Being taken off Coumadin for Pacemaker surgery - that okay?

[DanielB]

Hello everyone,

Got news today that some recent low heart rates and arythmias require that I get a pacemaker. I'm not surprised as I have had left bundle branch block since surgery and was expecting one before I was released from the AV replacement surgery last fall, but I showe4d improvement and was released without one. I even posted the question while in the hospital. Fast forward to today, when my cardio personally supervised a treadmill test (this after a month of 'event' monitoring). After discussing it with an electrophysiologist, they agreed a pacemaker was in order. No suprise, but what I found interesting was that he said the accepted protocal now is to take me off coumadin for the surgery - no bridging, just wean me off, do the surgery and bring it back into the picture. Anybody out there who had one of these implanted have the same?

 

[Protimenow]

I haven't had a pacemaker implanted, but it's my understanding that it's a fairly simple procedure. I'm not sure how much bleeding is involved.

However, recent research suggests that, for a person who is more than 3 months post-op (which you are), the risk of throwing a clot when your INR is below 2.0 for just a few days is minimal. The On-X valve is supposedly less prone to clot formation than some of the other valves (like the St. Jude's vale clicking away in my chest). I'm assuming that your surgeon is planning to do surgery once your INR drops below 2.0 (or, perhaps, below 1.5). You may wind up waiting a day or two after surgery to start bridging or taking increased doses of warfarin, briefly, to bring your INR back up.

In this case, it sounds like your surgeon is looking to reduce bleeding (and bleeding complications), and is following reasonable protocol to so, without significantly increasing your risk of clot formation on your valve.

It sounds like your surgeon is right on top of current thinking about anticoagulation, risks, and surgery.

 

[DanielB]

Thanks Protimenow. I did some digging on the web and found that it appears as though there is a large scale study going on looking at this - surgery for those on coumadin staying on it through a surgery or being taken off and bridging, but it still ongoing so no results. This will be the first time I'll have any proceedure that this would apply to since my Ox valve was placed, so it's all new to me. I'll keep asking questions as I meet with more doctors involved and see what they tell me.

 

[Protimenow]

Yup. It pays to ask questions -- even if you get different answers from different doctors. Ultimately, of course, it's YOUR life, and not theirs, so it pays to learn what you want to know -- or decide on a doctor or team of doctors who you trust with your safety and follow their advice.

 

[ElectLive]

I don't have an answer on this one but I do have a question: is there really a significant need (more so than the brief exposure to additional stroke risk, in other words) to take you off Coumadin to put in a pacemaker? Now, obviously your doctor thinks there is a justifiable need, otherwise he wouldn't suggest this, but just for the sake of argument, it seems to me that a lot of valve patients, including several of our own members that I can think of, have had a pacemaker put in anywhere from 3-7 days post valve replacement. For anyone with a mechanical valve, they are obviously anticoagulated at the time, as are many with tissue valves (although I was not - just Aspirin 81). Anyway, just curious.

Maybe someone else from the pacemaker club will chime in: Steve (epstns) or Julian, or anyone else, weren't you all anticoagulated at the time your pacemaker was put in?

 

[DanielB]

Good question ElectLive. I'll be interested in hearing from anyone who had a pacemaker chime in with thier experiences on this.

 

[Jkm7]

I don't have an answer on this one but I do have a question: is there really a significant need (more so than the brief exposure to additional stroke risk, in other words) to take you off Coumadin to put in a pacemaker? Now, obviously your doctor thinks there is a justifiable need, otherwise he wouldn't suggest this, but just for the sake of argument, it seems to me that a lot of valve patients, including several of our own members that I can think of, have had a pacemaker put in anywhere from 3-7 days post valve replacement. For anyone with a mechanical valve, they are obviously anticoagulated at the time, as are many with tissue valves (although I was not - just Aspirin 81). Anyway, just curious.

Maybe someone else from the pacemaker club will chime in: Steve (epstns) or Julian, or anyone else, weren't you all anticoagulated at the time your pacemaker was put in?

For many people 4 or 5 days post op, they are not yet near their INR range.
I have tissue valve and my range for the brief time I was on coumadin was 2.0 - 3.0. For days after starting coumadin, I was only at about 1.3 or 1.4 INR. We've heard of many who are kept in the hospital longer because their INR was too low despite having been started on it soon post op.

 

[DanielB]

Good point. As I recall I was below 2 for several days after my surgery.

 

[ElectLive]

For many people 4 or 5 days post op, they are not yet near their INR range.
I have tissue valve and my range for the brief time I was on coumadin was 2.0 - 3.0. For days after starting coumadin, I was only at about 1.3 or 1.4 INR. We've heard of many who are kept in the hospital longer because their INR was too low despite having been started on it soon post op.

Right...which actually was what I would have guessed they normally do...in other words, just try to keep patients at the bottom end of INR range for the implant to help balance out bleeding and stroke concerns. Obviously, many are even lower then, though, as you say. But it's interesting that this recommendation is a complete wean, though, not a lowering of INR, nor bridging. I wonder if the fact that many pacemaker implants are done outpatient is part of the consideration?

Anyway, again I was more asking a question, not trying to make any sort of recommendation, so I should probably shut up before I go too far. Obviously, any invasive intervention is certainly subject to potential internal bleeding concerns. For what it's worth though, Daniel, I was on Aspirin everyday prior to my surgery, too, and I was impacted a lot by the cath (an amazing amount of bruising) but really not at all by the pacemaker implant.

 

[Greg a]

You may want to ask on this board (ICD support) http://www.icdsupportgroup.org/board/

 

[DanielB]

ElectLive - thanks again. I am simply gathering informaton so I can have an intelligernt discussion with my Electrophysiologist and your points are very good ones. I have been very happy with the group of caregivers in my medical group so far, but I always like to make sure I am understanding what I'm getting into and the risks in case there is some room for doing things a bit safer. Never hurts to discuss and ask a doctor is what I say.

Greg - thanks for the link. I'll look into it as well.

 

[Julian]

Hey DanielB, I had my pacemaker implanted 7 days post op from AVR while still in the hospital. They didn't start me on coumadin until the second day AVR post op. 5mg I think it was then on the 5th day post op they stopped the coumadin because they knew in two days they would probably give me a pacemaker, I think my INR was 1.4 at the time they stopped it. The pacemaker surgeon did not want to operate on me with an INR above 1.5. I was kept off the coumadin until discharged from the hospital on the 8th day. It took me two weeks after that to get my INR in safe range.

I personally was worried that I was at such a high risk for stroke especially only a week post op. My cardio and the surgeons that visited me in the hospital didn't think I was at a very high risk of stroke. My cardio told me that the risk of stroke with a mechanical valve without any anti-coagulation was somewhere around 10% for the year and probably less with the On-X valve I had. That didn't make me feel much better, I was still worried about it.

When I was released from the hospital I was also on 325mg of aspirin and 5mg of wafarin until at about 2 weeks they raised my does to 10mg wafarin and put me on 81mg aspirin. I've pretty much been in range ever since and I'm now on 7.5mg of warfarin and 81mg aspirin daily. Funny thing is in the hosptial I got name brand coumadin, at home I got generic wafarin.

Of course I'm no doctor but in theory your risk for stroke being off coumadin for 1-2 weeks is probably very low, I'd venture to say 1-5%. But its my life and I don't even like the odds of 5% so I would see if there was some way we can bridge or something, just to give a little extra cushion. There's always that risk I hate to admit it...

 

[Protimenow]

Bridging is not going to prevent operative bleeding or post-operative bleeding.

I'd probably trust the surgeon, who probably knows what he (or she) is doing and the risks associated with INR above a certain level. Being below 2.0 briefly carries relatively little risk. It's being below 2.0 and STAYING below 2.0 for an extended period that seems to get people into trouble.

 

[AgilityDog]

When I got my defib, 18 months after MVR and pacer implant, I was taken off coumadin Friday, Saturday, Sunday. On Monday my INR was 1.9 (where one normally starts bridging), and surgery was done that day. I started back on my coumadin that night. So by what, Wednesday? I was back in range 2.5-3.5. So I was below range about 48 hours, give or take, and not by much. Of course, I was hospitalized the entire weekend, starting sotalol after going into vtach while driving 65 mph on the highway on Friday morning. La de dah.

The 2 week window on going off coumadin without severe risk of stroke is for A-fib patients, not valvers. We have a few days with INR below 2, particularly mitral valvers.

So if they are saying to take you off the coumadin for 5 days or more and no bridging, I'd get another opinion on bridging. You bridge, but stop the lovenox about 16 hours prior to surgery.
If they are saying hold 2-3 days off coumadin, bring your INR down around 2, and we'll do surgery on day 3 or day 4, that's very different, and probably just fine.
BUT there are now studies showing there's little excess bleeding doing pacer replacements while patients continue on coumadin with INR in range. I think there may be a sticky on this.

 

[DanielB]

Good info! I meet with the electrophyisiologist next week and will have plenty of good questions for her now - thanks!

 

[Protimenow]

Taking you off warfarin before surgery is not to prevent clotting -- it's to minimize bleeding.

According to a Duke protocol, and a text I read recently, even valvers can be below 2.0 for probably up to a week (possibly more) with minimal risk of throwing a clot.

(In my case, having recently thrown a clot, I may have been below 2.0 for a few weeks because of a probable error in my meter's results that made me THINK I was in range when I actually wasn't. However, there's at least one person on this board who claims to have had a stroke after missing his warfarin dose for only a few days. It's rough being that one exception to a statistical probability)