To Bridge or not to Bridge

[tom in MO]

The gall bladder surgery - cholecystectomy - is minimally invasive. The tools go into your body through small incisions in your abdomen (unless they've figured out some way to go through your mouth).

There shouldn't be much blood lost. Maybe the doctors are concerned with potential blood loss if the robotic surgery encounters a problem and they have to open you up.

This is the reason that they want your INR to be down.

While it's possible that clots may develop post-op, they'll probably have you on heparin while you're in the hospital - but may discharge you on the same day as your surgery.

If you take your normal dose for three or four days, your INR will return to normal.

OTOH - bridging WILL help prevent clots from forming while your INR gets back to normal.

In the case of this surgery, it may make sense to bridge for a few days after surgery.

But, of course, the decision should be made by your surgeon - she's done a lot more of these operations than you or I have....

The surgeon is unaware of the specific valve type an individual has. The decision should be made by the surgeon (i.e. what INR do they want) and your cardiologist (how low can the INR go and for how long before your valve needs bridging).

 

[Mr V]

Saw the cardiologist and he is ok with not bridging. INR was 2.7 yesterday and wants me to stop 4 days prior ( so last dose will be tomorrow). Sent surgeon the message and hopefully he is fine with that as well.

 

[pellicle]

Saw the cardiologist and he is ok with not bridging. INR was 2.7 yesterday and wants me to stop 4 days prior ( so last dose will be tomorrow).

stopping 4 days prior can be far too much. I would directly engage with the surgeon (if you have not already) and ask what INR he'd want you to be for the surgery.
I would expect that its anything below 1.4 (that's been my experience) I would again recommend you read the following carefully
https://cjeastwd.blogspot.com/2022/05/rapid-dust-off-inr-management.html
and look at the times and the reductions and aim to minimise your time out of therapeutic window.

 

[Mr V]

Thanks for the info. Am I correct in stating that a mechanical mitral valve would have a greater risk for thromboembolism than a mechanical aortic valve at INR of less than 1.4? Since I do not self manage my INR at this time it would also put me at more risk not knowing exactly what my INR has dropped to in the days I stop taking warfarin. Now I am rethinking that maybe the risk of lovenox causing temporary spike in liver enzymes is not worth the risk of an event happening from my INR being too low. My PCP who manages my INR replied today that he recommends I still do the bridging.

Here is what my cardiologist replied

Given that history and the lack of additional risk factors other than the valve, it would be OK to hold anticoaguation for the minimun amount of time prior to the procedure and resume as soon as possible afterward without bridging. I would suggest stopping 4 days prior and resuming one day after surgery.

I have not yet heard from the surgeon on his thoughts. I am now thinking that if did want to go without bridging I should do it once I have started self managing my INR and delay the surgery. If I don't delay then I should probably bridge.

Thank you very much for your insight.

 

[Mr V]

I read a couple more publications of the same kind of liver enzyme elevation from heparin types of medication. I appears that none of the cases were found to have any permanent liver damage. Once the lovenox is stopped the levels return to normal like they did for me 10 years ago. I think everything considered it is probably safer for me to bridge with lovenox while I stop taking coumadin.

 

[pellicle]

Am I correct in stating that a mechanical mitral valve would have a greater risk for thromboembolism

Yes, mitral is a higher thrombosis risk, which is why it's target INR is usually set 0.5 units higher

 

[pellicle]

once I have started self managing my INR and delay the surgery.

If you aren't self managing then you have probably zero feel (or data) for how your INR responds to dose.

The procedure of management above is for people who have self management experience and knowledge.
From the first (in order of publication date) is this note :

This post is about my experiences in the perioperative management of my INR around my colonoscopy and thus is here also as a guide for those who (like me) self manage.

At the end is the following additional caution :

Warning​

This post contains what to the best of my knowledge is the current best practice. It is good advice if you don't have any other issues that are unknown to me. As long as you measure and follow the INR levels in here I believe that you'll be fine. Indeed if I were doing it again (which unless I die soon I will be) I'll probably just restart warfarin directly after the procedure and trust my knowledge of the INR fall and go off earlier.

BUT: Don't f*ck with this stuff if you don't have a clue. You may get hurt, and that hurt may be permanent. Instead get a clue and start by having a read my other posts on INR management (use the INR tag in the tag list) keeping records and being on top of your own health. Reach out to me for assistance if you wish.

I can only trust that you read all of it with the attention and diligence required.

Lastly, I agree with your assessment of prudence.

Best wishes