Anticoagulation Management in Patients with Valve Replacement.

Background: Prosthetic valve implantation requires postoperative prophylactic anticoagulation to preclude thrombotic events. The aim of this review is to assess the role of anticoagulation therapy in the management of valve replacement patients. Methodology: Literature from PubMed, Embase, Medline and Google Scholar were searched using the terms "valvular heart disease", "anticoagulant", "mechanical heart valve", "bioprosthesis", "bridging", "Vitamin K antagonist (VKA)", and "acenocoumarol". A committee comprising leading cardiothoracic surgeons from India was convened to review the literature and suggest key practice points. Results: Prosthetic valve implantation requires postoperative prophylactic anticoagulation to preclude thrombotic events. A paramount risk of thromboembolic events is observed during the first three months after surgery for both mechanical and bioprosthetic devices. The VKA therapy with individualized target international normalized ratio (INR) is recommended in patients after prosthetic valve replacement. Therapies for the management of prosthetic valve complications should be based on the type of complications. Special care is mandated in distinguished individuals and those with various co-morbidities. Conclusion: In patients with prosthetic valve replacement, anticoagulant therapy with VKA seems to be an effective option. The role for non-VKA oral anticoagulants in the setting of prosthetic valve replacement has yet to be established. Furthermore, whether the novel oral anticoagulants are safe and efficacious in patients after placement of a bioprosthetic valve remains unanswered.

Acenocoumarol: A Review of Anticoagulant Efficacy and Safety.

Anticoagulant treatment is required for the treatment and prevention of thromboembolic disorders. Vitamin K antagonists are commonly used oral anticoagulants worldwide. Acenocoumarol is mono-coumarin derivative with racemic mixture of R (+) and S (-) enantiomers. Efficacy and safety of acenocoumarol has been evaluated in atrial fibrillation, cardiac valve replacement, after myocardial infarction, treatment of deep vein thrombosis, after major surgeries and after critical illness requiring prolonged hospitalization. Acenocoumarol is effective and safe in all age groups. It offers an advantage over warfarin in terms of better stability of anti-coagulant effect. Due to its economic advantage acenocoumarol may be suitable oral anticoagulant for long term use in countries like India.

Follow-up and management of valvular heart disease patients with prosthetic valve: a clinical practice guideline for Indian scenario.

PURPOSE: Valvular heart disease (VHD) patients after prosthetic valve implantation are at risk of thromboembolic events. Follow-up care of patients with prosthetic valve has a paramount role in reducing the morbidity and mortality. Currently, in India, there is quintessential need to stream line the follow-up care of prosthetic valve patients. This mandates the development of a consensus guideline for the antithrombotic therapy in VHD patients post prosthetic valve implantation. METHODS: A national level panel was constituted comprising 13 leading cardio care experts in India who thoroughly reviewed the up to date literature, formulated the recommendations, and developed the consensus document. Later on, extensive discussions were held on this draft and the recommendations in 8 regional meetings involving 79 additional experts from the cardio care in India, to arrive at a consensus. The final consensus document is developed relying on the available evidence and/or majority consensus from all the meetings. RESULTS: The panel recommended vitamin K antagonist (VKA) therapy with individualized target international normalized ratio (INR) in VHD patients after prosthetic valve implantation. The panel opined that management of prosthetic valve complications should be personalized on the basis of type of complications. In addition, the panel recommends to distinguish individuals with various co-morbidities and attend them appropriately. CONCLUSIONS: Anticoagulant therapy with VKA seems to be an effective option post prosthetic valve implantation in VHD patients. However, the role for non-VKA oral therapy in prosthetic valve patients and the safety and efficacy of novel oral anticoagulants in patients with bioprosthetic valve need to be studied extensively.

Pregnancy After Cardiac Surgery.

Heart disease is one of the common, indirect obstetric causes of maternal death. Management of these cases may challenge the entire team providing care to the mother and fetus. Advances in cardiac surgery has improved quality of life and level of functioning of cardiovascular system of patients with congenital or acquired heart disease. These diseases complicate 0.1-4 % pregnancies. Maternal complications in the form of thromboembolic, hemorrhagic episode and heart failure may occur. The fetus is in danger of effects of oral anticoagulation therapy and other medications given to the patient in order to support cardiovascular system, intrauterine growth restriction and danger of hypoxia. In recent era, we are facing more pregnant patients with previous history of surgical correction of congenital or rheumatic heart disease. In this review, we have attempted to draw a management protocol of such patients based on the available literature and various international guidelines. In pregnant women with mechanical heart valves, recent data support warfarin use throughout pregnancy, followed by a switch to heparin and planned induction of labor. However, the complexity of this situation demands a cafeteria approach where the patient herself can choose from the available options that are supported by evidence-based information. Preconception counseling, evaluation and antenatal high-risk management protocol with the help of cardiologist and cardiac surgeon improves maternal and neonatal outcome.