Hospital stays, talk with surgeon

[Jimmyk]

ok I’m in i he hospital,today and the surgeon who did my AVR last year, stopped in for a visit.
After informing him that I have been hospitalized 3 times for bleeding issues. I asked him for any solutions. Without thinking, he asked if I would consider taking the valve out, and replacing it with a biological one? I thought he was joking. He said he had done it numerous times. He says there is a biological valve that he can easily replace it with. I asked how long would it last for? He told me 15 years, then can be changed with a catheter.
I’m seriously considering it.
I’m tired of these hospital stays .
I’d like to ask if anyone else has ever done this before? Is it something that sounds completely off the wall? Please, if it sounds crazy, let me know, I can take it.
Another thing that the cardiologists are monitoring on me is a Aortic aneurysm, and another valve that’s leaking. It doesn’t have to be attended to now, but eventually will be.
I can get everything fixed at the same time.
Thanks for any input.

 

[pellicle]

surgeons love to do surgery ... its what they get paid for.

sounds crazy ... what would you do if you had the valve changed, got an infection and then had other problems and (*bonus points) the tissue valve caused thrombosis and you needed to be on warfarin anyway (about 15% do that BTW)

 

[pellicle]

out of interest,
what was the causes of your bleeds and
what was your INR at the time,
ow well is your INR managed and
what's the usual range you're in?

 

[Jimmyk]

Pellicle,
I always look for your comments. I consider you a very smart logical person.
I admit the bleeding has all been from the same issue every time.
My INR levels have been in range , testing twice weekly at home.
The thought of him asking me the question he asked, seriously sounded like a joke.
Once again, I really respect your inputs.
Possibly I’m jumping the gun. Thank you!

 

[Jimmyk]

Maybe I posted the wrong topic,
administrators please remove post if you can.

 

[pellicle]

Hi

Pellicle,
I admit the bleeding has all been from the same issue every time.

May I ask what that is?

My INR levels have been in range , testing twice weekly at home.

Ok, that rules the idea of high INR being the culprit. I just wanted to be sure.

The thought of him asking me the question he asked, seriously sounded like a joke.
...Possibly I’m jumping the gun

Possibly, but it's always good to thrash there ideas around, one always gains something from discussion, always more than stooling on it.

And I don't think there is anything wrong with where this discussion is located within the forum hierarchy...

Best Wishes

 

[Warrick]

FWIW my surgeon pre-surgery told me he has swapped out mechanicals for tissue for people who haven't been able to take the valve clicking, so it is a done thing
I don't know much about ulcers but have they been able to repair or stop the bleeding from your esophagus?
Or will it be an on going thing? From what I see it's not uncommon for these ulcers to bleed warfarin or not, is it caused by a bacterium or reflux? One seems more treatable than the other.

Sounds like a diificult time for you

 

[Agian]

I hope they sort out this ulcer, so things can settle down.

I met a guy in cardiac rehab. who told me he sometimes sits patiently half-expecting the clicking to stop. He seemed pretty down. I think it gets to some people, but you don't know what came first, the sadness or the clicking.

I think it odd that the clicking has become normal for me. It doesn't actually make sense that I have accepted this contraption as an organic part of me. I think the heart has a lot of cultural luggage associated with it. But, it is no more important than other organs like our lungs, or the thing at the back of our throat, what looks like a punching bag.

 

[Jimmyk]

Pellicle, The issue is a ulcer of the esophagus.
It seems to be under control. I guess all the preparation work to do any type of medical procedure .The blood thinners always seem to have the doctors scratching their heads.Perhaps I should concentrate more on being healthy.
I guess I’ve been here a little too long, getting anxious about going home.

 

[pellicle]

Hi

Pellicle, The issue is a ulcer of the esophagus.

that's pretty serious, as Warwick pointed out it can be diagnosed as being from an organism (Helicobacter pylori) with a trivial test. Its important to sort out the cause because it can be a strong risk factor in developing esophageal cancer (my mates dad died of that 3 years back, strikes before you know it and is then 3 months till death with no hope of treatment without early detection ... due to the difficulties in observing symptoms early detection is rare and its the highest mortality rate cancer right now (if uncommon in itself).

So see to that if you can

It seems to be under control. I guess all the preparation work to do any type of medical procedure

did the ulcer exist prior to surgery? Was it damage from the intubation?

The blood thinners always seem to have the doctors scratching their heads

I know, its weird isn't it ... given just how many people are on them you'd think they have a clue about it by now ... but no. My advice is become your own expert, be proactive in learning about it and don't take it up the arse because they suggest you should.

Like when I went in for my colonoscopy, the secretary (usually the worst offenders for being up themselves while having no actual medical expertise or training) insisted I go off warfarin for a week, commence heparin and then submit to the procedure, then asking me in a supercilious voice "would that be ok?". I said no, actually it wouldn't ... the silence was prolonged and she asked me what I meant. Long story short when I got to speak with the practitioner she was totally fine with my plan (written up on my blog http://cjeastwd.blogspot.com/2017/12/perioperative-management-of-inr.html).

Perhaps I should concentrate more on being healthy.

an excellent plan and only you can do it ... and you can

Best Wishes and feel free to get in touch if you feel down and need a chat.

 

[Jimmyk]

The esophagus problem has started about 6 months ago.
While at a Christmas party at work, a bite of barbecue chicken got caught in my windpipe.
After managing to cough up most of it, a very small piece stayed in the esophagus.
The air path was clear, but i could not swallow water or anything else. It would just come right back up.
About 5 and a half months later, my wife cooked some chicken soup. Now, maybe chickens are out to do me in..haha.
I chewed a piece of chicken, about the size of a nickel did the exact same thing.
Only this time, I was at a hospital that was very unsure about how to get it out.
So after they came up with a plan, and about 28 hours of coughing up my own saliva. I was given a plasma transfusion to lower my inr.
I was wheeled in, knocked out, and had an endoscopy done. Except this time it didn’t correct the problem.
The scariest part about this, was a whole team of GI docs had no explanations.
Forward 24 hours, I was able to swallow small sips of water, was put on a liquid diet , and was discharged a few weeks later.
Forward about 2 weeks, I started feeling very weak and nauseous, so my wife and I drove to the same hospital where I had my AVR.
After sitting in the ER , I was vomiting blood. This time, by the pint.
This time the doctors knew exactly what to do.
After another 4 transfusions because of the excessive blood loss, an endoscopy was performed, the esophagus was clamped, I had air tubes put down my throat, and put in a medically induced coma, waking up 3 days later in ICU .
When I did come to, the doctors reviewed the records from the last issue.
My wife informed me that the doctors were shocked to hear that the previous hospital had left the piece of chicken stuck in my throat for 28 hours. And was also the likely the cause of the ulcer.
We’re both praying that we can move forward from this.
Sorry about such a long comment, but maybe it can help another person out there.
As of now , it’s 8 days later, I’m eating a solid diet, the inr is showing good numbers, and there’s talk about going home tomorrow!!!

 

[pellicle]

Hi

The esophagus problem has started about 6 months ago.
While at a Christmas party at work, a bite of barbecue chicken got caught in my windpipe.

ahh, I seem to remember that ...

The air path was clear, but i could not swallow water or anything else. It would just come right back up.
About 5 and a half months later, my wife cooked some chicken soup. Now, maybe chickens are out to do me in..haha.
I chewed a piece of chicken, about the size of a nickel did the exact same thing.
Only this time, I was at a hospital that was very unsure about how to get it out.

you know, that sounds a little like dysphagia:

https://en.wikipedia.org/wiki/Dysphagia

I'd look into that ...

...After another 4 transfusions because of the excessive blood loss, an endoscopy was performed, the esophagus was clamped, I had air tubes put down my throat, and put in a medically induced coma, waking up 3 days later in ICU .

when you say the esophagus was clamped, you mean by them or it was restricted?

.
Sorry about such a long comment, but maybe it can help another person out there.
As of now , it’s 8 days later, I’m eating a solid diet, the inr is showing good numbers, and there’s talk about going home tomorrow!!!

not at all its good to get more details .. I hope you're homeward bound when you read this

Best Wishes

 

[Jimmyk]

Pellicle,
From what I was told, they used a laser then clamps as repair. They seem to think that this procedure was a permanent fix. The only thing they worried about was, once they got the inr back to therapeutic range that bleeding might happen.
At time of surgery, inr was 0.8 as of about 3 hours ago, it was 3.1....and no bleeding.

 

[Jimmyk]

I’ll have to look into dyphagia.
For almost for as long as I can remember, I was told that I suffered from a hyital hernia. Not sure if I spelled it right, but it’s a narrowing of the food pipe. I should have gotten it fixed a long time ago.
I’ve tried talking with doctors about getting it fixed. It’s a quite simple procedure, but because of the warfarin, I’m having a hard time finding a Dr to fix it.
Well ,time for a few hours sleep.

 

[user 16827]

insisted I go off warfarin for a week, commence heparin (written up on my blog http://cjeastwd.blogspot.com/2017/12/perioperative-management-of-inr.html).

Hi Pell thanks for sharing the blog, is there a reason you seem to be against heparin ? i read in the blog you went for a covering shot........

i underwent a shoulder opp after crashing the bike and i went on heparin cover

having learned a little since joining the forum i would dose myself down ( next time )

I'm just curious about your thoughts regarding the Heparin ?

 

[Jimmyk]

I’d be interested in knowing myself.

Just when I thought I was going home, I’m told that the inr results for yesterday were a false reading. The actual number was 1.36 this mornings number was 1.7 . They want it at 2.5 before I can leave.

 

[pellicle]

Good Moring (from Australian perspective that is)

Hi Pell thanks for sharing the blog, is there a reason you seem to be against heparin ? i read in the blog you went for a covering shot........

I'm not against heparin at all, its a very useful tool in the medical arsenal. The answer to my logic surrounds the points of "needed" and "beneficial" and "cost"

Heparin is quick acting and very predictable in its anticoagulation method. If interested you can find the mechanism of action at wikipedia:
https://en.wikipedia.org/wiki/Heparin#Mechanism_of_action

Heparin is direct while warfarin is indirect (acting on a different mechanism up-stream).

Heparin is also quick to wear off with a half life of about 5 hours unlike warfarin.

The goal around surgery is to return the body to a proper state of ability to form clots, and so in my situation I was asked to go of warfarin (which would resume the body being able to clot), but go on to heparin (which would block clotting at a different place in the biochemical process) and that could then be withheld the day before the procedure (surgery) whereupon I'd need to remain off heparin until it was clear that I wasn't bleeding out my bowel (as happened to my friend the week before).

The Doctor performing the procedure had no ide (none at all) how long it would take my INR to return to normal and so just picked a week prior to the surgery and commence heparin at that time (to be sure to be sure to be sure), but when I discussed with her my own results she was "wow, its that quick, I had no idea" ... and was fully onboard with my plan saying that as long as my INR was below 1.4 at the time of surgery she'd be happy.

My logic (as indeed is the logic of the authors of the medical journal I discussed) is that for the hassle of injecting myself, the hassle of going and buying 10 ampules (which aren't expensive in Australia under our PBS), of which I'd use half and toss them, I saw no net benefit to going onto that for very minor time.

They often call heparin "bridging therapy" ... but some creeks just aren't worth building a bridge over because you can just jump over them. Meaning that for low risk patients (like me, and perhaps you) the micromanagement of our anticoagulation is meaningless. Further it promotes a sense of unease in the community (which you'll see here many times) that we will suddenly have a stroke if we go off warfarin (the "oh my god I missed a dose..." ) . The reality is that for most of us valvers we can withhold warfarin for a few days surrounding a procedure with no net risk and indeed some benefit (assuming you observed the points of benefits in that article)

i underwent a shoulder opp after crashing the bike and i went on heparin cover

I don't know the details of your shoulder surgery but I'd say that probably there was no need

 

[pellicle]

leadville

worth a read:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4818019/

now, remember you're reading science where people are NOT loose with words , meanings of words and naming. Rember that "indicated" is not the same as "required every second of your life" and that "risk" is not certainty.

So they write:

Mechanical valves are known to have a higher risk of thrombosis; this risk further varies depending on the type of valve, its position, and certain individual factors. According to current guidelines, long-term anticoagulation is indicated in patients with metallic prosthetic valve disease

followed up with:

We report two unique cases of patients who survived 27 and 37 years event free, respectively, after mechanical aortic valve replacement (AVR) without being on any form of anticoagulation.

I submit what with modern bileaflet valves and no other indications of thrombosis (meaning a history of strokes or clots like DVT) that a few days here or there is very low risk.

The purpose of my blog post is not just to describe what I did, and not to recommend what you should do, but to assist people to see that "we are over anti-coagulation management" governed and that sometimes that has negative consequences (as discussed by those authors in my blog post).

Best Wishes

 

[pellicle]

Just when I thought I was going home, I’m told that the inr results for yesterday were a false reading. The actual number was 1.36 this mornings number was 1.7 . They want it at 2.5 before I can leave.

bugger ... always too slow in managing AC therapy ... may I ask (for my own learning)

• what was your daily dose before surgery
• what did they resume you on

Thanks

 

[Jimmyk]

I’m on 7.5 daily and on Friday’s I cut one in half and take 3.75.
Here, I’m still on 7.5 daily,with a10 mg dose on Friday.
also on heparin drip, which was just resumed now.
I have a midline port for drawing blood, as my arms and hands are still to swollen to find a vein.
Well, this morning while still half asleep, the nurse didn’t notice the midline, disconnected my heparin and drew blood from the same
port ,no wonder why they came up with a 3.1 inr ?
It caught someone’s attention in the lab, so after retesting, it turned out to be 1.8.
They need to see 2.5 before discharging me.