Needing non-cardiac surgery with a prosthetic heart valve and warfarin intake

[drleng]

Hi everyone, I've been reading the posts in this forum for years and I have found it to have been incredibly comforting to find like-minded survivors (nay, thrivers!) throughout my recovery. I now have a problem of requiring surgery for a non-cardiac problem and it requires stopping warfarin. There are risks of getting thromboses, endocarditis and embolic strokes which I fear most. Is there anyone out there who has been through the same problem?
I guess it's not much different from requiring cardiac surgery a 2nd time round for valve replacement. But this kind of surgery is a no-brainer decision - it's an immediate life saving procedure. What though for non-cardiac surgery? Not immediately life-threatening but if left untreated, can lead to same problems like sepsis and eventually possible endocarditis down the road? I think I know what to do but I guess right now, I'm just looking for courage.

 

[dick0236]

I am one of the lucky ones who has been able to live post-op without any additional major in-patient surgery of any kind. The risks you've outlined are real but modern hospitals and surgeons have the knowledge and tools to minimize the type of risks you've outlined. FWIW, I have known many valve recipient friends over the years who have undergone some very major surgeries......successfully. Your profile indicates you are in the medical field. Remember the old saying "sometimes we can't see the forest because the trees get in the way".

 

[pellicle]

Hi and welcome

I now have a problem of requiring surgery for a non-cardiac problem and it requires stopping warfarin. There are risks of getting thromboses, endocarditis and embolic strokes which I fear most. Is there anyone out there who has been through the same problem?

I'm sure you know much of this but, anyyway; this is actually a pretty detailed post, so I recommend you read it and the associated citations carefully
http://cjeastwd.blogspot.com/2017/12/perioperative-management-of-inr.html
The usual methodology has been bridging, however its emerging in the literature that this may be overly cautious on the ACT side while promoting bleeds (*because coagulation has a purpose).

Bridging is essentially ceasing warfarin, then commencing heparin

since heparin has a very short half life, it can be ceased when the INR has become low and thus coagulation will be normal. The surgical event can take place, At some point warfarin is restarted and heparin can be also commenced, it is withdrawn when the INR reaches the therapeutic range.

HTH

PS: just read your profile ... I agree with @dick0236

 

[drleng]

I am one of the lucky ones who has been able to live post-op without any additional major in-patient surgery of any kind. The risks you've outlined are real but modern hospitals and surgeons have the knowledge and tools to minimize the type of risks you've outlined. FWIW, I have known many valve recipient friends over the years who have undergone some very major surgeries......successfully. Your profile indicates you are in the medical field. Remember the old saying "sometimes we can't see the forest because the trees get in the way".

Thanks for the reassurance..and your words (about uneventful surgeries in friends) are worth alot A little knowledge is a dangerous thing. I just need to stop dwelling on the miniscule risk and get it over and done with! Thanks again!

 

[drleng]

Hi and welcome


I'm sure you know much of this but, anyyway; this is actually a pretty detailed post, so I recommend you read it and the associated citations carefully
http://cjeastwd.blogspot.com/2017/12/perioperative-management-of-inr.html
The usual methodology has been bridging, however its emerging in the literature that this may be overly cautious on the ACT side while promoting bleeds (*because coagulation has a purpose).

Bridging is essentially ceasing warfarin, then commencing heparin
View attachment 888183

since heparin has a very short half life, it can be ceased when the INR has become low and thus coagulation will be normal. The surgical event can take place, At some point warfarin is restarted and heparin can be also commenced, it is withdrawn when the INR reaches the therapeutic range.

HTH

PS: just read your profile ... I agree with @dick0236

Hi Pellicle, thankyou very much for referring me to that blog. It shows that despite a subtherapeutic INR for 8 days (normal for 4 days), that person did not thrombose. That is reassuring!
I would like to thank you not only for this post but your other postings throughout this site. I worked as a resident in a cardiothoracic ward for 3 months in my early years of training. You would think I knew enough about open heart surgery, right? It did nothing to prepare me for what I went through as a patient on the other side of the bed! Doctors know nothing about patients' sufferings unless they have been through it themselves! I was so glad to find this forum! Thanks again!
BTW, I am in Malaysia.

 

[pellicle]

Hi Pellicle, thankyou very much for referring me to that blog...

You're welcome (also that is my blog, so that person was me).

A good friend of mine specializes in education (PhD in teacher training), she is always on about experiential learning. Even before I met her I was aware of the term grok from "stranger in a strange land" from my early years. It is one thing to be able to recite from a text, another to go through it (always something extra I'm that )

Myself I believe that the reductionist approach which forms part of the discipline of science can neglect the details not associated with the specialisation. This it is that many who in their later years are confronted with the spectre of heard surgery go into what I consider to be a type of shock, or psychological trauma. Surgeons neglect this, nurses are ill equipped to really do much and people are released from hospitals still suffering (inside).

I believe this also manifests itself before surgery and makes proper "patient informing" impossible. Not least because there really is so much to learn.

That's why I do and write what I do here.

So thank you for your kind praise.

Best Wishes

 

[drleng]

You're welcome (also that is my blog, so that person was me).

A good friend of mine specializes in education (PhD in teacher training), she is always on about experiential learning. Even before I met her I was aware of the term grok from "stranger in a strange land" from my early years. It is one thing to be able to recite from a text, another to go through it (always something extra I'm that )

Myself I believe that the reductionist approach which forms part of the discipline of science can neglect the details not associated with the specialisation. This it is that many who in their later years are confronted with the spectre of heard surgery go into what I consider to be a type of shock, or psychological trauma. Surgeons neglect this, nurses are ill equipped to really do much and people are released from hospitals still suffering (inside).

I believe this also manifests itself before surgery and makes proper "patient informing" impossible. Not least because there really is so much to learn.

That's why I do and write what I do here.

So thank you for your kind praise.

Best Wishes

You are such an interesting person ..

 

[pellicle]

You are such an interesting person ..

Well that's probably the nicest thing any one has said publicly to me here. Thank you. ☺

Perhaps it is just that I'm unusual and because I grok this thing and have been through a lot have a lot of compassion for people suffering this.

https://www.sciencedaily.com/releases/2015/05/150512104034.htm
My sense of humour is not without quirks

Best Wishes

 

[MdaPA]

I now have a problem of requiring surgery for a non-cardiac problem and it requires stopping warfarin.

My wife recently had a “routine” 15 minute dental procedure/surgery. Her INR range is 2.5-3.5 and she was initially told that she would have to stop warfarin and “bridge” with Lovanox shots for the procedure (her Cardio agreed as well). When questioned about stopping warfarin and bridging, the dentist later told her this would not be necessary as long as her INR was 3.0 or below the day of the procedure. She pre-medicated with Clindamycin before the procedure and was told to continue taking it for an additional week after the procedure to prevent endocarditis with her mechanical AV and MV's.

The procedure went as expected (INR was 2.8) and she had minimal bleeding for 24-48hr after. She self-tested her INR the next couple of days as Clindamycin can interact with warfarin and impact INR. Sure enough, in a span of only three days, her INR went from 2.8 to 4.7. Clindamycin was the likely cause for her rapid elevation of her INR but other factors like not being able to eat solid food, less/no vitamin K rich foods, etc. could have also had an impact. With close guidance with her Cardio, her warfarin dosage was reduced from her normal dosage and all seemed fine.

Three days later, her mouth started bleeding at her surgical site (her INR was then 3.6). We could not control the bleeding and had to go back to her dentist for intervention. Two separate attempts on two separate days to stop the bleeding were unsuccessful. She was swallowing blood which eventually caused her to get sick which involved a visit to the ER. To make a long story short, we were told there was nothing they could do and we just needed to wait until her INR came down for it to heal on it's own. We were told that the bleeding was not life threatening so giving her vitamin K to get her INR down quickly was not indicated. That's well and good if you can put a tourniquet or bandage around it to stop the bleeding but when you are up 24/7 replacing gauze in your mouth, can't eat, can't sleep, losing weight, frustrated, etc, it seemed like she was going down hill quickly (BTW, it impacted me as caretaker the same). After three more days of closely managing her warfarin to get her INR down (it got down to a scary 1.4 at one point) and being off the Clindamycin, her bleeding eventually did stop.

Here are my observations/recommendations after this incident:

1 - Don't listen to or accept anyone who says a procedure is “routine” when you are on blood thinners/have artificial valves.
2 - Question the Dr. re the bleeding risks and if bridging is truly necessary or not.
3 - Know how things like lack of sleep, diet changes, and drugs (antibiotics, pain meds, etc) you will be taking may impact/interaction with your INR to prevent an unexpected bleeding episode.
4 - Make sure all your Dr's (surgeon, PCP, Cardio, INR clinic) are aware of your procedure and all agree to the same plan.

 

[user 15848]

Hi everyone, I've been reading the posts in this forum for years and I have found it to have been incredibly comforting to find like-minded survivors (nay, thrivers!) throughout my recovery. I now have a problem of requiring surgery for a non-cardiac problem and it requires stopping warfarin. There are risks of getting thromboses, endocarditis and embolic strokes which I fear most. Is there anyone out there who has been through the same problem?
I guess it's not much different from requiring cardiac surgery a 2nd time round for valve replacement. But this kind of surgery is a no-brainer decision - it's an immediate life saving procedure. What though for non-cardiac surgery? Not immediately life-threatening but if left untreated, can lead to same problems like sepsis and eventually possible endocarditis down the road? I think I know what to do but I guess right now, I'm just looking for courage.

Read Pellicle's posting.

 

[tom in MO]

I have had one surgery, a TURP-Transurethral Resection of the Prostate. My urologist wanted me to drop warfarin and aspirin for 5 days including the day of surgery but it would be up to my cardiologist. My urologist didn't tell me I had to meet a target INR. His nurse just stated I needed to check my INR right before surgery. My urologist didn't give an opinion bridging other than to say it was a possible route dependent upon my cardiologist's assessment.

My cardiologist decided to keep me on aspirin but take me off warfarin for 5 days. My cardiologist stated I need to check my INR 3 days before I go off the warfarin so they can make any needed last minute changes. My cardiologist said the St. Jude valve is robust and relatively clot-free, so I did not need a bridging procedure. My urologist agreed to the slightly different approach.

After surgery I had no blood in my urine, but some appeared about 2 days later. Per my urologist's nurse this is normal when my INR gets back to the 2-2.5 range. It takes a little longer for the wound to heal when on warfarin.

 

[Mr V]

I have had a couple procedures (colonoscopy and a GI exam) where I did the bridging. Did the lovenox shots for a few days while waiting for the warfarin to get out of my system. Think I stopped the lovenox the day before and both procedures we done in the morning. I think I restarted warfarin the next day. Like others have said you go back on the lovenox while waiting for the warfarin to get your inr back where it belongs.

 

[drleng]

My wife recently had a “routine” 15 minute dental procedure/surgery. Her INR range is 2.5-3.5 and she was initially told that she would have to stop warfarin and “bridge” with Lovanox shots for the procedure (her Cardio agreed as well). When questioned about stopping warfarin and bridging, the dentist later told her this would not be necessary as long as her INR was 3.0 or below the day of the procedure. She pre-medicated with Clindamycin before the procedure and was told to continue taking it for an additional week after the procedure to prevent endocarditis with her mechanical AV and MV's.

The procedure went as expected (INR was 2.8) and she had minimal bleeding for 24-48hr after. She self-tested her INR the next couple of days as Clindamycin can interact with warfarin and impact INR. Sure enough, in a span of only three days, her INR went from 2.8 to 4.7. Clindamycin was the likely cause for her rapid elevation of her INR but other factors like not being able to eat solid food, less/no vitamin K rich foods, etc. could have also had an impact. With close guidance with her Cardio, her warfarin dosage was reduced from her normal dosage and all seemed fine.

Three days later, her mouth started bleeding at her surgical site (her INR was then 3.6). We could not control the bleeding and had to go back to her dentist for intervention. Two separate attempts on two separate days to stop the bleeding were unsuccessful. She was swallowing blood which eventually caused her to get sick which involved a visit to the ER. To make a long story short, we were told there was nothing they could do and we just needed to wait until her INR came down for it to heal on it's own. We were told that the bleeding was not life threatening so giving her vitamin K to get her INR down quickly was not indicated. That's well and good if you can put a tourniquet or bandage around it to stop the bleeding but when you are up 24/7 replacing gauze in your mouth, can't eat, can't sleep, losing weight, frustrated, etc, it seemed like she was going down hill quickly (BTW, it impacted me as caretaker the same). After three more days of closely managing her warfarin to get her INR down (it got down to a scary 1.4 at one point) and being off the Clindamycin, her bleeding eventually did stop.

Here are my observations/recommendations after this incident:

1 - Don't listen to or accept anyone who says a procedure is “routine” when you are on blood thinners/have artificial valves.
2 - Question the Dr. re the bleeding risks and if bridging is truly necessary or not.
3 - Know how things like lack of sleep, diet changes, and drugs (antibiotics, pain meds, etc) you will be taking may impact/interaction with your INR to prevent an unexpected bleeding episode.
4 - Make sure all your Dr's (surgeon, PCP, Cardio, INR clinic) are aware of your procedure and all agree to the same plan.

Thankyou for sharing your story. I cringe every time I read a story where there has been medical negligence. I have 2 questions:
1) Did your dentist secure adequate haemostasis in the first place i.e. suture?
2) My local (Malaysia) INR clinic also advises not to bother manipulating the warfarin dose (or even check INR) until 5 days later at the completion of the course of antibiotic. I'll chuck this advice out the window. Where are you are what is the local advice in this respect?

 

[drleng]

I have had one surgery, a TURP-Transurethral Resection of the Prostate. My urologist wanted me to drop warfarin and aspirin for 5 days including the day of surgery but it would be up to my cardiologist. My urologist didn't tell me I had to meet a target INR. His nurse just stated I needed to check my INR right before surgery. My urologist didn't give an opinion bridging other than to say it was a possible route dependent upon my cardiologist's assessment.

My cardiologist decided to keep me on aspirin but take me off warfarin for 5 days. My cardiologist stated I need to check my INR 3 days before I go off the warfarin so they can make any needed last minute changes. My cardiologist said the St. Jude valve is robust and relatively clot-free, so I did not need a bridging procedure. My urologist agreed to the slightly different approach.

After surgery I had no blood in my urine, but some appeared about 2 days later. Per my urologist's nurse this is normal when my INR gets back to the 2-2.5 range. It takes a little longer for the wound to heal when on warfarin.

Thankyou for sharing your story. When exactly did you restart your warfarin after your TURP?

 

[MdaPA]

1) Did your dentist secure adequate haemostasis in the first place i.e. suture?

Yes, after the expected light bleeding stopped 24/48 hrs post-op, she went 3 to 4 days with no bleeding. Then all of a sudden on day 4 or 5, she started bleeding again. Reading that this may have been caused by tissue movement due to stitches dissolving. The dentist put in another stitch or two but she then soon developed a hematoma that made packing with the gauze to put pressure on it impossible. If you ask me, putting another stitch in while her INR was still high at that point was a mistake.

2) My local (Malaysia) INR clinic also advises not to bother manipulating the warfarin dose (or even check INR) until 5 days later at the completion of the course of antibiotic. I'll chuck this advice out the window. Where are you are what is the local advice in this respect?

I agree, I also would not follow that advise.

I would question the need for taking the entire course (5 days) of antibiotic if it might impact your INR. Is it really necessary or just a precaution? Also, are there antibiotics you can take that does not interact with warfarin/INR?

 

[drleng]

Yes, after the expected light bleeding stopped 24/48 hrs post-op, she went 3 to 4 days with no bleeding. Then all of a sudden on day 4 or 5, she started bleeding again. Reading that this may have been caused by tissue movement due to stitches dissolving. The dentist put in another stitch or two but she then soon developed a hematoma that made packing with the gauze to put pressure on it impossible. If you ask me, putting another stitch in while her INR was still high at that point was a mistake.

Yes, agree with you.


I agree, I also would not follow that advise.

I would question the need for taking the entire course (5 days) of antibiotic if it might impact your INR. Is it really necessary or just a precaution? Also, are there antibiotics you can take that does not interact with warfarin/INR?

If we need to take antibiotics (when necessary to control infection), then we should take the entire course to control it adequately. Provided we monitor the INR closely and make the necessary dose adjustments to warfarin.

The situation for taking antibiotics for endocarditis prophylaxis is a different story. It should just be that single dose just before surgery. The only indication for completing a full course is if it's a "dirty op" .

Unfortunately all antibiotics interact with warfarin. However, I am told (in our local context) Augmentin is the least problematic. So, if you don't have penicillin allergy, this is a good choice.

 

[MdaPA]

If we need to take antibiotics (when necessary to control infection), then we should take the entire course to control it adequately.

The situation for taking antibiotics for endocarditis prophylaxis is a different story. It should just be that single dose just before surgery. The only indication for completing a full course is if it's a "dirty op" .

She was told she was prescribed the antibiotic (Clindamycin 300mg X 2/day) for endocarditis prophylaxis just before surgery and 7 days post-op. She was told that there was very low risk of infection in her mouth from this procedure (i.e. she was not prescribed antibiotic to prevent an infection at the surgical site). So was the Rx for antibiotic 7 days post-op not necessary/overkill?

However, I am told (in our local context) Augmentin is the least problematic. So, if you don't have penicillin allergy, this is a good choice.

Unfortunately, she is allergic to almost everything, including Penicillin.

 

[drleng]

She was told she was prescribed the antibiotic (Clindamycin 300mg X 2/day) for endocarditis prophylaxis just before surgery and 7 days post-op. She was told that there was very low risk of infection in her mouth from this procedure (i.e. she was not prescribed antibiotic to prevent an infection at the surgical site). So was the Rx for antibiotic 7 days post-op not necessary/overkill?


Unfortunately, she is allergic to almost everything, including Penicillin.

If it was a clean operative field (assuming no abscess, etc), 1 week of antibiotics does sound like overkill, doesn't it? And it is infuriating because it caused it a lot of misery and hardship.

 

[MdaPA]

If it was a clean operative field (assuming no abscess, etc), 1 week of antibiotics does sound like overkill, doesn't it?

Yes. And her Cardio was aware of this but this was not challenged. Hopefully this experience will be of help to others.

 

[drleng]

Yes. And her Cardio was aware of this but this was not challenged. Hopefully this experience will be of help to others.

Indeed. Always, always challenge if in any doubt!
But just maybe (not trying to protect anyone) your dentist rationalised that the mouth is a dirty area and wanted antibiotic prophylaxis throughout the healing period?
However, UK guidelines don't advise endocarditis prophylaxis at all for dental procedures! (some study showed little benefit in preventing incidence of endocarditis) I think US guidelines are more conservative here.
At the end of the day, decisions must be based on the individual situation.