#JustIn: Indian Guideline 2019 for Valvular heart disease pa

Valvular heart disease patients with prosthetic valve: Follow-up & Mx Guideline

#JustIn First Indian practice guidelines in cardiac surgery #FirstOnPlexusMD

The first clinical practice guidelines on ‘Follow up and Management of Valvular Heart Disease patients with Prosthetic Valve’ have been recently published in the Indian Journal of Thoracic and Cardiovascular Surgery. A national level panel was constituted comprising 13 leading cardio care experts in India who thoroughly reviewed the up to date literature, formulated the recommendations, and developed the consensus document.

“The worldwide annual rate of valve replacement is projected around 275,000 to 370,000, of which 55% are mechanical heart valves and 45% are bioprosthesis heart valves. In India, this number is estimated to be in excess of 10,000”, the authors write in the guidance document.

Valvular heart disease (VHD) patients after prosthetic valve implantation are at risk of thromboembolic events. Follow-up care of patients with prosthetic valve has a paramount role in reducing the morbidity and mortality. The guideline recommends vitamin K antagonist (VKA) therapy with individualized target international normalized ratio (INR) in VHD patients after prosthetic valve implantation. In addition to that, the authors opine that management of prosthetic valve complications should be personalized on the basis of type of complications. Furthermore, the panel stresses upon distinguishing patients with various co-morbidities and attend them appropriately.

The recommendations have been made on the following topics:-

1. Anticoagulation
•  Anticoagulants in mechanical prosthesis
•  Anticoagulants in bioprosthesis
•  Anticoagulants in transcatheter aortic valve implantation
•  Bridging anticoagulants
•  Cardiac catheterization in patients with prosthetic valves


2. Initiation, monitoring and factors affecting anticoagulation
• Point-of-care INR testing
• Loading dose, dose adjustments, and frequency of INR monitoring
• Factors affecting VKA therapy Pharmacogenetics
• Anticoagulation in special patient populations Pregnancy


3. Mx of prosthetic valve complications
•  Thromboembolic events
•  Thrombosis of prosthetic valves
•  Bleeding complications
•  Prosthetic valve endocarditis (PVE)


4. Follow-up evaluations & Mx of concomitant cardiac disease
•  Heart failure
•  Coronary artery disease
•  Atrial fibrillation
•  Follow up cardiac evaluation
•  CT and MRI scan-post valve implantation

Proposed initiation and maintenance of VKA therapy

The key points of the guideline are:-

• Vitamin K antagonists (VKA) therapy with a target INR range of 2-3 in pts with mechanical aortic valve replacement (AVR) without risk factors

• VKA therapy with a target INR range of 2.5-3.5 in pts with mechanical AVR with risk factors-atrial fibrillation (AF), previous thromboembolism, left ventricular (LV) dysfunction, or hypercoagulable conditions

• With mechanical valves in both the aortic and mitral position, a target INR range of 2.5 to 3.5

• In pts after bioprosthetic AVR or MVR, long-term aspirin at a dose of 75 to 150 mg/day after withdrawal of VKA therapy

• It is not recommended to interrupt VKA therapy during minor dental procedures (cleaning), dermatological procedures and cataract surgery due to minimal bleeding

• When interruption of VKA therapy is required, stop for 2-4 days before the procedure. After stopping, check INR after 2 days and maintain <2. The VKA therapy should be restarted 12–24 h after surgery

• The reversal of VKA therapy during emergency surgeries can be achieved by administration of FFP. FFP requirement depends on the PT/INR value, liver function tests, and body weight of the pt

• VKA therapy may be reduced or withheld and bridging is considered for pts with the femoral approach in the electrophysiological procedure

• In pts who are at low risk of thromboembolic events, undergoing pulmonary vein isolation (PVI), VKA dose should be adjusted to maintain INR <2 and regular dose to be commenced after implantation

• The initial recommended dosages of VKAs are warfarin, 5 mg and acenocoumarol, 2 mg

• Avoid drugs that inhibit or enhance the activity of cytochrome P450 during the VKA therapy

• NSAIDs should not be used with VKAs, if at all NSAIDs are needed, paracetamol may be considered with close supervision

• Oral VKA therapy throughout pregnancy in pts with daily warfarin dose requirement of ≤ 5 mg (or equivalent acenocoumarol dose) with target INR of 3 (Before 36 weeks of gestation)

• If pt is hospitalized, VKA may be substituted with UFH. If not, VKA therapy should be discontinued prior to admission for delivery (At 36 weeks of gestation)

• Closely monitor VKA therapy in pts on chemotherapy

• Transesophageal echocardiogram (TEE) for assessing thrombus size and valve motion

• For pts with VKA-associated active bleeding, withhold VKA, and administer FFP. Administer vitamin K1 as slow IV infusion if uncontrolled

• ACE inhibitors and β blockers along with antithrombotics are recommended in pts with stage B, Chronic HF. Moreover, spironolactone and digoxin can be added if congestive failure supervenes despite regular medications

• Amiodarone at a dose of 100–200 mg daily for 3 months with dosage monitoring along with β blockers for transient perioperative AF

• MRI examination for pts with risk of endocarditis and valve dehiscence should be decided in consultation with a radiologist


Guideline Contributors

The VHD India consensus committee constitutes the following members along with the listed authors: Bipin Bihari Mohanty (Chief Consultant Cardiothoracic Surgeon, Aditya CARE Hospitals, Bhubaneshwar), Jagdish Mange (Chief Cardiothoracic Surgeon, Shree Mahavir Health and Medical Relief Society, Surat), Manish Puranik (Consultant Minimally Invasive Cardiac Surgeon, Seth Nandlal Dhoot Hospital, Aurangabad), Manoj P Nair (Senior Consultant, Cardio Vascular Thoracic Surgery, Aster Medcity, Kochi), Pankaj Goel (Director, Cardiothoracic & Vascular Surgery, Ivy Healthcare, Amritsar), RM Krishnan (Chief Cardiothoracic Surgeon, Meenakshi Mission Hospital, Madurai), Sathyaki Nambala (Chief Heart Surgeon, Apollo Hospitals, Bangalore). 

Note: This list is a brief compilation of some of the key recommendations included in the Guideline and is not exhaustive and does not constitute medical advice. Kindly refer to the original publication here: https://pxmd.co/PUXRK  

About Author
Dr. Prachi Chhimwal
Dr. Prachi Chhimwal is an Editor at PlexusMD and is a part of the Engagment Team. She curates the Technical Content posted daily on the news feed. She graduated from Army College of Dental Sciences (B.D.S) and went on to pursue her post-graduation (M.D.S) in Oral & Maxillofacial Pathology. After a decade in the field of dentistry she took a leap of faith and joined PlexusMD. A badminton enthusiast, when not working you can find her reading, Netflixing or enjoying stand-up comedy shows.
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