Long Term Outcomes and Anticoagulation in Mitral Valve Surgery - A Report from the Society of Thoracic Surgeons Database.

Overview

abstract

BACKGROUND: Anticoagulation following bioprosthetic mitral valve replacement (BMVR) and repair (MVrep) is controversial. We explore outcomes among BMVR and MVrep patients in the Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS-ACSD) based on discharge anticoagulation status. METHODS: BMVR and MVrep patients 65 years or older in the STS-ACSD were linked to Centers for Medicare and Medicaid Services (CMS) claims database. Long-term mortality, ischemic stroke, bleeding and a composite of the primary endpoints were compared as a function of anticoagulation. Hazard ratios were calculated using multivariable Cox regression. RESULTS: 26,199 BMVR and MVrep patients were linked to CMS database. 44%,4% and 52% were discharged on warfarin, NOAC (non-vitamin K dependent anticoagulant) and no anticoagulation (reference) (no-AC), respectively. Warfarin was associated with increased bleeding in the overall study cohort [HR(95%CI) 1.38(1.26-1.52)], in BMVR [1.32(1.13-1.55)] and in MVrep sub-cohorts [1.42 (1.26-1.60)]. Warfarin was associated with decreased mortality only among BMVR [(HR(95%CI) 0.87(0.79-0.96)]. Stroke and composite outcome did not differ across cohorts with warfarin. NOAC use was associated with increased mortality, bleeding and composite outcome: HR(95%CI): 1.33(1.11-1.59),1.37(1.07-1.74) and 1.26(1.08-1.47), respectively. CONCLUSIONS: Anticoagulation was used in less than half of mitral valve surgery. In MVrep patients, warfarin was associated with increased bleeding and was not protective against either stroke or mortality. In BMVR patients, warfarin was associated with a modest survival benefit, increased bleeding and equivalent stroke risk. NOAC was associated with increased adverse outcomes.