Recommendations J. Recommendations for management of antithrombotic therapy after prosthetic valve implantation or valve repair in the perioperative and postoperative periods.

Recommendations	Classa	Levelb
Management of antithrombotic therapy in the perioperative period
It is recommended that VKAs are timely discontinued prior to elective surgery to aim for an INR <1.5.c	I	C
Bridging of OAC, when interruption is needed, is recommended in patients with any of the following indications: • Mechanical prosthetic heart valve. • AF with significant mitral stenosis. • AF with a CHA2DS2-VASc score ≥3 for women or 2 for men.d • Acute thrombotic event within the previous 4 weeks. • High acute thromboembolic risk.e	I	C
Therapeutic doses of either UFH or subcutaneous LMWH are recommended for bridging. 476,504	I	B
In patients with MHVs, it is recommended to (re)-initiate the VKA on the first postoperative day.	I	C
In patients who have undergone valve surgery with an indication for postoperative therapeutic bridging, it is recommended to start either UFH or LMWH 12-24 h after surgery.	I	C
In patients undergoing surgery, it is recommended that aspirin therapy, if indicated, is maintained during the periprocedural period.	I	C
In patients treated with DAPT after recent PCI (within 1 month) who need to undergo heart valve surgery in the absence of an indication for OAC, it is recommended to resume the P2Y12 inhibitor postoperatively, as soon as there is no concern over bleeding.	I	C
In patients treated with DAPT after recent PCI (within 1 month) who need to undergo heart valve surgery in the absence of an indication for OAC, bridging P2Y12 inhibitors with short-acting glycoprotein IIb/IIIa inhibitors or cangrelor may be considered.	IIb	C
Patients with an indication to concomitant antiplatelet therapy
After uncomplicated PCI or ACS in patients requiring long-term OAC, early cessation (≤1 week) of aspirin and continuation of dual therapy with OAC and a P2Y12 inhibitor (preferably clopidogrel) for up to 6 months (or up to 12 months in ACS) is recommended if the risk of stent thrombosis is low or if concerns about bleeding risk prevail over concerns about risk of stent thrombosis, irrespective of the type of stent used. 505,506,507,508,509	I	B
Discontinuation of antiplatelet treatment in patients treated with an OAC is recommended after 12 months. 74,510,511,512	I	B
After uncomplicated PCI or ACS in patients requiring both OAC and antiplatelet therapy, triple therapy with aspirin, clopidogrel and OAC for longer than 1 week should be considered when the risk of stent thrombosis outweighs the risk of bleeding, with the total duration (≤1 month) decided according to assessment of these risks and clearly specified at hospital discharge.	IIa	C
In patients treated with a VKA (e.g. MHVs), clopidogrel alone should be considered in selected patients (e.g. HAS-BLED ≥3 or ARC-HBR met and low risk of stent thrombosis) for up to 12 months. 512,513	IIa	B
In patients requiring aspirin and/or clopidogrel in addition to VKA, the dose intensity of VKA should be considered and carefully regulated with a target INR in the lower part of the recommended target range and a time in the therapeutic range >65-70%. 505,514	IIa	B
Surgical valve replacement
OAC using a VKA is recommended lifelong for all patients with an MHV prosthesis. 472,473	I	B
For patients with a VKA, INR self-management is recommended provided appropriate training and quality control are performed. 482	I	B
OAC is recommended for patients undergoing implantation of a surgical BHV who have other indications for anticoagulation.f	I	C
NOACs should be considered over VKA after 3 months following surgical implantation of a BHV in patients with AF. 74,499,500,515,516,517,518	IIa	B
In patients with no baseline indications for OAC, low-dose aspirin (75-100 mg/day) or OAC using a VKA should be considered for the first 3 months after surgical implantation of an aortic BHV. 491,494	IIa	B
In patients with no baseline indications for OAC, OAC using a VKA should be considered for the first 3 months after surgical implantation of a bioprosthesis in the mitral or tricuspid position. 519,520	IIa	B
The addition of low-dose aspirin (75-100 mg/day) to VKA may be considered in selected patients with MHVs in case of concomitant atherosclerotic disease and low risk of bleeding.	IIb	C
The addition of low-dose aspirin (75-100 mg/day) to VKA should be considered after thromboembolism despite an adequate INR.	IIa	C
NOACs may be considered over VKA within 3 months following surgical implantation of a BHV in mitral position in patients with AF. 499	IIb	C
NOACs are not recommended in patients with a mechanical valve prosthesis. 474	III	B
Surgical valve repair
OAC with VKA should be considered during the first 3 months after mitral and tricuspid repair.	IIa	C
SAPT with low-dose ASA (75-100 mg/day) should be considered for the first 3 months after valve-sparing aortic surgery when there are no other baseline indications to OAC.	IIa	C
Transcatheter aortic valve implantation
OAC is recommended lifelong for TAVI patients who have other indications for OAC. 501 f	I	B
Lifelong SAPT is recommended after TAVI in patients with no baseline indication for OAC. 495,496,521	I	A
Routine use OAC is not recommended after TAVI in patients with no baseline indication for OAC. 497	III	B
ACS: acute coronary syndrome; AF: atrial fibrillation; ARC-HBR: Academic Research Consortium - high bleeding risk; ASA: acetylsalicylic acid; BHV: biologic al heart valve; DAPT: dual antiplatelet therapy; INR: internation al normalized ratio; LMWH: low-molecular-weight heparin; LV: left ventricle/left ventricular; PCI: percutaneous coronary intervention; MHV: mechanical heart valve; NOAC: non-vitamin K antagonist oral anticoagulant; OAC: oral anticoagulation; SAPT: single antiplatelet therapy; TAVI: transcatheter aortic valve implantation; UFH: unfractionated heparin; VKA: vitamin K antagonist. aClass of recommendation. bLevel of evidence. c≤5 days for warfarin and ≤3 days for acenocoumarol. dCHA2DS2-VASc, congestive heart failure, hypertension, age ≥75 (2 points), diabetes, prior stroke (2 points) - vascular disease, age 65-74, sex category (female). eLV apex thrombus, antithrombin 3 deficit and proteins C and/or S deficit. fAF, venous thromboembolism, hypercoagulable state or, with alesser degree of evidence, severely impaired LV dysfunction (ejection fraction <35%).