Eye surgery, particularly for cata- racts or glaucoma, is usually associated with very little bleeding and thus is frequently performed without alteration of anticoagulation with a VKA. 2. In patients with a bileaflet mechanical AVR and no other risk factors, the risk of thromboembo- lism after stopping anticoagulation with a VKA is small if the drug is withheld for only a few days. In these low-risk patients, the inconvenience and expense of bridging anticoagulation can be avoided. When it is necessary to interrupt VKA therapy, the agent is stopped 2 to 4 days before the procedure and restarted as soon as bleeding risk allows, typically 24 hours after surgery.2,3 3. In patients with mechanical valves on long-term VKA therapy who require emergency surgery or invasive procedures, anticoagulation can be reversed by administration of intravenous pro- thrombin complex concentrate. It replaces the coagulation factors that are decreased by VKAs and contains all coagulant factors, including II, VII, IX, and X, in inactivated form. Onset of effect is within 5 to 15 minutes, and duration of effect persists for 12 to 24 hours. With fresh frozen plasma, onset of effect is longer (1 4 hours), and duration of effect is shorter (<6 hours), depending on the dose given. The effect of prothrombin complex concentrate can be prolonged with vitamin K, if indicated.4 4. Although the large phase III trials comparing NOACs with warfarin excluded patients with moderate to severe rheumatic MS or mechani- cal heart valves, some did include patients with other VHD and bioprosthetic valve replacement Many patients who develop an indica- tion for anticoagulation late after bioprosthetic heart valve replacement or native valve repair are treated safely with direct oral anticoagulants, as predicated on their CHA2 -VASc score and the predicted risks of bleeding. 