For patients with bioprosthetic valves or annuloplasty rings who are receiving a direct oral anticoagulant and who require immediate reversal of anticoagulation because of uncontrollable bleeding, treatment with idarucizumab (for dabigatran) or andexanet alfa (for anti-Xa agents) is reasonable.1 5 For patients with a mechanical prosthetic valve and supratherapeutic INR (>5.0) who are not actively bleeding, the benefit of individualized treatment with oral vitamin K, in addition to temporary withdrawal of the VKA, is uncertain. Synopsis Excessive VKA anticoagulation greatly increases the risk of hemorrhage. However, a rapid decrease in INR to a subtherapeutic level may increase the risk of thrombo- Nevertheless, for patients who require im- mediate reversal of VKA anticoagulation because of severe or life-threatening bleeding or the need for an emergency procedure, reversal is indicated.7 Preference is placed on the use of rapid-acting and reliable agents, such as prothrombin complex concentrate or its acti- vated form. Addition of vitamin K can be considered on an individual basis.8 13 Specific antidotes are available to reverse the effects of dabigatran (idarucizumab) and the oral anti-Xa (andexanet alfa) anticoagulants. Recommendation-Specific Supportive Text 1. Four-factor prothrombin complex concentrate includes factors II, VII, IX, and X. Onset of effect is within 5 to 15 minutes, and duration of effect is 12 to 24 hours. It is a more specific and reliable reversal agent than fresh frozen plasma.8 2. 