Journal of Thrombosis and Thrombolysis

, Volume 18, Issue 3, pp 199–203 | Cite as

Perioperative Anticoagulation for Patients with Mechanical Heart Valves: A Survey of Current Practice

  • David A. Garcia
  • Walter Ageno
  • Edward N. Libby
  • John Bibb
  • James Douketis
  • Mark A. Crowther


Background: Patients with mechanical heart valves (MHV) require temporary interruption of warfarin when undergoing invasive procedures. Current guidelines addressing this subject are discordant because there is no high quality evidence to support any single management strategy. We tested the hypothesis that there is significant practice variation amongst clinicians caring for patients with MHV who require temporary cessation of their warfarin therapy.

Methods: A survey describing 4 hypothetical patients with mechanical heart valves was distributed to all clinicians attending an anticoagulation specialty meeting. For each scenario, the attendee was given several choices for preoperative and postoperative anticoagulation management. Information about each respondent’s profession, specialty and the frequency with which they make perioperative anticoagulation recommendations was also collected.

Results: Three hundred twenty-four of 650 surveys were returned. In each of the case scenarios, a majority of respondents selected subcutaneous low molecular weight heparin (LMWH) or subcutaneous unfractionated heparin (UH) as the preferred pre- and postoperative anticoagulant. Significant variation in practice was noted: for none of the questions was a single strategy selected by greater than 80% of respondents.

Conclusion: Expert clinicians differ in their perioperative management strategies for patients with MHV who require interruption of warfarin. Although subcutaneous LMWH/UH was the treatment of choice in all scenarios, the lack of consensus found in our survey highlights the need for randomized controlled clinical trials of peri-procedural anticoagulant therapy.

Abbreviated Abstract

This survey of anticoagulation experts reveals that there is significant practice variation in scenarios where temporary interruption of warfarin is necessary in patients with mechanical heart valves. Despite discordant guidelines and a lack of high-quality data to support any strategy, a majority of the respondents surveyed would use low molecular weight heparin (or subcutaneous unfractionated heparin) to anticoagulate patients with mechanical heart valves during the peri-operative period.

Key Words

heart valves perioperative anticoagulation surgery 


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  1. 1.
    Martinell J, Jimenez A, Rabago G, Artiz V, Fraile J, Farre J. Mechanical cardiac valve thrombosis. Is thrombectomy justified? Circulation 1991;84(5 Suppl):III70–III75.PubMedGoogle Scholar
  2. 2.
    Tiede DJ, Nishimura RA, Gastineau DA, et al. Modern management of prosthetic valve anticoagulation. [Review] [169 refs].Mayo Clin Proc 1998;73(7):665–680.PubMedGoogle Scholar
  3. 3.
    Longstreth WT, Jr., Bernick C, Fitzpatrick A, et al. Frequency and predictors of stroke death in 5,888 participants in the Cardiovascular Health Study. Neurology 2001;56(3):368–375.PubMedGoogle Scholar
  4. 4.
    Ansell J, Hirsh J, Poller L, Bussey H, Jacobson A, Hylek E. The pharmacology and management of the vitamin K antagonists: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126(3 Suppl):204S–33S.CrossRefPubMedGoogle Scholar
  5. 5.
    Hirsh J, Fuster V, Ansell J, Halperin JL. American Heart Association/American College of Cardiology Foundation guide to warfarin therapy. Circulation 2003;107(12):1692–1711.CrossRefPubMedGoogle Scholar
  6. 6.
    Douketis J, Crowther M, Cherian SS, Kearon C. Physician preferences for perioperative anticoagulation in patients with a mechanical heart valve who are undergoing elective noncardiac surgery.Chest 1999;116:1240–1246.CrossRefPubMedGoogle Scholar
  7. 7.
    Gould MK, Dembitzer AD, Doyle RL, Hastie TJ, Garber AM. Low-molecular-weight heparins compared with unfractionated heparin for treatment of acute deep venous thrombosis. A meta-analysis of randomized, controlled trials. Ann Intern Med 1999;130(10):800–809.PubMedGoogle Scholar
  8. 8.
    Ridker PM, Goldhaber SZ, Danielson E, et al. Long-term, low-intensity warfarin therapy for the prevention of recurrent venous thromboembolism.N Engl J Med 2003.Google Scholar
  9. 9.
    Carrel TP, Klingenmann W, Mohacsi PJ, Berdat P, Althaus U. Perioperative bleeding and thromboembolic risk during non-cardiac surgery in patients with mechanical prosthetic heart valves: an institutional review. J Heart Valve Dis 1999;8(4):392–398.PubMedGoogle Scholar
  10. 10.
    Katholi RE, Nolan SP, McGuire LB. The management of anticoagulation during noncardiac operations in patients with prosthetic heart valves. A prospective study. Am Heart J 1978;96(2):163–165.CrossRefPubMedGoogle Scholar
  11. 11.
    Kovacs MJ, Kearon C, Rodger M, et al. Single-arm study of bridging therapy with low-molecular-weight heparin for patients at risk of arterial embolism who require temporary interruption of warfarin. Circulation 2004;110(12):1658–1663.CrossRefPubMedGoogle Scholar
  12. 12.
    Ferreira I, Dos L, Tornos P, Nicolau I, Permanyer-Miralda G, Soler-Soler J. Experience with enoxaparin in patients with mechanical heart valves who must withhold acenocumarol. Heart 2003;89(5):527–530.CrossRefPubMedGoogle Scholar
  13. 13.
    Tinmouth AH, Morrow BH, Cruickshank MK, Moore PM, Kovacs MJ. Dalteparin as periprocedure anticoagulation for patients on warfarin and at high risk of thrombosis. Ann Pharmacother 2001;35(6):669–674.CrossRefPubMedGoogle Scholar
  14. 14.
    Spandorfer JM, Lynch S, Weitz HH, Fertel S, Merli GJ. Use of enoxaparin for the chronically anticoagulated patient before and after procedures. Am J Cardiol 1999;84(4):478–480, A10.CrossRefPubMedGoogle Scholar
  15. 15.
    Bonow RO, Carabello B, de Leon AC, Jr., et al. Guidelines for the management of patients with valvular heart disease: Executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Valvular Heart Disease).Circulation 1998;98(18):1949–1984.PubMedGoogle Scholar
  16. 16.
    Salem DN, Stein PD, Al-Ahmad A, et al. Antithrombotic therapy in valvular heart disease–native and prosthetic: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126(3 Suppl):457S–82S.CrossRefPubMedGoogle Scholar
  17. 17.
    Asch DA, Jedrziewski MK, Christakis NA. Response rates to mail surveys published in medical journals. J Clin Epidemiol 1997;50(10):1129–1136.CrossRefPubMedGoogle Scholar
  18. 18.
    Holden J, Holden K. Comparative effectiveness of general practitioner versus pharmacist dosing of patients requiring anticoagulation in the community. J Clin Pharm Ther 2000;25(1):49–54.CrossRefPubMedGoogle Scholar
  19. 19.
    Taylor FC, Gray A, Cohen H, Gaminara L, Ramsay M, Miller D. Costs and effectiveness of a nurse specialist anticoagulant service. J Clin Pathol 1997;50(10):823–828.PubMedGoogle Scholar
  20. 20.
    Willey ML, Chagan L, Sisca TS, et al. A pharmacist-managed anticoagulation clinic: six-year assessment of patient outcomes. Am J Health Syst Pharm 2003;60(10):1033–1037.PubMedGoogle Scholar

Copyright information

© Springer Science + Business Media, Inc. 2004

Authors and Affiliations

  • David A. Garcia
    • 1
    • 4
  • Walter Ageno
    • 2
  • Edward N. Libby
    • 1
  • John Bibb
    • 1
  • James Douketis
    • 3
  • Mark A. Crowther
    • 3
  1. 1.Internal MedicineUniversity of New MexicoAlbuquerque
  2. 2.Internal MedicineUniversity of InsubriaVareseItaly
  3. 3.Internal MedicineMcMaster UniversityHamilton
  4. 4.Internal MedicineUniversity of New MexicoAlbuquerque

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