Prevention of thromboembolism with ticlopidine shortly after valve repair or replacement with a bioprosthesis

Abstract

Background and aims of the study: This study investigated the efficacy of postoperative ticlopidine as antiplatelet therapy in patients shortly after heart valve repair or replacement.

Methods: Between 1990 and 1995, 235 consecutive patients underwent either valve repair (n = 67) or replacement with a bioprosthesis (n = 168). The bioprostheses used were Carpentier-Edwards porcine or pericardial (n = 158) valves, Prima stentless valves (n = 3) and cryopreserved homografts (n = 7). Types of repair were aortic (one), mitral annuloplasty with Carpentier ring (65) and tricuspid repair (one). Mean patient age was 67 (range: 16 to 83) years for valve replacement and 57 (range: 32 to 74) years for repair (p < 0.01). Atrial fibrillation occurred in 34% of patients. The hospital mortality rate was 11% (26 patients). Of the 209 survivors, 137 were assigned to antiplatelet treatment with ticlopidine for the first three months of follow up. The other 72 received either oral anticoagulation (coumadin; n = 40), aspirin (n = 14) or no medication (n = 18). In 15 patients, ticlopidine treatment was interrupted due to diarrhea (13 cases), mild allergic reaction (one) or anemia (one). The mean follow up was 3.2 years (range: 1 month to 6 years); cumulative follow up was 684 patient-years (pt-yr) and was complete in 96% of cases.

Results: There were two episodes of thromboembolism in the ticlopidine group at 1 month and 6 months respectively, with a linearized incidence of 0.5% pt-yr. In the coumadin group there were four episodes of thromboembolism, three within the first three months of follow up. The linearized incidence was 3% pt-yr (p < 0.01). There were three episodes of hemorrhage in the ticlopidine group in the first three months of follow up and one in the coumadin group. The linearized incidence was 0.75% pt-yr.

Conclusions: Following heart valve repair or replacement with a bioprosthesis, the first three months is a high-risk period for thromboembolism. Ticlopidine seems to prevent this complication better than conventional therapy with oral anticoagulants. Nevertheless, hemorrhage continues to be a problem with ticlopidine therapy.