Anticoagulation Valvular Disease

Question 1

Bioprosthetic Heart Valve Risk

Answer 1

first 3 months is the highest-risk period of thromboembolism after bioprosthetic heart valve implantation, especially with mitral valves. lower long-term risk of thromboembolism than do mechanical heart valves.

Question 2

Surgical aortic bioprosthetic and mitral bioprosthetic valve therapy

Answer 2

Low-dose aspirin for patients without another indication for oral anticoagulation
Patients at low-risk of bleeding can receive warfarin to a target INR 2-3 for 3-6 months

Question 3

Transcatheter aortic valve replacement therapy

Answer 3

Low-dose aspirin for patients without another indication for oral anticoagulation
Low-dose aspirin and clopidogrel for 3–6 months for patients at low-risk of bleeding
Warfarin at a target INR of 2-3 for at least 3 months for patients at low risk of bleeding

Question 4

Bioprosthetic valve therapy with concomitant AF

Answer 4

based on the patient’s CHA2DS2-VASc score;
If valve placement was more than 3 months ago, a DOAC is an effective alternative to warfarin
If AF onset is within 3 months of valve placement, warfarin should be used

Question 5

Mechanical Heart Valve Target INR 2-3

Answer 5

Aortic bileaflet or current-generation single-tilting disk valve and no risk factors for thromboembolism

Question 6

Mechanical Heart Valve Target INR 2.5-3.5

Answer 6

risk factors for thromboembolism (i.e., AF, prior thromboembolism, LV systolic dysfunction, hypercoagulable state); an older-generation valve (e.g., ball-in-cage), mitral heart valve

Question 7

On-X aortic valve Target INR

Answer 7

no risk factors for thromboembolism should have a target INR of 2-3 for the first 3 months, followed by a target INR of 1.5–2.0 with low-dose aspirin

Question 8

Bridging after mechanical valve placement

Answer 8

patients should be bridged with an injectable anticoagulant for at least 5 days and an INR within the therapeutic range.

Question 9

mechanical heart valves undergoing a minor procedure

Answer 9

(e.g., dental extraction or cataract removal) where bleeding is easily controlled, continue warfarin with a therapeutic INR

Question 10

mechanical heart valves undergoing invasive procedure

Answer 10

patients with a bileaflet mechanical aortic valve and no other risk factors for thromboembolism, no bridging is needed while the INR is subtherapeutic; for other patients bridging anticoagulant therapy while the INR is subtherapeutic is reasonable,