Preoperative bridging On-X valve

[Bonbet]

Hi folks. I've been gone awhile-long story. So I was doing pretty fine with my On-X valve which I got May 24, 2017.
Back at gym, INR freakishly stable. This January I received a diagnosis for invasive ductal cancer and I am headed for a likely lumpectomy in a couple of weeks. The bridging for my biopsy was badly botched by the surgeon who I subsequently fired.
Since it all happened so fast, I was a bit slow on the uptake of information. (btw-have ordered a home monitor but it is a lot of red tape to get one here in the USA.) I have a consult tomorrow at the Knight Ca Center at OHSU and have inquired about their bridging protocol - which hopefully they will address tomorrow.

In the meantime, I contacted my cardiologist form Mayo with this question that I have been asking all providers to no avail.
If my therapeutic range is 1.5 to 2.5, couldn't I dose down to 1.6 or so and avoid bridging altogether? This occurred to me when the biopsy DR. said that even though I was bridging with Lovenex they would not perform the procedure unless my INR was below 1.9

Well couldn't I have just brought the INR down to 1.6 or so and have been in range therapeutically and reduce the risk of bleeding form the Lovenex. (Which I did. A hematoma formed at the biopsy site and that ended up obscuring the MRI that I had the following week making it inconclusive.)(If you ever have to do this then be sure that they do the MRI before the biopsy!)
Not to mention my abdomen was a huge purple and red hematoma by the time the bridging was complete.

Anyway, my cardio said that as a low risk person with a Mech valve - meaning no previous strokes and no Afib - I don't need to bridge at all. I can just stop the warfarin for 1-3 days before the procedure and the same after the procedure. He said being off of warfarin for 5-7 days is considered safe by ACC/ACH. He said that if the surgeon wanted to do the procedure with my "low range" INR that is basically up to the surgeon. He also said to NEVER stop the low-dose ASA.

So, what do you think about that??!!
Bonbet/or McBon I am not sure what they call me these days.

 

[pellicle]

This is what I did and why and my valve is the ATS (which to my mind is equivalent to the On-X

http://cjeastwd.blogspot.com/2017/12/perioperative-management-of-inr.html

 

[Bonbet]

Pellicle, I read the articles and blog. So I was just reaching out to see what other valvers' experiences might be. Has anyone just skipped warfarin, or dosed down to low but therapeutic INR? Has anyone heard or read research to the contrary or had experiences with their providers about this alternative to bridging? Currently, without a home tester, I cannot track my INR's to the extent that you did for your research post.
Thanks Bonbet

 

[pellicle]

Pellicle, I read the articles and blog. So I was just reaching out to see what other valvers' experiences might be.

sorry mate, wasn't sure

 

[Warrick]

Certainly not the same as a biopsy but when I had my sternum wires removed my INR was 2.1 just before I went in,

two x 2 inch incisions so must have been a bit of poking around and bleeding. I was never told I needed my INR at a certain level but as I self manage decided for me I was better off at the low end so adjusted accordingly.

 

[jwinter]

I have an ON-X(November 2016) and had colonoscopy/endoscopy this last September. I stopped warfarin 6 days before and started bridging 3 days before. First day after procedure I started the warfarin and continued to bridge 2(or 3?) more days following test. I was then therapeutic and stopped Lovenox. I am about to have a port put in and hematologist says he wants me at 2 for this procedure. No real problems with INR besides getting it there to start with(right after AVR). I still go to Coumadin Clinic once a month and target is 2.5 to 3.5.

I do not take low dose and sorry to hear your bridge area got so much damage. Coumadin girls helped show me and I used a "smile" pattern under navel. I also tried to do the shots straight in as possible. Not sure if it will help you but doesn't hurt to ask the people that work with this every day.

Like you, I had my surgery at Mayo. Since then I have used a cardiologist from Billings. I have found that getting the cardio and surgeon both involved works well. That and make sure the hospital is able to handle your case (our small local hospital won't do much more than INR for me)

I did receive a letter from valve manufacturer about a month ago stating the statistics and recommendation to use 1.5 for target for this valve, but that is a whole other story that I will discuss with cardio this spring and probably report my findings here.

 

[tom in MO]

I had a TURP last year and did not need to bridge. My urologist/surgeon would give no opinion on warfarin or bridging as that's not his expertise. He told me to "get thee to your cardiologist" and he would do what the cardio says. He did say my recovery period would be longer since once my INR gets up, this slows down the healing process. A TURP leaves a big scab on the prostate that can crack open with activity.

The cardio-nurse said stop warfarin a few days before and start up when you get home (surgery is one day stay.) She told me my St. Jude is very stable with low INR and there was no cause for worry.

Being on warfarin does not mean you must bridge for surgery. It depends upon why you are on warfarin and if due to a valve, what kind of valve you have, and how much bleeding will be caused by the surgery. My MIL was on warfarin for a reason other than a valve and she had a stroke when bridged to replace her aortic valve.

 

[Bonbet]

Thank you everybody for all your responses. Sounds like there is a lot of variability depending on procedure, doctor and valve. I have decided to go back to Mayo for the lumpectomy, I still have a cardiologist there. That gives me a certain amount of reassurance. When I chose the mechanical valve I didn't realize how few randomized trials had been done to standardize bridging. I was concerned about bridging but other factors outweighed it. Of course, who knew I would get diagnosed with breast cancer 8 months after AVR. I was a healthy specimen not too long ago.

I was OK with the shots as long as I felt I was protected from stroke. When my cardio said I don't have to bridge, I felt it was too-good-to-be-true. But, guess I may as well trust him.

Warrick; they took your sternum wires out??? Was there a reason? Because they told me they just leave them in.

 

[pellicle]

...When I chose the mechanical valve I didn't realize how few randomized trials had been done to standardize bridging. I was concerned about bridging but other factors outweighed it. Of course, who knew I would get diagnosed with breast cancer 8 months after AVR. I was a healthy specimen not too long ago.

sorry to hear that you have yet another health issue to deal with. I did a quick literature scan and found only briefly that

• chemotherapy may influence structural valve degradation in tissue prosthetic valves
• INR wasn't significantly more challenging to monitor and control

Meaning that you may not be in a bad place with the decision you made in the past. As always, PM me or email me if you ever wish to.

 

[Bonbet]

Wow, thank you pellicle. That is nice thought. Radiation is also not so good for hearts/valves//lungs. I am trying to traverse all that new input in a brief time window. Maybe this site should start a new forum for "Complicating factors" like cancer etc.

 

[pellicle]

Hi
despite my reputation I do try to assist and support people ;-)

Wow, thank you pellicle.That is nice thought. Radiation is also not so good for hearts/valves//lungs. I am trying to traverse all that new input in a brief time window. Maybe this site should start a new forum for "Complicating factors" like cancer etc.

my view is

• usually the heart problems we discuss here are valve, and there is nothing wrong with the muscle tissue of the heart (unlike some diseases). So its often plumbing not structure
• (I think reiterated) chemo is perhaps worse than radio therapy for long term tissue damage (but I will need to substantiate that thought)
• don't run at it in attempting to grab a decades worth of research in one go ... its exactly what we tell those who "first hear" of their valve condition. Something will just unfurl in their own time. Are there any particular "decision branches" you are at where you need more information to decide" - if so put it down here and someone can have a go at it

as to new forums ... well at least 1/3 of the discussions are not well categorised and at least 2/3 of the information about question X appears in a subset of the off track discussions about subject Y ... any attempt to further create subset forums would in my view be like attempting to "herd cats"

The primary thing with successful treatment of cancer is early detection and treatment. I suspect that's the case here (early detection) ... so myself I'd worry about that one as the primary and stuff like INR management can be dealt with as a side issue. I believe what I read in the literature simply supports that many places are unable to manage INR.

Best Wishes

 

[Warrick]

Warrick; they took your sternum wires out??? Was there a reason? Because they told me they just leave them in.

They were causing me irritation where they stuck up over my sternum, and aching radiating out across my chest muscles.

100% better afterwards !

 

[dick0236]

.........they took your sternum wires out??? Was there a reason? Because they told me they just leave them in.

Bombet, usually the wires are left in for added strength while the sternum heals. Some have them removed later if they become a problem. After all this time I still have mine.