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Otto et al 2020 ACC/AHA Guideline for the Management of Valvular Heart Disease

February 2, 2021 Circulation. 2021;143:e72–e227. DOI: 10.1161/CIR.0000000000000923 e142

CLINICAL STATEMENTS AND GUIDELINES observational study, the expected durability of a bioprosthetic mitral valve replacement was 11.4 years in patients <60 years of age, 16.6 years in those 60 to 70 years of age, and 19.4 years in those >70 years of age.11 In the 2017 report from the California Office of Statewide Health Planning and Development,1 overall survival rates were similar for patients 70 to 79 years of age who underwent mechanical versus bioprosthetic mitral valve replacement, and bleeding risk was lower with a bioprosthetic valve.1

8.	 Replacement of the aortic valve with a pulmonary autograft (the Ross procedure) is a complex operation involving replacement of the aortic valve by the patient’s own pulmonic valve, along with placement of a pulmonic valve homograft. The Ross procedure allows the patient to avoid a prosthetic heart valve and the risks of anticoagulation, and it provides excellent valve hemodynamics. However, both the pulmonic homograft in the pulmonic position and the pulmonary autograft (the neoaortic valve) are at risk of valve degeneration. The failure of the Ross procedure is most often attributable to regurgitation of the neoaortic valve in the second decade after the operation. In addition, at least half of pulmonic homograft valves require reintervention within 10 to 20 years. Calcification of the homograft and adhesions between the homograft and neoaorta may increase the difficulty of reoperation. The Ross procedure typically is reserved for younger patients with appropriate anatomy and tissue characteristics in whom anticoagulation is either contraindicated or undesirable, and it is performed only at Comprehensive Valve Centers by surgeons experienced in this procedure.12–14,32

11.2 Antithrombotic Therapy

Recommendations for Antithrombotic Therapy for Prosthetic Valves Referenced studies that support the recommendations are summarized in Online Data Supplement 36.

COR LOE Recommendations

1 A 1.  In patients with a mechanical prosthetic valve, anticoagulation with a VKA is recommended.1–5

1 B-NR 2.  For patients with a mechanical bileaflet or current-generation single-tilting disk AVR and no risk factors for thromboembolism, anticoagulation with a VKA to achieve an INR of 2.5 is recommended.6–8

1 B-NR 3.  For patients with a mechanical AVR and additional risk factors for thromboembolism (eg, AF, previous thromboembolism, LV dysfunction, hypercoagulable state) or an older-generation prosthesis (eg, ball-in-cage), anticoagulation with a VKA is indicated to achieve an INR of 3.0.9,10 1 B-NR 4 For patients with a mechanical mitral valve

replacement, anticoagulation with a VKA is indicated to achieve an INR of 3.0.9,11

2a B-R 5.  For patients with a bioprosthetic TAVI,

aspirin 75 to 100 mg daily is reasonable in the absence of other indications for oral anticoagulants.12–14

2a B-NR 6 For all patients with a bioprosthetic SAVR or

mitral valve replacement, aspirin 75 to 100 mg daily is reasonable in the absence of other indications for oral anticoagulants.9,15–18

2a B-NR 7 For patients with a bioprosthetic SAVR or

mitral valve replacement who are at low risk of bleeding, anticoagulation with a VKA to achieve an INR of 2.5 is reasonable for at least 3 months and for as long as 6 months after surgical replacement.15,19–25

2b B-R 8 For patients with a mechanical SAVR or mitral

valve replacement who are managed with a VKA and have an indication for antiplatelet therapy, addition of aspirin 75 to 100 mg daily may be considered when the risk of bleeding is low.26

2b B-R 9 For patients with a mechanical On-X AVR and

no thromboembolic risk factors, use of a VKA targeted to a lower INR (1.5–2.0) may be reasonable starting ≥3 months after surgery, with continuation of aspirin 75 to 100 mg daily.27,28

2b B-NR 10.  For patients with a bioprosthetic TAVI who are at low risk of bleeding, dualantiplatelet therapy with aspirin 75 to 100 mg and clopidogrel 75 mg may be reasonable for 3 to 6 months after valve implantation.12,13,29

2b B-NR 11.  For patients with a bioprosthetic TAVI who are at low risk of bleeding, anticoagulation with a VKA to achieve an INR of 2.5 may be reasonable for at least 3 months after valve implantation.23,31–33

3: Harm B-R 12.  For patients with bioprosthetic TAVI, treatment with low-dose rivaroxaban (10 mg daily) plus aspirin (75–100 mg) is contraindicated in the absence of other indications for oral anticoagulants.30

3: Harm B-R 13.  For patients with a mechanical valve prosthesis, anticoagulation with the direct thrombin inhibitor, dabigatran, is contraindicated.4,5

3: Harm C-EO 14.  For patients with a mechanical valve prosthesis, the use of anti-Xa direct oral anticoagulants has not been assessed and is not recommended.34–37

Synopsis

Antithrombotic therapy after prosthetic valve implantation is provided to prevent valve/leaflet thrombosis and reduce the incidence of thromboembolic complications. The use of any strategy must be balanced against the risk of bleeding. VKAs remain the cornerstone of therapy

Recommendations for Antithrombotic Therapy for Prosthetic Valves (Continued)

COR LOE Recommendations

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