Perioperative bleeding and thromboembolic risk during non-cardiac surgery in patients with mechanical prosthetic heart valves: An institutional review

Background and aims of the study: The study aim was to determine the risk o f thromboembolic and bleeding complications in patients with mechanical hea rt valve prostheses who underwent non-cardiac surgery under different regim ens of perioperative anticoagulation. Data were analyzed on the basis of su rgery type and underlying disease. Methods: A series of 235 patients (mean age 63 +/- 4.5 years) with one or t wo mechanical heart valves underwent subsequent non-cardiac surgery compris ing abdominal, vascular and thoracic, orthopedic, urologic, neurosurgery, E NT, plastic and reconstructive, and gynecologic operations. Mean interval b etween heart valve replacement and non-cardiac surgery was 3.9 +/- 3.3 year s. Perioperative oral anticoagulation was managed by discontinuation of ora l anticoagulation and intravenous heparin administration; or by discontinua tion and early postoperative re-institution of oral anticoagulation without intravenous heparin; or by no withdrawal of oral anticoagulation. Patients with bioprostheses were excluded. Results: Overall hospital mortality during non-cardiac surgery was 2.9%. Th romboembolic events included cerebral embolism with transient deficit (n = 3), residual defect (n = 1) and irreversible defect (n = 1), as well as per ipheral embolism (n = 11). Hemorrhagic complications included wound hematom a (n = 10) and increased postoperative bleeding (n = 8) with re-exploration in five patients. Thromboembolic complications occurred most often in pati ents with prosthetic mitral valve and atrial fibrillation;the lowest risk w as in patients with sinus rhythm after aortic valve replacement. Most compl ications occurred after discharge and in patients with surgery for malignan cy,within 10 days of instituting oral anticoagulation, and despite a therap eutic INR value. Conclusions: Minor surgical procedures can be performed safely without disc ontinuing anticoagulation. When major non-cardiac surgery is planned, disco ntinuing oral anticoagulation and starting perioperative intravenous hepari n minimizes bleeding and thromboembolic risks. Thromboembolic complications may occur within one month of surgery, despite adequate oral anticoagulati on, though permanent morbidity is low.