Surgery and Coumadin (question for Al L)

[Gnusgal]

Alright, I posted a little about this in the Heart Talk forum, but I'm fairly certain Al L. doesn't read any forum except the coumadin one, so I'm posting here too. So, if you've read it already, I guess you can skip this one.

Yesterday I went to see my ACHD doc because I'd been having a bad heart week (no need to go into details, you can read them in the heart forum). I've also been having a hard time getting my EP to schedule me for an AICD implant. She keeps dragging her feet, saying she doesn't think she can get insurance to cover it. My opinion is she doesn't think I need it, even though the ACHD doc, my regular card, and several other cardiologists seem to think it would be a good idea, based on research. Anyway, I had a holter monitor a couple of weeks ago, that was supposed to be to help give her data to convince insurance and I have yet to hear back from her and when my regular card tried to contact her she didn't call her back either. So when I was at the ACHD doc's office I said something about it. She suggested talking to one of the EP docs in her group (this is a HUGE group of docs) while I was there. So I did. He said he could get me in for surgery on Dec. 28th and didn't think there would be any problem with insurance. So I told him I'd discuss it with my cardiologist and get back to him.

Then I remembered to ask the important question: "What about my coumadin?" He said "I'd have you stop taking it 5 days prior to surgery." I asked, "What about bridging?" He said, "I don't do bridging." He could tell I was taken aback by that answer and continued "I see more problems with bleeding with bridging than I do with clotting." I pointed out that I have a mechanical valve and he said "Your valve is a St. Jude's. They don't clot easily. Bjork-Shelly's clot, but not St. Jude's."

Now tell me if I'm wrong, but I really don't feel comfortable with the idea of being off of coumadin for 5 days with NO backup. I've got my regular card checking into things for me, but I wanted your opinion on things. She was pretty surprised herself, so I feel confident that she'll look into it further. Have you heard of this "research" he was spouting???

Thanks for your thoughts!

 

[Guest]

I was away at a meeting for the last week.

One of the things that was said at the meeting is what we have discussed so many times here, "Doctors cause bleeds, but clots are an act of God." Patients fear clots but doctors fear bleeds.

Bridging does introduce its own set of problems. The presentation that I gave at the reunion addressed this. While you are less likely to clot, you are somewhat more likely to bleed. The people who did the worst on bridging were those who bled. Then their warfarin was held - maybe even longer than necessary - and they had more heart attacks and strokes. In the study of this, nobody died but some did develop disabilities.

"Studies show that there is no answer."

 

[Karlynn]

I was away at a meeting for the last week.

One of the things that was said at the meeting is what we have discussed so many times here, "Doctors cause bleeds, but clots are an act of God." Patients fear clots but doctors fear bleeds.

Bridging does introduce its own set of problems. The presentation that I gave at the reunion addressed this. While you are less likely to clot, you are somewhat more likely to bleed. The people who did the worst on bridging were those who bled. Then their warfarin was held - maybe even longer than necessary - and they had more heart attacks and strokes. In the study of this, nobody died but some did develop disabilities.

"Studies show that there is no answer."

Al, sure would like to hear/read your talk for the reunion attendees. Anyone tape it? Do you have your notes?

 

[Guest]

You shoulda been there!

I'll try to post the slides when I get a few moments.

 

[Karlynn]

You shoulda been there!

I'll try to post the slides when I get a few moments.

Don't I know it!

 

[Gnusgal]

Okay, Al, so now you've made me full of more questions... I have never clotted (that I know of), but I have had problems with bleeding.

I don't know if you remember, but about two years ago I had an ovarian cyst that burst and the bleeding didn't stop. I had to have emergency surgery to cauterize it, remove all of the blood (about 2 liters) from my abdomen, and had 4 units of blood and 2 units of plasma transfused. This was when my INR was only around 2.5.

And there was another time (my INR was actually high this time, though) that I had bleeding behind my ear drum when I had a sinus infection. That one did stop on its own, fortunately.

So my question is, would going without bridging actually be a better idea??? I just don't know! I don't want to have a stroke, but I don't want to have a bleed either. I didn't post it here (I posted it in my other thread), but when I talked to my cardiologist she was also shocked at the EP saying no bridging. And when she talked to the ACHD doc that recommended the EP she also didn't like the idea. So it's such a confusing situation. I wish it wasn't so hard!

Thanks for "listening" to me whine...

 

[Guest]

Niki,
The reason that it is confusing is that it IS confusing. A few months ago, I was probably one of the strongest supporters of bridging, but now I don't know where to stand. There is no "right" answer. Unfortunately, the right answer can only be discovered at the end of the tunnel when you either say, "I'm glad we went the route we did," or "If only we had made the other choice".

It is a helpless feeling for those who are going to be directly affected by the outcome. It is only slightly less helpless when those of us who are supposed to be experts have to say that we just do not know.

The only thing that you can do is to get all of the information that you can and discuss it with your doctors and then go with the decision that comes from the person who is going to be the one handling you at the time you have the procedure done. That person is going to be the one who has the most knowledge of you and the procedure. That person will have heard your questions, gotten input from your other doctors and is the one who knows most about the risks of the procedure.

 

[Gnusgal]

Well, at least now this new EP doesn't seem completely off his rocker... Though I still don't know what to do. Thanks for being honest, though. I truly appreciate it. I feel so much better just having heard from you.