Blood thinners and surgery

[Nocturne]

I am (hopefully) years away from needing valve replacement, but I am wondering about how lifelong coumadin (or some future blood thinner) will affect me. One thing I am concerned about is how being on an anticoagulant affects your ability to tolerate future surgeries. If you have a mechanical valve, can you just stop taking blood thinners for a while before surgery? What happens if you need emergency surgery?

 

[dick0236]

There are drugs available that allow for "bridging" if major surgery is required. Those drugs, as I understand, would allow you to be off warfarin for the surgery.

 

[Nocturne]

Are those newer drugs?

What happens if you are in a car accident or need emergency surgery on the spot for some other reason?

It occurs to me that I am fortunate enough to LIVE with a hematologist -- I should just ask her!

 

[pellicle]

Are those newer drugs?

no, they are quite well established. There are trade names for products and there are chemical names that are common - the drugs are heparin. In the USA it can be called Lovenox.

What happens if you are in a car accident or need emergency surgery on the spot for some other reason?

ER's have quite well established protocols for re-establishing clotting for warfarin, which btw has over 50 years of knowledge and experience with it. Vitamin K may be given either as a tablet or injection depending on your INR (which they'll find in 3 minutes flat as all us self testers do) and that re-establishes clotting as per normal.

After that window of clotting being needed your normal INR state can be returned.

As I understand it surgery on AC therapy is just one more box for the team to tick. For instance
Ultimately your surgeon should know more about this than us (me). I have had 2 serious surgeries while "on warfarin". The usual drum is that a day or two before surgery you discontinue warfarin and then after the surgery (depending on the scale of the surgery) you may either wait a day and then when the surgeon is satisfied you will commence heparin and or recommence warfarin.

good reading also here:
http://circ.ahajournals.org/content/126/4/486.long

Low-risk patients not requiring bridging therapy include the following: AF with CHADS-2 score ≤2 and no previous thromboembolism or intracardiac thrombus; bileaflet mechanical aortic valve prosthesis in sinus rhythm with no previous thromboembolism;

all perfectly doable

 

[Protimenow]

These have all been pretty much answered. I recently had a cardiac catheterization procedure. My doctor had me discontinue warfarin a few days before the procedure then inject Lovenox (enoxaparin) for the next few days. I started Warfarin the night after the procedure, and continued with Lovenox for two more days. The doctor wanted me to inject for four days - but because I had a meter, I was able to detect when my INR was back in range and stop using Lovenox.

As Pellicle noted, Warfarin has been used for decades. Emergency rooms know how to deal with high INRs if you show up after an accident. Most competent surgeons know how to manage pre-op and post-op for scheduled surgeries. (FWIW - the effects of Lovenox are brief - they provide anticoagulation effects that diminish after twelve hours or so. The bridging when you go off of, and return to, Warfarin helps to keep your anticoagulation where it should be without putting you at risk of stroke)

 

[Catie]

Hope it's ok to follow with a question here. I'm still learning about anticoagulation and will need one or more surgeries after my valve is replaced. I've been aware of the bridging process (heparin or maybe now lovenox is what's in vogue) and that makes sense and sounds safe. One of my doctors led me to believe she would have me stop warfarin cold for five days before the procedure and resume a few days afterward. I wasn't so fond of the idea of the surgery without some sort of "bridge." Do doctors vary on their approaches, and would you be leery of stopping altogether for several days?

 

[dick0236]

I would be impossible to convince that being off warfarin, without bridging, for more than a day or two is safe......been there, done that and strokes are forever.

 

[pellicle]

I'm still learning about anticoagulation and will need one or more surgeries after my valve is replaced. I

You still haven't said what sort of valve : tissue or mechanical

It makes a huge difference

 

[Catie]

Thank you, Dick. That's exactly the info I sought--and what I originally thought some years back.

I was speaking here in the event of having a mechanical valve.

Pellicle, I don't want to hijack Nocturne's thread; the answer is a little complicated. I thought I explained on one of my threads but will revisit things. ....Okay. I've tried to give the clearest answer I can on my in the post I wrote today here. http://www.valvereplacement.org/for...n/865620-warfarin-stomach-and-questions/page2

 

[pellicle]

Hi

firstly I think that this thread is not being hijacked by a discussion on exactly that topic, but as I said "over there" I think this question warrants its own unified discussion.

I think its better to look more clearly and holistically at this question and not just plink away at it with a pellet here or there.

Thank you, Dick. That's exactly the info I sought--and what I originally thought some years back.

I was speaking here in the event of having a mechanical valve.

Sugery is entirely possible when on AC therapy (and I deliberately avoid the use of the term blood thinners because its wrong, and misleading and causes mistakes which cost lives) however it does require more management.

Consider that coagulation is the first line in the body stopping bleeding, beyond that first line it is of no further purpose. What is essential to wound healing is the tissue regrowth around the incision or wound. In surgery we have things like sutures and modern adhesives to perform the front line task of bringing the tissues together to facilitate regrowth. These tools work far better than coagulation ever could.

Thus re-establishing AC therapy quickly after surgery is critical. Modern guidelines suggest that AC therapy be restarted within 2 or 3 days from surgery. How critical that is depends on a number of factors which are lumped into "your risk factor" ... these factors are primarialy concerning your risk of a clot forming due to your valve and your other health issues. Now if you were the user of modern bileafllet valve such as a St Jude, On-X or Medtronics valve then that risk factor is low. Indeed it is so low that a few days to even a week without AC therapy would be a small risk. There is no shortage of cases supporting that with people simply not taking their warfarin after surgery. My friend who was a pathologist at a NT hospital used to see people who were admitted after a month of not taking their warfarin because (get this) they took it all just before seeing their cardio!

I would refer you to this advice to medical practitioners and surgeons in Australia:
https://www.nps.org.au/australian-p...e-perioperative-management-of-anticoagulation

One of the earlier valves or a patient of higher risk (such as having AF) would be much crazier to do this as they are categorised as higher risk.

We had a person here who had a small surgery (Gail in CA) and she resumed AC therapy too soon (in my view) and that (in my view) led directly to the wound not healing properly and a very long and highly risky time with infections. All because she had a mole.

Now do not be confused about AC therapy - Heparin (or lovenox as US known product name is) is AC therapy, it just works differently. It works fast and it has a short half life which is why its used for "bridging". If you re-establish AC therapy too soon after surgery there are risks of the wound seeping plasma around it.

If you read my threads on my own 'debridement' surgery you'll observe that I was recommenced on Warfarin about 2 days after surgery ... a surgery which was quite destructive and left an open wound.

So (assuming you do tolerate warfarin and do choose a mechanical valve) there is much to learn about proper techniques and proper handling of AC therapy so that you can be an informed patient and not just a victim of medical practitioners ignorance (and you'll find plenty of evidence to support that they are ignorant in dealing with AC therapy on this site).

Best Wishes and I look forward to discussing your valve choice in all its complexity.

 

[Catie]

Thank you for your extensive reply, Pellicle. I recognize and appreciate your taking a chunk of time to give me such thorough information.

I did not realize that with the newer valves you cited, the risk factor is low.

Thank you for providing the link to the Australian article. It may not actually be as complicated as it sounds, but whew, it does sound complex to the uninitiated, such as myself! If nothing else, reading those risks, parameters and recommendations, makes me want to be in most excellent and experienced hands for even "minor" surgeries, should I have a mechanical valve implanted. It sounds like there is nothing routine about bridging, and I don't doubt that this is not an area many practitioners can be trusted to be knowledgeable about and fluent in navigating.

 

[pellicle]

Hi

I did not realize that with the newer valves you cited, the risk factor is low.

its good to know isn't it

...It may not actually be as complicated as it sounds, but whew, it does sound complex to the uninitiated, such as myself! If nothing

it isn't ... if you just delete the parts that don't apply to you and realise that what they are saying is "there is no evidence to support briding is even needed for low risk valves" then that's it in a nutshell right there.

makes me want to be in most excellent and experienced hands for even "minor" surgeries, should I have a mechanical valve implanted.

then take the time to patiently inform yourself here and be that expert yourself

 

[Catie]

Thank you, Pellicle. I'm trying to become more informed as time goes on. Bit by bit.

 

[Protimenow]

We've had some members a few years ago who would 'bridge' any time their INRs dropped below 2.0. It seemed then (and still does now) to be a rather extreme reaction to a 'snapshot' that indicated a possibly low INR value. For people like me, with an earlier generation valve (mine is about 25 years old), having an INR below 2 CAN be dangerous, but it takes a few days to form a clot, and increasing the warfarin dosage should be enough to bring it into range.

I recently had a cardiac catheterization. I stopped my warfarin three days before the test, started bridging a day or two later, then continued to bridge until a day or two after the procedure (I started warfarin the night after the procedure) until my meter gave me a value that was in range.

I once had a tooth extracted - stopped coumadin a day or two before the extraction - and my INR dropped below 2.0. I didn't bridge. It took a while for the blood to clot, then I went back on coumadin. My INR was below 2 (probably closer to 1.4 or 1.5 - maybe lower) for a day or two, but aside from a bit more bleeding than I would have liked, there were really no negative effects.

For people with the newer valves, the range is, of course, lower. The knee-jerk reaction of some people with older valves to bridge before ANY procedure or whenever the INR drops below 2, is probably unwarranted and unnecessary with the newer valves. And, with an older valve, just making slight adjustments to your dosage, and self testing daily, if necessary, to confirm that you're in range should be all that's needed.

 

[Protimenow]

I should add that my dosage changes when I had my extraction and my cardiac catheterization were under the direction of my doctor and/or dentist, and that I tested my INR before the procedure and after resuming warfarin.

 

[Janet UK]

I am 64 years old and have had a St Jude bi-leaflet mechanical heart valve for the past 4 years. My INR is within a range of 2.5 to 3.5 and I take lifelong Warfarin.
I wanted to share something that happened to me while on holiday in Barcelona (I live in the UK). Half way through the week long holiday I had a massive spontaneous bleed into my right eye known as haemo-vitreous. I saw what appeared to be hundreds of black floaters (blood) and a curtain came down on my eyesight and I was unable to see.
I attended the emergency eye hospital and told to return the next day to see the Consultant. He said I needed surgery (the sooner the better) as the retina had torn and detached (presumably with the bleed) and it would be best to stay in Barcelona for the surgery as flying home could make it worse. They couldn't operate as soon as they wanted as the warfarin had to get out of my system. I had clear instructions from the anaesthetist re bridging with heparin injections (into my stomach - yuk) when I stopped the warfarin 3 days before surgery was scheduled. On the day of the surgery my INR was 1.3 but they would not risk surgery until the INR was at 1.0 so another 3 days to wait. The upshot was that the team in Barcelona did a vitrectomy and reattachment of the retina with a scleral buckle, crioprexy and gas bubble insertion and some of my sight returned and is OK now with glasses. I had to wait for the gas bubble to disappear which took 2 weeks before I could fly again safely. I had to continue with heparin injections for a further week until i got back into range. They were a great team and I will always be grateful to those skilled and highly professional Spanish Ophthalmologists. But getting back to warfarin, it is scary enough having lost my sight in an emergency in a foreign country(!) to having to deal with the INR (which meant waiting) and bridging with heparin. I do wonder if the bleed in my eye was caused by being on warfarin in the first place? Anyway I'm a little wary of flying now and wonder if the combination of warfarin and flying is not a good one. Would love some advice about this.

 

[Janet UK]

I am 64 years old and have had a St Jude bi-leaflet mechanical heart valve for the past 4 years. My INR is within a range of 2.5 to 3.5 and I take lifelong Warfarin.
I wanted to share something that happened to me while on holiday in Barcelona (I live in the UK). Half way through the week long holiday I had a massive spontaneous bleed into my right eye known as haemo-vitreous. I saw what appeared to be hundreds of black floaters (blood) and a curtain came down on my eyesight and I was unable to see.
I attended the emergency eye hospital and told to return the next day to see the Consultant. He said I needed surgery (the sooner the better) as the retina had torn and detached (presumably with the bleed) and it would be best to stay in Barcelona for the surgery as flying home could make it worse. They couldn't operate as soon as they wanted as the warfarin had to get out of my system. I had clear instructions from the anaesthetist re bridging with heparin injections (into my stomach - yuk) when I stopped the warfarin 3 days before surgery was scheduled. On the day of the surgery my INR was 1.3 but they would not risk surgery until the INR was at 1.0 so another 3 days to wait. The upshot was that the team in Barcelona did a vitrectomy and reattachment of the retina with a scleral buckle, crioprexy and gas bubble insertion and some of my sight returned and is OK now with glasses. I had to wait for the gas bubble to disappear which took 2 weeks before I could fly again safely. I had to continue with heparin injections for a further week until i got back into range. They were a great team and I will always be grateful to those skilled and highly professional Spanish Ophthalmologists. But getting back to warfarin, it is scary enough having lost my sight in an emergency in a foreign country(!) to having to deal with the INR (which meant waiting) and bridging with heparin. I do wonder if the bleed in my eye was caused by being on warfarin in the first place? Anyway I'm a little wary of flying now and wonder if the combination of warfarin and flying is not a good one. Would love some advice about this.

 

[Janet UK]

I am 64 years old and have had a St Jude bi-leaflet mechanical heart valve for the past 4 years. My INR is within a range of 2.5 to 3.5 and I take lifelong Warfarin.
I wanted to share something that happened to me while on holiday in Barcelona (I live in the UK). Half way through the week long holiday I had a massive spontaneous bleed into my right eye known as haemo-vitreous. I saw what appeared to be hundreds of black floaters (blood) and a curtain came down on my eyesight and I was unable to see.
I attended the emergency eye hospital and told to return the next day to see the Consultant. He said I needed surgery (the sooner the better) as the retina had torn and detached (presumably with the bleed) and it would be best to stay in Barcelona for the surgery as flying home could make it worse. They couldn't operate as soon as they wanted as the warfarin had to get out of my system. I had clear instructions from the anaesthetist re bridging with heparin injections (into my stomach - yuk) when I stopped the warfarin 3 days before surgery was scheduled. On the day of the surgery my INR was 1.3 but they would not risk surgery until the INR was at 1.0 so another 3 days to wait. The upshot was that the team in Barcelona did a vitrectomy and reattachment of the retina with a scleral buckle, crioprexy and gas bubble insertion and some of my sight returned and is OK now with glasses. I had to wait for the gas bubble to disappear which took 2 weeks before I could fly again safely. I had to continue with heparin injections for a further week until i got back into range. They were a great team and I will always be grateful to those skilled and highly professional Spanish Ophthalmologists. But getting back to warfarin, it is scary enough having lost my sight in an emergency in a foreign country(!) to having to deal with the INR (which meant waiting) and bridging with heparin. I do wonder if the bleed in my eye was caused by being on warfarin in the first place? Anyway I'm a little wary of flying now and wonder if the combination of warfarin and flying is not a good one. Would love some advice about this.

 

[Agian]

Definitely food for thought. There is a thread about flying.
For what it's worth, I had retinal detachments in both eyes and needed lasering. Something to do with being shortsighted and the vitreous pulling the retina away from the back of the eye. I also got the curtain experience in my left eye. Being on Warfarin might have made any bleeding worse. What a scary experience.

 

[Agian]

BTW Janet, is your valve mitral or aortic? Just curious because your range is 2.5-3.5. Usual for aortic valves it's 2-3.