Thromboembolism in Adults with St. Jude Medical® Valves on Ticlopidine and Aspirin Maintenance
We evaluated the risks of thromboembolism, valve thrombosis, anticoagulant hemorrhage, and sudden cardiac death in two groups of patients. The groups were similar in age, sex, and associated cardiovascular diseases except for the method of prevention of thromboembolism and length of follow-up. The group receiving warfarin consisted of 74 patients with 85 valves. Patients were maintained on long-term warfarin therapy. Eight of the 74 patients in the warfarin group did not survive the operative period, for a mortality of 10.8%. Prevention of thromboembolism was managed solely with warfarin to maintain the prothrombin time of 1.5 times control. The group receiving ticlopidine and aspirin consisted of 88 patients with 93 heart valves. Patients received ticlopidine (500 mg) and aspirin (500 mg) daily for 3 months postoperatively and in half doses thereafter. Three of the 88 patients did not survive the operative period, for an operative mortality of 3.4%. Warfarin was added postoperatively for 3 months for 39 of the 88 ticlopidine and aspirin group patients with high risk factors. Patients were follow ed-up from 36 to 120 months, with a mean of 33.5 months, in the warfarin group; and 1 to 36 months, with a mean of 8.5 months in the ticlopidine and aspirin group. At the most recent follow-up, 90% of the patients were in New York Heart Association (NYHA) Classes I and II. There were 5 late deaths in the warfarin group, 3 due to thromboembolism and 2 due to anticoagulant-related cerebral hemorrhage. Nonfatal attacks of thromboembolism and anticoagulant-related hemorrhage were noted in 10 other cases during follow-up. There were no late deaths in the ticlopidine and aspirin group during the short period of follow-up, except i case 35 days after mitral valve replacement, already included in the operative deaths. There was no case of primary valve failure or anticoagulant-related hemorrhage, except minor epistaxis and hypermenorrhea in the ticlopidine and aspirin group during this follow-up. It is our strong impression that combining ticlopidine and aspirin in low-risk adults has a synergistic effect and had superior results in preventing thromboembolism without anticoagulant-related hemorrhage. Warfarin is also necessary in high-risk adults for preventing early thrombus formation along the valve suture line. We recommend antiplatelet aggregator therapy with ticlopidine and aspirin in low-risk adult patients with ST. JUDE MEDICAL® valves and additional warfarin for 3 months in the high-risk adults with ST. JUDE MEDICAL valves.
KeywordsAspirin Warfarin Hydrochloride Epinephrine Dine
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