Perioperative care of non-cardiac surgery patients with prosthetic heart valves undergoes anesthetic care that is quite challenging because of the competing interests of thromboembolism and bleeding. We present an anesthetic control of a 65-year-old female patient with a metallic mitral valve prosthesis and atrial fibrillation undergoing biopsy and resection of a right femoral mass. The patient had been under chronic warfarin treatment. The warfarin was stopped four days before surgery and bridging heparin with low molecular weight heparin (LMWH) was initiated. LMWH was given as the last dose six hours before surgery. Preoperative coagulation test was 1.3 INR. The general anesthesia was used with invasive monitoring of the arterial blood pressure. Midazolam, nalbuphine, propofol were used to induce, which was followed by atracurium that had to block neuromuscular activity. IGEL supraglottic airway device was used to secure the airway. Metoprolol was used to achieve intraoperative heart rate control. The estimated blood loss was 700 ml and it was corrected using crystalloid infusion. LMWH was initiated in the evening of the surgery after the operation, and warfarin therapy was recalled in the morning of the next day with the monitoring of coagulation parameters on a daily basis. Postoperative echocardiography revealed the presence of normal functioning prosthetic valve, free of thrombus. The patient did not experience any thromboembolic or bleeding disease and was discharged on the tenth postoperative day. This case illustrates the necessity of close perioperative anticoagulation, hemodynamic stability and infection prophylaxis in patients with mechanical heart valves that have undergone non cardiac surgery.

• Prosthetic Heart Valve; Anticoagulation Bridging; Mechanical Mitral Valve; Perioperative Management; General Anesthesia; Non-Cardiac Surgery

Tariq A, Ahmad W, Younis W (2026) Anesthetic Management of a Patient with Prosthetic Heart Valve for Non-Cardiac Surgery: A Case Report. Int J Clin Anesthesiol 13(1): 1134.

LMWH: Low Molecular Weight Heparin; INR: International Normalized Ratio; PT: Prothrombin Time APTT: Activated Partial Thromboplastin Time; NPO: Nil Per Oral; LV: Left Ventricle

The patients who have prosthetic heart valves pose specific perioperative complications because of the need to use anticoagulants throughout their lifetime and the potential of thromboembolism. Stopping anticoagulant therapy predisposes to the valve thrombosis and systemic embolism, whereas maintaining the treatment predisposes to bleeding during surgery. Hence, the anticoagulation therapy has to be balanced.

The mechanical type of mitral valve prostheses is especially linked to increased thromboembolic risk as opposed to the aortic prostheses. It has been argued that warfarin interruption without bridging may cause thromboembolism to become a major risk [1-3]. Guidelines of the international standards suggest perioperative bridging heparin to high-risk patients [4-6]. The case illustrates the practical implementation of anticoagulation management using guidelines in a patient who is undergoing surgery that is non-cardiac.

This is a case report of a single patient that presents the management of perioperative anesthetic and anticoagulation.

This case study is about a 65-year-old woman who has undergone right femur biopsy and and had a history of chronic atrial fibrillation (2013). She was taking oral warfarin 1 mg per day. Atrial fibrillation with a ventricular rate of 110 beats/minute and blood pressure of 156/86 mmHg were detected in preoperative examination. Echocardiography revealed 55% ejection fraction, well functioning metallic mitral prosthetic valve and mild pulmonary hypertension.

Four days before the operation warfarin was discontinued. LMWH 60mg twice a day was initiated and ceased six hours before surgery. Two pints of blood were arranged. Before the incision, antibiotic prophylaxis was given 30 minutes with ceftriaxone and aminoglycoside.

Midazolam 2 mg, nalbuphine 6 mg, propofol 100 mg and atracurium 40 mg were used to induce general anesthesia and the invasive blood pressure monitoring was used. Oxygen and isoflurane were used to maintain the patient. Rate control was through metoprolol 3mg.

There is a need to strike a balance between thrombotic and bleeding dangers in the perioperative management of mechanical valve patients. Research demonstrates how warfarin discontinuation can raise the risk of thromboembolism to 1-20 percent according to the type of valve and atrial fibrillation [1,3]. Mechanical mitral valves are considered to be of high risk in thrombosis than the aortic valves [4].

The American College of Chest Physicians and European Society of Cardiology suggest that the anticoagulation should be bridged with heparin in patients at high risk during the warfarin interruption [5,6]. LMWH has consistent pharmacodynamics and administration (Table 1).

Table 1: Preoperative Laboratory Values

In this instance, the stability of the perioperative course was achieved by anticoagulation bridging, strict monitoring of INR, invasive blood pressure monitoring, and controlled heart rate. Postoperative LMWH and warfarin did prevent thrombotic complications.

The key conclusions of this case are:

1-Good bridging anticoagulation reduced the risk of thromboembolism.

2-Safe surgical intervention was made possible by controlled INR (1.3).

3-Hemodynamic stability was ensured by invasive monitoring.

4-Valve thrombosis was prevented by the early anticoagulation resumption in the postoperative period.

5-There were no embolic complications or bleeding.

6-The case facilitates evidence-based anticoagulation management measures during perioperative period in mechanical mitral valve patients.

Careful perioperative planning, appropriate anticoagulation bridging, and vigilant monitoring allow safe non-cardiac surgery in patients with mechanical heart valves.

Limitations

This is a single case report and lacks comparative analysis or statistical validation. Long-term follow-up data are limited.

Recommendations

Future studies should focus on standardized bridging protocols and comparative studies evaluating LMWH versus unfractionated heparin in high-risk valve patients.

The authors acknowledge the operating room and high dependency unit staff for perioperative assistance.

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