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Chapter 53: Antithrombotic Therapy for Valvular Heart Disease

A 62-year-old man with a prior history of idiopathic dilated cardiomyopathy was admitted to the cardiology unit with advanced heart failure and severe functional mitral regurgitation. During his admission, the patient suffered from recurrent pulmonary edema complicated by intractable hemodynamic instability. After discussing the case with the heart team, the patient underwent percutaneous edge-to-edge repair for mitral regurgitation using the MitraClip device. Which of the following antithrombotic regimens would you recommend to reduce this patient’s risk of thromboembolic events post-procedure?

A. Warfarin indefinitely

B. Apixaban indefinitely

C. Aspirin for 6 months along with clopidogrel for 30 days

D. Warfarin indefinitely along with aspirin for 6 months

E. No specific antithrombotic therapy is recommended

The answer is C. (Hurst’s The Heart, 14th Edition, Chap. 53) Following percutaneous edge-to-edge repair for mitral regurgitation using the MitraClip device, aspirin (325 mg/d) is recommended for 6 months along with clopidogrel (75 mg/d) for 30 days after the procedure.1

A 75-year-old woman with a prior history of rheumatic heart disease and stage 5 chronic kidney disease presented to the emergency department following a fall complicated by a femoral neck fracture. She denied any history of falls prior to this event, and she had been generally very active and well. Her physical examination revealed an irregularly irregular pulse and a metallic click best heard at the apex. After reviewing her old medical notes, you noticed that the patient underwent a successful mechanical mitral valve replacement (MVR) surgery 15 years ago for which she was taking warfarin. The patient was subsequently evaluated by the orthopedic team, and the plan was to proceed with hip arthroplasty surgery. Which of the following antithrombotic regimens would you recommend during the peri­operative period?

A. Stop warfarin 2 to 4 days before surgery, start intravenous unfractionated heparin when the INR falls to < 2.0, and restart warfarin 12 to 24 hours after surgery if bleeding risk allows

B. Stop warfarin 2 to 4 days before surgery, start low molecular weight heparin when the INR falls to < 2.0, and restart warfarin 12 to 24 hours after surgery if bleeding risk allows

C. Stop warfarin 2 to 4 days before surgery and restart warfarin 12 to 24 hours after surgery if bleeding risk allows

D. Do not stop warfarin (maintain therapeutic INR), and proceed with hip surgery because the patient’s risk for thromboembolic events is very high

E. Cancel the hip surgery and manage the patient conservatively

The answer is A. (Hurst’s The Heart, 14th Edition, Chap. 53) For patients with a mechanical mitral valve, bridging ...

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