Prosthetic heart valves and the COVID-19 pandemic era: What should we be concerned about?

Background: The disturbance in the international normalized ratio (INR) in patients receiving warfarin therapy is of concern. We aimed to evaluate coagulation features in hospitalized patients under warfarin treatment for prosthetic heart valves during the novel coronavirus disease 2019 (COVID-19) pneumonia pandemic.

Methods: Between 20 February and 28 March 2020, 10 patients (7 males) who were under warfarin therapy for prosthetic heart valves were hospitalized after a diagnosis of COVID-19 in Tehran Heart Center, Tehran, Iran. The clinical, paraclinical, and in-hospital outcomes were described. The patients were followed for 4 weeks.

Results: The median age was 62 years. All the patients received antiviral treatment, either lopinavir/ritonavir or oseltamivir. The serum level of high-sensitivity C-reactive protein ranged between 0.24 and 15.24 mg/dL. Alanine aminotransaminase was normal in all the patients except for two, with levels 1.6 and 4.2 times above normal values. The INR increased in all the patients. One (10%) patient died in the hospital. No bleeding, ischemic, or thrombotic events occurred during the hospital stay and within the 4-week follow-up.

Conclusions: Antiviral therapy in patients with COVID-19 with prosthetic heart valves might be an issue responsible for an uncontrolled INR. Liver injury may happen in a minority of patients. Bridging in these patients during the antiviral treatment might be required and because of significant INR fluctuations, it might be safer to prescribe antiviral treatment in an inpatient setting.

Keywords: COVID-19; coronavirus; international normalized ratio; lopinavir/ritonavir; prosthetic heart valve; warfarin.