Division of Pharmacy, MD Anderson Cancer Center, Houston, TX, USA.
Ann Pharmacother. 2012 Mar;46(3):e9. doi: 10.1345/aph.1Q643. Epub 2012 Feb 21.
To report a case of successful use of fondaparinux for bridging early after aortic and mitral mechanical heart valve replacement (MHVR).
A 71-year-old female underwent aortic and mitral valve replacements with St. Jude medical bileaflet prostheses, as well as DeVega tricuspid annuloplasty and coronary artery bypass graft. Anticoagulation was initially withheld following the procedure because of thrombocytopenia, large amount of chest tube drainage (~1 L/day), and concerns regarding postoperative bleeding. The thrombocytopenia (baseline platelet count 183 x 10(3)/μL; postoperative platelet count 44 × 10(3)/μL) was thought to be a consequence of the cardiopulmonary bypass; there was a low probability of heparin-induced thrombocytopenia. However, the care team preferred to avoid heparin products and initiated fondaparinux 7.5 mg subcutaneously once daily on postoperative day 8 once the patient's platelet count had recovered to >100 x 10(3)/μL. The treatment was bridged to warfarin on postoperative day 13 and the patient was discharged home after receiving 8 days of fondaparinux. Throughout the patient's hospitalization and upon follow-up on postoperative day 31, there were no signs or symptoms of thromboembolic events or bleeding.
Unfractionated heparin and low-molecular-weight heparins are the standard of care for bridging to warfarin in patients with MHVR. The use of fondaparinux following MHVR has not been studied in randomized controlled trials. In vitro studies support the effectiveness of fondaparinux in preventing thrombus formation on mechanical heart valves. However, the only data available in humans as of December 2011 are 3 case reports. Two of these case reports described the successful use of fondaparinux for anticoagulation in a patient with an aortic valve replacement. In the third case report, the patient had an aortic and mitral valve replacement. Our case report is novel because it describes the use of fondaparinux early after MHVR, which is the most critical time period for effective thromboprophylaxis.
The use of fondaparinux for postoperative bridging in our patient early after combined aortic and mitral MHVR was effective. However, until studies evaluate the efficacy and safety of fondaparinux in patients with MHVR, its use should be considered only when heparin products are contraindicated.
报告 1 例成功使用磺达肝癸钠桥接主动脉瓣和二尖瓣机械心脏瓣膜置换术后抗凝的病例。
一名 71 岁女性因主动脉瓣和二尖瓣疾病接受 St. Jude 医疗公司双叶瓣置换术、DeVega 三尖瓣环成形术和冠状动脉旁路移植术。由于血小板减少症（血小板计数基线为 183×103/μL，术后血小板计数 44×103/μL）、大量胸腔引流管引流量（约 1 L/天）和对术后出血的担忧，术后最初未进行抗凝治疗。该血小板减少症被认为是体外循环的结果；肝素诱导的血小板减少症的可能性较低。然而，医疗团队更倾向于避免肝素产品，并在患者血小板计数恢复至>100×103/μL后于术后第 8 天开始每日皮下注射磺达肝癸钠 7.5mg。术后第 13 天桥接至华法林治疗，患者接受磺达肝癸钠治疗 8 天后出院。在整个住院期间和术后第 31 天随访时，患者均无血栓栓塞事件或出血的迹象或症状。
对于接受二尖瓣机械心脏瓣膜置换术的患者，标准的桥接治疗是使用普通肝素和低分子肝素。尚未在随机对照试验中研究过二尖瓣机械心脏瓣膜置换术后使用磺达肝癸钠。体外研究支持磺达肝癸钠在预防机械心脏瓣膜上血栓形成方面的有效性。然而，截至 2011 年 12 月，唯一可获得的人体数据来自 3 例病例报告。其中 2 例病例报告描述了在主动脉瓣置换术患者中成功使用磺达肝癸钠进行抗凝治疗。在第 3 例病例报告中，患者接受了主动脉瓣和二尖瓣置换术。我们的病例报告是新颖的，因为它描述了在二尖瓣机械心脏瓣膜置换术后早期使用磺达肝癸钠进行桥接治疗，这是有效血栓预防的最关键时期。
在我们的患者中，在二尖瓣机械心脏瓣膜置换术后早期联合使用磺达肝癸钠进行桥接治疗是有效的。然而，在研究评估磺达肝癸钠在二尖瓣机械心脏瓣膜置换术后患者中的疗效和安全性之前，仅在肝素产品禁忌时才应考虑使用磺达肝癸钠。
