Is a heparin bridge necessary for a patient with bleeding from an arteriovenous fistula (AVF) and a bioprosthetic valve who is prescribed Eliquis (apixaban)?

Management of Bleeding from Aneurysmal AVF in a Patient with Bioprosthetic Valve on Apixaban

Heparin bridging is not necessary for a patient with a bioprosthetic valve on apixaban who has active bleeding from an aneurysmal arteriovenous fistula (AVF). 1

Rationale for Avoiding Heparin Bridging

Bioprosthetic Valves vs. Mechanical Valves

• Bioprosthetic valves have a significantly lower thrombotic risk compared to mechanical valves
• The 2021 ACC/AHA guidelines clearly distinguish between management approaches:
  • For mechanical valves: Bridging is recommended during interruption of anticoagulation 1
  • For bioprosthetic valves: Bridging decisions should follow the same strategy as for patients with atrial fibrillation without mechanical prostheses 1

Active Bleeding Considerations

• For patients with active bleeding (such as from an aneurysmal AVF), the immediate priority is to control the bleeding rather than maintain anticoagulation 1
• The 2021 ACC/AHA guidelines state that for patients with bioprosthetic valves who have uncontrollable bleeding, immediate reversal of anticoagulation is reasonable 1

Management Algorithm for This Patient

1. Temporarily discontinue apixaban

   • No bridging with heparin is needed during this interruption 1
   • Allow sufficient time for bleeding to stop and healing to occur

2. Manage the bleeding AVF

   • Address the underlying cause of the aneurysmal AVF bleeding
   • Consider surgical or interventional repair once bleeding is controlled

3. Resumption of anticoagulation

   • Restart apixaban once bleeding is controlled and it is safe to resume anticoagulation
   • The timing should balance the risk of thromboembolism against the risk of recurrent bleeding

Evidence Supporting This Approach

The 2021 ACC/AHA guidelines for valvular heart disease specifically state that for patients with bioprosthetic heart valves who are receiving anticoagulation for atrial fibrillation, "it is reasonable to consider the need for bridging anticoagulant therapy around the time of invasive procedures on the basis of the CHA2DS-VASc score weighed against the risk of bleeding." 1

In this case, with active bleeding already present, adding heparin would significantly increase the bleeding risk without providing substantial benefit, as bioprosthetic valves have lower thrombotic risk than mechanical valves.

Important Considerations and Caveats

• Duration of apixaban interruption: Keep as short as safely possible to minimize thrombotic risk
• Timing of bioprosthetic valve implantation: If the valve was implanted within the past 3-6 months, there may be a slightly higher thrombotic risk, but active bleeding still takes precedence 2
• Underlying indication for apixaban: If the patient has additional indications for anticoagulation (e.g., atrial fibrillation with high CHA2DS2-VASc score), this should be considered when determining when to restart anticoagulation, but does not justify bridging during active bleeding 1

Monitoring After Anticoagulation Interruption

• Monitor for signs of valve thrombosis (new murmurs, symptoms of heart failure)
• Consider echocardiography if there are concerns about valve function after prolonged interruption
• Once bleeding is controlled, promptly reassess for safe resumption of apixaban

The evidence clearly supports that for patients with bioprosthetic valves (unlike mechanical valves), the risk-benefit analysis favors avoiding heparin bridging during periods of active bleeding, as the thrombotic risk is lower and the bleeding risk would be substantially increased.