Anticoagulation-Related Complications after an Isolated Mitral Valve Repair

Objectives: The need of oral anticoagulation following an isolated mitral valve repair (MVR) is still controversial and current guidelines are discordant on this topic. In Germany, vitamin K antagonists are routinely prescribed for three months following MVR. We aimed to examine the prevalence of anticoagulation-related complications over the period of three months after an isolated MVR.

Methods: We identified retrospectively consecutive patients who underwent an isolated mitral valve repair during a period of three years (2015–2017) from our institutional database. We excluded all patients with a history of atrial fibrillation and all concomitant surgeries. Primary endpoint was the incidence of thromboembolic and bleeding events under oral anticoagulation during the first three postoperative months. Thromboembolic events included ischemic stroke, transient ischemic attack, cardiac valvular/wall thrombus and peripheral thromboembolism. Bleeding events were defined as fatal bleeding, hemorrhagic stroke, symptomatic bleeding into a critical organ (i.e., pericardial effusion), or hemothorax and epistaxis. Follow-up protocol consisted of structured clinical questionnaire.

Results: A total of 103 consecutive patients (mean age: 57.4 ± 12.1 years, 77% male) were analyzed. Two patients died during the in-hospital course (cardiac = 1; perioperative stroke = 1). Two thromboembolic events (2.0%) occurred during the 3-month follow-up, including an ischemic stroke and peripheral embolism. Both events occurred during the second postoperative month.

The prevalence of hemorrhagic events was 11.9% (n = 12) including pericardial effusion (n = 4), hemothorax (n = 3), epistaxis (n = 4), and hematuria (n = 1). All these complications occurred under oral anticoagulation after hospital discharge. Hospital readmission was required in eight patients. Intervention for pericardial effusion and hemothorax was necessary in five cases, while two patients were managed conservatively. Hematuria was treated with continuous bladder irrigation.

Conclusion: The risk of bleeding complications under oral anticoagulation after an isolated mitral valve repair is significant, given the fact that every tenth patient experienced a bleeding event. Therefore, anticoagulation regime following mitral valve repair should be reconsidered. Ideally, a prospective study comparing oral anticoagulation versus antiplatelet therapy following an isolated mitral valve repair should be performed.