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Managing the heart value
- 1. Managing the Heart Valve “ Oral Anticoagulation Therapy” Dr. Atul A. Maslekar (AIIMS) FICS, FIACS Sr. Consultant – Cardiothoracic Surgeon Narayana Multispecialty Hospital - Ahmedabad
- 2. Anatomy of Heart Valve
- 3. Classification of Prosthetic Heart Valve • Mechanical Valves • Ball & Cage • Tilting disc • Bileaflet • Biological Valve • Auto grafts • Homografts • Xenografts • Biovine Pericardial
- 4. Picture of Mechanical Valve Tilting disc valve Ball and cage valveBileaflet valve
- 5. Picture of Biological Valve Porcine (pig) stentless valve Porcine (pig) stented valve Bovine (cow) Pericardial stented valve
- 6. Management of Patients with Prosthetic Heart valve Antithrombotic therapy: • Fewer complications of Valvular Heart Disease can be more devastating than systemic embolic. • Patients with mechanical heart valve receive life long, high intensity oral anticoagulation therapy to prevent thromboembolic complications. • Antithrombotic therapy can reduce although not eliminate the likelihood of the catastrophe. • Unfortunately, antithrombotic therapy carries a substantial risk of bleeding depending upon – Drugs used – Intensity of anticoagulation – Individual
- 7. Risk of Thromboembolism / Bleeding Sex: Women have a slightly higher risk of both thromboembolism and bleeding than men. • Incidence of Thromboembolism Women: 0.86 per 100 patient year. Men: 0.6 per 100 patient year. • Incidence of Bleeding Women: 3.1 per 100 patient year Men: 2.4 per 100 patient year Age: 50 yr≤ Thromboembolic risk of 0.1 per 100 patient year > 50 yr Thromboembolic risk of 0.8 per 100 patient year Risk of bleeding did not vary much with age for patients 70 yr,≤ but was twice for pt > 70 yrs. Position of valve: Aortic: 0.5 per 100 patient years Mitral: 0.9 per 100 patient year Double valve: 1.2 per 100 patient year.
- 8. All adverse events Incidence rate for Different age group
- 9. All Adverse events according to valve position
- 10. Incidence of all Adverse events according to valve type
- 11. Adverse Events Minor : Reported but not requiring additional test or admission. Major : Requiring treatment. At least 2 units of blood. Life Threatening : Leading to Cardiac Arrest Needing Surgical Intervention Irreversible Sequelae.
- 12. Risk factors for Adverse events • Intensity of treatment • Patient Characteristics » H/O GI Bleed » H/O stroke » Co morbid Conditions » Age is controversial • Frequency of Blood testing » Patient Compliance » Additions/ Subtraction of Medicines » Changes in diet
- 13. Blood Test for Optimal Anticoagulation • PT: Traditional method of determining efficacy of anticoagulation • INR: A mathematical calculation that corrects for the results attributable to the variable sensitivities of thromboplastic agents
- 14. Ranges • Healthy People : INR 0.9 – 1.0 • PT with AF : INR 2 – 2.5 • PT with Mech. valve Mitral INR : 3- 3.5 Aorta INR : 2 – 2.5 Double INR : 3.5 – 4.0 • INR < 2 : ↑ Thromboembolism • INR > 5 : ↑ Bleeding
- 15. What is an optimal anticoagulation therapy? One at which the Incidence of both Thromboembolic and Bleeding Complications are the least.
- 16. Factors affects INR Medicine : Aspirin ↑ Anti Inflammatory ↑ Antibiotics ↑ OCP’s ↑ Food : Spinach ↑ Lettuce ↑ Brocolli ↑ Liver ↑
- 17. Management of Adverse Events Bleeding: 2 general principle 1. attempt to Identify 2. Is there a possibility to lower the anticoagulation Minor: > Observe & record > Repeat PT / INR > Reassurance Major: > Admission > Attempts to Identify the source > Repeat PT/ INR > FFP / Fresh blood / Vit K Life Threatening: > Admission (urgent) > Urgent Blood transfusion(Blood / FFP) > Special Investigation > Surgical (Invasive) Intervention
- 18. Management of Adverse efforts – Thrombosis Prosthetic valve obstruction may be caused by – Thrombus – Pannus – Combination Knowledge of clinical presentation & special Investigation (TOE) is essential as treatment varies, Pannus: Thrombolytic therapy ineffective valve thrombectory / replacement Thrombus: Thrombolysis therapy - Streptokinase - Urolinase Duration depends upon resolution of Pressure gradient, valve area + disc movements
- 19. Aspirin in Combination with anticoagulants • Met analysis supports the concept that the rate of thromboemboli is diminished with aspirin in Combination with VIT K antagonist. • Aspirin in Combination with anticoagulants (INR 2.0-3.5) was associated with bleeding (minor) incidence of 1.1 – 5.1 % per patient year. • Indian senario where INR control is poor due to Poor Patient Compliance, in addition of aspirin in dosage (75mg – 150 mg) may be beneficial)
- 20. Thromboleytic Therapy • Thrombolytic therapy should be stopped at 24 hrs there is no hemodynamic improvement or after 72 hrs if recovery is incomplete. • If successful → IV heparin until OAC achieves INR 3-4
- 21. Risks of Thrombolytic Therapy • Ineffective in 16% - 18% of patients • Acute mortality – 6% • Thromboembolism – 12% • Stroke – 3% - 10% • Major bleeding expiring - 5% • Recurrent Thrombosis – 1% Patient's with large clot, with evidence of valve obstruction & NYHA III/ IV should under go immediate reoperation.
- 22. Regime that we follow - OAC • OAC usually started on Day 1 Post-OP • Target INR is achieved by 4-5 days Post-OP • Use of LMWH/ Heparin in addition • PT / INR monitoring daily for the full 7 days. • Aspirin started is dose (75mg – 150mg) for Day 1. Target INR • Mitral 3.0 – 3.5 • Aorta 2.5 – 3.0 • Doulle 3.5 – 4.0
- 23. OAC : Post discharge (Ideal) • PT/ INR, 1 week post discharge • Every 15 days thereafter for 3 months • Once a month for 3 months • Once every 3 months for 6 months • 6 monthly there after. • Continue Aspirin for life.
- 24. Special Situations • Pregnancy • Invasive Procedures
- 25. Special Situation - Pregnancy • Unfortunately, no definite fixed guidelines OAC crosses placenta – Spontaneous Abortion – Premature birth – Still birth – Embryopathy Highest risk - 6-12 weeks of Gestation
- 26. Dose related dependency Vitale et al J. Am col. card 1999 warfarin > 5mg / day – 9% incidence of embryopathy < 5 mg /day – low fetal complication but no embryopathy
- 27. • Meschengieser et al – Heart 1999 92 pregnancies in 59 women to MHV 31 pregnancies → Subcut → Heparin 1st trimester warfarin – 2nd Trimester onwards 61 pregnancies → OAC continued • Abortion / fetal loss → similar • Embolic effect → 4.9% in Heparin gp 0.3% in OAC gp
- 28. • Chan et al – Arch. Inter. Med 2000 Review of literature • OAC throughout → 6.4% embryopathy • Heparin 6 wks - 12 wks → 9.2 % valve thrombosis
- 29. LMWH • More promising – Does not cross placenta – No need for frequent patient. – Lower ½ life – Lower incidence of thrombocytopenia & osteoporosis No major recorded data.
- 30. Recommendations
- 31. Recommendations Recommendations for Anticoagulation During Pregnancy in Patients With Mechanical Prosthetic Valves: After the 36th Week Indication Class 1. Warfarin should be stopped no later than week 36 and heparin substituted in anticipation of labor. 2. If labor begins treatment with warfarin, a caesarian section should be performed. 3. In the absence of signification bleeding, heparin ca be resumed 4 to 6 hours after delivery and warfarin begun orally IIa IIa IIa
- 32. Management of OAC during Invasive Procedure • Assess the risk of bleeding v/s risk of Thrombosis • Elective Procedures Minor : – Stop OAC for 1-2 days – Safely done if INR< 2.0 – Restart OAC immediately. – Dose of Heparin / LMWH Major: – Stop OAC 4-5 days prior – Switch to LMWH / Heparin – VIT K 24 hrs prior – Adequate reserve of FFP / Blood – Restart OAC as soon as possible.