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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. If there are additional risk factors in patients with a mechanical AVR (atrial fibrillation, previous thromboembolism, LV dysfunction, hypercoagulable state, or presence of older valve such as a ball-in-cage), then the INR for a mechanical AVR should be similar to a mechanical mitral valve replacement. Guidelines currently suggest the following as well: (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 at least 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. 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 and it should not be used. It is acceptable, though, to use DOACs for the treatment of atrial fibrillation in patients with bioprosthetic valves. For patients with a TAVR valve, it is reasonable to use dual antiplatelet therapy (clopidogrel and aspirin) for 3–6 months after the procedure. After that, lifelong low-dose aspirin should be used. As noted earlier, using warfarin for at least 3 months after TAVR is reasonable (class IIb), although that practice is widely variable. Randomized trials have not shown a benefit with DOACs after TAVR.

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.

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