Managing mechanical mitral valve on warfarin therapy with gross hematuria: a case report with unfractionated heparin as a bridging therapy

A dilemma can happen to a physician when managing bleeding case on a patient with mechanical heart valve with anticoagulant therapy. Major bleeding on anticoagulant treatment usually affects gastrointestinal tract (40-60 %) and urinary tract (15%). To manage the bleeding, vitamin K was restrictedly used in a patient with a mechanical heart valve and only can be used if there is major bleeding. The hypercoagulable state also must be considered when reinitiating warfarin therapy, once the bleeding already stopped. A 51-year-old female with St Jude Medical mechanical mitral valve replacement for 13 years and on regular warfarin therapy came with gross hematuria. INR level was 5.6, and nothing was found that can be the cause of the bleeding from the urinalysis, Urology ultrasonography, and CT Scan. Warfarin was stopped for 3 days, and bleeding still occurred. Unfractionated heparin then was given to the patient to prevent thromboembolism event and as a bridging therapy. On the sixth day, hematuria was stopped, and hemoglobin was reduced only by 2 mg/dL. No rebleeding was found from the patient until 3 months later.