Is anticoagulation reversal recommended in patients with mechanical heart valves undergoing emergent surgery?

From the Guidelines

Anticoagulation reversal is recommended in patients with mechanical heart valves undergoing emergent surgery, using 4-factor prothrombin complex concentrate (or its activated form), as stated in the 2020 ACC/AHA guideline for the management of patients with valvular heart disease 1.

Key Considerations

• The decision to reverse anticoagulation should be made on an individualized basis, weighing the risks of bleeding against the benefits of thromboembolism prevention.
• For patients with mechanical heart valves who require immediate/emergency noncardiac surgery or an invasive procedure, administration of 4-factor prothrombin complex concentrate (or its activated form) is reasonable, according to the 2020 ACC/AHA guideline 1.
• The use of bridging anticoagulation therapy during the preoperative time interval when the INR is subtherapeutic is reasonable on an individualized basis, with the risks of bleeding weighed against the benefits of thromboembolism prevention, particularly for patients with a mechanical AVR and any thromboembolic risk factor, an older-generation mechanical AVR, or a mechanical mitral valve replacement 1.

Management Approach

• In cases where anticoagulation reversal is necessary, a careful balance must be struck between bleeding risk and thrombotic risk.
• Following surgery, anticoagulation should be restarted as soon as hemostasis is achieved, typically with therapeutic-dose heparin or low-molecular-weight heparin as a bridge until warfarin reaches therapeutic levels.
• The high thrombotic risk associated with mechanical valves, particularly in the mitral position, necessitates this cautious approach to anticoagulation management, as complete reversal could lead to catastrophic valve thrombosis and systemic embolization.

From the Research

Anticoagulation Reversal in Patients with Mechanical Heart Valves

• Reversal of anticoagulation-induced bleeding in patients with mechanical heart valves can be challenging, particularly in emergent surgery situations 2.
• The American College of Chest Physicians recommends anticoagulation with Warfarin at an INR range of 2-3 for patients with a bileaflet mechanical valve in the aortic position, and an INR of 2.5-3.5 for patients with a mechanical valve in the mitral position 3.

Management of Anticoagulation in Emergent Surgery

• In cases of emergent surgery, the management of anticoagulation in patients with mechanical heart valves is crucial to prevent bleeding complications 4.
• The use of prothrombin complex concentrates has been reported as an alternative to fresh frozen plasma for reversing anticoagulation-induced bleeding in patients with mechanical heart valves 2.
• Low molecular weight heparin (LMWH) is often used as a bridging anticoagulant in patients with mechanical heart valves undergoing surgery, with the dose and duration of therapy varying depending on the individual patient's risk factors 3, 4.

Timing of Anticoagulation Reversal and Resumption

• The timing of anticoagulation reversal and resumption in patients with mechanical heart valves undergoing emergent surgery is critical to balance the risk of bleeding and thromboembolism 5, 6.
• The safe period for restarting anticoagulation in patients with warfarin-induced major bleeding and mechanical heart valves varies from 7-14 days after the onset of bleeding for patients with intracranial bleed, and 48-72 hours for patients with extra-cranial bleed 6.

Treatment Options for Anticoagulation Reversal

• Treatment options for reversing anticoagulation-induced bleeding in patients with mechanical heart valves include vitamin K, fresh frozen plasma, prothrombin complex concentrates, and recombinant activated factor VIIa 6.
• The use of argatroban, a short-acting and titratable anticoagulant, has been reported in patients with mechanical heart valves and antithrombin deficiency, with careful monitoring of coagulation parameters 5.