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Recommendations for perioperative and postoperative antithrombotic management of valve replacement or repair Management of antithrombotic therapy in the perioperative period It is recommended that VKAs are timely discontinued prior to elective surgery to aim for an INR <1.5. I C Bridging of OAC, when interruption is needed, is recommended in patients with any of the following indications: • Mechanical prosthetic heart valve. • AF with significant mitral stenosis. • AF with a CHA2DS2-VASc score >_3 for women or 2 for men. • Acute thrombotic event within the previous 4 weeks. • High acute thromboembolic risk. I C Therapeutic doses of either UFH or subcutaneous LMWH are recommended for bridging. I B In patients with MHVs, it is recommended to (re)-initiate the VKA on the first postoperative day. I C In patients who have undergone valve surgery with an indication for postoperative therapeutic bridging, it is recommended to start either UFH or LMWH 1224 h after surgery. I C In patients undergoing surgery, it is recommended that aspirin therapy, if indicated, is maintained during the periprocedural period. I C In patients treated with DAPT after recent PCI (within 1 month) who need to undergo heart valve surgery in the absence of an indication for OAC, it is recommended to resume the P2Y12 inhibitor postoperatively as soon as there is no concern over bleeding. I C Patients with an indication to concomitant antiplatelet therapy After uncomplicated PCI or ACS in patients requiring long-term OAC, early cessation (<_1 week) of aspirin and continuation of dual therapy with OAC and a P2Y12 inhibitor (preferably clopidogrel) for up to 6 months (or up to 12 months in ACS) is recommended if the risk of stent thrombosis is low or if concerns about bleeding risk prevail over concerns about risk of stent thrombosis, irrespective of the type of stent used. I B Discontinuation of antiplatelet treatment in patients treated with an OAC is recommended after 12 months. I B Surgical valve replacement OAC using a VKA is recommended lifelong for all patients with a MHV prosthesis. I B For patients with a VKA, INR self-management is recommended provided appropriate training and quality control are performed. I B OAC is recommended for patients undergoing implantation of a surgical BHV who have other indications for anticoagulation. I C NOACs are not recommended in patients with an MHV. III B Transcatheter aortic valve implantation OAC is recommended lifelong for TAVI patients who have other indications for anticoagulation. I B Lifelong SAPT is recommended after TAVI in patients with no baseline indication for OAC. I A Routine use of OAC is not recommended after TAVI in patients who have no baseline indication for OAC. III B Recommendations on management of prosthetic valve dysfunction Mechanical prosthetic thrombosis Urgent or emergency valve replacement is recommended for obstructive thrombosis in critically ill patients without serious comorbidity. I B Bioprosthetic thrombosis Anticoagulation using a VKA and/or UFH is recommended in bioprosthetic valve thrombosis before considering reintervention. I C Haemolysis and paravalvular leak Reoperation is recommended if a paravalvular leak is related to endocarditis or causes haemolysis requiring repeated blood transfusions or leading to severe heart failure symptoms. I C Bioprosthetic failure Reoperation is recommended in symptomatic patients with a significant increase in transprosthetic gradient (after exclusion of valve thrombosis) or severe regurgitation. I C

ACS = acute coronary syndrome; AF = atrial fibrillation; BHV = biological heart valve; BSA = body surface area; CABG = coronary artery bypass grafting; CAD = coronary artery disease; CRT = cardiac resynchronization therapy; DAPT = dual antiplatelet therapy; EuroSCORE = European System for Cardiac Operative Risk Evaluation; GDMT = guidelinedirected medical therapy; h = hours; INR = international normalized ratio; LMWH = low-molecular-weight heparin; LV = left ventricle/left ventricular; LVEF = left ventricular ejection fraction; LVESD = left ventricular end-systolic diameter; MHV = mechanical heart valve; MR = mitral regurgitation; NOAC = non-vitamin K antagonist oral anticoagulant; OAC = oral anticoagulation; PCI = percutaneous coronary intervention; PMC = percutaneous mitral commissurotomy; RV = right ventricle/right ventricular; SAPT = single antiplatelet therapy; SAVR = surgical aortic valve replacement; SMR = secondary mitral regurgitation; STS-PROM = Society of Thoracic Surgeons  predicted risk of mortality; SVD = structural valve deterioration; SVi = stroke volume index; TAVI = transcatheter aortic valve implantation; UFH = unfractionated heparin; VHD = valvular heart disease; VKA = vitamin K antagonist. ESC/EACTS 2021 Downloaded from academic.oup.com/eurheartj/article/43/7/561/6358470 by guest on 07 October 2026