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Continue VKA

(Class I) Mechanical heart valve replacement

Start UFH or LMWH bridging and VKA within 24 h or as soon as considered safe

(Class I)

Lifelong VKA with INR based on individual patient profile and valve characteristics

Promote patient education and training for self-monitoring to improve TTR

(Class I)

Specific clinical scenarios

Elective NCS

or invasive procedures

Minor or minimally

invasive interventionsa If documented adequate

INR, increase INR target,

or add low-dose ASA

(Class IIa) Add low-dose ASA based on individual

bleeding profile

(Class IIa)

Symptomatic atherosclerotic

disease

Cardioembolic complication

Thromboembolic risk factorsb

Heparin bridgingc

(Class IIa)

VKA interruption at least 4 days before surgery and resumption within 24 h or as soon as considered safe

(Class I) VKA interruption (3–4 days before surgery) and resumption

(within 24 h) without bridging

(Class IIb)

Figure 18 Antithrombotic therapy following mechanical heart valve implantation. AF, atrial fibrillation; ASA, acetylsalicylic acid; INR, international normalized ratio; LMWH, low-molecular-weight heparin; LV, left ventricle/left ventricular; LVEF, left ventricular ejection fraction; MHV, mechanical heart valve; MS, mitral stenosis; N, no; NCS, non-cardiac surgery; TTR, time in therapeutic range; UFH: unfractionated heparin; VKA, vitamin K antagonist; Y, yes. aSkin; minor eye surgery including cataract; dental cleaning, treatment of caries, and dental extractions; pacemaker or device implantation; and diagnostic cardiac catheterization. bMHV in mitral or tricuspid position, older MHV generations in any position, inherited or acquired hypercoagulable state, LV dysfunction (LVEF <35%), AF with significant MS, recent (<12 months) major thrombotic event (i.e. cardioembolic stroke, deep vein thrombosis, pulmonary embolism). cBridging needs to be started as soon as INR reaches a sub-therapeutic value and on the first postoperative day or as soon as considered safe. Downloaded from academic.oup.com/eurheartj/article/46/44/4635/8234488 by guest on 07 October 2026