Author + information
- Alexander C. Flint, MD, PhD∗ (, )
- Ramesh Lingamneni, MD,
- Vivek A. Rao, MD,
- Sheila L. Chan, MD,
- Xiushui Ren, MD,
- Jasmeen Pombra, MD,
- J. Claude Hemphill III, MD, MAS and
- Robert O. Bonow, MD
- ↵∗Department of Neuroscience, Kaiser Permanente, Redwood City, 1150 Veterans Boulevard, Redwood City, California 94025
Intracranial hemorrhage in patients with mechanical heart valves carries a risk of thrombosis and of rehemorrhage. Because interruption of anticoagulation with a mechanical heart valve may lead to thrombotic events, cardiologist recommendations generally lean toward minimizing the time off anticoagulation, although valve guidelines do not specifically address the duration of anticoagulation interruption (1,2). At the same time, when anticoagulation is resumed in these patients, there is a risk of recurrent hemorrhage, and longer periods of anticoagulation interruption should, in theory, reduce the risk of rehemorrhage. Because this scenario is rare, the extent of these 2 competing risks is poorly understood. Data regarding these risks come from small single-center retrospective case series, with the largest series to date consisting of 52 patients with intracranial hemorrhage on anticoagulation for mechanical valves (3).
To help clarify the risks of thrombosis and rehemorrhage during the early management of intracranial hemorrhage in patients with mechanical heart valves, we performed a multicenter retrospective chart review over a 16-year period (1996 to 2011) in an integrated health care delivery system (Kaiser Permanente Northern California: 18 hospital centers, >3 million patients). Patients were identified by clinical database query with confirmation of all cases by manual chart review. Patients with mechanical valves with or without concomitant atrial fibrillation were included, but patients with bioprosthetic valves were not included.
We identified 141 mechanical heart valve patients who had a total of 153 intracranial hemorrhage events. Forty-four patients died from their initial intracranial hemorrhage; the remaining 109 hemorrhage events had both interruption and resumption of anticoagulation without hemorrhage expansion during anticoagulation interruption. All 109 received warfarin reversal agents and completed warfarin reversal. Operative neurosurgical intervention for the hemorrhage event was performed in 32 of 109 (29.4%). Ninety-eight mechanical heart valves (63.8%) were 1 device type (St. Jude Medical, St. Paul, Minnesota). Thirty-nine (27.7%) mechanical valves were in the mitral position, 78 (55.3%) were in the aortic position, 21 (14.9%) were in both mitral and aortic positions, and 3 (2.1%) were in another position.
Thrombotic events occurred in 7 of 109 patients during anticoagulation interruption (6.4%; 95% CI: 2.6% to 12.8%), including 5 ischemic strokes, 1 episode of valve thrombosis, and 1 fatal cardiac arrest of unknown etiology. Thrombotic events occurred in 5 of 52 patients (9.6%) with mechanical valves in the mitral position (with or without another mechanical valve), compared to 2 thrombotic events in 57 patients without a mitral mechanical valve (3.5%), but this difference was not significant (p = 0.26). The type of warfarin reversal agent used was not predictive of the risk of thrombotic events.
Rehemorrhage within 2 weeks of anticoagulation resumption occurred in 4 of 109 patients (3.7%; 95% CI: 1.0% to 9.3%). All rehemorrhage events occurred in patients with subdural hematomas (4 of 48 patients; 8.3%) and consisted of significant increase in subdural hemorrhage with clinical deterioration; no rehemorrhages occurred in other types of intracranial hemorrhage (0 of 61 patients; 0%) (p = 0.04). No rehemorrhages occurred in the 32 patients who had neurosurgical intervention for their initial hemorrhage, compared to 4 recurrent hemorrhages in the 77 patients without neurosurgical intervention, but this difference was not significant (p = 0.32).
All rehemorrhage events occurred during anticoagulation resumption after ≤7 days of anticoagulation interruption, while less than one-half of the thrombotic events occurred during an anticoagulation interruption of ≤7 days (Figure 1).
Both thrombotic and rehemorrhage events are relatively uncommon when anticoagulation is interrupted in mechanical heart valve patients with intracranial hemorrhage. While clinical decisions regarding anticoagulation interruption must be tailored to an individual patient’s clinical situation, a general strategy of interrupting anticoagulation for 7 to 10 days may minimize the risk of both thrombotic and rehemorrhage events. Mechanical heart valve patients with subdural hematoma may be a group with a higher risk of recurrent hemorrhage.
Please note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- American College of Cardiology Foundation
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- for the Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC),
- European Association for Cardio-Thoracic Surgery (EACTS)