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Antiplatelet versus oral anticoagulant therapy as antithrombotic prophylaxis after mitral valve repair

Selected in The Journal of Thoracic and Cardiovascular Surgery by S. Head

References

Authors

Paparella D, Di Mauro M, Bitton Worms K, Bolotin G, Russo C, Trunfio S, Scrofani R, Antona C, Actis Dato G, Casabona R, Colli A, Gerosa G, Renzulli A, Serraino F, Scrascia G, Zaccaria S, De Bonis M, Taramasso M, Delgado L, Tritto F, Marmo J, Parolari A, Myaseodova V, Villa E, Troise G, Nicolini F, Gherli T, Whitlock R, Conte M, Barili F, Gelsomino S, Lorusso R, Sciatti E, Marinelli D, Di Giammarco G, Calafiore AM, Sheikh A, Alfonso JJ, Glauber M, Miceli A; GIROC Investigators.

Reference

J Thorac Cardiovasc Surg. 2016 May;151(5):1302-1308.e1

Published

May 2016

Link

Read the abstract

My Comment

Background

Theoretically there is an increased risk of thromboembolism within the first postoperative months after mitral valve repair due to implantation of a ring, surgical knots and other features. Therefore, it is recommended to use antithrombotic therapy. However, it remains unclear whether antiplatelet or anticoagulation therapy should ne initiated.

Results

  • Retrospective study from 19 centers
  • Patient inclusion was through 2011-2013, during which 1882 patients were included; oral anticoagulant therapy was given in 1517 patients for the first 3 months and antiplatelet therapy with 100mg aspirin in 365 patients
  • Sole basis for antithrombotic therapy was mitral valve repair, with exclusion of patients with atrial fibrillation or any concomitant surgery
  • Choice of antithrombotic prophylaxis was based on center and/or surgeon preference
  • Propensity-matching took place in a 3:1 sample, matching 858 and 286 patients receiving anticoagulation and antiplatelet therapy, respectively
  • Over 6-month follow-up, thromboembolic complications were comparable between patients receiving antiplatelet or anticoagulation therapy (2.1 vs 1.6%, respectively; p=0.50), while major bleeding was significantly higher with anticoagulation therapy (0.7 vs 3.9%, respectively; p=0.01)
  • Mortality at 6 months was 0.3% for patients receiving antiplatelet therapy and 2.7% for those receiving anticoagulation therapy (p=0.02), mainly due to death in patients who had a major bleeding
  • In a multivariate model, anticoagulation therapy was an independent predictor of major bleeding (OR 5.2, 95% CI 1.2-15.7) as well as 6-month mortality (OR 11.1, 95% CI 1.4-25.2)

My comments

This is a well-performed study that sheds important light on the issue of antithrombotic therapy early after mitral valve repair. There is a great variability in the use of oral anticoagulants after mitral valve repair, which likely reflects surgeon preferences and is less well based on evidence. The fact that there is only a class C level of evidence supporting guideline recommendations points to the fact that large studies are needed. The current study provides strong data in favour of antiplatelet instead of anticoagulation therapy. However, despite the propensity-matching, this was an observational study and data from a randomized controlled trial will still be required to determine which antithrombotic strategy should be preferred.

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