Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Antithrombotic therapy for prosthetic heart valves: Management of bleeding and invasive procedures

William H Gaasch, MD
Barbara A Konkle, MD
Section Editors
Catherine M Otto, MD
Lawrence LK Leung, MD
Deputy Editors
Susan B Yeon, MD, JD, FACC
Jennifer S Tirnauer, MD


Replacement of a diseased heart valve aims to relieve symptoms and prolong life but also exchanges the native disease for potential prosthesis-related complications. The frequency of serious complications depends upon the valve type and position, and other clinical risk factors. Complications include embolic events, bleeding, valve obstruction (due to thrombosis or pannus), infective endocarditis, structural deterioration (particularly for bioprosthetic valves), paravalvular regurgitation, hemolytic anemia, and patient-prosthesis mismatch.

Thromboembolic- and anticoagulation-related problems are by far the most frequent complications of mechanical valves. The long-term risk of thromboembolism is generally lower with bioprosthetic valves, though there is an increased risk of thromboembolism for bioprosthetic as well as mechanical valves early after valve implantation.

The anticoagulants used to prevent valve thrombosis and thromboembolic events in patients with prosthetic heart valves are vitamin K antagonists (VKA; eg, warfarin; generally for long-term therapy) and heparin (mainly unfractionated heparin or low molecular weight heparin; generally for short-term bridging therapy), with indications as described below. Aspirin is recommended as an antiplatelet agent in addition to anticoagulation in patients with mechanical valve prosthesis and is suggested in patients with bioprosthetic aortic or mitral valves. (See "Antithrombotic therapy for prosthetic heart valves: Indications".)

This topic will review management of bleeding and invasive procedures in patients receiving antithrombotic therapy to reduce the risk of prosthetic valve thrombosis and thromboembolism. Indications for antithrombotic therapy for prosthetic valves, therapeutic use of VKA, endocarditis prophylaxis, evaluation of valve function, other complications of prosthetic valves (including valve thrombosis and thromboembolism), and management of antithrombotic therapy in pregnant patients with prosthetic heart valves are discussed separately. (See "Antithrombotic therapy for prosthetic heart valves: Indications" and "Overview of the management of patients with prosthetic heart valves" and "Antimicrobial prophylaxis for the prevention of bacterial endocarditis" and "Diagnosis of mechanical prosthetic valve thrombosis or obstruction" and "Management of antithrombotic therapy for a prosthetic heart valve during pregnancy".)


The risk of major bleeding with vitamin K antagonist (VKA; eg, warfarin) begins to rise steeply when the International Normalized Ratio (INR) increases to values ≥5 (figure 1), although some patients have bleeding at therapeutic or even subtherapeutic INR levels. However, rapid reversal of anticoagulation, leading to subtherapeutic INRs, increases the risk of valve thrombosis and thromboembolism. Given these concerns, we suggest an individualized approach based largely on expert opinion that is generally consistent with the 2014 American Heart Association/American College of Cardiology (AHA/ACC) and 2012 European Society of Cardiology guideline recommendations [1,2]:

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Aug 15, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC), European Association for Cardio-Thoracic Surgery (EACTS), Vahanian A, et al. Guidelines on the management of valvular heart disease (version 2012). Eur Heart J 2012; 33:2451.
  2. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 63:e57.
  3. Bonow RO, Carabello BA, Chatterjee K, et al. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2008; 118:e523.
  4. Yiu KH, Siu CW, Jim MH, et al. Comparison of the efficacy and safety profiles of intravenous vitamin K and fresh frozen plasma as treatment of warfarin-related over-anticoagulation in patients with mechanical heart valves. Am J Cardiol 2006; 97:409.
  5. Levi M, Levy JH, Andersen HF, Truloff D. Safety of recombinant activated factor VII in randomized clinical trials. N Engl J Med 2010; 363:1791.
  6. Skolnick BE, Mathews DR, Khutoryansky NM, et al. Exploratory study on the reversal of warfarin with rFVIIa in healthy subjects. Blood 2010; 116:693.
  7. Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e326S.
  8. Woods K, Douketis JD, Kathirgamanathan K, et al. Low-dose oral vitamin K to normalize the international normalized ratio prior to surgery in patients who require temporary interruption of warfarin. J Thromb Thrombolysis 2007; 24:93.
  9. Birnie DH, Healey JS, Wells GA, et al. Pacemaker or defibrillator surgery without interruption of anticoagulation. N Engl J Med 2013; 368:2084.
  10. White RH, McKittrick T, Hutchinson R, Twitchell J. Temporary discontinuation of warfarin therapy: changes in the international normalized ratio. Ann Intern Med 1995; 122:40.
  11. Amorosi SL, Tsilimingras K, Thompson D, et al. Cost analysis of "bridging therapy" with low-molecular-weight heparin versus unfractionated heparin during temporary interruption of chronic anticoagulation. Am J Cardiol 2004; 93:509.
  12. Spyropoulos AC, Frost FJ, Hurley JS, Roberts M. Costs and clinical outcomes associated with low-molecular-weight heparin vs unfractionated heparin for perioperative bridging in patients receiving long-term oral anticoagulant therapy. Chest 2004; 125:1642.
  13. Kovacs MJ, Kearon C, Rodger M, et al. Single-arm study of bridging therapy with low-molecular-weight heparin for patients at risk of arterial embolism who require temporary interruption of warfarin. Circulation 2004; 110:1658.
  14. Goldstein JN, Refaai MA, Milling TJ Jr, et al. Four-factor prothrombin complex concentrate versus plasma for rapid vitamin K antagonist reversal in patients needing urgent surgical or invasive interventions: a phase 3b, open-label, non-inferiority, randomised trial. Lancet 2015; 385:2077.
  15. Tinker JH, Tarhan S. Discontinuing anticoagulant therapy in surgical patients with cardiac valve prostheses. Observations in 180 operations. JAMA 1978; 239:738.
  16. Deviri E, Sareli P, Wisenbaugh T, Cronje SL. Obstruction of mechanical heart valve prostheses: clinical aspects and surgical management. J Am Coll Cardiol 1991; 17:646.
  17. Katholi RE, Nolan SP, McGuire LB. The management of anticoagulation during noncardiac operations in patients with prosthetic heart valves. A prospective study. Am Heart J 1978; 96:163.