IMPROVING EFFICIENCY AND SAFETY OF ANTICOAGULATION THERAPY IN PATIENTS WITH PROSTHETIC HEART VALVES

Purpose. To improve efficiency and safety of anticoagulant therapy in patients with prosthetic heart valves by developing and implementing original approaches: 1) sinus rhythm restoration after simultaneous mitral valve replacement with maze procedure, 2) pharmacogenetics approach for individual choice of anticoagulants, and 3) the implementation of patient education program.

Materials and methods. 525 patients with prosthetic heart valves were included in the study using cluster sampling in the period from 2008–2013. Group 1 (n=118) patients underwent the study aimed at assessing the restoration of sinus rhythm using original approaches, Group 2 (n=249) patients were included in the study aimed at assessing the efficiency of education program, and Group 3 (n=216) patients were included in the study aimed at assessing the efficiency of pharmacogenetics-based warfarin therapy. All patients underwent on-pump heart valve replacement. Genomic methods as well as non-invasive ultrasound monitoring of intracardiac hemodynamic parameters were used in the study.

Results. Simultaneous mitral valve replacement with maze procedure resulted in the restoration of sinus rhythm in 61,8 % of cases; scheduled cardioversion 1,5 months after cardiac surgery ensured sinus rhythm restoration in 84,8 % of patients, and radiofrequency catheter ablation in patients with biological prosthetic heart valves 6 months after cardiac surgery allowed both sinus rthym restoration and warfarin withdrawal. The introduction of pharmacogenetic approach to warfarin dosing in the early postoperative period resulted in a 2-fold reduction in the time of warfarin dose adjustment and a 25,2 % increase of the therapeutic range of anticoagulation level. The implementation of training program based on the continuity of inpatient and outpatient care allowed decreasing 1,8-fold the risk of thrombotic complications and 2,6-fold hemorrhagic complications 2 years after heart valve replacement. The introduction of the strategy aimed at the improvement of efficiency and safety of warfarin therapy demonstrated the benefits of biological heart valve replacement and the feasibility of an integrated approach.

Conclusion. The introduction of the integrated approach composed of the strategies for sinus rhythm restoration, information and motivational approach, and pharmacogenetic approach, ensures a reduction in hemorrhagic and thrombotic complications, improving quality control for warfarin therapy, awareness, and treatment adherence.

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