Imminent AVR - 40 y.o. female - advice please

[Keithl]

Finally got out of the hospital yesterday, on post-op day 6, after my INR reached 2.2 from 1.5, with the help of a heparin drip for almost 24 hours. There was some confusion with the surgeon’s nurse who for some reason thought my range should be 2.0-3.0, with a mechanical valve (not on-x) - if not for that I might still be there now, instead of relaxing at home with a cup of tea, in my own clothes, in the quiet; no more being stuck and poked and tortured by the phlebotomy sadists & nurses on power trips that walk the halls. I need to remember that good things can also come from other people not knowing what they’re talking about, ha ha.

A question: they wanted me to reduce my warfarin dose last night from 5 to 2.5, before returning to 5 tonight... Even if my range really was 2.0-3.0, having had a last INR of 2.2, would thatve been the right thing to do?... Were they expecting / Are there late effects from the heparin?

I took 5 mg. With a twinge of conscience from disobeying my very first order for my first experience dosing Warfarin...

Any thoughts?
Thank you, guys.

Heparin should not be detected in an INR number, there is separate blood reading they do for how effective Heparin is. If you range is 2-3 and you are at 2.2 Why do they want to you half your dose. One frustration I have with the INR people was the constant dosage tweaking and the alternating doses they wanted me taking. I like predictable dosing. I eventually stopped using the service becasue my PCP will write my scripts now. She knows how anal I am about this stuff and I have a spreadsheet over the last 2 years since my surgery showing every dose and every reading I took.

I was taking 6.75 daily (a 4mg and a 1/2 of a 7.5mg )for a long time and while I had swings they were always in range. I have an On-X and take a daily 81mg aspirin and I use 2.0-3.0 as my range and my cardio agreed to that. I very rarely fall below 2. 5, btu occasionally get as high as 3.4. If you look ta the atts (posted somewhere on this forum) the sweet spot is 2.5-3.0 but going a little over does not change the risk much. Late last years I was running low liek 2.1-2.2 so I moved my does up to 7.5, but lately I have had more 3.1-3.4 reading that I care for so I have gone to 1-2 days week I take 1/2 of a 7/5mg until I see if I need to go back to 6.75 or get something in line with 7.0-7.25. I don't want to be mixing and splitting a bunch of pills so right now the 1-2x a week split my 7.5 will work until I see the new trend.

Most people can expect a dose change to impact in about 3 days, my body is more like 1 week or more.

 

[Amy]

If you look ta the atts (posted somewhere on this forum) the sweet spot is 2.5-3.0 but going a little over does not change the risk much.

Look ta the what?

 

[Keithl]

Look ta the what?

Sorry stats. There are some published statistics listed on here from studies done that shows the number of events based on years is lowest in the 2.5 - 3.0


https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6482495/#!po=39.2857
From the report;
When we combined the 6 INR groups into 3 INR groups (INR less than 2.0, INR 2.0–3.4, and INR greater than 3.4), INR 2.0–3.4 had significantly lower combined thromboembolic and bleeding complications than both INR greater than 3.4 and INR less than 2.0.


https://journals.sagepub.com/doi/full/10.1177/0897190017734765

 

[Amy]

I was looking for those stats! I KNOW I read papers / evidence recommending an INR of 2.5-3.5 for mechanical valves in the aortic position but now I can’t find it. Have to dig through my giant stack of papers.

 

[pellicle]

Sorry stats. There are some published statistics listed on here from studies done that shows the number of events based on years is lowest in the 2.5 - 3.0

and my fav which supports that and combines two of those graphs into one

http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/415179
so just chill and take your pill and test

 

[user 15848]

So, what is your target range? Mine is as stated above (2.0 to 3.0). Is yours different?

My target peace of mind for a AVR is 2-3, for the Aortic Valve, works for me; the other valve probably needs higher range

 

[pellicle]

A question: they wanted me to reduce my warfarin dose last night from 5 to 2.5, before returning to 5 tonight... Even if my range really was 2.0-3.0, having had a last INR of 2.2, would thatve been the right thing to do?...

not to my way of thinking.

are you obese? If you are then they could be concerned about warfarin necrosis ... if you aren't then the worse it will do will be put you into perhaps INR=3

I recommend you consider normalising your doses, not dose then double dose then dose then double dose ... that's spakko

this is a model of warfarin levels in your system with 10 and 7.5mg alternating

the changes will be more pronounced with greater differences. If one seeks stability in INR I don't see how shaking things around helps.

 

[Amy]

That was my reasoning in staying with 5 mg last night even after a 3.3 reading. I only have 5 mg (or broken in half, 2.5 mg) pills right now. And also I’m curious to see what maintaining the dose, while eating my usual amount of vegetables, will do when I check INR tomorrow. If I had changed the dose, I wouldn’t have had a clue what may have changed it.

 

[Amy]

A question -

My heart rate gets up to 130-140 on a short walk, though it’s at 60-70 resting. Is that too much of a jump? Should I try harder to avoid even tiny hills? Should I not be trying to skip one (or two..) of the three metoprolol doses each day and just find a way to deal with the side effects? bp is only 98/55 but maybe it’s more important than I think not to push heart rate at this early stage (postop day 9)? Wish I’d had more guidance on stuff like this, but what are you gonna do? There are always more questions.

 

[pellicle]

My heart rate gets up to 130-140 on a short walk, though it’s at 60-70 resting. Is that too much of a jump?

this soon after surgery I'd call that expected.

just manage it by downing your pace a bit ... I'd always go with the basic rule of thumb:

to estimate your maximum age-related heart rate, subtract your age from 220. For example, for a 50-year-old person, the estimated maximum age-related heart rate would be calculated as 220 – 50 years = 170 beats per minute (bpm).​

and go with lower for "training" than your max, for instance 70% max.

but what are you gonna do?

ask for opinions here, draw an intersection set if the replies are not to your liking / different.

 

[Maineiacs]

The two places that I feel pain at this point, 18 days out, are my neck and between some of my ribs. My neck gets pretty stiff most days- neck rubs help. I think they probably had it in a funky position for hours during surgery and it just needs time to recover.
I also get some pain between my ribs- more on the side and between the ribs. They are tender to the touch and the tenderness comes and goes. This may or may not be due to the fact that I had a mini-sternotomy. It is a small opening, and they use a powerful vise to pry the opening up. My guess is that this prying process creates small tears in the costal cartilage between the ribs. I've had similar injuries with sports and it usually heals in a few weeks. Tylenol seems to be enough to take care of that pain at this point.

Everything has swelling. Eat super healthy. Took me almost a year to wear a normal bra!
Surgery. 9/11/2018— this past summer my daughter cracked my back into place. It’s been out forever. Felt great.
Go for massages. And also osteopathic

 

[Chuck C]

Go for massages

Now that I am vaccinated for Covid, I intend to get a massage very soon

 

[Amy]

A question about chest tube holes... this morning when I got out of the shower I noticed a big white colored something under the steri-strips, which the nurse had told me to leave on till they fell off but which never did...

I took them off and there was this big white sort of coagulated material there, like you get when you skin your knee or something, you know? A bit peeled off with the steri-strips but I left the rest there.. it turned yellowish and now, six hours later is hardening into a sort of light brown.

IS THIS NORMAL????? Is it infected?..

I tried to find something on the forum about this. Some people mentioned using betadine or iodine swabs or even hydrogen peroxide on it.. I don’t have anything like that at home and can’t drive to get it, plus I didn’t know if I should mess with it... I tried calling the surgeon’s office. One woman said to go to urgent care to have it looked at; one who called me back later after someone finally listened to the message I’d left much earlier said to take an antibiotic, Augmentin, for five days, ‘just in case’. If this is normal though, I don’t really want to take antibiotics unnecessarily...

I don’t have a fever, or pain in the area, or chills. The little weeping from the wound is just 10-15 clearish drops a day, from what I’ve seen on my clothes.

Should I leave it open to air, or cover it with gauze? Should I tape Saran Wrap over it in the shower so it doesn’t get the slightest bit wet, or should I wash it with soap and water everyday?

Just wanted to hear your experience with your chest tube hole healing. Thank you.

 

[pellicle]

...it turned yellowish and now, six hours later is hardening into a sort of light brown.

sounds exactly like a scab ... how long is it since you've had a cut or skinned knee

if its oozing yellow liquid then its infected ... if it dries then its a scab

This is what an infection looks like in your gauze covering

look for signs of angry redness around the wound and/or weeping

that's mine.

remember there is

1. colonisation; which is still on the surface
2. invasion; where it enters the blood stream
3. proliferation; where it goes all over the joint

 

[Amy]

Thank you. It looked a little like your second picture this morning, as far as the whitish-yellowish pus-like stuff, but without the liquid drop. Now it’s drying out; this

is a couple hours ago:

 

[pellicle]

Thank you. It looked a little like your second picture this morning, as far as the whitish-yellowish pus-like stuff, but without the liquid drop. Now it’s drying out; t
his a couple hours ago:

ok, well I would obtain some betadine and apply that to the wound and surrounding skin. It might be early stages of surface colonisation.

apply with a cotton bud and allow to dry ... I'd paint it about like that.

I'd leave it uncovered for a while unless you need to protect it from abrasion. A light gauze covering will be sufficient

 

[Zoltania]

My chest tube and drain tube holes were open and "weeping" for nearly three weeks, though I don't recall any scabs. The home health nurse that Kaiser sent occasionally to check on me provided betadine swabs, gauze, and surgical tape. I swabbed the area and replaced the gauze and tape twice a day. I left the area open when I showered. The tape became irritating after a while, so I alternated between vertical and horizontal placement of the tape to give my skin a rest. The holes eventually closed up into slits and stopped draining. (In case you saw one of my earlier posts about this, you'll remember that my boyfriend and I called these my "arrow wounds.") It was creepy and annoying but not serious.

 

[johnmarkos]

Congratulations on your surgery, Amy!

. . . I have a 23mm St Jude mechanical aortic valve . . .

I got the same model and size in January, 2020!

 

[Amy]

How long till you guys could drive?

I had a minimally invasive AVR 2 1/2 weeks ago. I stopped pain meds a week ago. I can turn to look over my shoulders. Incision site looks pretty good:

My cardiologist was supposed to clear me to drive, but as one of you fellow posters put it best, he was an ‘arrogant, ignorant *******’ who didn’t even look at the incision site.

Thank you in advance for sharing your experience.

 

[Chuck C]

How long till you guys could drive?

I had a minimally invasive AVR 2 1/2 weeks ago. I stopped pain meds a week ago. I can turn to look over my shoulders. Incision site looks pretty good:View attachment 887764

My cardiologist was supposed to clear me to drive, but as one of you fellow posters put it best, he was an ‘arrogant, ignorant *******’ who didn’t even look at the incision site.

Thank you in advance for sharing your experience.

Your incision is looking great!

Like you, I had minimally invasive. Mini-sternotomy. The plan was to have my wife do all the driving. But, when she received the Covid vaccine she had flu like symptoms and could not drive. So, I was driving with short trips to the drug store or market after 9 days. I have power steering and felt very comfortable driving. There was no turning of the wheel that used more than 1 pound of pushing or pulling.
Two weeks after surgery I had my follow up with both my cardiologist and surgeon separately- long drive, two hours each way. My wife was still out of it- willing to give it a try, but I did not feel we would be safe, as she already has anxiety driving on the freeway, and then to do so while feeling sick sounded like a real bad idea.

So, I drove myself. I was fully open about it with my surgeon's nurse practitioner. She said that they normally like people to wait 6 weeks, but that it was totally understandable and based on how quickly I was healing was not surprised that I felt comfortable doing so.

That was tiring day for me. It was not painful at all, but after 4 hours of driving and 2 doctor appointments, it felt great to get home to my recliner and relax.

I have been driving consistently since then. I am very careful not to twist or turn in any way that puts strain on my sternum and drive about as cautiously as my 78 year old mother. As of today I am 4 weeks out and technically they would want me to wait another 2 weeks. But, practically speaking that would be extremely difficult for me.