From the Guidelines
Guardian, a medication likely referring to an anticoagulant, should be held 2 to 4 days before surgery in patients with a bileaflet mechanical AVR and no other risk factors, as the risk of thromboembolism after stopping anticoagulation is small if the drug is withheld for only a few days. This recommendation is based on the 2021 ACC/AHA guideline for the management of patients with valvular heart disease 1. The guideline suggests that in low-risk patients, the inconvenience and expense of bridging anticoagulation can be avoided by stopping the anticoagulant 2 to 4 days before the procedure and restarting it as soon as bleeding risk allows, typically 24 hours after surgery.
When considering the management of anticoagulation in patients undergoing surgery, it is essential to weigh the risks of thromboembolism and bleeding. In patients with mechanical valves on long-term VKA therapy who require emergency surgery or invasive procedures, anticoagulation can be reversed by administration of intravenous prothrombin complex concentrate 1. However, for planned surgeries, stopping the anticoagulant 2 to 4 days before the procedure is often sufficient.
Some key points to consider when managing anticoagulation in the perioperative period include:
- The type of anticoagulant being used
- The patient's underlying risk factors for thromboembolism and bleeding
- The type of surgery being performed
- The patient's kidney function, as this can affect the half-life of certain anticoagulants
In general, the decision to hold or bridge anticoagulation should be individualized and based on the specific clinical context. However, for patients with a bileaflet mechanical AVR and no other risk factors, holding the anticoagulant 2 to 4 days before surgery is a reasonable approach 1. After surgery, the anticoagulant can typically be resumed once adequate hemostasis has been achieved, usually within 24 hours depending on the procedure's bleeding risk.
From the Research
Guardian Hold Time Before Surgery
There is no direct information on how soon before surgery Guardian needs to be held. However, the provided studies discuss the management of anticoagulation therapy in patients undergoing surgery.
Anticoagulation Management
- The decision to hold anticoagulation therapy before surgery depends on the patient's individual risk of thromboembolism and bleeding 2, 3.
- Studies suggest that bridging anticoagulation may not be necessary for all patients and may increase the risk of bleeding 2.
- The American College of Chest Physicians guidelines recommend assessing the patient's risk of thromboembolism and bleeding before making decisions about anticoagulation therapy 4, 5.
Bleeding Risk Assessment
- Validated bleeding risk assessments, such as HAS-BLED, should be performed to identify patients at high risk of bleeding 6.
- Modifiable factors that increase the risk of bleeding should be addressed before surgery 6.
Anticoagulation Therapy
- Direct oral anticoagulants are first-line agents for eligible patients for treating venous thromboembolism and preventing stroke in those with nonvalvular atrial fibrillation 6.
- Vitamin K antagonists are recommended for patients with mechanical valves and valvular atrial fibrillation 6.
- Low-molecular-weight heparin continues to be recommended as a first-line treatment for patients with venous thromboembolism and active cancer 6.