Why worry about a missed dose!!

[Guest]

This took place is Turkey

A 10-year-old girl underwent tetralogy of Fallot (TOF) repair and subsequent pulmonary valve replacement with a St. Jude Medical mechanical heart valve prosthesis. Valve replacement was necessary due to right heart failure resulting from pulmonary regurgitation occurring three months after TOF repair. At the age of 25 years, when she became pregnant, routine cardiac evaluation indicated that she had not used oral anticoagulation during the past 15 years. The patient was of rural origin, and of poor socioeconomic status, but is currently in her 15th postoperative year, with neither clinical problems nor any sign of valve failure.

J Heart Valve Dis. 2004 Jan;13(1):149-51.

 

[fyrfytr]

Someone must be looking over her, but I am still going to keep taking mine.
Take Care

 

[catwoman]

Lots of questions

Lots of questions

Al:

The journalist in me has some questions.
1. Seems like the surgeon/cardiologist/PCP/whatever would have prescribed anticoagulant therapy for such a patient -- and someone would have been following up on her. Was this not done?
2. Did she never see a doctor after her surgery? No medical history taken since?
3. Wouldn't any physician examining such a patient detect the mechanical PV?
4. Why didn't a surgeon use a biotissue valve on such a patient -- from rural area, poor socioeconomic status -- who might be apt not to use anticoagulant therapy?
5. Are anticoagulants not used in Turkey?

Seems like it's a 1-minute-mile here. I had a co-worker look at your post and he was also amazed. Again, this is just the journalist in me, always the sceptic...

But odder things have certainly occurred.

 

[dwfreck]

Considering how much diet can affect INR, one has to wonder: what has this young lady been eating all these years?

 

[catwoman]

Shudda had a copy editor

Shudda had a copy editor

<Again, this is just the journalist in me, always the sceptic... >

Oops! Should have had the copy editor in me slaving away on this. It's skeptic, not sceptic.

Dale:
Yeah, I kinda wondered what she had eaten, too. What would the diet be like for someone from a poor socioeconomic status in a rural area of Turkey?

 

[Granbonny]

Our beloved member, Gisele ..was off it for a long time. Maybe she will post..how long? She had her mech. valve replaced with a tissue.. Bonnie

 

[Guest]

Cat:
1. She was a poor kid in a remote area in a country that ranks 30th in the world in health care spending.
2 & 3. Her family probably needed her to work and it would have been a major impact on everyone's income to take her back to the city. They probably only went to the doctor when they were sick. My guess is that they considered that the doctors had cured her -- like having your appendix out.
4. Maybe somebody donated the mechanical valve to this poor country and they couldn't afford one of the biotissue valve.
5. Turkey is actually pretty advanced when it comes to health care. If they are 30th in spending then there are about 180 countries that are worse off. Their people don't even get valve replacements. One person who wrote to me from Thailand said that it took years of begging on the streets to get enough money for a valve replacement.

DW:
If you don't take warfarin, your INR is always 1.0, the diet has no effect.

Cat:
Just so you are not septic!!

Gran:
It wasn't 15 years.

RCB went without it for years in the 1960s when they had no idea whether you needed it forever after a valve replacement.

 

[tommy]

If you don't take warfarin, your INR is always 1.0, the diet has no effect.

So loading up on spinach has no effect on clotting if you are not taking warfarin/coumadin?

 

[Guest]

The INR only measures the portion of the clotting cascade that is affected by warfarin. Therefore, if you are not taking warfarin your INR will always be about 1.0. (I've seen as low as 0.8 and as high as 1.3 but always about 1.0.) So the INR is not a picture of the ability of the blood to form a clot, only a picture of warfarin's ability to prevent a clot. It may be possible to eat enough spinach to cause a clot. People who do not take warfarin and get a clot have an INR of 1.0.

 

[LUVMyBirman]

Indeed, this young lady was very fortunate.

Bonnie, if you recall...when Gisele had the surgery to convert her valve from mechanical to tissue...they did find a clot in or around the valve. If my memory serves correct... she was off Coumadin for 3 months or less. She's very lucky that the clot did break free and travel north!

 

[Lisa in Katy]

My brother has a mechanical aortic and was off Coumadin for some time - probably starting about the time he got divorced from his wife, who is a nurse, and lost his health benefits. He remained off until he had a mild (luckily) stroke - I'm guessing about 5 years. He had no long-term effects, but I think it was a wake-up call to take his Coumadin. He tends to think he's immortal, and has been fairly non-compliant since the surgery.

This lady is very lucky, but I'm not surprised that was the way it happened in Turkey. We are very lucky in the U.S. to have the healthcare system that we do, even though it is often a pain in the butt.

 

[catwoman]

Al:

I'm amazed she has lived 15 years with the mechanical and in apparently OK/normal health until the pregnancy. Della Reese must have been looking after her.

Like I said, odder things have certainly occurred. When I was copy desk chief in our newsroom, we collected stranger-than-fiction true stories. Most of them were hard to believe at first look. Like this one. But all substantiated/verified.

Did the article mention if she delivered without problems? Or go on warfarin afterward?

 

[Guest]

I don't know any more. I do not have the actual journal article, all I found was the abstract on Pub Med and I copied all of that to this website.

 

[DANIEL]

VR Believe it or not

VR Believe it or not

In 3rd world countries a mechanical valve is the valve that is used in most VR situations. Maybe because they are easier to store prior to the operation, I believe most tissue valves are kept frozen (?!?!), maybe it is the valve of choice. ......The use of an anticoagulant after the op is many times difficult to obtain due to the far-away location of the recipient, the scarcity of a nearby (local) well-stocked pharmacy and espcecially the cost. Bottomline many of these recipients live very well without Coumadin, though the risk of a clot is very real. However, we need to understand their options are few when the valve needs to be replaced.

 

[catwoman]

Al:

What studies/reports have you seen about nonuse of anticoagulants with mechanical valves?

 

[Guest]

No studies.

Very few case reports.

I know of a handful of cases where people go years without warfarin.