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Mechanical Valve Perioperative Bridging Transplant — ESENeph MCQ

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HardTransplantationMechanical Valve Perioperative Bridging TransplantESENeph

A 65-year-old man with ESKD is being considered for kidney transplantation. He has had a mechanical aortic valve replacement 5 years ago and is on lifelong warfarin. He is otherwise a good transplant candidate. What specific perioperative anticoagulation challenge does this present?

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Correct answer: C — Perioperative anticoagulation requires careful bridging — balancing thromboembolism vs surgical bleeding risk

Patients with mechanical heart valves on warfarin present a specific transplant challenge: warfarin must be stopped before surgery to allow haemostasis, but the thromboembolic risk from an unprotected mechanical valve is significant. Bridging anticoagulation with unfractionated heparin (IV, titratable, short half-life) is required perioperatively. The timing of warfarin cessation (typically 5 days pre-op), heparin bridge initiation, surgical haemostasis, and warfarin restart must be carefully coordinated. DOACs are contraindicated for mechanical valves (RE-ALIGN trial showed increased thromboembolism with dabigatran). A mechanical valve is NOT a contraindication to transplantation but requires MDT planning with haematology and cardiac surgery.

Reference: BTS/UKKA 2018 – Transplant Guidelines; ESC 2021 – Valvular Heart Disease; RE-ALIGN Trial 2013