Anticoagulation following mitral valve repair

Efficacy and safety of anti-thrombotic therapy after surgical mitral valve repair: a scoping review

BACKGROUND

Mitral valve repair (MVr) is the gold standard treatment for degenerative mitral regurgitation, yet there is ongoing controversy regarding optimal anti-thrombotic therapy post-MVr. This scoping review aimed to summarise current evidence on the safety and efficacy of anti-thrombotic therapy after MVr, identify knowledge gaps and propose a future study design.

METHODS

We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Clinicaltrials.gov, the WHO International Clinical Trials Registry Platform and bibliographies of included trials, guidelines and other reviews from inception to 17 September 2024. Randomised controlled trials (RCT) and cohort and case-control studies assessing any anti-thrombotic therapy with any outcomes after MVr were included. Using a predefined collection form, two authors independently extracted data on study characteristics and results were summarised narratively into themes based on the PICO elements.

RESULTS

Of 1296 screened references, we included 11 studies (10 cohort and one non-inferiority RCT). All studies compared vitamin K antagonist (VKA) to an anti-platelet, direct oral anti-coagulant or no anti-thrombotic therapy for median duration of 90 days. Thromboembolic and bleeding event incidences ranged from 0% to 14.3% and 0% to 9.1%, respectively. Seven studies reported no difference in thromboembolic events, and three reported reduced rates with VKA compared with control, while results for bleeding events varied widely. The RCT found edoxaban was non-inferior to warfarin for thromboembolic outcomes, but not for bleeding. Substantial methodological and clinical heterogeneity, high risk of bias and insufficient mitigation of confounders, such as concomitant atrial fibrillation, were prevalent across studies.

CONCLUSION

Based on this scoping review, existing literature on anti-thrombotic therapy after MVr is inconclusive due to design limitations. We proposed a study design for a pragmatic RCT that addresses prior study limitations and that could provide definitive evidence to guide anti-thrombotic management in MVr patients.

Outcomes of Mechanical Thrombectomy for Acute Ischemic Stroke Following Cardiac Interventions: A Systematic Review and Meta-Analysis

PURPOSE

The purpose of this study is to pool the evidence on the safety and efficacy of mechanical thrombectomy (MT) in patients who develop acute ischemic stroke (AIS) due to large vessel occlusion (LVO) following recent cardiac interventions.

METHODS

PubMed, Embase and Scopus were searched from inception up to February 2024 using a combination of "cardiac interventions" and "mechanical thrombectomy" as keywords. Studies that evaluated AIS within 30 days of a recent cardiac intervention who underwent MT were included. The proportion of mortality, favorable functional outcome (modified Rankin Scale (mRS) 0-2), successful reperfusion (TICI ≥ 2b or TIMI ≥ 2) and symptomatic intracranial hemorrhage (sICH) were pooled using generalized linear mixed model.

RESULTS

Thirty-one case reports/series and 11 observational studies including 195 MT procedures were included. The patients' mean age was 72 years. The most common cardiac intervention associated with AIS was transcatheter aortic valve replacement/implantation in 96/192 cases (50%). The median onset of stoke was 0 (IQR 0-3) days after cardiac intervention. Rate of successful reperfusion was 79.4% [95%confidence interval (CI) 66.7-88.1%], rate of mRS 0-2 after 90 days was 42.7% [95%CI 32.5-53.6%], and rate of mortality at 90 days was 30.3% [95%CI 21.7-40.6%]. The rate of sICH was 11.6% [95%CI 5.9-21.5%].

CONCLUSION

MT to treat AIS due to LVO after cardiac interventions may result in good rates of functional recovery, though mortality and sICH may be higher. Regular and repeated neurological examinations should be performed following cardiac interventions, with special attention to stroke. If stroke is detected, MT should be considered as a viable option.

Five-year outcomes of mitral valve repair for leaflet prolapse at a medium-sized Norwegian university hospital

Objective. To evaluate patient characteristics and 5-year outcomes after surgical mitral valve (MV) repair for leaflet prolapse at a medium-sized cardiothoracic center. Background. Contemporary reports on the outcome of MV repair at medium-sized cardiothoracic centers are sparse. Methods. Patients receiving open-heart surgery with MV repair due to primary mitral regurgitation caused by leaflet prolapse between 2015 and 2021, without active endocarditis, were included. Clinical data, complications, re-interventions, mortality, and echocardiographic data were retrospectively registered from electronical patient charts, both pre-operatively and from post-operative follow-ups. Results. One hundred and three patients were included, 83% male, with a mean age of 62 years. All-cause mortality was 9% during a median follow-up time of 4.9 years. Re-intervention rate on the MV was 4%. Post-operative complications before last available follow-up visit at median 3.0 years were infrequent, with new-onset atrial fibrillation/flutter in 16%, post-operative MV regurgitation grade II or above in 17% and post-operative tricuspid regurgitation grade II or above in 14%. Conclusions. These data demonstrate that surgical MV repair for leaflet prolapse at a medium-sized cardiothoracic center was associated with low re-intervention rate and few severe complications. The presented results are comparable to data from surgical high-volume centers, indicating that surgical MV repair can be safely performed at selected medium-sized cardiothoracic centers.

Nurses' knowledge, attitudes, and practices about rehabilitation of patients after heart valve surgery in Namibia

Background

A cardiac rehabilitation programme is a medically supervised intervention to assist patients in recovery after heart surgeries and to prevent potential complications. Nurses should have the knowledge, a positive attitudes, and good practices to improve patient quality of life during the recovery process.

Aim

This study aimed to describe the knowledge, attitudes, and practices of the nurses regarding cardiac rehabilitation for patients after heart valve surgery.

Setting

The study setting was Windhoek Central Hospital, Cardiac Unit, in Windhoek, Namibia.

Methods

A quantitative and descriptive research design was used for convenient non-probability sampling of (N = 23) nurses who consented to participate in the study. Data were collected through self-administered questionnaires and analyzed using SPSS Version 26. Descriptive statistics were used and Fischer's Exact test for associations of variables was performed.

Results

The study results showed a high level of knowledge, good attitudes, and poor to fair practices toward cardiac rehabilitation. However, the respondents demonstrate a lack of knowledge about the indications, and benefits of cardiac rehabilitation, negative attitudes regarding counselling of patients on sexual activities, and poor practice regarding exercises and counseling of patients and caregivers on cardiac rehabilitation. Furthermore, there is a positive relationship between the respondents' older age, senior rank, and having been trained I cardiac conditions and their knowledge, attitudes and practices regarding some core components of cardiac rehabilitation with P-value < 0.050.

Conclusion

There is a need for a cardiac rehabilitation programme to improve nurses' attitudes and practices toward cardiac rehabilitation.

Contribution

Understanding the gap in knowledge, attitudes, and practices among the nurses regarding cardiac rehabilitation would guide the Ministry of Health and Social Services (MoHSS) in the implementation of the cardiac rehabilitation for patients after heart valve surgery.

Oral Anticoagulation Versus Antiplatelet Treatment After Mitral Valve Repair: A Systematic Review and Meta-Analysis

Oral anticoagulation with vitamin K antagonists is currently advised for a period of 3 months after surgical mitral valve repair, regardless of the rhythm status. The evidence supporting this recommendation is weak and recent studies have challenged the safety and efficacy of this recommendation. A systematic review of literature was conducted by searching PubMed, Embase, Web of Science, Emcare, and Cochrane Library databases for original publications comparing the efficacy and safety of oral anticoagulation with vitamin K antagonists to antiplatelet treatment early after mitral valve surgery in patients with no atrial fibrillation. Study end points included thromboembolic complications, bleeding complications and survival. A total of 5 studies, including 5,093 patients, met the inclusion criteria; 2,824 patients were included in the oral anticoagulation and 2,269 in the antiplatelet treatment group. Pooled analyses demonstrated no beneficial effect of oral anticoagulation on the incidence of thromboembolic complications (risk ratio 1.14, 95% confidence interval 0.76 to 1.70, p = 0.53, I2 = 8%). Moreover, oral anticoagulation did not result in a significantly increased risk of bleeding complications (risk ratio 0.89, 95% confidence interval 0.32 to 2.44, p = 0.81, I2 = 87%). When combining the efficacy and safety end points, no difference was observed between groups (risk ratio 1.01, 95% confidence interval 0.51 to 1.97, p = 0.99 I2 = 85%). Likewise, mortality did not differ between groups (risk ratio 0.89, 95% confidence interval 0.15 to 5.23, p = 0.90 I2 = 71%). Our results confirmed the safety but failed to confirm the efficacy of oral anticoagulation in patients who underwent mitral valve surgery. A randomized controlled trial would provide the evidence needed to support treatment recommendations.

Thrombectomy in special populations: report of the Society of NeuroInterventional Surgery Standards and Guidelines Committee

BACKGROUND

The purpose of this guideline is to summarize the data available for performing mechanical thrombectomy (MT) for emergent large vessel occlusion (ELVO) stroke in special populations not typically included in large randomized controlled clinical trials, including children, the elderly, pregnant women, patients who have recently undergone surgery, and patients with thrombocytopenia, collagen vascular disorders, and endocarditis.

METHODS

We performed a literature review for studies examining the indications, efficacy, and outcomes for patients undergoing MT for ischemic stroke aged <18 years and >80 years, pregnant patients, patients who have recently undergone surgery, and those with thrombocytopenia, collagen vascular diseases, or endocarditis. We graded the quality of the evidence.

RESULTS

MT can be effective for the treatment of ELVO in ischemic stroke for patients over age 80 years and under age 18 years, thrombocytopenic patients, pregnant patients, and patients with endocarditis. While outcomes are worse compared to younger patients and those with normal platelet counts (respectively), there is still a benefit in the elderly (in both mRS and mortality). Data are very limited for patients with collagen vascular diseases; although diagnostic cerebral angiography carries increased risks, MT may be appropriate in carefully selected patients in whom untreated ELVO would likely result in disabling or fatal outcome.