Management of Periprocedural Anticoagulation in Patients with a Prosthetic Heart Valve

Resident Grand Rounds Kattron Cofield, HOIII March 13, 2008

Recommendations for managing periprocedural anticoagulation

• First consider the patient’s risk of thromboembolism and risk of bleeding associated with the patient’s procedure.

Procedure risk of bleeding	Risk of Thromboembolism High	Low
Moderate - High	Stop warfarin 3-5 days before the procedure and anticoagulate with heparin when INR is subtherapeutic. Postprocedure, restart warfarin and consider heparin	Stop warfarin 3-5 days before the procedure and restart after procedure
Low	No change in anticoagulation	No change in anticoagulation

Recommendations for managing periprocedural anticoagulation

• Utilize a standardized periprocedural anticoagulation regimen based on risk stratification.

Day	Intervention
-5 or -6 -3 or -4 -1	Preprocedure Stop warfarin Start SC dalteparin sodium 100 IU/kg BID Last preprocedural dose of LMWH given no less than 12h before start of surgery or procedure
0	Day of the Procedure Assess postoperative hemostasis after surgery or procedure; Resume warfarin on evening of or day after procedure
+1 +4 +7 to +10	Postprocedure Low-Mod Bleeding Risk High Bleeding Risk Procedure Procedure Start dalteparin sodium No dalteparin 100 IU/kg BID* administered INR testing (stop dalteparin if INR≥2) INR testing INR testing INR testing
	*Dalteparin may be delayed until hemostasis is secured