We continue to use full dose therapeutic low molecular weight heparin (LMWH) for bridging in the pre-operative period. However, we now use post-operative prophylactic LMWH as an alternative bridging strategy in patients undergoing high-risk bleeding procedures. In patients at high risk of thromboembolism (including mechanical mitral valve and atrial fibrillation) undergoing a high-risk bleeding procedure, we are now less aggressive in resuming full dose therapeutic anticoagulation, as we feel comfortable using prophylactic LMWH for up to several days post-operatively before resuming therapeutic anticoagulation.
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