Having a procedure and bridging with heparin

[Bugsy]

I've been researching lovenox bridging on the site and wonder if any of you have input on an upcoming procedure I'm having. Some background information, I have had a carbomedics mitral valve since 2006 and have successfully managed my INR from home for the majority of that time. I have rosacea and as a result am having a rhinophyma removed via CO2 laser. My cardiologist wants me to stop warfarin 5 days prior to the procedure and bridge with lovenox. After doing some reading here (and this article Pellicle referenced in another post The perioperative management of anticoagulation) I'm wondering if there may be more risk in taking the lovenox. I'd have to look at the notes my doc gave me to be sure but I believe it was 5 days prior to procedure stop warfarin, 4 and 3 days prior one shot lovenox per day, 2 days prior 2 shots lovenox, day before procedure 1 shot lovenox, day of procedure nothing and day after 1 shot lovenox, resume warfarin and check INR. Does this sound correct or is my doc being overly cautious?

 

[Superman]

Sounds about right. I used Lovenox instead of Heparin, but same basic idea. Had to do that for my second open heart and for an elective procedure (I love my five kids. But they’re all I can manage).

When I had my gallbladder out, they managed it all in the hospital. A couple days off warfarin, then laparoscopic.

 

[Bugsy]

Sounds about right. I used Lovenox instead of Heparin, but same basic idea. Had to do that for my second open heart and for an elective procedure (I love my five kids. But they’re all I can manage).

When I had my gallbladder out, they managed it all in the hospital. A couple days off warfarin, then laparoscopic.

Ah, he did prescribe lovenox, thanks for the response. I'll edit my post.

 

[MdaPA]

My cardiologist wants me to stop warfarin 5 days prior to the procedure and bridge with lovenox.

What does your surgeon recommend you do or is he/she just deferring it to your cardio? Ideally it should be a joint decision between the surgeon doing the procedure and your Cardio who manages/prescribes your anti-coagulation. That way the risks of bleeding from the procedure can be weighed against the risks of bridging or not.

 

[Bugsy]

What does your surgeon recommend you do or is he/she just deferring it to your cardio? Ideally it should be a joint decision between the surgeon doing the procedure and your Cardio who manages/prescribes your anti-coagulation. That way the risks of bleeding from the procedure can be weighed against the risks of bridging or not.

Surgeon has deferred to my cardiologist but says she will stop the procedure if she encounters too much bleeding. If that happens I would need another procedure at a later date to finish things up.

 

[pellicle]

(and this article Pellicle referenced in another post The perioperative management of anticoagulation) I'm wondering if there may be more risk in taking the lovenox.

well that's my take on what they said in the journal article I cited.

Note that journal articles are "actual science publications" not "I read it on the web somewhere"

As noted in that my proctologist was quite comfortable with no heparin, and I'd have probably not had heparin if I'd started back on warfarin that bit earlier. But as you'd see in the blog post I took it only the once.

There was no "strange thing" happen, no TIA even.

Its up to you, but I wouldn't start heparin for 24 hours if it was me ... and I see little reason to lead in with heparin given how fast INR drops. A number of others here have done similar things.

PS: doctors are always overly cautious because "malpractice suits" ... its up to you to make a call. I know what I'd do (and did again). You need to make a call, but even with a mitral valve there is very little risk window with 24 hours after procedure resumption (I mean you'll know if you have bleeding) and heparin isn't onerous.

 

[Bugsy]

Thanks everyone, I appreciate your input.

 

[RAS]

5 days prior to procedure stop warfarin, 4 and 3 days prior one shot lovenox per day, 2 days prior 2 shots lovenox, day before procedure 1 shot lovenox, day of procedure nothing and day after 1 shot lovenox, resume warfarin and check INR. Does this sound correct or is my doc being overly cautious?

I can't evaluate whether it is overly cautious or not since that depends on any known risks you have experienced (if any) under a low/no anti-coagulation situation vs bleeding risk and impact of the specific procedure. In my case I have a history of fibrin strands forming on my valve during low A/C periods, so I have to factor that into my risk assessment.

Your description seems to be a predetermined schedule unlinked to daily INR measurements. You'll want to check INR daily throughout the pre and post operative period so you're not flying blind. My schedule included stopping Warfarin 5 days prior to a procedure and starting Lovenox only after INR dropped below 2. No A/C therapy day of, then restarting Warfarin and Lovenox after the procedure until INR reached 2.0. Unfortunately even at that I still had fibrin strands form on my valve.

 

[Bugsy]

How did you know you had fibrin strands forming and if you don't mind me asking what valve do you have?

 

[RAS]

How did you know you had fibrin strands forming

They were visible on an echo.

I have an SJM Regent valve