There are relatively sparse data in patients with MVR that higher anticoagulation intensity protects against thromboembolic events as a tradeoff for a higher bleeding risk. Furthermore, not all metallic valves have the same design, structures, materials, and dynamics of function. Indeed, we have moved a long way from the now-historical “ball-and-cage” prosthetic valve (eg, the Starr-Edwards Silastic Ball Valve; production discontinued in 2007), which had a greater propensity for thrombus formation than the newer tilting-disk valves and the bileaflet metallic valves. Of note, the latter is the least thrombogenic among the various prosthetic valves. Because all valves are not the same in terms of thrombogenicity, the levels of intensity in anticoagulation may differ between new and old valve prostheses, given that anticoagulation is not without inherent risk of hemorrhage, coupled with its unstable pharmacokinetic and pharmacodynamic properties.