Is Bridging Anticoagulation with Heparin after Valve Replacement Surgery Mandatory? - A Prospective Observational Study in a Centre of Bangladesh

Background: This is a prospective observational single center study to determine whether bridging anticoagulation with heparin along with warfarin is mandatory in a heterogenous group of patients undergoing valve replacement surgery either single or multiple valve (with mechanical or tissue valve) in the post-operative period. Methods: Perioperative data were collected in 41 patients undergoing multiple valve replacement at this center from July/2019 to September/2019 irrespective of age, sex, number and type of valve replaced. No bridging anticoagulation was given in preoperative and postoperative period in these patients. They were prospectively observed for the incidence of any thromboembolic end bleeding events with daily measurement of International Normalized Ratio (INR) till INR reached at therapeutic level for oral anticoagulant warfarin and complications of warfarin therapy. Results: All the patient suffered from chronic Rheumatic heart disease. Single valve disease was in 70.73% and multiple valve disease was in 29.27% cases. Two patients had left atrial thrombus, seven patient (14.63%) had preoperative atrial fibrillation (AF). Postoperative new onset AF was present in 10 (24.39%) cases. No thromboembolism occurred in these patients and warfarin over anticoagulation was found in 1/41 patient. Conclusion: Patients undergoing valve replacement surgery without concomitant postoperative bridging anticoagulation with heparin do not suffer from any thromboembolic and bleeding complications even at lower level of INR. This study also shows that single and multiple valve (both mechanical and tissue valve) have the same in hospital outcome in relation to thromboembolism and bleeding complications. Cardiovasc. j. 2020; 13(1): 27-34

Markedly increased risk of postoperative bleeding complications during perioperative bridging anticoagulation in general and visceral surgery

Background Increasing numbers of patients receiving oral anticoagulants are undergoing elective surgery. Low molecular weight heparin (LMWH) is frequently applied as bridging therapy during perioperative interruption of anticoagulation. The aim of this study was to explore the postoperative bleeding risk of patients receiving surgery under bridging anticoagulation. Methods We performed a monocentric retrospective two-arm matched cohort study. Patients that received perioperative bridging anticoagulation were compared to a matched control group with identical surgical procedure, age, and sex. Emergency and vascular operations were excluded. The primary endpoint was the incidence of major postoperative bleeding. Secondary endpoints were minor postoperative bleeding, thromboembolic events, length of stay, and in-hospital mortality. Multivariate analysis explored risk factors of major postoperative bleeding. Results A total of 263 patients in each study arm were analyzed. The patient cohort included the entire field of general and visceral surgery including a large proportion of major oncological resections. Bridging anticoagulation increased the postoperative incidence of major bleeding events (8% vs. 1%; p < 0.001) as well as minor bleeding events (14% vs. 5%; p < 0.001). Thromboembolic events were equally rare in both groups (1% vs. 2%; p = 0.45). No effect on mortality was observed (1.5% vs. 1.9%). Independent risk factors of major postoperative bleeding were full-therapeutic dose of LMWH, renal insufficiency, and the procedure-specific bleeding risk. Conclusion Perioperative bridging anticoagulation, especially full-therapeutic dose LMWH, markedly increases the risk of postoperative bleeding complications in general and visceral surgery. Surgeons should carefully consider the practice of routine bridging.