Bridging Therapy

[Creed3]

Hi Everyone!
I am just wondering what you all may think of this.
I just recently read a thread by a member here who had visual effects while undergoing bridge therapy. Not sure if it was migraine or possible clots being thrown. Reading this thread led me to do some research online regarding bridge therapy being used on patients with mechanical valves.
I read several different pages that indicated that lovenox and heparin are not to be used on patients with mechanical valves. Some others said that they were safe to use for bridging therapy for short time use. Other articles seemed to indicate that the major issue was when bridging therapy was being used for longer periods of time, specifically with pregnant women with mechanical valves.
I guess now I am just a little worried because I am considering having a uterine ablation performed and I will need to undergo bridge therapy for the procedure. I am wondering if it wouldn't be safer to just stay on my coumadin.
Have any of you heard of any of the cons associated with bridge therapy on mechanical valve patients?
I'll try to go back online and find the articles and post the links here. I did print them out for my doctors to read. I am just really concerned that maybe I am making the wrong decision by wanting to have the ablation.

Take Care Everyone!
Gail

 

[Creed3]

Links

Links

Here are two of the links.

www.news-medical.net/?id=6723

www.vapbm.org/criteria/enoxaparincriteria.pdf

 

[Ross]

I'm leaving this for Al to answer.

Which patients on warfarin
should receive heparin bridging before surgery?
High risk for thromboembolism: bridging advised
Known hypercoagulable state as documented by a thromboembolic event and one of the following:
Protein C deficiency
Protein S deficiency
Antithrombin III deficiency
Homozygous factor V Leiden mutation
Antiphospholipid-antibody syndrome
Hypercoagulable state suggested by recurrent (two or more) arterial or idiopathic venous
thromboembolic events (not including primary atherosclerotic events, such as stroke or
myocardial infarction due to intrinsic cerebrovascular or coronary disease)
Venous or arterial thromboembolism within the preceding 1?3 months
Rheumatic atrial fibrillation
Acute intracardiac thrombus visualized by echocardiogram
Atrial fibrillation plus mechanical heart valve in any position
Older mechanical valve model (single-disk or ball-in-cage) in mitral position
Recently placed mechanical valve (< 3 months)
Atrial fibrillation with history of cardioembolism
Intermediate risk for thromboembolism: bridging on a case-by-case basis
Cerebrovascular disease with multiple (two or more) strokes or transient ischemic attacks without
risk factors for cardiac embolism
Newer mechanical valve model (eg, St. Jude) in mitral position
Older mechanical valve model in aortic position
Atrial fibrillation without a history of cardiac embolism but with multiple risks for cardiac
embolism (eg, ejection fraction < 40%, diabetes, hypertension, nonrheumatic valvular heart
disease, transmural myocardial infarction within preceding month)
Venous thromboembolism > 3?6 months ago*
Low risk for thromboembolism: bridging not advised
One remote venous thromboembolism (> 6 months ago)*
Intrinsic cerebrovascular disease (such as carotid atherosclerosis) without recurrent strokes
or transient ischemic attacks
Atrial fibrillation without multiple risks for cardiac embolism
Newer-model prosthetic valve in aortic position
*For patients with a history of venous thromboembolism undergoing major surgery, consideration can be given to
postoperative bridging therapy only (without preoperative bridging)
TA B L E 1
PERIOPERATIVE ANTICOAGULATION JAFFER AND COLLEAGUES

http://www.ccjm.org/pdffiles/Jaffer1103.pdf

 

[Guest]

I just talked with a woman doctor yesterday who has a patient ready for a uterine ablation and she said that there was no reason to stop the warfarin.

I think that stopping warfarin for an ablation is another of those cases where the doctor would rather avoid a few drops of blood at the risk of leaving you paralyzed for life. If your doctor really thinks that you will lose so much blood that you may need a transfusion, I think that you need another doctor.

 

[Creed3]

Why Bridge???

Why Bridge???

I asked my gyn why he felt it necessary to bridge for a uterine ablation. He said most likely there wouldn't be a reason to come off coumadin but there is a chance bleeding could occur when he has to clamp the cervix. That is why he wants to be careful and bridge. I'm not sure exactly how much blood would actually be lost if there were bleeding from the clamp on the cervix.
I am having a catheter inserted next week into my uterus for an ultrasound. He said there is definitely no reason to stop coumadin for that procedure. He said there could be slight bleeding but not enough to cause any trouble. No different than if I was going to the dentist.
I think I will definitely need to check on how much blood could be lost by clamping the cervix during the ablation. I think I would rather just stay on my coumadin if I could.
I will also be checking with my pcp who regulates my coumadin as well as my cardio. My gyn thinks it is best for them to make the decision on the coumadin and bridge therapy.
Thanks again for all of your help and great information.

Take Care!
Gail

 

[Karlynn]

Gail, you mentioned my question "How much bleeding can occur from a clamped cervix?" We know there's confusion on whether to stop warfarin for tooth removal. Are we talking that type of bleeding (manageable)? I noticed your gyn used the words "chance for bleeding." Is this a case of -doctors fear bleeding, warfarin users fear clots-? Or is there a real possibility for severe bleeding? (I'm inclined to think that the cervix isn't as "frail" as that. Most women usually don't bleed from a a PAP. Or intercourse? Not to be gross, but the cervix does see some action. and must be resiliant.)

I have my ultrasound Wednesday (not looking forward to that!). I'll question my gyn some more and post what he says.

Al, do you have the ability to speak with this woman doctor after she's done the ablation and see what her thoughts are then?

 

[Sherry]

I'm meeting with my gyn on Friday. I'll share whatever I find out. I will say this, though, if she told me I had to come off coumadin, I wouldn't mess with it. The monthly bleeding is bad, but I can live with it.

 

[Karlynn]

I'm meeting with my gyn on Friday. I'll share whatever I find out. I will say this, though, if she told me I had to come off coumadin, I wouldn't mess with it. The monthly bleeding is bad, but I can live with it.

I'm not at the "I-can't-live-with-it-anymore" stage either. It sounds like Gail is, though, so I hope for her that the procedure is easily handled.

Now if my ultrasound shows something that needs to be taken care of and I have to go off my warfarin for that, I'm hoping they can do the ablation as well.

 

[Guest]

The doc I talked to is the PCP not the GYN. Sorry, I gave the wrong impression. She did say that she didn't want her to stop the warfarin.

 

[Karlynn]

Here we go.

Had my uterine ultrasound (not a bad experience at all). However, I have a thickened lining he needs to scrape, as well as a polyp, before he does the ablation, which he can do in the same procedure. But I will need to go off my Coumadin. The thought of postponing indefinately did occur to me, but it's a situation that will only get worse with time, so I may as well buck up.

He said he would have me go off my Coumadin 3 days prior and go on Heparin. At which time I said "What about Lovenox?". He said that he does not like to use Lovenox because he has seen more instance of post-surgical bleeding problems with it. So I said "So I would need to be in the hospital for 3 days prior for the Heparin?" He said that I can give myself Heparin shots at home. That he sees this as being a totally outpatient procedure. He is going to call and discuss this with my cardio and then defer to her on procedure.

So, for all you gals, I asked him if he would have had me go off Coumadin for just the ablation. He said NO. He said that the reason some doctors want you to is because you do have to clamp the cervix and that sometimes it can cause it to bleed a little. He said that if that happened, he would just use a disloving stitch at the site of the bleeding. He said the idea that someone could bleed so heavily from the clamped cervix wound to cause problems would be a real long-shot and certainly have an extremely high INR.

Of course a good strong course of antibiotics are a must.

I will be seeing my cardio prior to scheduling this procedure, in order to cover all bases since this will be the first time in 14 year of my mech valve that I will need to stop my Coumadin. I would be lying if I said this didn't worry me a bit.

I was under the impression that Heparin had to be administered in an IV drip. But the gyne says I can inject myself at home. So I did a search on the web, just to see if he was mistaken, and in my short search , I did find a few sites that gave instructions on Heparin self-injections at home. Does anyone have any contrary information on this?

 

[Creed3]

Hi Karlynn

Hi Karlynn

Thanks for the information. I am having my uterine ultrasound tomorrow. I just started my antibiotics today. I would really like to have the ablation done but stay on coumadin. I just don't feel it is necessary to come off coumadin for just the ablation. I will talk more to my gyn, pcp and cardio about it after I have the uterine ultrasound.
Regarding giving yourself heparin shots, yes I have heard of this. A friend of mine had to give herself heparin shots for awhile. I forget exactly why but it wasn't because of a valve issue.
I'll let you know what I find out tomorrow.

Take Care!
Gail

 

[Sherry]

Karlynn,
I was just checking the forum before I leave for my gyn appointment. I do have some experience with the home injections (many moons ago) and will PM you when I get home tonight. I'll also share what I find out from her on this thread.

 

[warrenr]

ablation

ablation

Thanks for the information. I am having my uterine ultrasound tomorrow. I just started my antibiotics today. I would really like to have the ablation done but stay on coumadin. I just don't feel it is necessary to come off coumadin for just the ablation. I will talk more to my gyn, pcp and cardio about it after I have the uterine ultrasound.
Regarding giving yourself heparin shots, yes I have heard of this. A friend of mine had to give herself heparin shots for awhile. I forget exactly why but it wasn't because of a valve issue.
I'll let you know what I find out tomorrow.

Take Care!
Gail

It sounds like this ordeal is stressing you Why not keep it simple and just find a Gyn that will do it fully anticoagulated.

Everybody keeps talking about bridge and what type of bridge for a lot of procedures that don't even require bridge. The written standard for these low bleed risk procedures is to conduct fully anticoagulated so don't get caught up in the bridge ordeal unless the written standard is to bridge.

 

[Blanche]

Low molecular weight heparin and unrefracted heparin

Low molecular weight heparin and unrefracted heparin

The experience that I have with the dilemma of which bridge therapy is more likely to provide positive results came several years ago when Al was bleeding internally and had to be hospitalized. He had to undergo several endoscopies and was given a small does of Vitamin K. After all the results were in and the problems solved, Coumadin therapy was resumed. First, they were going to send him home on Lovenox (a/k/a enoxaparin) which is low molecular weigh heparin that is administered by injection. Because of the FDA warning on Lovenox and mechanical valves, the decision was made to keep him hospitalized on heparin(UFH) which is unfractionated heparin that is administered IV.

One of the nurses told me that the heparin (UFH) which is usually given IV could also be administered by injection. Apparently this is sometimes done in hospital for patients who have problems with IV's. My husband's PC didn't like the idea at all but said he would go along with the cardiologist. Well, the cardiologist almost gave birth to a fuzzy bug on the spot when I suggested that I could take my darlin' home and give him heparin (UFH) shots. As I recall, he was concerned because heparin(UFH) is unstable and required constant monitoring and adjusting after administration. At that time I was dealing with the Cardiologist for more than ten years. He and gotten Al through endocarditis, valvereplacement, and two strokes, as well as the most recent problem of bleeding. I had a high level of trust in his judgment. Hubby stayed in hospital. I do remember that they did many blood tests for the four days and that several adjustments were done with the heparin dose.

I guess the bottom line for me was that administering heparin (UFH) outside of a controled medical environment, without regular monitoring and dose adjustment, was too dangerous to be undertaken. I also realized that I did not know one heparin for the next and that I had been confusing Lovenox with ufractionated heparin.

Hope this helps.
Blanche

 

[Birky]

bridging

bridging

I agree with you on being in a medical facility to get the heparin. I am having surgery on the 20th and will go off the coumadin on the 16th. Will get a protime done on the 18th and then if it is below 15, I will be admitted. Will have to stay until it is regulated again. The orthopedic doc and cardiologist both agreed that this is how it should be. Will have an IV drip prior to surgery and not sure what comes after surgery. This is for a carpal tunnel. Been told that this is not a bloody operation but I agree that it is better not to take a chance on having a stroke at 58. Some Drs. will have you come off with no bridging such as my cardiac surgeon when he repaired the hernia and took out wires but the orthopedic doc was not comfortable with us and either am I. Too young to have a stroke.

 

[Sherry]

Gail,
Just got back from my gyn appointment, and she said she wouldn't take me off coumadin for the ablation procedure. She said she's never done it on a coumadin patient before and would double check with cardio, but she was very confident that the procedure could be done while fully anti-coagulated. She said there is a slight risk of bleed from that clamp that is used but that it's really a miniscule risk. She and I discussed some other options, so I'm going to weigh out both and get back with her in the next month or two.

 

[Guest]

Birky brings up another problem. The pro time of 15 is an outdated test. It was what was used before the INR came into being. It varies with the sensitivity of the materials used in the testing. You really cannot reliably manage warfarin using protimes. It hasn't been the standard of care for 15 years. It is about as useful as "Yankees 3". You don't know the rest of the story.

Heparin given by injections under the skin is not very reliably absorbed. It is sort of a compromise between having you admitted for heparin IV and no bridging. I suspect that it is often done because the doctor doesn't want to "waste' the time fighting with the insurance company. Heparin is cheap and doesn't require insurance battles.

 

[Birky]

protime

protime

Al, you are right. The coumadin clinic uses INR not protime. The Cardiologist usually doesn't see them, the clinic regulates the coumadin. I haven't heard the word protime in years except when he said it yesterday. Guess someone should set him straight. I am sure he knows all this but just said the wrong thing. I have the test done and it is sent to Cliinic and then they call me in a few hours and tell me what to take and when to get tested again. Thanks,

 

[Guest]

Good (The one word message was too short to be accepted, so I had to add something.)

 

[Karlynn]

Heparin given by injections under the skin is not very reliably absorbed. It is sort of a compromise between having you admitted for heparin IV and no bridging. I suspect that it is often done because the doctor doesn't want to "waste' the time fighting with the insurance company. Heparin is cheap and doesn't require insurance battles.

Actually, I think he mentioned Heparin because he knows that I don't want to/and would have a hard time scheduling, a week off to spend in the hospital. I STRESSED that. A week in the hospital seems like a lot of over-kill for a procedure in which women go home a few hours after it's done. So there is apparently not a lot of bleeding. I obviously would find the time if I had to have an operation. But this is just a scraping of the uterus and the ablation. And I'm beginning to wonder if I really need to be fully coagulated or could just get by with getting down to an INR of 2.

What is the procedure for women who are pregnant and need to stop Coumadin and take Heparin or Lovenox? Surely they're not going to put a woman in the hospital for her entire first tri-mester just to have a Heparin drip?

I would opt for the Lovenox as opposed to a week in the hospital, if my cardio feels that at-home Heparin injections are too unpredictable. I need to do more research, but this procedure I need to have done is probably comparable to someone on Coumadin need polyps removed from the colon.