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Bridging Anticoagulation - Mechanical Valve — EECC MCQ

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ModerateGeneral CardiologyBridging Anticoagulation - Mechanical ValveEECC

A 48-year-old woman with a mechanical mitral valve on warfarin is diagnosed with breast cancer requiring surgery followed by adjuvant chemotherapy. The oncologist asks about perioperative anticoagulation management. She has no additional thromboembolic risk factors beyond the mechanical valve. What is the recommended approach?

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Correct answer: B — Interrupt warfarin and bridge for the mechanical mitral valve

Patients with mechanical heart valves are at high thromboembolic risk and require bridging anticoagulation when warfarin is interrupted for surgery. The ESC/EACTS VHD Guidelines and perioperative guidelines recommend: (1) Stop warfarin 3-5 days before surgery (to allow INR to fall below 1.5); (2) Bridge with therapeutic-dose LMWH (e.g. enoxaparin 1 mg/kg bd) or IV unfractionated heparin when the INR falls below 2.0; (3) Stop LMWH 12-24 hours before surgery (UFH 4-6 hours before); (4) Restart heparin bridging 12-24 hours postoperatively when haemostasis is secured, and restart warfarin concurrently; (5) Continue bridging until the INR is therapeutic. DOACs are absolutely contraindicated with mechanical valves.

Reference: ESC/EACTS (2025): Guidelines for VHD; ESC (2022): Non-cardiac Surgery Guidelines: https://bnf.nice.org.uk/drugs/warfarin-sodium/