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Bridging for Mechanical Valve Surgery — EECC MCQ

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ModerateValvular Heart DiseaseBridging for Mechanical Valve SurgeryEECC

A 65-year-old man with a St Jude mechanical aortic valve is admitted for non-cardiac surgery. His warfarin is stopped preoperatively. The INR has fallen to 1.5. Should bridging anticoagulation with LMWH be used?

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Correct answer: A — Bridging with therapeutic LMWH is recommended for mechanical valves in the mitral position or with additional thromboembolic risk factors; for low-risk mechanical AVR without additional risk factors, bridging may not be necessary

Perioperative anticoagulation management for mechanical valves is nuanced. The 2025 ESC VHD Guidelines recommend: (1) High thrombotic risk (mitral mechanical valve, older-generation aortic valve, or any mechanical valve with additional risk factors — AF, prior stroke, LV dysfunction, hypercoagulable state): therapeutic LMWH bridging is recommended; (2) Lower thrombotic risk (modern bileaflet aortic mechanical valve without additional risk factors): bridging may be considered but is not mandatory — the risk of bridging-related bleeding may outweigh the thromboembolic risk. (3) DOACs must NEVER be used for bridging mechanical valves (RE-ALIGN showed harm). Warfarin should be restarted as soon as adequate haemostasis is achieved post-operatively.

Reference: ESC/EACTS (2025): VHD Guidelines