How should a 35-year-old woman with a mechanical tricuspid valve on acenocoumarol, low-dose aspirin (acetylsalicylic acid) and metoprolol be managed when she presents with 3–4 days of per-vaginal bleeding and a hemoglobin of 7.4 g/dL?

Management of Menorrhagia in a Patient with Mechanical Tricuspid Valve and Severe Anemia

This patient requires immediate hospitalization for blood transfusion, urgent gynecological evaluation to control bleeding, temporary cessation or reversal of anticoagulation with close monitoring, and multidisciplinary coordination between cardiology, gynecology, and hematology to balance thrombotic versus hemorrhagic risk.

Immediate Hemodynamic Stabilization

• Admit the patient immediately for hemoglobin of 7.4 g/dL with ongoing bleeding, as this represents severe anemia requiring urgent intervention 1
• Transfuse packed red blood cells to target hemoglobin >8-9 g/dL to prevent hemodynamic compromise and tissue hypoxia 1
• Establish large-bore IV access and initiate continuous monitoring of vital signs, as patients with mechanical valves and severe anemia are at risk for both thrombotic and hemorrhagic complications 1

Anticoagulation Management During Active Bleeding

Temporarily hold acenocoumarol (Acitrom) immediately while bleeding is active and hemoglobin is critically low, as the risk of exsanguination outweighs short-term thrombotic risk 1

INR Assessment and Reversal Strategy

• Check INR urgently to determine degree of anticoagulation 1, 2
• If INR >3.5-4.0 with severe bleeding: Administer oral vitamin K 5-10 mg (preferred over IV due to lower anaphylaxis risk) 1
• If INR is extremely elevated (>10) or life-threatening bleeding: Consider prothrombin complex concentrate combined with vitamin K for rapid reversal 1
• Fresh frozen plasma is an alternative if prothrombin complex concentrate is unavailable, though less preferred 1

Aspirin Management

• Discontinue Ecosprin (aspirin) immediately during active severe bleeding, as the combination of anticoagulation plus antiplatelet therapy significantly increases bleeding risk 1
• Aspirin can be safely held for 7 days without substantially increasing thrombotic risk in mechanical valve patients 1

Gynecological Intervention for Bleeding Control

Urgent gynecological consultation is mandatory to identify and treat the underlying cause of menorrhagia:

• Transvaginal ultrasound to evaluate for structural causes (fibroids, polyps, endometrial pathology) 3
• Consider hormonal therapy (high-dose progestins or combined oral contraceptives) for immediate bleeding control once hemodynamically stable
• Endometrial ablation or surgical intervention may be required if medical management fails
• Rule out pregnancy before any intervention, as pregnancy in mechanical valve patients requires specialized management 1, 3

Bridging Strategy After Bleeding Control

Once bleeding is controlled and hemoglobin stabilized:

For Mechanical Tricuspid Valve Specifically

Mechanical tricuspid valves require higher intensity anticoagulation than left-sided valves due to lower flow velocities and higher thrombotic risk 1, 4

• Target INR for tricuspid mechanical valve: 3.0-4.0 (higher than aortic valves) 1, 4
• Tricuspid valve thrombosis occurs at rates of 12.1 episodes per 100 patient-years with inadequate anticoagulation 4

Bridging Protocol

• Initiate unfractionated heparin (UFH) infusion 12-24 hours after bleeding cessation, targeting aPTT 2-2.5 times control 1, 3
• Alternative: Low molecular weight heparin (LMWH) subcutaneously with anti-Xa monitoring (target 0.7-1.2 U/mL) 1, 5
• Restart acenocoumarol once bleeding fully controlled, overlapping with heparin until INR therapeutic for 48 hours 1, 2
• Target INR 3.0-3.5 for tricuspid mechanical valve (higher end of range given thrombotic risk) 1, 2, 4

Critical Monitoring During Transition

• Daily INR monitoring during warfarin restart until stable therapeutic range achieved 2
• Daily hemoglobin checks for first 3-5 days to ensure no rebleeding 1
• Clinical assessment for valve thrombosis: New dyspnea, elevated JVP, peripheral edema, new diastolic murmur, or muffled valve clicks 4
• Transthoracic echocardiography if any clinical suspicion of valve thrombosis develops 1, 4

Long-Term Management Strategy

Anticoagulation Optimization

• Once bleeding resolved, resume acenocoumarol targeting INR 3.0-3.5 for tricuspid mechanical valve 1, 2, 4
• Consider resuming low-dose aspirin (75-100 mg) only after 2-4 weeks of stable hemoglobin and controlled menstrual bleeding 1
• Investigate causes of INR instability: medication interactions, dietary changes, non-adherence 2
• Consider anticoagulation clinic management for patients with unstable INR or bleeding complications 1

Menorrhagia Prevention

• Hormonal suppression with continuous progestins or levonorgestrel IUD to prevent future heavy menstrual bleeding
• Tranexamic acid during menses (antifibrinolytic) may reduce bleeding without affecting anticoagulation
• Iron supplementation to replete stores and prevent recurrent anemia
• Definitive surgical management (endometrial ablation or hysterectomy) should be considered if medical management fails, given the mandatory lifelong anticoagulation requirement 3

High-Risk Complications to Monitor

Valve Thrombosis Risk

Tricuspid mechanical valves have exceptionally high thrombosis rates (12.1 per 100 patient-years) when anticoagulation is inadequate 4:

• Both leaflets typically involved in symptomatic thrombosis 4
• Clinical presentation: Right heart failure, elevated JVP, diastolic murmur, peripheral edema 4
• Diagnosis: Fluoroscopy showing limited leaflet motion, TEE showing thrombus 1, 4
• Treatment if thrombosis occurs: Thrombolysis or intensified anticoagulation usually successful for right-sided valves 5, 6, 4

Rebleeding Risk

• Bleeding while in therapeutic INR range suggests underlying gynecological pathology requiring definitive treatment 1
• Recurrent bleeding episodes mandate gynecological intervention rather than repeated anticoagulation interruption 1

Key Pitfalls to Avoid

• Never delay transfusion in mechanical valve patients with Hb <8 g/dL, as anemia increases cardiac workload and thrombotic risk 1
• Never restart full anticoagulation without confirming bleeding cessation, as this risks life-threatening hemorrhage 1
• Never use subtherapeutic INR targets for tricuspid valves (e.g., 2.0-3.0), as this dramatically increases thrombosis risk 1, 4
• Never ignore recurrent menorrhagia in anticoagulated patients—definitive gynecological treatment is essential 3
• Never bridge with LMWH without anti-Xa monitoring in mechanical valve patients, as inadequate levels increase thrombotic risk 1