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1176 Funambulism and the Art and Science of Periprocedural Anticoagulant Management age 1223 R emoving the anticoagulant “safety net” from a patient requiring an invasive procedure must be a deliberate decision that balances the twin goals of hemostasis and thrombus prevention. Indeed, it can feel like traversing a tightrope between 2 tall buildings, with the gravity of the procedurespecific bleeding risk on one side, and on the other, the patient-specific thrombotic propensity. And yet, these anticoagulant interruptions are common practice in medicine today. It is estimated that 6 million patients in the United States receive long-term anticoagulation, and approximately 10% of these patients require anticoagulant interruption each year for an invasive procedure. This statistic amounts to a large number of bridges to cross for patients and physicians alike requiring this form of management. Although there have been few randomized clinical trials of periprocedural anticoagulant management, there are a number of observational studies that can guide clinicians caring for patients taking warfarin. These studies have served as the basis for guideline statements regarding the evaluation and step-by-step management of patients with various indications for warfarin therapy. The introduction of low-molecular-weight heparin (LMWH) into this practice ushered in an era of aggressive anticoagulant “bridging” for all patients taking warfarin, regardless of either the indication or the procedure being pursued. Over time, it became clear that the general mantra of “stop the clot at all costs” was perhaps too aggressive. A more judicious approach was subsequently adopted once it became apparent that thrombotic events were infrequent and the use of bridging LMWH clearly increased major bleeding events. Where warfarin is concerned, bridging LMWH is now reserved for those patients with the highest risk of thrombosis. This population includes patients with a nonbileaflet mechanical cardiac valve prosthesis, a mechanical valve prosthesis in nonaortic locations, or a bileaflet aortic valve mechanical prosthesis