Management of Elevated INR in Patients with Mechanical Mitral Valves Undergoing Elective Non‑Cardiac Surgery
1. Decision to Postpone Surgery
2. Use of Vitamin K
3. Bridging Anticoagulation – Pre‑operative Phase
| Intervention | Details | Evidence Source |
|---|---|---|
| Therapeutic‑dose intravenous unfractionated heparin (UFH) | Start immediately; target activated partial thromboplastin time (aPTT) 60–80 seconds. | CHEST 2022 guideline. [3] |
| Timing of UFH cessation | Discontinue UFH ≥ 4 hours before the incision to reduce intra‑operative bleeding. | ESC 2009 guideline. [1] |
| Alternative LMWH regimen | Therapeutic dose (≈ 70 U/kg twice daily); last dose ≥ 12 hours before surgery if UFH is not feasible. | ESC 2009 guideline. [1] |
| Rationale for UFH preference | Evidence supporting IV UFH is stronger than for LMWH in patients with mechanical prosthetic heart valves, making UFH the preferred bridge. | ESC 2009 guideline. [1] |