Had AVR performed 2/25/21

[NorthWoods]

Was released from the hospital yesterday. Only spent 5 days recovering before doc said I could go home.
It's been interesting to say the least. I'm still feeling pretty achy as they performed a mini sternotomy. Installed 21mm On-X AV and the surgeon said it could not have gone better.

It did take a while for me to wake-up afterwards. Still coughing some, which hurts the incision area. I had an onset of stabbing pain in my left shoulder blade 2 days ago that left the doctors stumped. Not sure if it was a nerve, pulled muscle, reaction from the catheter from the block, or what. Still hurts this morning and has moved to the right side of my shoulders.

Sleeping last night in mu bed was nice, but a bit uncomfortable. One, Laying flat on my back put extra pressure on the incision area and lungs. The valve ticking lulled me to sleep so that was nice. Woke up in the middle of the night to pee, and it took a lot of extra effort to get-up. My girlfriend had a hard time trying to figure out what I was trying to do, but we eventually got it.

Still having a throbbing pain in my legs and upper thigh. Only hurts when I try to lift it up, but maybe my primary will figure it out.

Can't say the hospital visit was the best, but it is what it is. At least I am home now and recovering!

 

[ATHENS1964]

I wish you a speedy recovery .

 

[Superman]

Thanks for the update and glad to hear you’re at home recovering! Pain in the back / shoulder area is not unusual as spreading your rib cage open is not a natural position. Even with a mini sternotomy they have to open up the area. I think I had some back bruising with the clamps they used.

 

[Unicusp]

Was released from the hospital yesterday. Only spent 5 days recovering before doc said I could go home.
It's been interesting to say the least. I'm still feeling pretty achy as they performed a mini sternotomy. Installed 21mm On-X AV and the surgeon said it could not have gone better.

It did take a while for me to wake-up afterwards. Still coughing some, which hurts the incision area. I had an onset of stabbing pain in my left shoulder blade 2 days ago that left the doctors stumped. Not sure if it was a nerve, pulled muscle, reaction from the catheter from the block, or what. Still hurts this morning and has moved to the right side of my shoulders.

Sleeping last night in mu bed was nice, but a bit uncomfortable. One, Laying flat on my back put extra pressure on the incision area and lungs. The valve ticking lulled me to sleep so that was nice. Woke up in the middle of the night to pee, and it took a lot of extra effort to get-up. My girlfriend had a hard time trying to figure out what I was trying to do, but we eventually got it.

Still having a throbbing pain in my legs and upper thigh. Only hurts when I try to lift it up, but maybe my primary will figure it out.

Can't say the hospital visit was the best, but it is what it is. At least I am home now and recovering!

Glad to hear that you made it. Your comments brought back some memoires from my mini-sternotomy in 2013. Very similar. My right shoulder was messed up after surgery and hurt more than anything. They said they may have hit a nerve bundle, but it was bad and took months to recuperate that area. Was like the muscles were detached (due to severed nerves) and one side drooped. Lots of massage and exercise eventually cured it, and I'm sure the nerves grew back. Having just had a full sternotomy, I have less pain and issues than with the Mini.
Welcome to the On-X club! I just joined too. Today is day 12 (from surgery) for me. Yesterday took nice 1.5 mile walk in rolling hills with avg heart rate of 124. New valve working well. Hang in there. Every day gets better.

 

[Keithl]

Was released from the hospital yesterday. Only spent 5 days recovering before doc said I could go home.
It's been interesting to say the least. I'm still feeling pretty achy as they performed a mini sternotomy. Installed 21mm On-X AV and the surgeon said it could not have gone better.

It did take a while for me to wake-up afterwards. Still coughing some, which hurts the incision area. I had an onset of stabbing pain in my left shoulder blade 2 days ago that left the doctors stumped. Not sure if it was a nerve, pulled muscle, reaction from the catheter from the block, or what. Still hurts this morning and has moved to the right side of my shoulders.

Sleeping last night in mu bed was nice, but a bit uncomfortable. One, Laying flat on my back put extra pressure on the incision area and lungs. The valve ticking lulled me to sleep so that was nice. Woke up in the middle of the night to pee, and it took a lot of extra effort to get-up. My girlfriend had a hard time trying to figure out what I was trying to do, but we eventually got it.

Still having a throbbing pain in my legs and upper thigh. Only hurts when I try to lift it up, but maybe my primary will figure it out.

Can't say the hospital visit was the best, but it is what it is. At least I am home now and recovering!

while not the best sleep I used a wedge pillow for the first 4-5 weeks to take the load off my sternum, but I had a full crack. It was about 6 weeks before I could lay flat and sleep well.

 

[epstns]

Another possible cause for your shoulder pain, which BTW is pretty common after heart surgery, is the position they bend, pull and twist your body into for the procedure itself. I never saw, but was told, that in addition to having to open the sternum and pull the ribs open with retractors, they also pull your arms back to help open the rib cage. Think about carving chickens. . . same thing.

I had some terrible shoulder pain for a month or so, but it does gradually go away. I also had a lot of coughing right after my surgery. Did they teach you how to cough properly, protecting your sternum from the stress? My trick was to clasp both hands flat on my sternum and press gently inwardly, against the cough. It worked for me. Also, the pain on coughing or sneezing was one of the first to go away. Just keep an eye on coughing -- if it persists, have them check to be sure you don't have fluid build-up in your lungs. That can be painful, as I learned first-hand. Mine was medically minor, but painful. The remedy, for me, was just ibuprofen to reduce inflammation (but only with doctor's instructions, not self-medicated).

 

[pellicle]

Another possible cause for your shoulder pain, which BTW is pretty common after heart surgery, is the position they bend, pull and twist your body into for the procedure itself.

agreed ... I couldn't take my "sweat shirt" off by pulling it over my head from the bottom (as I'd done most of my life) for nearly a year

 

[NorthWoods]

Thank you all for the kind words and comments. Almost all of the coughing has stopped. My lungs are up to 2250ml of volume, just 250ml shy of pre-surgery volume. The chest tube drain clot has fallen off most of the way so now just using the 4 x 4 squares to cover it after showering.
Pain is still present, but getting duller. Only having to use the Oxycodone in the morning and night, and Tylenol during the day for pain managament.
Took the first out of hospital INR this morning and it was 2.1. Clinic called me and said it was spot-on.... no adjustments needed.. just keep taking the 6mg of Warfarin daily, plus 81mg baby aspirin.

 

[Keithl]

Another possible cause for your shoulder pain, which BTW is pretty common after heart surgery, is the position they bend, pull and twist your body into for the procedure itself. I never saw, but was told, that in addition to having to open the sternum and pull the ribs open with retractors, they also pull your arms back to help open the rib cage. Think about carving chickens. . . same thing.

I had some terrible shoulder pain for a month or so, but it does gradually go away. I also had a lot of coughing right after my surgery. Did they teach you how to cough properly, protecting your sternum from the stress? My trick was to clasp both hands flat on my sternum and press gently inwardly, against the cough. It worked for me. Also, the pain on coughing or sneezing was one of the first to go away. Just keep an eye on coughing -- if it persists, have them check to be sure you don't have fluid build-up in your lungs. That can be painful, as I learned first-hand. Mine was medically minor, but painful. The remedy, for me, was just ibuprofen to reduce inflammation (but only with doctor's instructions, not self-medicated).

Yeah they basically spread you arched backward to get best access, I did recall some discomfort for a while with shoulders. Then of course with full crack I had some creaky bones on a few occasions as the ribs kind of realigned/adjusted.

 

[pellicle]

Hey that's all good news

Took the first out of hospital INR this morning and it was 2.1. Clinic called me and said it was spot-on.... no adjustments needed.. just keep taking the 6mg of Warfarin daily, plus 81mg baby aspirin.

just so that you know, over the coming months (it depends on your recovery speed) you will need to increase the warfarin dose to maintain the INR you desire.

This is a normal and well documented (and understood) thing ; that nobody bothers to tell you about. Perhaps because they are fools and don't know, or perhaps because they don't care.

If you happen to want more info on this:

https://www.ajconline.org/article/S0002-9149(99)00463-4/fulltext
(*note: Published:August 16, 2004 )

Abstract​

The response to initiation of oral anticoagulants at a usual dose of 5 mg of warfarin has been retrospectively evaluated in patients following heart valve replacement (HVR). Patients starting oral anticoagulants after HVR have a lower target International Normalized Ratio (INR) (1.5 to 2.6) until the pacing wires are removed after operation. The mean daily doses and INR responses after HVR and nonsurgical patients were retrospectively compared during the first 5 days of warfarin treatment. ​

In a subset from both groups, the mean dose of warfarin was correlated with age, body weight, and albumin levels. Eighty-four HVR and 32 nonsurgical patients were studied. ​

The mean daily warfarin dosage was​

3.29 ± 1.29 mg after HVR and​

4.96 ±1.76 mg in controls (p <0.001),​

and the mean INRs ​

2.08 ± 0.60 and ​

1.60 ± 0.54, respectively (p <0.001). ​

Of the HVR patients and controls, 48.8% and 21.8%, respectively, exceeded the upper level of the targeted range (p = 0.014), 86.9% and 40.6% had the dose reduced after the first 5 mg (p <0.001), and 54.7% and 28.1%, respectively, had warfarin withheld for at least 1 day (p = 0.015). Thirty-nine patients were included in the subset analysis. ​

the key point is here:

​

Patients with serum albumin levels <35 g/L required significantly less warfarin (3.84 mg/day) than patients with levels ≥35 g/L (5.37 mg/day; p <0.05). Thus, patients starting oral anticoagulation after HVR are significantly more sensitive to warfarin than nonsurgical patients. Patients with serum albumin levels below the normal values require less warfarin than patients with normal values during the initial phase of treatment.​

then this:
https://www.aafp.org/afp/1999/0201/p635.html#sec-5

A knowledge of the pharmacokinetics of warfarin is helpful in understanding the initial response to therapy. Warfarin can be detected in the plasma one hour after oral administration, and peak concentrations occur in two to eight hours.10​

Warfarin is a racemic mixture of stereo isomers, which are 99 percent bound to albumin.11 The drug is metabolized in the liver and kidneys, with the subsequent production of inactive metabolites that are excreted in the urine and stool.10​

The half-life of racemic warfarin ranges from 20 to 60 hours. The mean plasma half-life is approximately 40 hours, and the duration of effect is two to five days.10 Thus, the maximum effect of a dose occurs up to 48 hours after administration, and the effect lingers for the next five days.​

​

So basically as you recover from surgery the amount of albumin in your blood serum increases and influences the interaction of warfarin.

Not important in itself, but just to let you know that you'll see changes in the coming weeks months.

Its a good sign as you need more.

 

[NorthWoods]

Thanks for the info! I'm taking 3 x 2mg tablets daily, so the doctor said I can cut one of the tablets in-half to go up one in dose if needed.

 

[almost_hectic]

Yeah I don't know what exactly they do to your arms but my shoulder is still kinda messed up five years later. It doesn't help that my natural tendency is to sleep on my left side... Its just a constant pain Ive grown used to I think.

 

[newarrior]

while not the best sleep I used a wedge pillow for the first 4-5 weeks to take the load off my sternum, but I had a full crack. It was about 6 weeks before I could lay flat and sleep well.

Damn

 

[pellicle]

I'm taking 3 x 2mg tablets daily, so the doctor said I can cut one of the tablets in-half to go up one in dose if needed.

So are you self testing and self managing?

 

[Unicusp]

Yeah they basically spread you arched backward to get best access, I did recall some discomfort for a while with shoulders. Then of course with full crack I had some creaky bones on a few occasions as the ribs kind of realigned/adjusted.

Actually I spoke with the surgical team at the CC prior to my surgery about this and asked if they move the arms at all after being put out. They said no. The arms always remain at the side. They do not move arms or shoulders. Issues are caused by contact with nerves during surgery or after with the tubes.

 

[NorthWoods]

I go to my clinic twice a week to test. After I see the results, then they call and say stay the same, go up, or go down in dose. They did the 2mg tablets to make it easier so I wouldn't have multiple bottles of different doses laying around.

 

[Unicusp]

Thank you all for the kind words and comments. Almost all of the coughing has stopped. My lungs are up to 2250ml of volume, just 250ml shy of pre-surgery volume. The chest tube drain clot has fallen off most of the way so now just using the 4 x 4 squares to cover it after showering.
Pain is still present, but getting duller. Only having to use the Oxycodone in the morning and night, and Tylenol during the day for pain managament.
Took the first out of hospital INR this morning and it was 2.1. Clinic called me and said it was spot-on.... no adjustments needed.. just keep taking the 6mg of Warfarin daily, plus 81mg baby aspirin.

Are you targeting 2.5? Funny that my INR was at 4.8 when on 5gm. Reduced to 4mg and now at 3.9 Reducing again to 3mg to hopefully get in the 2.0 to 3.0 range. Doctor prescribed all 1mg tablets so easy to adjust dosage.

 

[Chuck C]

Was released from the hospital yesterday. Only spent 5 days recovering before doc said I could go home.
It's been interesting to say the least. I'm still feeling pretty achy as they performed a mini sternotomy. Installed 21mm On-X AV and the surgeon said it could not have gone better.

It did take a while for me to wake-up afterwards. Still coughing some, which hurts the incision area. I had an onset of stabbing pain in my left shoulder blade 2 days ago that left the doctors stumped. Not sure if it was a nerve, pulled muscle, reaction from the catheter from the block, or what. Still hurts this morning and has moved to the right side of my shoulders.

Sleeping last night in mu bed was nice, but a bit uncomfortable. One, Laying flat on my back put extra pressure on the incision area and lungs. The valve ticking lulled me to sleep so that was nice. Woke up in the middle of the night to pee, and it took a lot of extra effort to get-up. My girlfriend had a hard time trying to figure out what I was trying to do, but we eventually got it.

Still having a throbbing pain in my legs and upper thigh. Only hurts when I try to lift it up, but maybe my primary will figure it out.

Can't say the hospital visit was the best, but it is what it is. At least I am home now and recovering!

Well done and thanks for the update! Best of luck on your recovery! Please continue to keep us posted.

 

[NorthWoods]

Are you targeting 2.5?

My doctor is having me target 2.0 - 3.0 for the first 3 months. Then 1.5 - 2.0 since I have the On-x valve. I'll stay with the higher to be on the safe side.

 

[Unicusp]

My doctor is having me target 2.0 - 3.0 for the first 3 months. Then 1.5 - 2.0 since I have the On-x valve. I'll stay with the higher to be on the safe side.

Same here. I also got the On-X 2 weeks ago today. Time Flys! Valve working great. Took a hilly 3.25 mile walk today. No issues.