Cerebral Microembolization After Bioprosthetic Aortic Valve Replacement

Comparison of Warfarin Plus Aspirin Versus Aspirin Only

Talal Al-Atassi, MD; Khanh Lam, MD, MPH; Melissa Forgie, MD; Munir Boodhwani, MD, MSc; Fraser Rubens, MD, MSc; Paul Hendry, MD;
Roy Masters, MD; William Goldstein, MD; Pierre Bedard, MD; Thierry Mesana, MD, PhD; Marc Ruel, MD, MPH

Circulation. 2012; 126: S239-S244

Abstract
Background—No human physiological data exists on whether aspirin only is as effective as warfarin plus aspirin in preventing cerebral microembolization in the early postoperative period after bioprosthetic aortic valve replacement (bAVR).

Methods and Results—We prospectively enrolled 56 patients who had no other indication for oral anticoagulation, who underwent bAVR and received, in an open-label fashion, either daily warfarin (for INR 2.0–3.0) plus 81 mg of aspirin (n=28) or 325 mg of aspirin only (n=28). Cerebral microembolization was quantified at 4 hours (baseline) and at 1 month postoperatively, by recording 1-hour bilateral middle cerebral artery (MCA) microembolic signals (MES). Platelet-function analysis (PFA) of closure times (CT) on collagen was also used as a marker of platelet-dependent activation. Follow-up to 1 year was complete. Preoperative demographics and baseline platelet function were equivalent in both groups. There was no mortality, stroke, or transient ischemic attack at 1 year in either group. No significant differences were found in the proportion of patients with MES among those receiving warfarin plus aspirin versus aspirin only, at baseline (68% versus 82%, respectively; P=0.4) and at 1 month (46% versus 43%; P=1.0) after bAVR. The total MES and PFA were also equivalent between groups, at baseline and follow-up.

Conclusions—Early after bAVR, the effects of these 2 antithrombotic regimens on cerebral microembolization and platelet function are equivalent. These data bring new mechanistic support to the premise that aspirin only may safely be used early after bAVR in patients who have no other indication for oral anticoagulation.