not to be?

We congratulate Fernandez et al. [1] for their recent article titled ‘Early Anticoagulation After Aortic Valve Replacement with Porcine Bioprosthesis Randomized Control Trial (ANTIPRO)’ published in the European Journal of Cardiothoracic Surgery. The study was a randomized open-label clinical trial comparing the effect of 3-month therapy with vitamin K antagonist (VKA) plus aspirin versus aspirin alone for the prevention of bioprosthetic valve thrombosis (BPVT) after surgical aortic valve replacement (AVR) using porcine bioprostheses. The study design, statistical methods and data interpretation were rigorous and appropriate. Furthermore, the target international normalized ratio of 2.5, the time spent in therapeutic range and the dose of aspirin (100 mg daily) used in the study were reflective of the treatment regimen currently used in clinical practice, thereby improving generalizability of the results. The study showed no difference in bioprosthetic valve haemodynamics, functional status and the incidence of thromboembolic and bleeding complication between the 2 groups. In this editorial, we will address the following issues: (i) BPVT diagnosis and treatment; (ii) BPVT prophylaxis; and (iii) clinical implications and knowledge gaps in the management of BPVT.