Thromboembolic events after major bleeding events in patients with mechanical heart valves: a 13-year analysis

Pascal Augustin; Stefan Andrei; Bernard Iung; Marylou Para; Peter Matthews; Christian de Tymowski; Nadine Ajzenberg; Philippe Montravers

doi:10.1007/s11239-024-02964-5

Thromboembolic events after major bleeding events in patients with mechanical heart valves: a 13-year analysis

J Thromb Thrombolysis. 2024 Mar 31. doi: 10.1007/s11239-024-02964-5. Online ahead of print.

Authors

Pascal Augustin¹, Stefan Andrei^{2

3}, Bernard Iung⁴, Marylou Para^{5

6}, Peter Matthews⁷, Christian de Tymowski^{2

8}, Nadine Ajzenberg^{6

9}, Philippe Montravers^{2

10}

Affiliations

¹ Department of Anesthesiology and Critical Care, Groupe Hospitalier Bichat-Claude Bernard, Assistance Publique Hôpitaux de Paris, 46 Rue Henri Huchard, Paris, 75018, France. pascalaugustin@hotmail.com.
² Department of Anesthesiology and Critical Care, Groupe Hospitalier Bichat-Claude Bernard, Assistance Publique Hôpitaux de Paris, 46 Rue Henri Huchard, Paris, 75018, France.
³ Group of Applied Mathematics and Computational Biology, CNRS UMR 8542, Paris, France.
⁴ Department of Cardiology, Assistance Publique Hôpitaux de Paris, Groupe Hospitalier Bichat Claude Bernard, University of Paris, Paris, France.
⁵ Department of Cardiovascular Surgery and Transplantation, Groupe Hospitalier Bichat-Claude Bernard, Assistance Publique Hôpitaux de Paris, Paris, France.
⁶ Laboratory of Vascular Translational Science, University of Paris, INSERM UMR 1148, Paris, France.
⁷ Centre de Recherche sur l'Inflammation, University of Paris, INSERM UMR 1149, CNRS ERL8252, Paris, France.
⁸ Division of Critical Care Services, Northwick Park and St Marks Hospital, London, UK.
⁹ Department of Hematology, Groupe Hospitalier Bichat Claude Bernard, Assistance Publique Hôpitaux de Paris, Paris, France.
¹⁰ Physiopathology and Epidemiology of respiratory diseases, University of Paris, INSERM UMR1152, Paris, France.

PMID: 38556579
DOI: 10.1007/s11239-024-02964-5

Abstract

Anticoagulation in patients with mechanical heart valves (MHV) is associated with a risk of major bleeding episodes (MBE). In case of MBE, anticoagulant interruption is advocated. However, there is lack of data regarding the thrombo-embolic events (TE) risk associated with anticoagulant interruption. The main objective of the study was to evaluate the rate and risk factors of 6-months of TEs in patients with MHV experiencing MBE. This observational study was conducted over a 13-year period. Adult patients with a MHV presenting with a MBE were included. The main study endpoint was 6-month TEs, defined by clinical TEs or an echocardiographic documented thrombosis, occurring during an ICU stay or within 6-months. Thromboembolic events were recorded at ICU discharge, and 6 months after discharge. Seventy-nine MBEs were analysed, the rate of TEs at 6-months was 19% CI [11-29%]. The only difference of presentation and management between 6-month TEs and free-TE patients was the time without effective anticoagulation (TWA). The Receiver Operator Characteristic curve identified the value of 122 h of TWA as a cut-off. The multivariate analysis identified early bleeding recurrences (OR 3.62, 95% CI [1.07-12.25], p = 0.039), and TWA longer than 122 h (OR 4.24, 95% CI [1.24-14.5], p = 0.021), as independent risk factors for 6-month TEs. A higher rate of TE was associated with anticoagulation interruption longer than 5 days and early bleeding recurrences. However, the management should still be personalized and discussed for each case given the heterogeneity of causes of MBE and possibilities of haemostatic procedures.

Keywords: Major bleeding event; Mechanical heart valve; Thromboembolic event; Time without anticoagulation.