Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; Department of Internal Medicine, Beaumont Health System, Royal Oak, Michigan.
Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
J Am Coll Cardiol. 2020 Mar 3;75(8):857-866. doi: 10.1016/j.jacc.2019.12.037.
Early in the prevention and treatment of bioprosthetic valve thrombosis (BPVT), anticoagulation is effective, but the long-term outcome after BPVT is unknown.
The goal of this study was to assess the long-term outcomes of patients with BPVT treated with anticoagulation.
This analysis was a matched cohort study of patients treated with warfarin for suspected BPVT at the Mayo Clinic between 1999 and 2017.
A total of 83 patients treated with warfarin for suspected BPVT (age 57 ± 18 years; 45 men [54%]) were matched to 166 control subjects; matching was performed according to age, sex, year of implantation, and prosthesis type and position. Echocardiography normalized in 62 patients (75%) within 3 months (interquartile range [IQR]: 1.5 to 6 months) of anticoagulation; 21 patients (25%) did not respond to warfarin. Median follow-up after diagnosis was 34 months (IQR: 17 to 54 months). There was no difference in the primary composite endpoint between the patients with BPVT and the matched control subjects (log-rank test, p = 0.79), but the former did have a significantly higher rate of major bleeding (12% vs. 2%; p < 0.0001). BPVT recurred (re-BPVT) in 14 (23%) responders after a median of 23 months (IQR: 11 to 39 months); all but one re-BPVT patient responded to anticoagulant therapy. Patients with BPVT had a higher probability of valve re-replacement (68% vs. 24% at 10 years' post-BPVT; log-rank test, p < 0.001).
BPVT was associated with re-BPVT and early prosthetic degeneration in a significant number of patients. Indefinite warfarin anticoagulation should be considered after a confirmed BPVT episode, but this strategy must be balanced against an increased risk of bleeding.
在生物瓣血栓形成（BPVT）的预防和治疗早期，抗凝治疗是有效的，但 BPVT 的长期预后尚不清楚。
本研究旨在评估接受抗凝治疗的 BPVT 患者的长期预后。
这是一项匹配队列研究，纳入了 1999 年至 2017 年期间在梅奥诊所因疑似 BPVT 接受华法林治疗的患者。
共 83 例因疑似 BPVT 接受华法林治疗的患者（年龄 57 ± 18 岁；45 例男性[54%]）与 166 例对照患者匹配；匹配因素包括年龄、性别、植入年份以及假体类型和位置。62 例（75%）患者在抗凝治疗 3 个月内（IQR：1.5 至 6 个月）超声心动图恢复正常；21 例（25%）患者对华法林无反应。诊断后中位随访时间为 34 个月（IQR：17 至 54 个月）。BPVT 患者与匹配对照患者的主要复合终点无差异（log-rank 检验，p=0.79），但前者大出血发生率明显更高（12% vs. 2%；p<0.0001）。14 例（23%）有反应的患者在中位时间 23 个月（IQR：11 至 39 个月）后再次发生 BPVT（再发 BPVT）；除 1 例外，所有再发 BPVT 患者均对抗凝治疗有反应。BPVT 患者瓣膜再次置换的概率更高（10 年后再发 BPVT 患者中分别为 68%和 24%；log-rank 检验，p<0.001）。
在相当数量的患者中，BPVT 与再发 BPVT 和早期假体退化有关。在确认发生 BPVT 后，应考虑无限期华法林抗凝，但这种策略必须与增加出血风险相平衡。
