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The risk of thromboembolism is much lower with bioprosthetic valves than mechanical prosthetic valves. Mechanical mitral valve prostheses also pose a greater risk for thrombosis than mechanical aortic valves. For that reason, the INR should be kept between 2.5 and 3.5 for mechanical mitral prosthetic valves but can be kept between 2.0 and 2.5 for most mechanical aortic prosthetic valves. Several changes were recommended regarding anticoagulation use in valvular heart disease with the publication of the 2017 update to the 2014 ACC/AHA valve guidelines, including (1) a recommendation (class IIa) to expand the use of vitamin K antagonists (VKAs), such as warfarin, for up to 6 months after initial bioprosthetic valve replacement; (2) a lower target INR of 1.5–2.0 for a mechanical AVR using the On-X valve (class IIb); and (3) a consideration of VKA use with an INR of 2.5 for 3 months after TAVR (class IIa). Data from 2018 suggest that antiplatelet medications are inferior to warfarin for the prevention of thrombus in patients with the On-X mechanical valve. The concern regarding thrombus formation on bioprosthetic valves (including TAVR valves) also led to a class I recommendation to use multimodality imaging to identify such thrombus (class I). The DOAC rivaroxaban has not been found to prevent stroke related to emboli from TAVR.

In 2015 the European Registry of Pregnancy and Cardiac Disease (ROPAC) reported on a registry that compared pregnant women who had undergone mechanical and bioprosthetic valve replacement to pregnant women who had not. Maternal mortality was similar between the mechanical and bioprosthetic valve patients (1.5% and 1.4%, respectively) but was much higher than those without an artificial valve (0.2%). When patients with either mechanical or bioprosthetic valves were further assessed, it was found that pregnant women with mechanical valves were more likely to suffer adverse events than women with bioprosthetic valves. Hemorrhagic events occurred in 23.1% versus 9.2%, miscarriage on warfarin occurred in 28.6% versus 9.2%, and late fetal death was noted in 7.1% versus 0.7%, respectively. These data suggest a high risk for mortality and morbidity for pregnant patients with mechanical heart valves, and in the WHO Classification of Maternal Cardiac Risk, the presence of a mechanical valve is considered a class III (out of IV) risk for pregnancy complications.

Stoppage of warfarin for noncardiac surgery is likewise dependent on which mechanical valve is involved, the patient-specific risk factors, and the procedure contemplated. The risk of thromboembolism is highest in the first few months after valve replacement. While the interruption of warfarin therapy is generally safe, most cases of valve thrombosis occur during periods of inadequate anticoagulation, so the time interval without coverage should be kept as short as possible. High-risk features include atrial fibrillation, a prior history of thromboembolism, heart failure or low LVEF, a hypercoagulable state, a mechanical valve in the mitral position, a known high-risk valve (ball-in-cage), or concomitant hypercoagulable state (such as with an associated cancer). The use of bridging VKAs, unfractionated ...

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