Antithrombotic therapy for a newly implanted surgical bioprosthetic valve

VKA: vitamin K antagonist (eg, warfarin); DOAC: direct oral anticoagulant; INR: international normalized ratio; LMWH: low molecular weight heparin; UFH: unfractionated heparin.
* For patients who will be treated with VKA after surgical bioprosthetic valve implantation, early therapeutic heparin bridging (with UFH or LMWH) is indicated. Heparin bridging is not indicated for patients who will receive a DOAC or no anticoagulant. Refer to UpToDate content on early bridging after surgical bioprosthetic valve replacement. The INR target described here follows the convention in the 2020 American College of Cardiology/American Heart Association (ACC/AHA) and 2021 European Society of Cardiology (ESC) valve guidelines, which specify INR targets rather than ranges. The acceptable range extends to 0.5 INR units on each side of the target. The use of targets was deemed preferable to ranges because it is more likely to reduce the time the INRs are closer to the upper or lower limit of the range.
¶ Indicators of elevated bleeding risk include previous major bleed, active peptic ulcer disease, uncontrolled hypertension, bleeding disorders, platelet count <50,000/microL, and barriers to adherence to anticoagulation monitoring and management. Refer to UpToDate content on risks of bleeding with oral anticoagulants.
Δ If anticoagulation for the concurrent indication is stopped within the first 3 to 6 months after surgical bioprosthetic valve implantation, then continue anticoagulation for the bioprosthetic valve to complete 3 to 6 months total if the bleeding risk is low. If the period of anticoagulation is finite, treat with aspirin 75 to 100 mg orally once daily after anticoagulation is stopped.
◊ For patients with a surgical bioprosthetic valve without a concurrent indication for anticoagulation, VKA is preferred based on greater experience with VKA than DOAC in this setting.
§ The decision on whether to proceed with aspirin therapy is based upon an individualized assessment of estimated benefits (reducing risk of thromboembolism and valve thrombosis) and risks (bleeding).