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 l evel was 5.6, and nothing was found that can be the cause of the bleeding from the urinalysis, U rology 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.