Valves, anticoagulation and

the pericardium

January 2019

Nik Sabharwal

Consultant Cardiologist

Oxford Heart Centre

nikant.sabharwal@ouh.nhs.uk

Contents

• Hypertension

• Anticoagulation

• Valve disease

• Pericardial disease

• Cases

Hypertension

• ACD approach

• ACEi/ARB (<55 years)

• CCB (>55 years)

• Diuretic (thiazide)

• Alpha-blocker (postural symptoms)

• Spironolactone

Anticoagulation Acronyms

• DAPT

• VKA

• DOACs

• LMWH

• UFH

Anticoagulation Acronyms

• DAPT

• Dual antiplatelet (aspirin + clopidogrel)

• VKA

• Warfarin

• DOACs

• Apixaban, Rivaroxaban, Edoxaban,

Dabigatran

• LMWH

• Dalteparin, Enoxaparin, Tinzaparin

• UFH

• Unfractionated heparin

Cardiac indications

• AF

• Mechanical valves

• (PE)

Stroke prevention

Mechanical/prosthetic heart valves

• Aortic – most common

• Mitral – second most common

• Tricuspid – rare

• Pulmonary – not done

Dangas et al. J Am Coll Cardiol 2016;68:2670–89

Dangas et al. J Am Coll Cardiol 2016;68:2670–89

Risk factors for mechanical valve

thrombosis

• Mitral position

• AF

• LV systolic dysfunction

• Non bileaflet valve

• Sluggish flow

• “smoke” on echocardiogram

Mechanical Heart Valves

• Annual incidence of obstruction

• 0.1-5.7%

• Higher in first 3 months post-op

• Annual incidence of thrombo-embolism

• 2.5-3.7%

• Any aetiology

Anticoagulation in prosthetic valves

• Warfarin

• LMWH

• UFH

• DOACs are not licenced

Bleedings Thromboses Death

Aortic valve prosthesis, N=3656

Actual INR 2.2–2.7 2.74 (2.41 to 3.12) 2.42 (2.10 to 2.77) 1.79 (1.53 to 2.08)

Actual INR 2.8–3.3 3.02 (2.35 to 3.81) 2.28 (1.71 to 2.98) 2.97 (2.36 to 3.69)

Mitral valve prosthesis, N=1031

Actual INR 2.2–2.7 4.73 (3.72 to 5.94) 2.95 (2.17 to 3.93) 2.48 (1.80 to 3 to 33)

Actual INR 2.8–3.3 3.97 (2.89 to 5.33) 2.63 (1.77 to 3.77) 4.17 (3.16 to 5.41)

Variability

≤0.4000 2.08 (1.78 to 2.41) 1.90 (1.61 to 2.22) 1.51 (1.26 to 1.79)

≥0.4001 4.33 (3.87 to 4.82) 2.96 (2.59 to 3.38) 3.31 (2.93 to 3.74)

Time in Therapeutic Range

≥70% 2.30 (2.03 to 2.60) 2.13 (1.86 to 2.41) 1.68 (1.47 to 1.93)

<70% 5.13 (4.51 to 5.82) 3.05 (2.58 to 3.59) 4.00 (3.50 to 4.54)

Rate of complications per 100 treatment years with 95% CI (https://heart.bmj.com/content/103/3/175)

Anecdotal data

• Aortic prostheses

• 27-37 years with no anticoagulation

• Local guidelines

• No need for bridging therapy if lower risk

• LMWH if prior thrombosis or higher risk valve

Patient with a mechanical

artificial heart valve is identified as

being in the last days to short weeks of life

Presence of high risk features

High Risk Type of Valve: Older valves in particular a Ball and cage type valve [Low risk valve types include tilting disc and bi-leaflet]

Nil high risk features

Consider stopping anticoagulation

High Risk Position: Mitral position Right sided valve

Presence of high risk factors for a thrombo-embolic event*: Previous VTE Proven hypercoagulable condition e.g. thrombophilia

Consider continuing

anticoagulation © Victoria Bradley

Draft Guideline for

mechanical valves

in EOL patients

Practical approach to MHV therapy

cessation

• Risk of obstruction/embolism

• CHADSVASC score helpful

• Alternative options

• Oral vs Subcut

• Informed consent

• Family discussion

MHV events per 100 patient years

VKA No VKA

Systemic

embolism 1 4

Valve thrombosis 0.2 1.8

Total

thromboembolism

risk

1.8 8.6

Summary (MHV)

• Mechanical valves and anticoagulation

concerns

• Complex decision making

• Not always evidence based/available

• Risk:benefit analysis

• Multi-disciplinary approach

• ED, AGM, Cardiac surgery, Haematology,

Gastroenterology, Radiology

Pericardial disease • Effusion

• Constriction

• Clinical

• Raised JVP with inspiration

• Drop in pulse volume/BP with inspiration

• Exaggerated tachycardia (c.f. PE)

• Postural hypotension

• Imaging

• Echo, CT

• CMR

Effusion management

• Avoid diuretics

• Anti-inflammatories

• NSAIDS, colchicene, steroids

• Percutaneous drainage

• Cardiology (once only)

• Surgical window

• Thoracic surgery (VATS)

• Cardiac surgery (subxiphoid window)

Constriction management

• Avoid diuretics

• Anti-inflammatories (acute phase only)

• NSAIDS, colchicene, steroids

• Pericardial strip

• Significant mortality depending on chronicity

• Thoracic surgery (VATS)

• Cardiac surgery (sternotomy)

Patient HM

• 60 female

• Smoker

• COPD

• SOBOE

• Weight loss

• Left pleural effusion

• CT chest

Summary (Pericardial)

• Pericardial effusion

• Tamponade physiology (gradual)

• Drained percutaneously

• Managed with Imatinib

• VATS not possible

• RV free wall stuck to pericardium

• Severe TR (functional)

• Ascites

Final Summary

• Prosthetic valves should not be feared

• Proposed algorithm for mechanical valves

• Pericardial disease

• Discuss with an imaging cardiologist

• Hypertension

• ACD approach

“There is no trouble so great or

grave that cannot be much

diminished by a nice cup of tea”

Bernard-Paul Heroux

Any questions?