How is anticoagulation managed in patients with mechanical valves undergoing left atrial ablation?

• A. Continue therapeutic anticoagulation (e.g., warfarin) if possible; if interrupted, bridge per protocol; intra-procedural heparin to maintain ACT > 300 s.
• B. Stop anticoagulation 5 days prior and after the procedure.
• C. Switch to antiplatelet therapy only.
• D. Do not manage anticoagulation and proceed with no adjustment.

Answer: (A)

Managing anticoagulation in patients with a mechanical left-sided valve during left atrial ablation focuses on preventing thrombosis without causing excessive bleeding. The safest and most effective approach is to continue therapeutic anticoagulation if possible; if it must be interrupted, bridge per protocol with heparin to maintain consistent anticoagulation. During the procedure, administering unfractionated heparin to keep the activated clotting time (ACT) above about 300 seconds helps prevent thrombus formation on catheters and on the valve itself. This combination—maintaining therapeutic anticoagulation, performing bridging when interruption is necessary, and ensuring adequate intra-procedural anticoagulation—minimizes the risk of valve thrombosis and stroke while managing bleeding risk appropriately. Stopping anticoagulation entirely or switching to antiplatelet therapy alone does not provide enough protection against valve thrombosis, and proceeding with no adjustment would leave a high thromboembolic risk in the presence of a mechanical valve.