Anticoagulation and Antiplatelet Strategies After On-X Mechanical Aortic Valve Replacement.


Journal Article

BACKGROUND: The burden oral anticoagulation is a limitation of mechanical valve prostheses. OBJECTIVES: The aim of this study was to test whether patients could be safely managed with dual-antiplatelet therapy (DAPT) (aspirin 325 mg and clopidogrel 75 mg) or lower warfarin after On-X mechanical aortic valve replacement (mAVR). METHODS: PROACT (Prospective Randomized On-X Anticoagulation Trial) (n = 576) is a multicenter (41 sites) noninferiority trial. From June 2006 through February 2014, 201 patients ≥18 years of age without thromboembolic risk factors undergoing mAVR were randomized to receive DAPT (n = 99) or standard warfarin plus aspirin (n = 102) 3 months after mAVR (low-risk arm). From June 2006 through October 2009, 375 patients with 1 or more thromboembolic risk factors were also randomized to lower intensity warfarin plus aspirin (international normalized ratio 1.5 to 2.0; n = 185) or standard warfarin plus aspirin (international normalized ratio 2.0 to 3.0; n = 190) 3 months after mAVR (high-risk arm). RESULTS: The low-risk arm was terminated for excess cerebral thromboembolic events (3.12% per patient-year vs. 0.29% per patient-year, p = 0.02) in the DAPT group at up to 8.8-year follow-up (631.6 patient-years), with no differences in bleeding or all-cause mortality. High-risk arm patients experienced significantly lower major (1.59% per patient-year vs. 3.94% per patient-year, p = 0.002) and minor (1.27% per patient-year vs. 3.49% per patient-year, p = 0.002) bleeding up to 8.7-year follow-up (2,035.2 patient-years), with no differences in thromboembolism (0.42% per patient-year vs. 0.09% per patient-year, p = 0.20) and all-cause mortality. CONCLUSIONS: DAPT was associated with higher rates of thromboembolism and valve thrombosis compared with control in the low-risk arm. International normalized ratios were safely maintained at 1.5 to 2.0 in high-risk patients, without differences in mortality or thromboembolic complications. (Randomized On-X Anticoagulation Trial [PROACT]; NCT00291525).

Full Text

Duke Authors

Cited Authors

  • Puskas, JD; Gerdisch, M; Nichols, D; Fermin, L; Rhenman, B; Kapoor, D; Copeland, J; Quinn, R; Hughes, GC; Azar, H; McGrath, M; Wait, M; Kong, B; Martin, T; Douville, EC; Meyer, S; Ye, J; Jamieson, WRE; Landvater, L; Hagberg, R; Trotter, T; Armitage, J; Askew, J; Accola, K; Levy, P; Duncan, D; Yanagawa, B; Ely, J; Graeve, A; PROACT Investigators,

Published Date

  • June 19, 2018

Published In

Volume / Issue

  • 71 / 24

Start / End Page

  • 2717 - 2726

PubMed ID

  • 29903344

Pubmed Central ID

  • 29903344

Electronic International Standard Serial Number (EISSN)

  • 1558-3597

Digital Object Identifier (DOI)

  • 10.1016/j.jacc.2018.03.535


  • eng

Conference Location

  • United States