Question for Al Lodwick

[weekycat]

When we met you in CO, you gave a presentation on why Coumadin should not be stopped before surgery. I don't remember a lot of what you said, probably because I was only on it for a few weeks following my repair, so it really didn't pertain to me.

However, my father is on Coumadin for A-fib, but is not a valver. He is having double knee replacement surgery tomorrow and they have taken him off of his Coumadin. My mother said they replaced it with "some other blood thinner" for a few days.

My question is, is he at as much risk for throwing a clot as someone who has had a valve replacement, or is it different when the Coumadin is for A-fib.

I know that they've already gone ahead with whatever procedure the surgeon wanted followed, and hopefully everything will be fine with him...but perhaps someone else could benefit from your answer in the future. Thanks! Jean

 

[LUVMyBirman]

Hey Jean,

Long time no see! Hope all is well with you and yours. I can give you some very general info here. My mother had double knee replacement this year. It sounds insane. But I can tell you, she made the right decision.

She does not take Coumadin on a regular basis. They did put her on it for 6 weeks post surgery for clotting I beleive 6 weeks to be standard protocol. My mother was told not to take Coumadin, Aspirin, NASIDS for three weeks prior to surgery. There is alot of cutting, sawing, fusing if you may with this surgery. The normal trasfusion rate is on the higher range. He may want to store a pint of two. In short, this is a surgery that he will have to be removed from his Coumadin. They may decide to use Lovenox injections in the interim? I was concerned with post surgical bleeding with the introduction of the Coumadin post surgery. None that we were aware of. I tend to have that issue when my levels come up.

Wishing you and yours the best!
Take care.

 

[ccrawford]

Jean - I don't know the answer to the question re relative risk of clot with afib vs a replacement valve. The following may help ease your mind. Either Heparin or Lovenox is used as a substitute for Coumadin before/after surgery because the time it takes to change the clotting effect (up or down) is significantly faster than Coumadin, therefore reducing the time the patient is unprotected. After surgery, the Heparin or Lovenox will be continued along with Coumadin until the INR comes up to the desired range. Hope this helps.

 

[LUVMyBirman]

Chris just posted the protocol I have used with my valve. A-Fib is still risky because it requires regular anticoagulation. But, I think Al may concur that the INR range for an A-Fib pt is much lower than the range of a mechanical valve pt. I beleive they keep A-Fib on the lower end of the scale? Please correct me if I am wrong In any event. They will figure it out. I stayed on top of Mom's regulation while she was on the Coumadin. Her range for the knee replacement was 2.0 flat. Mitral valvers are 3.0-3.5. Aortic 2.5-3.0?. They may keep him higer than the normal range for a-fib post knee replacement?

Keep us posted on the outcome!

 

[Guest]

The risk of a clot is a lot lower with a-fib than it is with an aortic valve and this is lower than for a mitral valve. Knee surgery is kless likely to cause a clot than hip surgery. If the other blood thinner is injections into the belly, the risk of a clot is very low. But the risk of a bleed goes up somewhat. It is all based more on opinion than science but it seems like the situation is being handled correctly.

 

[DrAllan]

I’d like to add some information to the excellent and succinct post by Al Lodwick (sorry for the confusion that he and I share a similar first name) There appears to be a reasonable correlation between the risk of AF, MV, AV and both valves that requires increases in the range of INR to account for the risk. This is separate from the risk of clotting in patients whom have surgery, particularly hip surgery. When you are immobile in bed then blood pools in the legs and can form clots. If these clots are in the deep leg veins, particularly the femoral vein, then they can break loose and travel to the lungs causing a pulmonary embolism. If large enough, this is immediately fatal. For this reason “normal” patients without valves, AF etc are anticoagulated until they are sufficiently mobile to prevent pooling of blood in the extremities. Thus Al’s statement that knee surgery is less likely to cause a clot than hip surgery is true and related to the postoperative period and immobility.

 

[weekycat]

Thank You

Thank You

Thanks everyone, for your input. As I said, I'm sure the surgeon knows what he's doing. He's got a very good reputation as an orthopedic surgeon, in fact, he operated on my ex-husband 25 years ago after a motorcycle accident. He's very likely dealt with these situations in the past.

My father is 73 years old and has always been very active. I just hope and pray that his recovery will be quick and complete. Thanks again, Jean