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BACKGROUND: Postoperative state is characterized by increased thrombotic risk by virtue of platelet activation. Whether aspirin ameliorates this risk in patients with established coronary artery disease undergoing cardiac or noncardiac surgery is unknown. We conducted a systematic review and meta-analysis to compare the risk of major adverse cardiac events (MACE) and the risk of bleeding in patients with early (3-5 or more days before surgery) vs. late discontinuation(<3-5 days)/no discontinuation of aspirin. METHODS: Multiple databases were searched from inception of these databases until March 2015 to identify studies that reported discontinuation of aspirin in patients undergoing surgery. The outcomes measured were all cause mortality, nonfatal myocardial infarction and other relevant thrombotic events (MACE) which also may include, fatal and nonfatal MI, stent thrombosis and restenosis, stroke, perioperative cardiovascular complications (heart failure, MI, VTE, acute stroke) and perioperative bleeding during the perioperative period to up to 30 days after surgery. RESULTS: A total of 1,018 titles were screened, after which six observational studies met the inclusion criteria. Our analysis suggests that there is no difference in MACE with planned discontinuation of aspirin (OR = 1.17, 95% CI = 0.76-1.81; P = 0.05; I2 = 55%). Early discontinuation of aspirin showed a decreased risk of peri-operative bleeding (OR 0.82, 95% CI = 0.67-0.99; P = 0.04; I2 = 42%). CONCLUSION: Our analysis suggests that planned short-term discontinuation in the appropriate clinical setting appears to be safe in the correct clinical setting with no increased risk of thrombotic events and with a decreased risk of bleeding. © 2016 Wiley Periodicals, Inc.
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Aspirina/administración & dosificación , Procedimientos Quirúrgicos Cardíacos , Enfermedad de la Arteria Coronaria/tratamiento farmacológico , Enfermedad de la Arteria Coronaria/cirugía , Anciano , Anciano de 80 o más Años , Aspirina/efectos adversos , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Procedimientos Quirúrgicos Cardíacos/mortalidad , Distribución de Chi-Cuadrado , Enfermedad de la Arteria Coronaria/diagnóstico , Enfermedad de la Arteria Coronaria/mortalidad , Trombosis Coronaria/etiología , Esquema de Medicación , Femenino , Hemorragia/inducido químicamente , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/etiología , Estudios Observacionales como Asunto , Oportunidad Relativa , Atención Perioperativa , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Most patients with left ventricular assist devices (LVADs) have concomitant cardiovascular implantable electronic devices (CIEDs). However, clinical presentation and outcome of CIED infection in the setting of LVAD has not been previously described. METHODS: We retrospectively reviewed 247 patients who underwent LVAD implantation at Mayo Clinic campuses in Minnesota, Arizona, and Florida, from January 2005 to December 2011. Demographic and clinical data of patients who met criteria for CIED infection were extracted. RESULTS: Of 247 patients with LVADs, 215 (87%) had CIED at the time of LVAD implantation and six (2.8%) subsequently developed CIED infections. Three patients developed CIED lead-related endocarditis and the other three had pocket infection. All three instances of CIED pocket infection were preceded by device generator exchange, whereas all three patients with CIED lead-related endocarditis had prior LVAD-related infections. Causative pathogens included Pseudomonas aeruginos (1), coagulase-negative staphylococci (2), methicillin-resistant Staphylococcus aureus (1), a gram-positive bacillus (1), and culture negative (2). All patients underwent complete CIED removal along with antimicrobial therapy. The three patients with CIED lead-related endocarditis and prior LVAD infections received chronic suppressive antibiotic therapy, and one patient had LVAD exchange. All but one remained alive at the last follow-up with a median duration of 15 months (7-46 months) from the time of CIED infection. CONCLUSION: Patients who are receiving LVAD therapy and develop CIED infection should be managed with complete CIED removal. Chronic suppressive antibiotic therapy is warranted in cases that have concomitant LVAD infection.
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Desfibriladores Implantables/estadística & datos numéricos , Insuficiencia Cardíaca/epidemiología , Insuficiencia Cardíaca/prevención & control , Corazón Auxiliar/estadística & datos numéricos , Marcapaso Artificial/estadística & datos numéricos , Infecciones Relacionadas con Prótesis/epidemiología , Adulto , Anciano , Antibacterianos/uso terapéutico , Causalidad , Comorbilidad , Remoción de Dispositivos/estadística & datos numéricos , Femenino , Florida/epidemiología , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Minnesota/epidemiología , Infecciones Relacionadas con Prótesis/prevención & control , Estudios Retrospectivos , Factores de Riesgo , Resultado del TratamientoRESUMEN
We report the case of a 56-year-old female with a past medical history of multiple sclerosis on disease-modifying therapy of fingolimod who presented with disseminated Coccidioides infection, initially of the ankles bilaterally before progressing to the central nervous system. CNS coccidiomycosis has thus far not been associated with any pharmacological therapy for multiple sclerosis. Clinicians should have a high degree of suspicion for Coccidioides infection in immunosuppressed patients living in endemic areas.
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A man in his 60s presented to the clinic due to night sweats and weight loss following pneumonia. He was found to have hyponatraemia due to a syndrome of inappropriate antidiuretic hormone (SIADH). CT of the thorax was concerning for pulmonary nodules. He was ultimately diagnosed with pulmonary coccidioidomycosis (CM) and started on fluconazole 400 mg daily with improvement in symptoms. Due to the report of headaches, head MRI was conducted which suggested central nervous system (CNS) involvement. Cerebrospinal fluid analysis was consistent with CNS CM and head magnetic resonance angiography confirmed the presence of CNS vasculitis. Fluconazole dose was increased to 800 mg daily which the patient continued to tolerate and showed improvement. This report depicts a case of SIADH associated with CNS CM with vasculitis and demonstrates the importance of high clinical suspicion for SIADH secondary to CNS CM in the setting of hyponatraemia and headache.
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Coccidioidomicosis , Hiponatremia , Síndrome de Secreción Inadecuada de ADH , Vasculitis , Masculino , Humanos , Síndrome de Secreción Inadecuada de ADH/complicaciones , Síndrome de Secreción Inadecuada de ADH/diagnóstico , Hiponatremia/complicaciones , Coccidioidomicosis/complicaciones , Coccidioidomicosis/diagnóstico , Coccidioidomicosis/tratamiento farmacológico , Fluconazol , Vasopresinas , Vasculitis/complicaciones , Sistema Nervioso CentralRESUMEN
BACKGROUND: Infection is a serious complication of left ventricular assist device (LVAD) therapy. Published data regarding LVAD-associated infections (LVADIs) are limited by single-center experiences and use of nonstandardized definitions. METHODS: We retrospectively reviewed 247 patients who underwent continuous-flow LVAD implantation from January 2005 to December 2011 at Mayo Clinic campuses in Minnesota, Arizona, and Florida. LVADIs were defined using the International Society for Heart and Lung Transplantation criteria. RESULTS: We identified 101 episodes of LVADI in 78 patients (32%) from this cohort. Mean age (± standard deviation [SD]) was 57±15 years. The majority (94%) underwent Heartmate II implantation, with 62% LVADs placed as destination therapy. The most common type of LVADIs were driveline infections (47%), followed by bloodstream infections (24% VAD related, and 22% non-VAD related). The most common causative pathogens included gram-positive cocci (45%), predominantly staphylococci, and nosocomial gram-negative bacilli (27%). Almost half (42%) of the patients were managed by chronic suppressive antimicrobial therapy. While 14% of the patients had intraoperative debridement, only 3 underwent complete LVAD removal. The average duration (±SD) of LVAD support was 1.5±1.0 years. At year 2 of follow-up, the cumulative incidence of all-cause mortality was estimated to be 43%. CONCLUSION: Clinical manifestations of LVADI vary on the basis of the type of infection and the causative pathogen. Mortality remained high despite combined medical and surgical intervention and chronic suppressive antimicrobial therapy. Based on clinical experiences, a management algorithm for LVADI is proposed to assist in the decision-making process.
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Corazón Auxiliar/efectos adversos , Infecciones Relacionadas con Prótesis/etiología , Infecciones Relacionadas con Prótesis/terapia , Adulto , Anciano , Antibacterianos/uso terapéutico , Distribución de Chi-Cuadrado , Femenino , Corazón Auxiliar/microbiología , Humanos , Masculino , Persona de Mediana Edad , Infecciones Relacionadas con Prótesis/microbiología , Estudios RetrospectivosRESUMEN
BACKGROUND: Anticoagulation with vitamin K antagonists such as warfarin has historically been used for the long term management of patients with thromboembolic disease. However, these agents have a slow onset of action which requires bridging therapy with heparin and its analogues, which are available only in parenteral route. To overcome these limitations, new oral anticoagulants such as factor Xa inhibitors and direct thrombin inhibitors have been developed. The aim of this article is to systematically review the phase 3 clinical trials of new oral anticoagulants in common medical conditions. METHODS: We searched PubMed (Medline) from January 2007 to February 2013 using "Oral anticoagulants", "New oral anticoagulants", "Randomized controlled trial", "Novel anticoagulants", "Apixaban", "Rivaroxaban", "Edoxaban", "Dabigatran etexilate", "Dabigatran" and a combination of the above terms. The available evidence from the phase 3 RCTs was summarized on the basis of individual drug and the medical conditions categorized into "atrial fibrillation", "acute coronary syndrome", "orthopedic surgery", "venous thromboembolism" and "medically ill patients". RESULTS: Apixaban, rivaroxaban and dabigatran have been found to be either non-inferior or superior to enoxaparin in prophylaxis of venous thromboembolism in knee and hip replacement with similar bleeding risk, superior to warfarin for stroke prevention in atrial fibrillation with significant reduction in the risk of major bleeding, non-inferior to aspirin for reducing cardiovascular death and stroke in acute coronary syndrome with significant increase in the risk of major bleed. Rivaroxaban and dabigatran are also superior to the conventional agents in the management of symptomatic venous thromboembolism. However, compared to enoxaparin, apixaban and rivaroxaban use lead to significantly increased bleeding risk in medically ill patients. Additional studies evaluating the specific reversal agents of these new drugs for the management of life-threatening bleeding or other adverse effects are necessary. CONCLUSION: Considering their pharmacological properties, their efficacy and bleeding complications, the new oral agents offer a net favourable clinical profile in orthopedic surgery, atrial fibrillation, acute coronary syndrome and increase the risk of bleeding in critically ill patients. Further studies are necessary to determine the long term safety and to identify the specific reversal agents of these new drugs.
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We report the case of a 78-year-old man with a past medical history of non-Hodgkin's lymphoma s/p chemotherapy and Myasthenia Gravis on chronic mycophenolate mofetil (MMF), who presented with altered mental status and was found to have ring enhancing brain lesions. A brain biopsy revealed organisms consistent with Toxoplasma gondii. Cerebral toxoplasmosis has been rarely reported in patients with hematologic malignancies or in those receiving immunosuppressive agents. There needs to be a high degree of suspicion for T. gondii in HIV-negative individuals who are on immunosuppressants drugs including MMF.
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BACKGROUND: Hepatocellular cancer is notorious for recurrence even after curative therapy. High recurrence determines the long term prognosis of the patients. Vitamin K2 has been tested in trials for its effect on prevention of recurrence and improving survival. The results are inconclusive from individual trials and in our knowledge no systematic review which entirely focuses on Vitamin K2 as a chemo preventive agent is available to date. This review is an attempt to pool all the existing trials together and update the existing knowledge on the topic. METHODS: Medline, Embase and Cochrane Register of Controlled trials were searched for randomized controlled trials where vitamin K2 or its analogues, in any dosage were compared to placebo or No vitamin K2, for participants of any age or sex. Reference lists and abstracts of conference proceedings were searched by hand. Additional papers were identified by a manual search of the references from the key articles. Attempt was made to contact the authors of primary studies for missing data and with the experts in the field.Trials were assessed for inclusion by two independent reviewers. Primary outcomes were recurrence rates and survival rates. There were no secondary outcomes. Data was synthesized using a random effects model and results presented as relative risk with 95% Confidence Intervals. RESULT: For recurrence of hepatocellular cancer after hepatic resection or local ablative therapy, compared with controls, participants receiving Vitamin K2, pooled relative risks for hepatocellular cancer were 0.60; 95% CI: 0.28-1.28, p = 0.64) at 1 yr 0.66; 95% CI: 0.47-0.91), p = 0.01) at 2 yr; 0.71; 95% CI: 0.58-0.85, p = 0.004) at 3 yr respectively. The results were combined using the random analysis model. CONCLUSION: Five RCTs evaluated the preventive efficacy of menatetrenone on HCC recurrence after hepatic resection or local ablative therapy. The meta-analysis of all five studies, failed to confirm significantly better tumor recurrence- free survival at 1 year. Improved tumor recurrence at 2nd and 3rd year may be just due to insufficient data. There was no beneficial effect on the overall survival. However, to confirm the beneficial effect or lack of it, large, higher quality randomized controlled trials are still required.
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Carcinoma Hepatocelular/tratamiento farmacológico , Neoplasias Hepáticas/tratamiento farmacológico , Recurrencia Local de Neoplasia/prevención & control , Vitamina K 2/uso terapéutico , Vitaminas/uso terapéutico , Carcinoma Hepatocelular/cirugía , Quimioprevención , Intervalos de Confianza , Supervivencia sin Enfermedad , Humanos , Neoplasias Hepáticas/cirugía , Ensayos Clínicos Controlados Aleatorios como AsuntoRESUMEN
OBJECTIVE: To evaluate the methods of disposal of used syringes employed by patients with hepatitis B and hepatitis C. METHODS: This cross sectional study was conducted at a tertiary care hospital of Karachi and a clinic at Khairpur, Sindh. Diagnosed cases of Hepatitis B and C currently receiving treatment in the form of Interferon alpha injection were included by convenient sampling. The study instrument was a well structured questionnaire meant to ascertain the disposal methods of used syringes once they had been employed for treatment purpose. Open-epi sample size calculator (Multi-purpose statistical software for calculation of the sample size) and SPSS 15.0 was used for data entry and analysis. RESULTS: A total of 203 patients were interviewed, 147 from Karachi and 56 from interior. The majority i.e. 164 were suffering from Hepatitis C, 27 from Hepatitis B and 2 were co-infected with Hepatitis B and D. The mean age of patients was 35.8 +/- 11.5 years. Regarding disposal of injections, the most frequent mode was disposal of used syringes in house trash i.e. 71 (37.4%), patients 46 (24.2%) responded that they utilized a needle cutter, 37 (19.5%) safety box (disposal method in tertiary hospitals where the needle is disposed off safely in a box), 12 (6.3%) disposed in sewage, 3 (1.6%) disposal in water, 3 (1.6%) buried the used syringes, while 2 (1.1%) reused the syringe and needle once they had been used for therapeutic purposes. CONCLUSIONS: The study suggests that the injection practices by the majority of patients suffering from viral hepatitis were unsafe. Majority of the patients were disposing the used syringes and needles in the house trash.
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Hepatitis B , Hepatitis C , Agujas , Jeringas , Adulto , Anciano , Estudios Transversales , Femenino , Hepatitis B/prevención & control , Hepatitis B/transmisión , Hepatitis C/prevención & control , Hepatitis C/transmisión , Humanos , Entrevistas como Asunto , Masculino , Persona de Mediana Edad , Población Rural , Factores Socioeconómicos , Encuestas y Cuestionarios , Población Urbana , Adulto JovenRESUMEN
We describe a case of native vertebral osteomyelitis (NVO) secondary to Listeria monocytogenes in a patient with polymyalgia rheumatica receiving chronic steroids. Treatment required surgical debridement of the epidural phlegmon and combination therapy with intravenous ampicillin and gentamicin.
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Background: Aspiration of intervertebral disc space is often done to confirm the diagnosis of native vertebral osteomyelitis. A study has not been done examining the utility of cell counts and differentials of the aspirated fluid in diagnosing native vertebral osteomyelitis (NVO). Methods: In this feasibility study, we prospectively enrolled patients with a suspected diagnosis of NVO referred to the Division of Neuroradiology for image-guided needle aspiration of the intervertebral disc. In this study, manual cell count was done on the aspirated fluid, followed by a differential cytospin technique and touch prep. We obtained demographic, lab, and microbiologic data and used the receiver operating curve (ROC) for statistical analysis. Results: Over 12 months, we performed 17 aspirates on 14 patients. The median age was 70.5 years (range: 45-77). The median manual cell count on the aspirated fluid was 52 cells⯠µ L - 1 (range: 0-6656), the median neutrophil percentage on the touch prep slide was 73â¯% (range: 5â¯%-100â¯%), and the median neutrophil percentage on the cytospin slide was 82â¯% (range: 0â¯%-100â¯%). Routine bacterial cultures were positive in five cases, and the 16S ribosomal RNA gene polymerase chain reaction was positive in two cases. The optimal cutoff for a cell count of 104 total nucleated cells offered a sensitivity and specificity of 86â¯%, and a neutrophil cutoff of 83â¯% was associated with a 71â¯% sensitivity and specificity. Conclusion: An image-guided aspirated specimen leukocyte differential of ≥ 83 â¯% neutrophils or a leukocyte count of ≥ 104 ⯠µ L - 1 was a sensitive and specific test for diagnosing patients with suspected NVO. Additionally, more extensive studies are warranted to confirm the findings.
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We describe a case of left hand extensor tenosynovitis due to histoplasmosis in a patient with dermatomyositis on chronic immunosuppression. Treatment involved surgical debridement and antifungal therapy. The patient experienced paradoxical worsening of tenosynovial inflammation during de-augmentation of immunosuppression felt to be immune reconstitution inflammatory syndrome.
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Cardiac metastasis from head and neck cancer is an extremely rare and devastating condition with an abysmal prognosis. Most of our knowledge about this condition is from case reports and series. We present a case of squamous cell carcinoma of the tonsils that was complicated by embolic stroke and critical limb ischemia that were found to be secondary to intracardiac metastasis. We believe that this condition is under-reported; hence, we conducted a thorough review of the literature to highlight the characteristics and previous therapeutic experiences with various presentations of cardiac metastasis from head and neck carcinoma. Clinicians are encouraged to report their experience with evaluating and managing this type of metastasis.
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Accidente Cerebrovascular Embólico , Neoplasias Cardíacas , Disección del Cuello/métodos , Nivolumab/administración & dosificación , Carcinoma de Células Escamosas de Cabeza y Cuello , Tonsilectomía/métodos , Quimioradioterapia Adyuvante/métodos , Diagnóstico Diferencial , Accidente Cerebrovascular Embólico/diagnóstico , Accidente Cerebrovascular Embólico/etiología , Accidente Cerebrovascular Embólico/fisiopatología , Resultado Fatal , Neoplasias Cardíacas/patología , Neoplasias Cardíacas/fisiopatología , Neoplasias Cardíacas/secundario , Neoplasias Cardíacas/cirugía , Humanos , Inhibidores de Puntos de Control Inmunológico/administración & dosificación , Masculino , Persona de Mediana Edad , Clasificación del Tumor , Estadificación de Neoplasias , Tonsila Palatina/diagnóstico por imagen , Tonsila Palatina/patología , Tonsila Palatina/cirugía , Tomografía Computarizada por Tomografía de Emisión de Positrones/métodos , Carcinoma de Células Escamosas de Cabeza y Cuello/patología , Carcinoma de Células Escamosas de Cabeza y Cuello/fisiopatología , Carcinoma de Células Escamosas de Cabeza y Cuello/cirugíaRESUMEN
Background: Fungal prosthetic joint infections (PJIs) are rare and often associated with poor outcome; however, risk factors are not well described. Methods: This was a retrospective case control study among all patients with PJIs from 2006-2016 at two major academic centers. Each fungal PJI case was matched 1:1 with a bacterial PJI control by joint (hip, knee, shoulder) and year of diagnosis. We compared demographics, comorbidities, and clinical characteristics between cases and controls using chi square/Fisher's exact or Wilcoxon rank sum test. Independent risk factors were identified with multivariable logistic regression. Results: Forty-one fungal PJIs occurred over the study and 61% were due to Candida albicans. The hip was involved in 51.2% of cases, followed by the knee (46.3%). Compared to bacterial PJI, fungal PJI cases were more likely to have received antibiotics within the previous 3 months (70.7% vs 34%, P=.001), wound drainage lasting >5 days (48% vs 9%, P=.0002), had a lower median CRP (2.95 mg/dl vs 5.99, P=.013) and synovial fluid white blood cell count (13,953 cells/mm3 vs 33,198, P=.007), and a higher proportion of prior two-stage exchanges (82.9% vs 53.6%, P=.008). After controlling for center, prolonged wound drainage (OR, 7.3; 95% CI, 2.02-26.95) and recent antibiotics (OR, 3.4; 95% CI, 1.2-9.3) were significantly associated with fungal PJI. Conclusion: In our study, Candida albicans was the most common species in fungal PJIs and prolonged wound drainage and recent antibiotics were independent risk factors. These clinical characteristics may help providers anticipate fungal PJI and adjust management strategies.
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Cystic fibrosis is the most frequently witnessed potentially lethal autosomal recessive, genetic disease but its incidence is extremely low in South-Asian population. We report a case Cystic Fibrosis in a patient with Situs inversus, a condition not witnessed in medical literature of Pakistan or more captivatingly even Asia. The patient was a three and half years old male child presenting with a history of fever, cough and jaundice. Physical examination lead to the initial diagnosis of situs inversus, which was confirmed by the chest radiograph, echocardiography and ultrasound of abdomen. Further evaluations were conducted to establish the cause of respiratory symptoms. The findings of pansinusitis as evidenced by the radiography and an exceedingly high sweat chloride concentration of 100 mmol/L resulted in the conclusive diagnosis of Cystic Fibrosis.
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Fibrosis Quística/diagnóstico , Situs Inversus/diagnóstico , Preescolar , Fibrosis Quística/complicaciones , Humanos , Masculino , Situs Inversus/complicacionesRESUMEN
Background: Actinomyces prosthetic joint infections (APJIs) are rare and optimal medical and surgical treatment strategies are unknown. The purpose of our study was to characterize the demographics, risk factors, management and outcomes of patients with PJIs due to Actinomyces spp. Methods: Using a retrospective cohort study design, the medical records of all patients with Actinomyces spp. total hip or knee arthroplasty infection (APJI) seen at a single institution between January 1, 1969 and December 31, 2016 were reviewed. We abstracted information including patient demographics, co-morbidities, joint age, surgical history, microbiology, management and outcomes. A simultaneous literature search via PubMed was performed to identify cases of APJI published in literature and a descriptive analysis was performed. Results: Eleven cases were identified over a 47 year study period at our institution. Seven patients (64%) were female. The median age at the time of diagnosis of infection was 71 years (range, 57-89). The knee was involved in six cases (55%) followed by the hip in 5 (45 %) cases. Three cases had dentures, broken teeth, or poor dentition. Actinomyces odonotlyticus was the most commonly found subspecies at our institution. Median ESR and CRP values were 61mm/hr and 64 mg/L respectively. Eight (72%) patients were managed with 2 stage exchange. Most patients received a course of beta-lactam therapy for 6 weeks. Ten cases (91%) were free of failure after a median duration of follow-up of 2 years (range, 0.67 - 5 years). The median duration from joint arthroplasty to the onset of symptoms was 162 days, range (20-3318). Six (54%) had a history of prior PJI with a different microorganism at the same joint site and 4 patients had history of prior 2 stage exchange (36%). In the literature group, we identified 12 cases and the most common subspecies was Actinomyces israelii; most patients underwent two stage exchange and were treated with 6 weeks of beta lactam antibiotics. Conclusions: Based on our observational study, Actinomyces PJI presents as a late complication of TJR, may be associated with prior PJI at the index joint and antecedent dental manipulation may portend as an additional risk factor. Treatment includes two stage exchange and beta- lactam therapy for 6weeks. These results will help clinicians in improved understanding and management of APJIs which although are rare but warrant special attention as population with implanted joint arthroplasties continues to rise.
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Terapia Conductista , Terapia Cognitivo-Conductual , Hipocondriasis/diagnóstico , Hipocondriasis/terapia , Inhibidores Selectivos de la Recaptación de Serotonina/uso terapéutico , Ansiedad/psicología , Ansiedad/terapia , Humanos , Pronóstico , Escalas de Valoración Psiquiátrica , Resultado del TratamientoRESUMEN
BACKGROUND: The American College of Cardiology guidelines recommend 3 months of anticoagulation after replacement of the aortic valve with a bioprosthesis. However, there remains great variability in the current clinical practice and conflicting results from clinical studies. To assist clinical decision making, we pooled the existing evidence to assess whether anticoagulation in the setting of a new bioprosthesis was associated with improved outcomes or greater risk of bleeding. METHODS AND RESULTS: We searched the PubMed database from the inception of these databases until April 2015 to identify original studies (observational studies or clinical trials) that assessed anticoagulation with warfarin in comparison with either aspirin or no antiplatelet or anticoagulant therapy. We included the studies if their outcomes included thromboembolism or stroke/transient ischemic attacks and bleeding events. Quality assessment was performed in accordance with the Newland Ottawa Scale, and random effects analysis was used to pool the data from the available studies. I(2) testing was done to assess the heterogeneity of the included studies. After screening through 170 articles, a total of 13 studies (cases=6431; controls=18210) were included in the final analyses. The use of warfarin was associated with a significantly increased risk of overall bleeding (odds ratio, 1.96; 95% confidence interval, 1.25-3.08; P<0.0001) or bleeding risk at 3 months (odds ratio, 1.92; 95% confidence interval, 1.10-3.34; P<0.0001) compared with aspirin or placebo. With regard to composite primary outcome variables (risk of venous thromboembolism, stroke, or transient ischemic attack) at 3 months, no significant difference was seen with warfarin (odds ratio, 1.13; 95% confidence interval, 0.82-1.56; P=0.67). Moreover, anticoagulation was also not shown to improve outcomes at time interval >3 months (odds ratio, 1.12; 95% confidence interval, 0.80-1.58; P=0.79). CONCLUSIONS: Contrary to the current guidelines, a meta-analysis of previous studies suggests that anticoagulation in the setting of an aortic bioprosthesis significantly increases bleeding risk without a favorable effect on thromboembolic events. Larger, randomized controlled studies should be performed to further guide this clinical practice.