For patients with AF and prosthetic heart valves, long-term anticoagulation with warfarin is recommended; the target INR may be increased and aspirin added depending on valve type and position, and on patient factors. The optimal choice of valve in middle-aged patients is not clear and the available options all have drawbacks. of Pages 5 ARTICLE IN PRESS Rev Port Cardiol. Thus, consideration should be … Prosthetic aortic valves are often required for patients with aortic stenosis. 1 The authors reported the management of a pregnant patient with a mechanical prosthetic valve in mitral position complicated by acute ischemic stroke (AIS). AHA and ACC guidelines and the ACCP guidelines.2,3 We endeavor to present current guidelines for bridging anticoagulation strategies for patients with MHVs undergoing noncardiac surgery, along with additional recommendations that are based on reports of institutional experiences. Patients with prosthetic heart valves (PHVs) require chronic oral anticoagulation. In this clinical scenario, physicians must be mindful of the thromboembolic and bleeding risks related to chronic anticoagulant therapy. Nishimura RA et al., 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Some authorities believe that anticoagulation increases the potential risk of cerebral haemorrhage after a thromboembolism whereas others, however, affirm that cessation of anticoagulation itself increases the risk of thromboembolism and subsequent morbidity and mortality. Combined and Multiple Valve Diseases 11. valve prosthesis implantation and intracranial hemorrhage and showed that discontinuation of anticoagulation for - weeks has a low probability of thromboembolic events in patients with high embolic risk [ ]. While current 2017 ACC/AHA guidelines do not recommend routine surveillance with TTE until after 10 years of bioprosthetic valve implantation in the absence of symptoms, our case highlights that early diagnosis and management of BPVT is critical. This paper reviews the main heart valve guidelines focusing on the use of oral anticoagulation in these patients. heparin for prosthetic heart valves peri-operatively. Dabigatran, Rivaroxaban, Apixaban, Edoxaban, etc) are NOT - Brunner & Suddarths (2012) 2. 1. thetic valve thrombosis, is among the most dreaded complications after aortic valve replacement, with an annual incidence of major thromboembolism approaching 1.8 and 8 events per 100 patient-years on and off anticoagulation, respectively. (CASE REPORT, Clinical report) by "Journal of Evolution of Medical and Dental Sciences"; Health, general Blood clot Care and treatment Development and progression Cardiovascular implants Complications and side effects Cardiovascular instruments, … For patients with AF and mitral stenosis, long-term anticoagulation with warfarin is recommended. We recommend against the use of anticoagulant (Grade 1C) and antiplatelet therapy (Grade 1B) for native valve endocarditis. Fibrinolysis Versus Surgery for Prosthetic Valve Thrombosis4. Little SH et al. are now available, current guidelines do not recommend their use for antithrombotic therapy in patients with PHVs , , .Vitamin K antagonists (mainly warfarin) remain the most widely used agents for this purpose. Introduction. The FDA has now taken the stance that dabigatran is contraindicated in patients with mechanical heart valves, further noting that its use in bioprosthetic recipients “has not been evaluated and cannot be recommended.” 6,7. Although reportedly anticoagulation can be safely withheld for less than seven days without valve complications in the setting of intracranial haemorrhage, subtherapeutic INR values for 16.3 ± 9.0 days have been associated with a 1% risk of thromboembolism. risk Table 3: Risk evaluation for GI endoscopic procedures Procedure Condition High Risk Procedures Polypectomy valve in mitral position ERCP with sphincterotomy Prosthetic heart valve and The risk of stopping “While anticoagulation therapy remains a necessity for mechanical valve ... mechanical heart valves are the “standard of care” for patients younger than 60 years of age who require an aortic valve replacement 3. Anticoagulation management in patients with acute intracerebral haemorrhage (ICH) and mechanical heart valves (MHVs) who require long-term oral anticoagulation (OAC) represents a growing therapeutic dilemma. Prosthetic valve thrombogenicity and bleeding complications associated with life-long anticoagulation are constant potential causes of morbidity and mortality following prosthetic valve implantation. The rationale for this is to prevent valve thrombosis and thromboembolic complications without increasing the risk of excess bleeding. Patients who undergo mechanical valve replacement are at major risk for thrombus formation on the prosthetic valve and subsequent arterial thromboem-bolic … A simplified guidelines, developed by Panduranga P et al., for anticoagulation management in developing countries where factor Xa measurement facility is not available in hospital suggest that the anticoagulant treatment suitable for pregnant women with mechanical valve prosthesis is dependent on the availability of anti-factor Xa level monitoring facilities, the patient’s pre-pregnancy … Free Online Library: Mitral mechanical prosthetic valve thrombosis four years after discontinuing anticoagulation: a case report. DOAC contraindicated with mechanical valve — DOACs should not be used in patients with mechanical … Anticoagulation with warfarin is now routinely practiced with mechanical prosthetic heart valves to reduce e re has been, report of discontinuation of anticoagulation for months without thromboembolic or thrombosis events [ ]. Most prosthetic valves require open heart surgery. How early abnormal gradients can be detected prior to diagnosis and how fast they normalise with anticoagulant therapy is unknown. 84 How to treat these conditions after TAVI is an area of uncertainty and data from trials and registries are controversial. On-X Aortic Valve: 50% Closer to a Normal INR1 On-X Aortic Valve patients with an INR of 1.5–2.0 had a >60% reduction in bleeding events and no increase in TE compared to patients with an INR of 2.0–3.0. Mechanical valves have excellent durability and SVD does not occur.3 In addition, newer-generation mechanical valves have superior hemodynamic profiles compared with stented bioprosthetic valves. In MPHV, long-term antithrombotic treatment with only vitamin K antagonists (VKAs) is needed [3]. Review of anticoagulation options for mechanical valve prosthesis. The risk/benefit ratio of mechanical and bioprosthetic valves has led American and European guidelines on valvular heart disease to be consistent in recommending the use of mechanical aortic valve prostheses in patients younger than 60 years of age (Figure 2). We have recently read with great interest the article by Morgado et al. Am Coll Chest Physicians 2008 Dentali F et al. In our study, the incidence of prosthetic valve thrombosis was 12.15%. Favor Surgery. 10. 1–4 During the hyper-acute phase of ICH, altered coagulation needs to be normalized as soon as possible to stabilize the haematoma, 5, 6 specifically by administering … Prosthetic Valves 11.1 Choice of prosthetic valve 5 11.2 Management after valve intervention 12. guidelines, when appropriate and feasible, an analysis of the value of a drug, device, or intervention may be per-formed in accordance with the ACC/AHA methodology 3 To ensure that guideline recommendations remain cur-rent, new data are reviewed on an ongoing basis, with full guideline revisions commissioned in approximately 6-year 1 & Munir Boodhwani*,1. 3. The need for perioperative anticoagulation in patients with mechanical heart valves has been questioned in a recent review. Effective anticoagulation is therefore critical in such patients but remains problematic, since oral anticoagulation and both unfractionated and low-molecular-weight heparin may be associated with important fetal and maternal side effects. For patients with a bioprosthetic valve in the mitral position, therapy with warfarin to a target INR of 2.5 (range, 2.0-3.0) for the first 3 months after valve insertion is recommended. Although newer oral antithrombotic agents (rivaroxaban, apixaban, dabigatran, etc.) … * All other bileaflet aortic valve anticoagulation should … No change in anticoagulation is recommended unless the INR is greater than 3 either due to over-anticoagulation or a previously desired higher target range. Dabigatran is the new generation anticoagulation medication which is taken orally and does not require frequent monitoring. 92 It has recruited TAVI patients with an underlying indication for long-term OAC and is investigating the 12-month net clinical benefit of OAC monotherapy with VKA or DOAC versus double therapy with aspirin plus … ACCP & ACC/AHA guidelines recommend life-long anticoagulation with a VKA in patients with mechanical heart valves. However, both guidelines recommend interruption of VKA with bridging anticoagulation in patients with any mitral valve prosthesis, caged-ball, tilting disc aortic valve prosthesis, bileaflet AVR with additional risk factors such as the recent (within 6 months) stroke or transient ischemic attack, prior thromboembolism during the temporary interruption of VKAs. 2017;135:e1159-95. 85–88 Importantly, when AF or other … Guidelines or consensus statements which address the approach to patients who require long-term anticoagulant therapy for AF and … Overview of the management of patients with prosthetic heart valves The potential impact of Transcatheter Aortic Valve Replacement (TAVR) after a bioprosthetic valve replacement may, in time, impact this decision making. Bioprosthetic Valves Long-term anticoagulation for patients with bioprosthetic valves is not indicated as the risk of thrombosis and thromboembolism is low (about 0.2%/year): Non-cardiac surgery in patients with prosthetic heart valves poses risks of infective endocarditis, bleeding and acute/subacute valve thrombosis or systemic thromboembolism associated with interrupted anticoagulation. Yung-Chih Chen, Charles Jia-Yin Hou, Ta-Chun Hong, Transesophageal Echocardiography in the Detection of Prosthetic Mitral Valve Thrombosis Caused by Inadequate Anticoagulation, Journal of Medical Ultrasound, 10.1016/S0929-6441(09)60047-3, 11, 3, (111-114), (2003). We compared the recommendations from the 2017 American College of Cardiology/American Heart Association guidelines for management of patients with prosthetic heart valves with the 2017 European Society of Cardiology guidelines. The latest guideline from ACC/AHA in 2008 on anticoagulation for prosthesis is as follows [1]. (1) After aortic valve replacement (AVR) with mechanical prostheses, warfarin is indicated to achieve an INR of 2.0 to 3.0. If the patient has risk factors, warfarin is indicated to achieve an INR of 2.5 to 3.5. The optimal approach to antiplatelet and anticoagulant therapy after bioprosthetic valve replacement is still under debate Guidelines vary somewhat between the American Heart Association/American College of Cardiology and the European Society of Cardiology/European Association for Cardio-Thoracic Surgery Anticoagulation. Mechanical heart valves are associated with a risk of thromboembolism and anticoagulation is generally recommended. patients with heart valve replacements. New novel oral anticoagulants (e.g. Acute mechanical prosthetic valve thrombosis after initiating oral anticoagulation therapy. The decision on whether to stop anticoagulation and/or when to stop it depends on the risk of a stroke or other thromboembolism in relationship to the reason the patient takes the blood thinner and the relative risk of the procedure planned. This approach is outdated and is not actually supported by the current ACCP-NHLBI recommendations. Objectives: The practices and the guidelines over the perioperative management of the anticoagulation of patients with cardiac valves prothesis are the object of no consensual attitude. PROSTHETIC VALVES. 1. The current guideline recommends warfarin on all mechanical valves. 3 In addition, new data are emerging regarding a less aggressive anticoagulation regimen with the newer generation prostheses. Hadi Toeg. This article provides guidelines for anticoagulant management tailored to thromboembolic risk, duration of lowered anticoagulation and risk of haemorrhage. This drug is approved for treatment for atrial fibrillation and venous thromboembolism, but the latest large trial … Prosthetic valve thrombosis (PVT) is a rare but serious complication of valve replacement, most often encountered with mechanical prostheses. oral anticoagulation therapy (OAC) for non-cardiac surgery, invasive procedures or dental care; and management of prosthetic valve thrombosis. The guideline has been based upon the European Society of Cardiology Guidelines (2007) and American College of Cardiology/American Heart Association Guidelines (2008) on Management J Thromb Thrombylysis 1998:5 Suppl 1:S19–24. Currently, only vitamin K antagonists are approved for this indication. Anticoagulation of Prosthetic Valves Guideline Reference Number P121214(01) Version 2 Issue Date: 20/11/2018 Page 7 of 13 It is your responsibility to check on the intranet that this printed copy is the latest version Liaise closely with Cardiology in all cases of suspected or possible prosthetic valve thrombosis. Antithrombotic therapy for prosthetic valves: Mechanical valves: Anticoagulation with vitamin K antagonists (VKAs) is recommended to achieve varying international normalized ratios (INRs) dependent on valve characteristics and patient risk factors (all Class 1). The choice of a cardiac valve prosthesis must be based on several factors related to the prosthesis (valve durability, expected hemodynamics, and need for anticoagulation) as well as for the individual patient (surgical or interventional risk, reoperative risk, bleeding risk) and, most importantly, the patient’s own values and preferences. DEFINITION “Prosthetic heart valve is a device implanted in the heart of a patient with valvular heart disease.”. The current guideline recommends warfarin on all mechanical valves. The conflict between over- and under-anticoagulation is even more of a problem when other surgical interventions are required. meta-analysis for mainly mechanical valve prosthesis demonstrated a significant reduc-tion in thromboembolic events with OAC and addition of one antiplatelet drug, but the perceived benefit was challenged with . Objective Bioprosthetic valve thrombosis (BPVT) is increasingly recognised as a major cause of prosthetic dysfunction in the first years postimplantation. Mechanical prosthetic valve thrombosis is a clinical emergency which is associated with high rates of morbidity and mortality. When compared to surgery, TAVI has produced superior, or at least comparable, results, and thus a trend to broaden treatment indications to lower-risk patients has erupted as a natural consequence, even though there is a lack of long-term evidence. The Anticoagulation Alone Versus Anticoagulation and Aspirin Following Transcatheter Aortic Valve Interventions (AVATAR; NCT02735902) trial is expected finish in April 2020. entitled “A pregnant woman with a prosthetic mechanical valve”. Although valve rheumatic disease is decreasing [1]. 1. Objective Bioprosthetic valve thrombosis (BPVT) is increasingly recognised as a major cause of prosthetic dysfunction in the first years postimplantation. However, this is inevitably associated with a risk of intracranial bleeding. +Model REPC-569; No. Mechanical (Metallic) prosthetic heart valves All patients with mechanical heart valves require life-long anticoagulation with a Vitamin K antagonist, i.e. This paper reviews the main heart valve guidelines focusing on the use of oral anticoagulation in these patients. How early abnormal gradients can be detected prior to diagnosis and how fast they normalise with anticoagulant therapy is unknown. Cochrane database of systematic reviews 2003; issue 4 Salen DN, O’Gara PT, Madias C et al. valve thrombosis have identified inadequate anticoagulation, valve endocarditis, and the type of valve employed as risk factors. READ RESULTS Background In January of 2006, The US FDA… The current American College of Cardiology/Ameri-can Heart Association guidelines for valvular heart disease recommend only short-term (3 months) anti- The management of pregnant women with prosthetic heart valves is a clinical challenge. According to the American Heart Association guidelines (1), 'the risk of increased bleeding during a procedure performed on a patient receiving antithrombotic therapy has to be weighed against the increased risk of thromboembolism caused by stopping the therapy. 2. Jesse Raiten. Warfarin 1 mg or 2 mg daily is generally an acceptable starting dose. Antiplatelet Drugs for Prosthetic Valves Although current guideline shown previously recommends addition of aspirin to warfarin for mechanical valves and bioprosthetic valves with risk factors, antiplatelet drugs are not without a risk. We suggest holding VKA therapy until the patient is stabilized without neurologic complications for infective endocarditis of a prosthetic valve (Grade 2C). Bioprosthetic valve thrombosis (BVT) beyond 3 months of valve implantation remains an under-recognised clinical entity contributing to late prosthetic valve dysfunction. For patients at higher risk of valve thrombosis (ie, patients with 2 prosthetic valves or with caged-ball type of valves), whether LMWH provides adequate anticoagulant protection is unclear. Transcatheter aortic valve implantation (TAVI) has been developed as a very reproducible and safe procedure, as shown in many trials. RISK OF THROMBOEMBOLISM “A surgical implant used to replace an abnormal heart valve. Implantation of prosthetic valve requires consideration for anticoagulation. ey e most recent meta-analysis from Cochrane review in has looked into this issue [ ]. Guidelines •CLASS I –Initial TTE after AVR (2-4 weeks or sooner if ... –Annual TTE in bioprosthetic valves after the first 10 years (5 years in prosthetic statement 2008) but not mechanical valves Nishimura et al 2014. Antiplatelet and anticoagulation for patients with prosthetic heart valves. DOACs are not approved for use in patients with mechanical prosthetic heart valves. Anticoagulation management of valve replacement patients Anticoagulation regimens vary according to surgeon, nature of the valve (mechanical or biological), its position and other risk factors for stroke. A major bleeding rate of 4% per patient-year has been reported for patients on warfarin for prosthetic valves. Bio Prosthetic Valve Thrombosis Dr G. Raghu Kishore Bioprosthetic Valve Thrombosis. Abstract Anticoagulation Therapy Following Embolic or Hemorrhagic Stroke in the Patient with a Mechanical Heart Valve. tive valve diseases. Introduction. Anticoagulation for Stroke Prevention in non-valvular AF: Joint Primary and Secondary Care Guidance NHS Rotherham CCG and The Rotherham Found ation Trust version 1.0 Nov 2019 Page 1 of 13 * Non-valvular AF is defined as AF in the absence of a mechanical prosthetic heart valve or moderate to severe mitral stenosis (usually of rheumatic origin) in the United States to be 2.5%, with prevalence estimates in those over the age of 75 to be as high as 13.3%.4 Publish date: January 27, 2016. The guidelines clarify that a recommendation to use antibiotic prophylaxis to reduce the risk of infective endocarditis in patients with prosthetic valves undergoing dental procedures applies to patients with transcatheter valves and those with prosthetic material used for valve repair, such as annuloplasty rings and chords. The regular, preoperative use of antiplatelet medications like aspirin and clopidogrel have been associated with increased perioperative blood loss as well as with the need for blood products in surgery patients—as such, a thorough understanding of current guidelines pertaining to their use prior to surgery is requisite. Patients with prosthetic heart valves require chronic oral anticoagulation. Mechanical prosthetic heart valves have been used for many decades to replace damaged native valves. Currently, only vitamin K antagonists are approved for this indication. Implantation of mechanical prosthetic heart valves (MPHV) is associated with a reduction in valve-related morbidity compared to biological valves [2]. 1 The Prospective Randomized On-X Valve Anticoagulation Clinical Trial (PROACT) Update: In April 2015 FDA approved the On-X aortic heart valve with INR 1.5–2.0 following 3 months of standard anticoagulation therapy based on the successful completion of the AVR high risk arm of the PROACT study. … Accurate identification of BVT over structural valve degeneration is crucial as most patients with BVT respond very well to anticoagulation therapy. The use of anticoagulant therapy in prosthetic valve endocarditis is a controversial management issue. … with surgical bioprosthetic heart valves, a DOAC is a reasonable choice. The most frequent indication for long-term anticoagulation is AF, followed by mechanical valve prostheses, deep vein thrombosis/pulmonary embolism, left ventricular thrombi, pulmonary hypertension or clotting disorders. anticoagulation therapy aortic regurgitation aortic stenosis bicuspid aortic valve cardiac surgery guidelines infective endocarditis mitral regurgitation mitral stenosis mitral transcatheter edge-to-edge repair prosthetic valve pulmonic regurgitation pulmonic The thrombotic risk over the time is well known. Many laboratories continue to use the older recommendations for prosthetic valve anticoagulation-that is, an INR of 3.0 to 4.5. The evidence suggests that anticoagulation with either heparin may not be required for all patients. All mechanical prosthetic valves, however, are thrombogenic and require lifelong anticoagulation to prevent thromboembolic complications.3 In addition, pregnancy is … Anticoagulation Management of Patients With Prosthetic Valves As authors of previous European guidelines on anticoagu-lation of patients after valve surgery and as members of a No clear consensus exists on the optimal artificial valve and anticoagulation strategy for … monitoring and intensity of oral anticoagulation therapy in valvular heart disease. Combined aspirin-oral anticoagulant therapy compared with oral anticoagulant • Lifelong anticoagulation is needed after the mechan-ical aortic valve replacement; however, the necessity and duration of anticoagulation after bioprosthetic aortic valve remain controversial. In patients with a bioprosthetic mitral valve who are in sinus rhythm and have no other indications for anticoagulant therapy, 3 months of warfarin therapy (international normalized ratio [INR] range: 2.0-3.0) after valve replacement is suggested, to be followed by long-term acetyl Patients undergoing mechanical mitral valve replacement require lifelong anticoagulation. Management during Pregnancy 13.1 Native valve disease Favor Fibrinolysis. oral anticoagulation (OAC) and structural valve deterioration, a valve repair strategy should be considered [5]. The significant morbidity and mortality associated with this condition warrants rapid diagnostic evaluation. 20, 21 Recommendations for using a bioprosthetic valve are above the age of 65 in European guidelines and above the age … Valvular and structural heart disease. Current ACCP guidelines and the AHA and ACC guidelines suggest that mechanical aortic valves in the absence of other TE risks should be maintained at a target international normalized ratio (INR) of 2.5, whereas mechanical aortic valves with additional thromboembolic risks and mechanical mitral valves should be maintained at a target INR of 3. Management during Noncardiac Surgery 12.1 Preoperative evaluation 12.2 Specific valve lesions 12.3 Perioperative monitoring 13. Based upon the data outlined below, the AHA/ACC Guidelines for Valvular Heart Disease 13 produced a set of recommendations for clinicians, which were in accordance with the recommendations that had been arrived at … Anticoagulation requirements: Biological (Tissue) prosthetic heart valves or Valve repair: Aortic position: No warfarin anticoagulation needed (current recommendation is only for an anti-platelet aggregatory agent, such as Aspirin, for 3 … Low-molecular-weight heparin is often used for anticoagulation in pregnant women including those with MPHV. Recommendations for Evaluation of Prosthetic Valves With Echocardiography and Doppler Ultrasound A Report From the American Society of Echocardiography’s Guidelines and Standards Committee and the Task Force on Prosthetic Valves, Developed in Conjunction With the American College of Cardiology Cardiovascular Imaging Committee, Cardiac Imaging For people with atrial fibrillation, there is no need to achieve anticoagulation rapidly; a slow-loading regimen is safe and achieves therapeutic anticoagulation in most people within 3–4 weeks. 2. In a retrospective review over 23 years, evaluating 6700 patients Guidelines mandate the use of anticoagulant therapy in patients with mechanical prosthetic valves of any type, irrespective of the position in the heart. The approach to the management of anticoagulation in patients with prosthetic valves undergoing non-cardiac surgery remains controversial. The need for perioperative anticoagulation in patients with mechanical heart valves has been questioned in a recent review. Valve replacement can be done with either a bioprosthetic (tissue) or a mechanical prosthesis. However, diagnosis can be challenging, mainly because of variable clinical presentations and the degree of valvular obstruction. If additional risk factors for thromboembolism are present (AF, previous thromboembolism, left ventricular dysfunction), a target INR of 2.5 (range, 2.0-3.0) is recommended. It depends of the type or the location on the valve, of their associations and the age of the patient. Warfarin, guided by regular monitoring of the international normalised ratio (INR) to inform dosing. The approach to the management of anticoagulation in patients with prosthetic valves undergoing non-cardiac surgery remains controversial. Prosthetic valve occlusion has been estimated to occur in 1- 13 percent of cases [5]. Implantation of prosthetic valve requires consideration for anticoagulation. The final decision should take into account individual patient factors such as the surgical procedure, the type and location of the prosthetic valve and whether or not there are other indications for anticoagulation. Stop NSAIDS (Celebrex, Naproxen, Ibuprofen, etc) 2 days prior to procedure 2. Introduction • Bioprosthetic valve (BPV) thrombosis is considered a relatively rare clinical entity in the past. On-X Prosthetic Valve Instructions for Use. There remains limited data regarding the optimal anticoagulation regimen in pregnant women with mechanical valve prostheses, and controversy continues. Background: An estimated 95,000 heart valve replacements are performed annually in the United States.Prosthetic valves may be either mechanical or … Case Report Singapore Med J 2008; 49 (1) : e1 Prosthetic valve thrombosis despite seemingly -adequate anticoagulation: the dangers of transient lapses in anticoagulation Jafary F H, Hassan K ABSTRACT We report a I9 -year -old woman with thrombosis of a prosthetic mitral valve that was most likely due to a short dip in anticoagulation in the days preceding the event. 3. Mechanical heart valves. Warfarin is best for anticoagulation in prosthetic heart valve pregnancies . Anticoagulation Guidelines 1. American College of Cardiology/American Heart Association guidelines recommend monitoring of plasma anti-Xa factor peak levels and adjustment of the dose to achieve peak levels of 0.7 to 1.2 U/mL. In this clinical scenario, physicians must be mindful of the thromboembolic and bleeding risks related to chronic anticoagulant therapy. Patients with prosthetic heart valves require chronic oral anticoagulation. Background: Pregnancy is associated with an increased risk of thrombosis in women with mechanical prosthetic heart valves. Bioprosthetic valve: may forgo anticoagulation o Tricuspid valve Bioprosthetic valve, normal ventricular function: low dose aspirin Bioprosthetic valve, decreased right ventricular function or risk factors: warfarin: INR goal of 2.0-3.0 o Aortic and mitral valve follow same guidelines as children Beware of prosthetic valve thrombosis despite therapeutic anticoagulation @article{Foley2007BewareOP, title={Beware of prosthetic valve thrombosis despite therapeutic anticoagulation}, author={P. Foley and R. Sharma and Paul R Karla}, journal={Emergency Medicine Journal}, year={2007}, volume={24}, pages={e18 - e18} } Prosthetic heart valves (PHV) have been used to treat patients with both congenital and acquired valve lesions since the first surgical replacement in 1960.1 The two principal types of PHV are the mechanical prostheses and the tissue or bioprostheses. Prosthetic heart valve interventions continue to evolve with new innovations in surgical and transcatheter technologies.

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