Hanania G, Maroni J P, el Hajj Y
Service de cardiologie, hôpital Robert-Ballanger, 93602 Aulnay-sous-Bois, France.
Ann Cardiol Angeiol (Paris). 2003 Nov;52(5):290-6. doi: 10.1016/s0003-3928(03)00097-0.
Prosthetic valve replacement has transformed the outcome of patients with severe or poorly tolerated valvular heart disease. Between the two main families of prostheses, only mechanical prostheses require indefinite anticoagulant therapy to lower the thromboembolic risk. National and international guidelines have been published within the past decade. They have outlined how anticoagulation, essentially oral anticoagulant therapy and transient heparin, should be used. The intensity of anticoagulation depends on the type of prosthesis, its position, the presence of atrial fibrillation and the individual's risk of thromboembolism. Monitoring is based on the INR. Temporary recourse to heparin therapy is necessary for all situations in which the risk of major hemorrhage requires more flexible treatment (postoperative period, extracardiac surgery, stroke, severe hemorrhage) or when warfarin is contraindicated because of its risk of inducing malformation (pregnancy). Low molecular weight heparins are not yet authorized for use in prosthesis bearers. Nonetheless, they are being prescribed by more-and-more teams, seduced by the facility of their use, their more stable action and, usually, no need for biological monitoring. And their use is supported by the most recent guidelines, several favorable publications, and the excellent results obtained with them in treating other thromboembolic pathologies. Indispensable to lower the rate of thromboembolic events, anticoagulant therapy bears a hemorrhagic risk that is higher for prolonged and marked anticoagulation. On the other hand, despite effective anticoagulation, the occurrence of thromboemboli can lead to considering the adjunction, in certain cases, of anti-platelet aggregating agents, particularly favored in North America, and recommended in Europe for patients with a predilection for atheromas.
人工瓣膜置换术改变了重症或耐受性差的瓣膜性心脏病患者的治疗结局。在两大类人工瓣膜中，只有机械瓣膜需要长期抗凝治疗以降低血栓栓塞风险。过去十年间已发布了国内和国际指南。这些指南概述了抗凝治疗（主要是口服抗凝治疗和短期肝素治疗）的使用方法。抗凝强度取决于人工瓣膜的类型、其位置、房颤的存在以及个体的血栓栓塞风险。监测基于国际标准化比值（INR）。在所有因大出血风险需要更灵活治疗的情况下（术后阶段、心外手术、中风、严重出血），或者当华法林因有致畸风险而禁忌使用时（妊娠），临时采用肝素治疗是必要的。低分子量肝素尚未被批准用于人工瓣膜携带者。尽管如此，越来越多的医疗团队在使用它，这是因为其使用方便、作用更稳定，且通常无需进行生物学监测。其使用得到了最新指南、一些有利的出版物以及在治疗其他血栓栓塞性疾病中取得的优异成果的支持。抗凝治疗对于降低血栓栓塞事件发生率不可或缺，但长期和显著抗凝会带来更高的出血风险。另一方面，尽管进行了有效的抗凝治疗，但血栓栓塞的发生在某些情况下可能导致考虑加用抗血小板聚集药物，这在北美尤为普遍，在欧洲，对于易患动脉粥样硬化的患者也有推荐。
