How is anticoagulation managed in patients with mechanical valves undergoing LA ablation with warfarin continuation?

• A. Stop warfarin and bridge with IV heparin.
• B. Maintain therapeutic INR; use IV heparin during the procedure to maintain ACT > 300 s; no unnecessary interruption of warfarin if possible.
• C. Discontinue all anticoagulation.
• D. Use antiplatelet therapy only.

Answer: (B)

Maintaining the anticoagulation plan that protects a mechanical valve is essential during an atrial ablation. The safest approach is to keep warfarin in the therapeutic range and add intra-procedural IV heparin to achieve a high activated clotting time (ACT), typically greater than 300 seconds. This combination minimizes the risk of thrombus formation on the valve, catheters, or left atrial structures during the procedure, while avoiding unnecessary interruption of warfarin. Stopping warfarin and bridging with heparin, discontinuing all anticoagulation, or using antiplatelet therapy alone would leave mechanical valves vulnerable to thrombosis and embolic events; these patients rely on continuous anticoagulation with warfarin, with careful intra-procedural heparin dosing to control bleeding risk.