Recommendations for Bridging Therapy for Prosthetic Valves

CORLOERecommendationsComment/Rationale
ICContinuation of VKA anticoagulation with a therapeutic INR is recommended in patients with mechanical heart valves undergoing minor procedures (such as dental extractions or cataract removal) where bleeding is easily controlled.2014 recommendation remains current.
ICTemporary interruption of VKA anticoagulation, without bridging agents while the INR is subtherapeutic, is recommended in patients with a bileaflet mechanical AVR and no other risk factors for thrombosis who are undergoing invasive or surgical procedures.2014 recommendation remains current.
IIaC-LDBridging anticoagulation therapy during the time interval when the INR is subtherapeutic preoperatively is reasonable on an individualized basis, with the risks of bleeding weighed against the benefits of thromboembolism prevention, for patients who are undergoing invasive or surgical procedures with a 1) mechanical AVR and any thromboembolic risk factor, 2) older-generation mechanical AVR, or 3) mechanical MVR (199,214,215).MODIFIED: COR updated from I to IIa, LOE updated from C to C-LD. RCTs of bridging anticoagulant therapy versus no bridging therapy for patients with AF who do not have a mechanical heart valve have shown higher risk of bleeding without a change in incidence of thromboembolic events. This may have implications for bridging anticoagulation therapy for patients with prosthetic valves.
See Online Data Supplement 21
(Updated From 2014 VHD Guideline)
“Bridging” therapy with either intravenous unfractionated heparin or low-molecular-weight heparin has evolved empirically to reduce thromboembolic events during temporary interruption of oral anticoagulation in higher-risk patients, such as those with a mechanical MVR or AVR and additional risk factors for thromboembolism (e.g., AF, previous thromboembolism, hypercoagulable condition, older-generation mechanical valves [ball-cage or tilting disc], LV systolic dysfunction, or >1 mechanical valve) (214).
When interruption of oral VKA therapy is deemed necessary, the agent is usually stopped 3 to 4 days before the procedure (so the INR falls to <1.5 for major surgical procedures) and is restarted postoperatively as soon as bleeding risk allows, typically 12 to 24 hours after surgery. Bridging anticoagulation with intravenous unfractionated heparin or subcutaneous low-molecular-weight heparin is started when the INR falls below the therapeutic threshold (i.e., 2.0 or 2.5, depending on the clinical context), usually 36 to 48 hours before surgery, and is stopped 4 to 6 hours (for intravenous unfractionated heparin) or 12 hours (for subcutaneous low-molecular-weight heparin) before the procedure.
There are no randomized comparative-effectiveness trials evaluating a strategy of bridging versus no bridging in adequate numbers of patients with prosthetic heart valves needing temporary interruption of oral anticoagulant therapy, although such studies are ongoing. The evidence used to support bridging therapy derives from cohort studies with poor or no comparator groups (214,215). In patient groups other than those with mechanical heart valves, increasing concerns have surfaced that bridging therapy exposes patients to higher bleeding risks without reducing the risk of thromboembolism (199). Accordingly, decisions about bridging should be individualized and should account for the trade-offs between thrombosis and bleeding.
IIaCAdministration of fresh frozen plasma or prothrombin complex concentrate is reasonable in patients with mechanical valves receiving VKA therapy who require emergency noncardiac surgery or invasive procedures.2014 recommendation remains current.