Perioperative Management

• Decision making regarding whether warfarin needs to be held depends on type of surgery and balance of bleeding versus thrombosis risk. If it is indicated, warfarin should be held 5-7 days prior to procedure for complete reversal.
• Bridge with another anticoagulant once INR is at lower end of target (e.g., when INR <2 for patient with INR goal of 2-3).
  • If bridging with enoxaparin, consider holding the enoxaparin for 24-48 hours prior to procedure.
  • If bridging with continuous heparin infusion, consider holding the infusion 4-6 hours prior to procedure.
• Restart warfarin and enoxaparin after the procedure as soon as adequate hemostasis has been established and once cleared by the surgeon or interventionist.
• Continue enoxaparin or continuous heparin until INR in therapeutic range.

• Low risk of thromboembolism includes no recent (> 3 months) venous thromboembolism, atrial fibrillation without a history of stroke or other risk factors, or bileaflet mechanical cardiac valve in aortic position.
• High risk of thromboembolism includes recent (3 months) history of venous thromboembolism, mechanical cardiac valve in mitral position, or old model of cardiac valve (ball/cage).