To Bridge or not to Bridge

[Mr V]

Going to have gall bladder out in Oct. I believe they want me to bridge. About 10 years ago I had a colonoscopy so I bridged for that. While on lovenox my liver enzymes increased dramatically. I did some googling today and there are some studies showing that can be a side effect of lovenox. So I am thinking of lobbying to not bridge but wanted to get some other opinions. The part I don't know is if these high enzyme level can cause any permanent damage. If I remember correctly I was measuring 3-4 times what the upper limit should be.

Coming up on year 27 with my St. Jude mitral valve.

 

[Protimenow]

Personally, I've found that bridging is unnecessary. It takes a week or more at an INR below 2.0 for a clot to form (according to a Duke Clinic study). When you're in surgery, they're probably giving you heparin to keep your blood from clotting.

Once you return to warfarin, it'll only take 3-5 days (in my case, and in most cases, it only takes 3 days) for your INR to return to the levels before you started skipping doses. I've had some minor procedures - and even more major probing my veins for a cause of arrhythmias - and I resumed warfarin. Three days and my warfarin level was back to 'normal.'

I'd try to convince my surgeon (who probably doesn't know this much about anticoagulation or is trying to cover his butt) that you don't think it's necessary - your INR will be back to normal days before there is any risk related to having an INR that's too low.

Of course, this isn't medical advice, I'm just talking from past experience.

 

[pellicle]

Of course, this isn't medical advice, I'm just talking from past experience

and nobody should ever listen to anybody in here ;-)

 

[pellicle]

While on lovenox my liver enzymes increased dramatically. I did some googling today and there are some studies showing that can be a side effect of lovenox. So I am thinking of lobbying to not bridge but wanted to get some other opinions.

this may be of interest to you, give these a read and then

1. ask your provider what they're willing to accept in INR
2. hit me (or @Chuck C ) up with any specific questions

https://cjeastwd.blogspot.com/2017/12/perioperative-management-of-inr.htmlthen
https://cjeastwd.blogspot.com/2022/05/rapid-dust-off-inr-management.html
Best Wishes

 

[Mr V]

Thank you, I will take a look

 

[tom in MO]

You didn't need to bridge for that colonoscopy unless you had something snipped. The colonoscopy by itself does not require bridging per current guidance and my colo-rectal surgeon. When I had prostate surgery, the urologist left it up to the cardiologist who said due to my valve type and location bridging was unnecessary. Has your cardiologist weighed in?

 

[Mr V]

Since it was 10 years ago it may have changed. I will be seeing my cardiologist next month and was going to ask him. I do have the added risk of what they have called a “severely” enlarged atrium in addition to the mitral valve seeming to be the one that puts you at the most risk.

 

[pellicle]

Hi

Since it was 10 years ago it may have changed.

what I've proposed above is what I've worked out and what I've worked out in consultation with the specalists who are doing the procedure (colonoscopy, foot surgery, or other invasive surgical procedure)

I will be seeing my cardiologist next month and was going to ask him. I do have the added risk of what they have called a “severely” enlarged atrium in addition to the mitral valve seeming to be the one that puts you at the most risk.

the risks I'm talking about are the risks of thromboembolic issues, which the warfarin is for (and the bridging is for). If the enlarged atrium contributes to thrombogenesis risks then that will need to be accounted for.

I would recommend reading the citations I made in that first blog post (its a medical journal) and printing that to take and discuss with your cardiologist for their input on your risk at various INR.

I'd also suggest they look at this analysis
http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/415179

which shows that the risks in general the generals population (including mitral valve paitents) for being between INR 1.4 and 1.9 to be under one incident per year of being on that INR.

I suggest that supports the findings of:

Do the benefits of anticoagulation outweigh the risks?

The approach to the management of anticoagulation in patients with prosthetic valves undergoing non-cardiac surgery remains controversial. The need for perioperative anticoagulation in patients with mechanical heart valves has been questioned in a recent review. The authors argue that for every 10 000 patients with mechanical heart valves who are given perioperative intravenous heparin, three thromboembolic events are prevented at the cost of 300 major postoperative bleeding episodes

its entirely your and your cardiologists call.

 

[DachsieMom]

For my recent colonoscopy, they did not have me bridge. 3 days without warfarin. My INR was 2.1 still the morning of….I did not have any polyps. my surgeon said she would have been comfortable taking them if she found them (I used a surgeon, not GI dr, just in case).

 

[pellicle]

Hi

just wondering

...3 days without warfarin. My INR was 2.1 still the morning of…

did you know your INR before you ceased
what is your daily dose

.I did not have any polyps

I love the good news stories

 

[Gator Chief]

Going to have gall bladder out in Oct. I believe they want me to bridge. About 10 years ago I had a colonoscopy so I bridged for that. While on lovenox my liver enzymes increased dramatically. I did some googling today and there are some studies showing that can be a side effect of lovenox. So I am thinking of lobbying to not bridge but wanted to get some other opinions. The part I don't know is if these high enzyme level can cause any permanent damage. If I remember correctly I was measuring 3-4 times what the upper limit should be.

Coming up on year 27 with my St. Jude mitral valve.

Going to have gall bladder out in Oct. I believe they want me to bridge. About 10 years ago I had a colonoscopy so I bridged for that. While on lovenox my liver enzymes increased dramatically. I did some googling today and there are some studies showing that can be a side effect of lovenox. So I am thinking of lobbying to not bridge but wanted to get some other opinions. The part I don't know is if these high enzyme level can cause any permanent damage. If I remember correctly I was measuring 3-4 times what the upper limit should be.

Coming up on year 27 with my St. Jude mitral valve.

 

[Gator Chief]

I’m assuming that your 60 + and have been on ACT for many years. I’ve had many surgeries both major and minor in the 10 years I’ve been on ACT. Bridging with lovenox has always been a concern for me as I had a major bleeding event following a knee replacement in the hospital. They started warfarin the evening after the surgery and Dr on call insisted on continuing the lovenox with the warfarin for the next 24 hrs. The bleeding started after the second shot and took forever to stop the bleeding. Needless to say I’m not a fan of bridging. Most of my surgeries were hold warfarin till INR was 1.5 the day before the surgery and start again the evening of the surgery and I was back in range in two days.
Sorry to hear the gall bladder has to go, but if your suffering like my wife did, I bet you can’t wait to get it out. She thought she was having a heart attack at times. Shortness of breath and arrhythmias too. Good luck with the surgery.

 

[DachsieMom]

Hi

just wondering

did you know your INR before you ceased
what is your daily dose

I love the good news stories

I can check, but I recall it was over 3 (not ideal, a weird blip).

 

[DachsieMom]

I can check, but I recall it was over 3 (not ideal, a weird blip).

Although not bridging was the norm. It wasn’t because my INR was high. In fact, they didn’t even ask. They just said be off for 3 days.

 

[Mr V]

The INR clinic I go to want to discuss the bridging. I will be talking to my cardiologist before I make any decisions. With the side effects I had last time taking lovenox I am hoping to just lower my INR before surgery. I believe it may be robotic surgery so not sure if that changes anything.

 

[pellicle]

I believe it may be robotic surgery so not sure if that changes anything.

where is the surgery to (what part of your body)

 

[Mr V]

gall bladder

 

[pellicle]

gall bladder

right ... extremities would have been something I could comment on.

PS: and now that its there I can bloody see it in the original post ...

 

[carolinemc]

I had to bridge for breast biopsy, hated the bruising on the stomach. But the biopsy came out negative.

 

[Protimenow]

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....