Should a patient with mitral valve prolapse discontinue aspirin (acetylsalicylic acid) and statin (HMG-CoA reductase inhibitor) prior to undergoing non-invasive mitral valve surgery?

From the Guidelines

Patients awaiting non-invasive mitral valve surgery for mitral valve prolapse should typically continue their statin medication but may need to stop aspirin 5-7 days before the procedure, as recommended by the most recent guidelines 1. The decision about medication management should ultimately be made by the surgical team, as recommendations can vary based on individual patient factors and specific surgical approach. Statins are generally continued through surgery because they have beneficial anti-inflammatory effects and sudden discontinuation might increase cardiovascular risk, as supported by the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery 1. Aspirin, however, inhibits platelet function and increases bleeding risk during surgery, which is why it's often temporarily suspended, with some studies suggesting that it may be reasonable to continue aspirin in patients undergoing nonemergency/nonurgent noncardiac surgery without prior coronary stenting when the risk of increased cardiac events outweighs the risk of increased bleeding 1. Some surgeons may allow low-dose aspirin (81mg) to continue if the patient has high cardiovascular risk factors, while others strictly require discontinuation. After surgery, aspirin is usually restarted within 24-48 hours as directed by the surgical team. Patients should never stop these medications on their own but should discuss the specific timing of any medication changes with their surgical team at the pre-operative appointment, as individual circumstances may require personalized approaches. Key considerations include:

• The risk of bleeding versus the risk of cardiac events
• The type of surgery and anesthesia used
• The patient's overall health status and medical history
• The potential benefits and risks of continuing or discontinuing aspirin and statin therapy, as outlined in the 2020 ACC/AHA guideline for the management of patients with valvular heart disease 1.

From the Research

Pre-Surgery Medication Management

When awaiting mitral valve non-invasive surgery for mitral valve prolapse, the management of medications such as aspirin and statins is crucial. However, the provided studies do not directly address the question of whether to stop aspirin and statin prior to surgery.

Relevant Studies

• The study by 2 focuses on minimally invasive mitral valve repair for anterior leaflet prolapse, discussing patient characteristics, intraoperative data, and short- and long-term outcomes, but does not mention medication management.
• The review article by 3 discusses the evolution of minimally invasive mitral valve surgery, including procedural planning, operative techniques, and perfusion strategies, but does not address pre-surgery medication management.
• The study by 4 investigates the long-term risk of ventricular arrhythmias after surgery in patients with mitral annular disjunction and mitral valve prolapse, but does not provide information on medication management prior to surgery.
• The article by 5 details the approach to mitral valve repair at the Mayo Clinic, including techniques and outcomes, but does not discuss pre-surgery medication management.
• The study by 6 compares outcomes of the minimally invasive port access approach and the traditional redo sternotomy approach for reoperations on the mitral valve, but does not address medication management prior to surgery.

Medication Management

Given the lack of direct evidence from the provided studies, it is essential to consider general guidelines for medication management before surgery. Typically, the decision to stop or continue medications like aspirin and statins before surgery is made on a case-by-case basis, considering the patient's individual risk factors, the type of surgery, and the potential risks and benefits of continuing or discontinuing these medications.

Key Points to Consider

• The risk of bleeding associated with continuing aspirin and other antiplatelet agents during surgery must be weighed against the risk of thrombotic events if these medications are stopped.
• Statins are often continued before surgery due to their potential benefits in reducing cardiovascular risk, but this decision should be made in consultation with the patient's healthcare provider.
• It is crucial for patients to discuss their medications, including aspirin and statins, with their surgeon and other healthcare providers to determine the best course of action before undergoing mitral valve non-invasive surgery.