Question about Other surgery and going off blood thinners

[Protimenow]

Right. I saw the month and day and didn't pay enough attention to the year. It looks like his immediate risks are reduced from a year ago, according to papers I've read.

 

[hook]

Had another meeting with the surgeon yesterday, and because the procedure is known for bleeding risk post-op, he wants me at 1.4 INR or less at the time of surgery, and for about 48 hours after the procedure. He does not want me to use lovenox post-op because there is no way to reverse the anti coagulation of the med.

I may suggest to him that we use heparin the evening after the surgery, so that if bleeding/hematoma does happen they could cut the drip and deal with the draining.

Has anyone been at a low INR for this period of time? My cardio does not seem overly concerned about it; I wonder if he knows some new literature that I don't about the time it takes clots to form with my circumstances.

 

[Protimenow]

Todd:

I recently dropped to a 1.1, and it took me days to bring the INR up. I'm still not entirely sure what made it drop (I suspected a supplement that I had just started taking).

Lovenox is low molecular weight heparin -- so doing a heparin drip is probably the same thing your doctor considered and ruled out for you. Cutting off the drip (rather than just a large injection) will probably not cut off the effects of the heparin as quickly as the doctor would want.

I have an aortic valve - not a mitral like yours, but I suspect that keeping at 1.4 for a few days is probably worth the risk -- because you're more than 3 months post-op, and have a bileaflet valve.

It seems as if your MD is on top of things regarding anticoagulation and risk factors.

 

[Lynlw]

Here are a couple general questions for the masses.
1) Are mitral valve clots considered more dangerous that throwing a clot from another valve?
2) Do newer bi-leaflet valves have less risk of forming a clot

I had a final meeting with the surgeon yesterday, and he seemed very concerned about the risk of surgery with the valve. I am not sure if it is because the valve is not his area of expertise, or if my risk is that much elevated over someone with a normal valve. He kind of scared me off a bit.

I'm not quite sure what your asking when you ask if clots thrown from mitral valves are more dangerous, than others, but As Marsha said the Mitral tends to form/throw clots more often than Aortic because the pressure/blood flowing thru it is lower. But the "dangerous" compared to all the valves, he might be talking about how clots that form on the Left side of the heart, (Aortic & Mitral) would have better chances of going to the brain and causing a stroke, compared to the right sided (pulm and Tricuspid) that most likely would go to the lungs and cause a pulmonary embolism.

 

[hook]

I am blown away by hospital politics. My cardio communicated that he would recommend lovenox for a bridging, and my surgery was set in stone; the best part is insurance will cover 100%.

My thoracic surgeon sent a note to the plastic surgeon that stated lovenox is not recommended for valve recipients, and I would have to have a heparin bridge. The plastic surgeon said he would not do it under those circumstances. What BS

 

[Protimenow]

Hospital politics can certainly be a big pain. So can conflicting articles.
An article that I referred to a few months ago described the circumstances for NO bridging -- it didn't matter if it was Heparin or Lovenox. Perhaps your thoracic surgeon can send a copy of his source for that opinion to the plastic surgeon -- or perhaps they can pick up the phone and try to work this out.

24 hours at 1.4, with a mitral valve, is probably not all that risky, from what I've read. Hospital politics aside, perhaps your dermatologist can update his/her reading on risk and confirm that with the thoracic surgeon said doesn't represent current thinking.

 

[TXGal]

I went off Coumadin for my egg retrieval in 2007 and was bridged on Lovenox. Had no problem.. best of luck

 

[hook]

Perhaps your thoracic surgeon can send a copy of his source for that opinion to the plastic surgeon -- or perhaps they can pick up the phone and try to work this out.
.

Two doctor taking the time to talk, that would be ideal. This comunication breakdown is the nurses quoting old literature to one another. After hours of reading it seems risk with lovenox is very low, with the exception of pregnant women.

Kristen
After your procedure, did they start the lovenox back until your coumadin got back into range? It is so great you were able to do this.

 

[Protimenow]

It appears that the risks are relatively low in either case. If you follow your cardio's recommendations -- to reduce to 1.4 and maintain it at 1.4 for 24 hours after the surgery, your risk of clots is still quite low, and the surgical area should close up almost as quickly as it would if you weren't anticoagulated. OTOH - if you were bridging, the risk of excessive bleeding is also pretty low -- if this isn't an outpatient procedure, the hospital should be able to handle any hemorrhaging at the surgical site. It's been noted that it's hard to reverse the excessive anticoagulation that bridging can sometimes cause.

If this all comes down to your risk of throwing a clot from your mitral valve - and not to other factors related to your surgery - I'm really not sure about the need for bridging, based on the Duke guidelines.

Lovenox may provide a comfort zone relating to the minimal risk of a mitral valve clot -- but will this complicate the surgery from the surgeon's standpoint? Will the necessary clotting in the surgical area take much longer than normal because of the bridging? Or, perhaps, will the surgeon cauterize the vessels in either case, making the issue of bridging or even of reducing your INR pre-op somewhat moot?

As others have noted, taking your normal warfarin dose the morning of (or the night before) the surgery should be safe, anyway, because the anticoagulant effects of the warfarin take a few days to develop.

(I've put a link to the Duke paper in an earlier post in this thread -- your surgeon will probably be 'above' the need to read something that a patient shows him, but it may be worth a try to show it to one of the nurses and see if it'll filter from nurse to surgeon)

 

[Lynlw]

I am blown away by hospital politics. My cardio communicated that he would recommend lovenox for a bridging, and my surgery was set in stone; the best part is insurance will cover 100%.

My thoracic surgeon sent a note to the plastic surgeon that stated lovenox is not recommended for valve recipients, and I would have to have a heparin bridge. The plastic surgeon said he would not do it under those circumstances. What BS

I am sorry this is causing so much unneeded stress and aggrevation. Is this procedure one that "normally" would be an outpatient procedure? Or an inpatient one that usually has a short stay after.
How long before surgery are they reccomending you stop your Coumadin to get to the 1.4? Do any of your doctors rec bridging before the surgery? I'm not sure why the plastics doc is willing to go along with the lovenox, but not the heparin, or why the surgeon doesn't agree with lovenox, especially since you'd have to be admited a couple days before surgery if they bridge wth heparin, but could stay home on the Lovenox, at least pre op. Post op if you were inpatient on Heparin and did start bleedig, it would be relatively quick to reverse it.

I'm not sure I would agree that stopping coumadin with a mechanical bileaf Mitral valve for a few days would be low risk, but again, like most people here I'm not a doctor. Do you know what the name of the surgery is, maybe it would help to find recomendations for that surgery specifically.

 

[TXGal]

Kristen
After your procedure, did they start the lovenox back until your coumadin got back into range? It is so great you were able to do this.

I am so sorry I just saw this.. My RE kept in touch with my cardiologist before the procedure and made a plan.. Yes, after my procedure I stayed on Lovenox injections until I was in range with my Coumadin. Best of luck to you!