Skip to main content

Antithrombotic Therapy in Valvular Heart Disease

  • Chapter
  • First Online:
  • 894 Accesses

Abstract

Patients with valvular heart disease (VHD) are at increased risk for thrombo-emboligenic events and often require antithrombotic therapy. This needs to be clearly weighted against the bleeding risk as this is often also increased. This chapter will provide an overview of current evidence available in patients with VHD. We will discuss general indications of antithrombotic therapy, its duration, dose, bridging during procedures and treatment options during pregnancy.

This is a preview of subscription content, log in via an institution.

Buying options

Chapter
USD   29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD   79.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD   99.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD   139.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Learn about institutional subscriptions

References

  1. Baumgartner H, Falk V, Bax JJ, et al. 2017 ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J. 2017;38:2739–91.

    Article  PubMed  Google Scholar 

  2. Nishimura RA, Vahanian A, Eleid MF, et al. Mitral valve disease—current management and future challenges. Lancet. 2016;387(10025):1324–34.

    Article  PubMed  Google Scholar 

  3. Lavall D, Hagendorff A, Schirmer SH, et al. Mitral valve interventions in heart failure. ESC Heart Fail. 2018;5(4):552–61.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Heidbuchel H, Verhamme P, Alings M, et al. Updated European Heart Rhythm Association practical guide on the use of non-vitamin-K antagonist anticoagulants in patients with non-valvular atrial fibrillation: executive summary. Eur Heart J. 2017;38(27):2137–49.

    CAS  PubMed  Google Scholar 

  5. Lip GYH, Jensen M, Melgaard L, et al. Stroke and bleeding risk scores in patients with atrial fibrillation and valvular heart disease: evaluating ‘valvular heart disease’ in a nationwide cohort study. Europace. 2019;21(1):33–40.

    Article  PubMed  Google Scholar 

  6. Whitlock RP, Sun JC, Fremes SE, Rubens FD, Teoh KH. Antithrombotic and thrombolytic therapy for valvular disease. Chest. 2012;141:e576S–600S.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  7. Shaw TR, Northridge DB, Sutaria N. Mitral balloon valvotomy and left atrial thrombus. Heart. 2005;91(8):1088–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. Drobinski G, Montalescot G, Evans J, et al. Systemic embolism as a complication of percutaneous mitral valvuloplasty. Cathet Cardiovasc Diagn. 1992;25(4):327–30.

    Article  CAS  PubMed  Google Scholar 

  9. Kang DH, Song JK, Chae JK, et al. Comparison of outcomes of percutaneous mitral valvuloplasty versus mitral valve replacement after resolution of left atrial appendage thrombi by warfarin therapy. Am J Cardiol. 1998;81(1):97–100.

    Article  CAS  PubMed  Google Scholar 

  10. Delling FN, Vasan RS. Epidemiology and pathophysiology of mitral valve prolapse: new insights into disease progression, genetics, and molecular basis. Circulation. 2014;129(21):2158–70.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Grigioni F, Tribouilloy C, Avierinos JF, et al. Outcomes in mitral regurgitation due to flail leaflets a multicenter European study. JACC Cardiovasc Imaging. 2008;1:133–41.

    Article  PubMed  Google Scholar 

  12. Barnett HJ, Boughner DR, Taylor DW, et al. Further evidence relating mitral-valve prolapse to cerebral ischemic events. N Engl J Med. 1980;302:139–44.

    Article  CAS  PubMed  Google Scholar 

  13. Gilon D, Buonanno FS, Joffe MM, et al. Lack of evidence of an association between mitral-valve prolapse and stroke in young patients. N Engl J Med. 1999;341:8–13.

    Article  CAS  PubMed  Google Scholar 

  14. Leitman M, Tyomkin V, Peleg E, et al. Clinical significance and prevalence of valvular strands during routine echo examinations. Eur Heart J Cardiovasc Imaging. 2014;15(11):1226–30.

    Article  PubMed  Google Scholar 

  15. Roldan CA, Shively BK, Crawford MH. Valve excrescences: prevalence, evolution and risk for cardioembolism. J Am Coll Cardiol. 1997;30(5):1308–14.

    Article  CAS  PubMed  Google Scholar 

  16. Freedberg RS, Goodkin GM, Perez JL, et al. Valve strands are strongly associated with systemic embolization: a transesophageal echocardiographic study. J Am Coll Cardiol. 1995;26(7):1709–12.

    Article  CAS  PubMed  Google Scholar 

  17. Cevik C, Otahbachi M, Nugent K, et al. Mitral regurgitation reduces systemic coagulation activity in patients with rheumatic heart disease. J Heart Valve Dis. 2009;18(3):278–83.

    PubMed  Google Scholar 

  18. Asgar AW, Mack MJ, Stone GW, et al. Secondary mitral regurgitation in heart failure: pathophysiology, prognosis, and therapeutic considerations. J Am Coll Cardiol. 2015;65(12):1231–48.

    Article  PubMed  Google Scholar 

  19. Abramowitz Y, Jilaihawi H, Chakravarty T, et al. Mitral annulus calcification. J Am Coll Cardiol. 2015;66(17):1934–41.

    Article  PubMed  Google Scholar 

  20. Benjamin EJ, Plehn JF, D’Agostino RB, et al. Mitral annular calcification and the risk of stroke in an elderly cohort. N Engl J Med. 1992;327:374–9.

    Article  CAS  PubMed  Google Scholar 

  21. Eischer JC, Soto FX, DeNaidai L, et al. Possible association of thrombotic, nonbacterial vegetations of the mitral ring: mitral annular calcium and stroke. Am J Cardiol. 1997;79:1712–5.

    Article  Google Scholar 

  22. Mohan JC, Shukla M, Mohan V, et al. Mobile thrombus originating from densely calcified mitral annulus with cerebral embolism. Indian Heart J. 2016;68(Suppl 2):S131–4.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Roberts WC. Valvular, subvalvular and supravalvular aortic stenosis. Morphologic features. Cardiovasc Clin. 1993;5(1):97.

    Google Scholar 

  24. Kawahira Y, Kishimoto H, Lio M. Spontaneous aortic thrombosis in a neonate with multiple thrombi in the main branches of the abdominal aorta. Cardiovasc Surg. 1995;3(2):219–21.

    Article  CAS  PubMed  Google Scholar 

  25. Méndez RJ, Cianciulli TF, Parisi CE, et al. Recurrent systemic embolism caused by thrombosis in a stenotic bicuspid aortic valve. Eur J Echocardiogr. 2008;9(1):196–8.

    Article  PubMed  Google Scholar 

  26. Goldbarg SH, Elmariah S, Miller MA, et al. Insights into degenerative aortic valve disease. J Am Coll Cardiol. 2007;50(13):1205–13.

    Article  PubMed  Google Scholar 

  27. Rajamannan NM, Evans FJ, Aikawa E, et al. Calcific aortic valve disease: not simply a degenerative process: A review and agenda for research from the National Heart and Lung and Blood Institute Aortic Stenosis Working Group. Executive summary: calcific aortic valve disease-2011 update. Circulation. 2011;124(16):1783–91.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Bekeredjian R, Grayburn PA. Valvular heart disease: aortic regurgitation. Circulation. 2005;112(1):125–34.

    Article  PubMed  Google Scholar 

  29. Paolillo V, Gastaldo D, Barretta A, et al. Idiopathic organized thrombus of the tricuspid valve mimicking valvular tumor. Tex Heart Inst J. 2004;31:192–3.

    PubMed  PubMed Central  Google Scholar 

  30. Konishi H, Fukuda M, Kato M, et al. Organized thrombus of the tricuspid valve mimicking valvular tumor. Ann Thorac Surg. 2001;71:2022–4.

    Article  CAS  PubMed  Google Scholar 

  31. Saxena P, Mejia R, Tam RK. A rare presentation of tricuspid valve thrombus in a normal heart. Ann Thorac Surg. 2005;80:1498–500.

    Article  PubMed  Google Scholar 

  32. Basarici I, Belgi A, Yalcinkaya S. Tricuspid valve thrombus: a case report associated with gonadotropin-releasing hormone analogue therapy and review of the literature. Can J Cardiol. 2008;24(5):401–3.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Angelos G, et al. Mobile pulmonary valve thrombus as a cause of chronic thromboembolic pulmonary hypertension. Int J Cardiol. 2008;129(3):e81–3.

    Article  Google Scholar 

  34. Chakravarty T, Søndergaard L, Friedman J, et al. Subclinical leaflet thrombosis in surgical and transcatheter bioprosthetic aortic valves: an observational study. Lancet (London, England). 2017;389(10087):2383–92. https://doi.org/10.1016/S0140-6736(17)30757-2.

    Article  Google Scholar 

  35. Laplace G, Lafitte S, Labèque J-N, et al. Clinical significance of early thrombosis after prosthetic mitral valve replacement: a postoperative monocentric study of 680 patients. J Am Coll Cardiol. 2004;43(7):1283–90. https://doi.org/10.1016/j.jacc.2003.09.064.

    Article  PubMed  Google Scholar 

  36. Ageno W, Turpie AG. Exaggerated initial response to warfarin following heart valve replacement. Am J Cardiol. 1999;84(8):905–8.

    Article  CAS  PubMed  Google Scholar 

  37. Goldhaber SZ. “Bridging” and mechanical heart valves: perils, promises, and predictions. Circulation. 2006;113(4):470–2. https://doi.org/10.1161/CIRCULATIONAHA.105.598268.

    Article  PubMed  Google Scholar 

  38. Généreux P, Cohen DJ, Mack M, et al. Incidence, predictors, and prognostic impact of late bleeding complications after transcatheter aortic valve replacement. J Am Coll Cardiol. 2014;64(24):2605–15. https://doi.org/10.1016/j.jacc.2014.08.052.

    Article  PubMed  Google Scholar 

  39. Vahanian A, Baumgartner H, Bax J, et al. Guidelines on the management of valvular heart disease: the task force on the management of valvular heart disease of the European Society of Cardiology. Eur Heart J. 2007;28(2):230–68. https://doi.org/10.1093/eurheartj/ehl428.

    Article  PubMed  Google Scholar 

  40. Webb J, Rodés-Cabau J, Fremes S, et al. Transcatheter aortic valve implantation: a Canadian Cardiovascular Society position statement. Can J Cardiol. 2012;28(5):520–8. https://doi.org/10.1016/j.cjca.2012.04.015.

    Article  PubMed  Google Scholar 

  41. Rodés-Cabau J, Masson J-B, Welsh RC, et al. Aspirin versus aspirin plus clopidogrel as antithrombotic treatment following transcatheter aortic valve replacement with a balloon-expandable valve: the arte (aspirin versus aspirin + clopidogrel following transcatheter aortic valve implantation) randomized clinical trial. JACC Cardiovasc Interv. 2017;10(13):1357–65. https://doi.org/10.1016/j.jcin.2017.04.014.

    Article  PubMed  Google Scholar 

  42. Collet J-P, Berti S, Cequier A, et al. Oral anti-Xa anticoagulation after trans-aortic valve implantation for aortic stenosis: the randomized ATLANTIS trial. Am Heart J. 2018;200:44–50. https://doi.org/10.1016/j.ahj.2018.03.008.

    Article  CAS  PubMed  Google Scholar 

  43. Windecker S, Tijssen J, Giustino G, et al. Trial design: rivaroxaban for the prevention of major cardiovascular events after transcatheter aortic valve replacement: rationale and design of the GALILEO study. Am Heart J. 2017;184:81–7. https://doi.org/10.1016/j.ahj.2016.10.017.

    Article  CAS  PubMed  Google Scholar 

  44. Latib A, Naganuma T, Abdel-Wahab M, et al. Treatment and clinical outcomes of transcatheter heart valve thrombosis. Circ Cardiovasc Interv. 2015;8(4):e001779–e001779. https://doi.org/10.1161/CIRCINTERVENTIONS.114.001779.

  45. Fiedler KA, Maeng M, Mehilli J, et al. Duration of triple therapy in patients requiring oral anticoagulation after drug-eluting stent implantation: the ISAR-TRIPLE trial. J Am Coll Cardiol. 2015;65(16):1619–29. https://doi.org/10.1016/j.jacc.2015.02.050.

    Article  PubMed  Google Scholar 

  46. Nishimura RA, Otto CM, Bonow RO, 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(2):252–89. https://doi.org/10.1016/j.jacc.2017.03.011.

    Article  PubMed  Google Scholar 

  47. Keuleers S, Herijgers P, Herregods M-C, et al. Comparison of thrombolysis versus surgery as a first line therapy for prosthetic heart valve thrombosis. Am J Cardiol. 2011;107(2):275–9. https://doi.org/10.1016/j.amjcard.2010.09.013.

    Article  PubMed  Google Scholar 

  48. Tong AT, Roudaut R, Ozkan M, et al. Transesophageal echocardiography improves risk assessment of thrombolysis of prosthetic valve thrombosis: results of the international PRO-TEE registry. J Am Coll Cardiol. 2004;43(1):77–84.

    Article  PubMed  Google Scholar 

  49. Özkan M, Gündüz S, Biteker M, et al. Comparison of different TEE-guided thrombolytic regimens for prosthetic valve thrombosis: the TROIA trial. JACC Cardiovasc Imaging. 2013;6(2):206–16. https://doi.org/10.1016/j.jcmg.2012.10.016.

    Article  PubMed  Google Scholar 

  50. Makkar RR, Fontana G, Jilaihawi H, et al. Possible subclinical leaflet thrombosis in bioprosthetic aortic valves. N Engl J Med. 2015;373(21):2015–24. https://doi.org/10.1056/NEJMoa1509233.

    Article  CAS  PubMed  Google Scholar 

  51. Jander N, Kienzle R-P, Kayser G, Neumann F-J, Gohlke-Baerwolf C, Minners J. Usefulness of phenprocoumon for the treatment of obstructing thrombus in bioprostheses in the aortic valve position. Am J Cardiol. 2012;109(2):257–62. https://doi.org/10.1016/j.amjcard.2011.08.038.

    Article  CAS  PubMed  Google Scholar 

  52. Dvir D, Webb JG, Bleiziffer S, et al. Transcatheter aortic valve implantation in failed bioprosthetic surgical valves. JAMA. 2014;312(2):162–70. https://doi.org/10.1001/jama.2014.7246.

    Article  CAS  PubMed  Google Scholar 

  53. Webb JG, Wood DA, Ye J, et al. Transcatheter valve-in-valve implantation for failed bioprosthetic heart valves. Circulation. 2010;121(16):1848–57. https://doi.org/10.1161/CIRCULATIONAHA.109.924613.

    Article  PubMed  Google Scholar 

  54. Phan K, Zhao D-F, Wang N, Huo YR, Di Eusanio M, Yan TD. Transcatheter valve-in-valve implantation versus reoperative conventional aortic valve replacement: a systematic review. J Thorac Dis. 2016;8(1):E83–93. https://doi.org/10.3978/j.issn.2072-1439.2016.01.44.

    Article  PubMed  PubMed Central  Google Scholar 

  55. Habib G, Lancellotti P, Antunes MJ, et al. 2015 ESC guidelines for the management of infective endocarditis. Eur Heart J. 2015;36(44):3075–128. https://doi.org/10.1093/eurheartj/ehv319.

    Article  PubMed  Google Scholar 

  56. Linkins L-A, Dans AL, Moores LK, et al. Treatment and prevention of heparin-induced thrombocytopenia: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(2 Suppl):e495S–530S. https://doi.org/10.1378/chest.11-2303.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  57. Anavekar NS, Tleyjeh IM, Anavekar NS, et al. Impact of prior antiplatelet therapy on risk of embolism in infective endocarditis. Clin Infect Dis. 2007;44(9):1180–6. https://doi.org/10.1086/513197.

    Article  PubMed  Google Scholar 

  58. Baddour LM, Wilson WR, Bayer AS, et al. Infective endocarditis in adults: diagnosis, antimicrobial therapy, and management of complications. Circulation. 2015;132(15):1435–86. https://doi.org/10.1161/CIR.0000000000000296.

    Article  CAS  PubMed  Google Scholar 

  59. Anavekar NS, Schultz JC, De Sa DDC, et al. Modifiers of symptomatic embolic risk in infective endocarditis. Mayo Clin Proc. 2011;86(11):1068–74. https://doi.org/10.4065/mcp.2011.0111.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  60. Tornos P, Almirante B, Mirabet S, Permanyer G, Pahissa A, Soler-Soler J. Infective endocarditis due to Staphylococcus aureus: deleterious effect of anticoagulant therapy. Arch Intern Med. 1999;159(5):473–5.

    Article  CAS  PubMed  Google Scholar 

  61. Asaithambi G, Adil MM, Qureshi AI. Thrombolysis for ischemic stroke associated with infective endocarditis: results from the nationwide inpatient sample. Stroke. 2013;44(10):2917–9. https://doi.org/10.1161/STROKEAHA.113.001602.

    Article  PubMed  Google Scholar 

  62. Scott WR, New PF, Davis KR, Schnur JA. Computerized axial tomography of intracerebral and intraventricular hemorrhage. Radiology. 1974;112(1):73–80. https://doi.org/10.1148/112.1.73.

    Article  CAS  PubMed  Google Scholar 

  63. Regitz-Zagrosek V, Blomstrom Lundqvist C, Borghi C, et al. ESC guidelines on the management of cardiovascular diseases during pregnancy: the task force on the management of cardiovascular diseases during pregnancy of the European Society of Cardiology (ESC). Eur Heart J. 2011;32:3147–97.

    Article  PubMed  Google Scholar 

  64. D’Souza R, Ostro J, Shah PS, Silversides CK, Malinowski A, Murphy KE, Sermer M, Shehata N. Anticoagulation for pregnant women with mechanical heart valves: a systematic review and meta-analysis. Eur Heart J. 2017;38:1509–16.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Bernard Cosyns .

Editor information

Editors and Affiliations

Rights and permissions

Reprints and permissions

Copyright information

© 2020 Springer Nature Switzerland AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Droogmans, S., Vanhentenrijk, S., Cosyns, B. (2020). Antithrombotic Therapy in Valvular Heart Disease. In: Zamorano, J., Lancellotti, P., Pierard, L., Pibarot, P. (eds) Heart Valve Disease. Springer, Cham. https://doi.org/10.1007/978-3-030-23104-0_16

Download citation

  • DOI: https://doi.org/10.1007/978-3-030-23104-0_16

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-23103-3

  • Online ISBN: 978-3-030-23104-0

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics