Question about Other surgery and going off blood thinners

[hook]

I have not posted in a while, so I hope you don’t hold that against me. I am just over a year of having my mitral valve replaced with a St Jude mechanical. Aside from still having the underlying cardiomyopathy I am doing very well.

I would like to get some elective plastic surgery to clean out some scar tissue in my chest caused by the spironalactone and surgical procedure. The surgeon needs to have my INR at 1.4 for the surgery, and have it there for about 24 hours after the procedure during the risk window for bleeding.:eek2:

Does anyone know the risk involved with dropping to those levels for a day.

 

[dick0236]

I've never had to have any surgery that required lowering my INR, but several on here have. There are ways to "bridge", using Lovenox and/or other drugs that will protect you from stroke while allowing your INR to reach a safe surgical range. I would think that you would get your cardio involved to make sure the "bridging" is done properly. I know that someone with better first hand knowledge will be along shortly to help you out.

 

[Guest]

Hi Todd, do you home test? I had to have foot surgery last December, withheld coumadin, then bridged with Lovenox. Home testing makes it a lot easier.

The physician will tell you how many days he/she would like to have you off of coumadin prior to the procedure. If you go to a coumadin clinic, they should know best. My range is 2 to 3, mitral valve is 2.5 to 3.5 if I remember correctly.

My foot surgery required me to be off coumadin 3 days prior, I dropped to 2 two days prior, started Lovenox that evening because I knew I'd be below 2 by next morning. Shot next morning, then I withheld a shot the evening before the procedure and the morning of the procedure. Had my surgery, started coumadin and lovenox that evening. Took me 5 days to get back in range. Not too bad.

I had the lovely over 50 test, gastro doc wanted me off of coumadin 7 days, I told her NO WAY and she agreed to 5. Same plan, once I hit 2 I started lovenox that evening, withheld the night before and morning of. Resumed both after procedure. I know folks wait until they fall below their range but with this all new to me post op, I felt comfortable with my decisions, with guidance from the Coumadin Clinic (mine knows what they are doing). Good thing I was bridging, had 4 polyps removed.

Doseage after foot surgery was 7, 7, 7, then 5, (resumed normal weekly dosing) I think the doseage was too low that's why it took so long to get back in range. This second time, I took 7, 10, 10, 7 and was back in range in 4 days (resumed normal weekly dosing). Hey, any day without having to do the lovenox injections is a good day.

Best of luck to you.

 

[JimL]

I had to have several cysts removed, which probably is less severe than the surgery you are talking about. I had to search around to find a surgeon who would do the surgery while I continued on coumadin. But I did find one, and had the surgeries with no bleeding problems at all. He did do some cauterizing of the incision to reduce the potential problems, but I had no problems.

 

[hook]

Hi Todd, do you home test? I had to have foot surgery last December, withheld coumadin, then bridged with Lovenox. Home testing makes it a lot easier.

The physician will tell you how many days he/she would like to have you off of coumadin prior to the procedure. If you go to a coumadin clinic, they should know best. My range is 2 to 3, mitral valve is 2.5 to 3.5 if I remember correctly.

My foot surgery required me to be off coumadin 3 days prior, I dropped to 2 two days prior, started Lovenox that evening because I knew I'd be below 2 by next morning. Shot next morning, then I withheld a shot the evening before the procedure and the morning of the procedure. Had my surgery, started coumadin and lovenox that evening. Took me 5 days to get back in range. Not too bad.

I had the lovely over 50 test, gastro doc wanted me off of coumadin 7 days, I told her NO WAY and she agreed to 5. Same plan, once I hit 2 I started lovenox that evening, withheld the night before and morning of. Resumed both after procedure. I know folks wait until they fall below their range but with this all new to me post op, I felt comfortable with my decisions, with guidance from the Coumadin Clinic (mine knows what they are doing). Good thing I was bridging, had 4 polyps removed.

Doseage after foot surgery was 7, 7, 7, then 5, (resumed normal weekly dosing) I think the doseage was too low that's why it took so long to get back in range. This second time, I took 7, 10, 10, 7 and was back in range in 4 days (resumed normal weekly dosing). Hey, any day without having to do the lovenox injections is a good day.

Best of luck to you.

Yes, I do home test. Were you able to get your testing supply company to petition your insurance to cover additional test strips? My main concern was the risk of that 24 hour period where blood is at almost normal coagulation. When does stroke risk become a real issue?

 

[Guest]

Yes, I do home test. Were you able to get your testing supply company to petition your insurance to cover additional test strips? My main concern was the risk of that 24 hour period where blood is at almost normal coagulation. When does stroke risk become a real issue?

I am fortunate to have good coverage on my strips, I met my deductible this year already but I usually pay 1/2 ($75.00) for 12 strips. I'm afraid to shop the internet for better pricing. Strips I need going forward should be covered 100%. You should try to petition for additional strips if you need them.

I can't answer the stroke issue piece, you should ask your cardiologist as he/she knows best.

I feel for myself that if I am out of range I need to bridge with lovenox. I asked the 24 hour question also. Coumadin clinic says I am ok for this time period but need to resume lovenox and coumadin the night of the procedure. So if your surgeon says you can continue lovenox and coumadin the night of your procedure, you should be ok until your INR is back in range.

 

[Protimenow]

I've been getting my strips over the Internet -- either from medical supply companies or from vendors on eBay. So far, I've had absolutely no problems with strips I bought online. (I DID have some issues with strips for the Coaguchek S - but I think it was just user error). If you're using any of the new meters (and not a CoaguChek S), the strips have quality controls built in, so if there's a problem with the test, the meter should report it. The ProTime strips are unusable after the expiration date, and should be refrigerated after you get them, but the InRatio are somewhat less sensitive to high temperatures.

As long as your vendor will take back defective strips - should you be unfortunate to actually wind up with bad strips - your fear of buying over the Internet may be overblown.

 

[bvdr]

.....

I would like to get some elective plastic surgery to clean out some scar tissue in my chest caused by the spironalactone and surgical procedure. The surgeon needs to have my INR at 1.4 for the surgery, and have it there for about 24 hours after the procedure during the risk window for bleeding.:eek2



I've had to be off my warfarin numerous times for procedures or surgery. Most of the time I've bridged with Lovenox. Most of the time it has taken several days to get back into my target area and lovenox gives me a sense of security for those days. If you only have to be l.4 for 24 hours or so you can even start your warfarin again when you have your surgery since it won't start raising your INR for at least 24 hours. Lovenox hasn't actually be approved for bridging for valve patients but it is used that way.

 

[djteako]

Like everyone else said , you need to discuss this with your cardiologist , have them involved , and be bridged with enoxiparin(lovenox) or heparin . I have had to do this several times for dental proceedures , and even a cardiac cath .

bvdr , I'm surprised lovenox isn't approved for bridging there !!! Up here in Canada its even fully approved as a coumadin alternative , and we're ussually the last ones to approve anything regarding medicine !!

 

[Protimenow]

Yes, you should certainly discuss this with your cardiologist or anticoagulation clinic. I don't know if the fact that you're having a procedure done increases the risk that your heart valve will throw a clot. A paper by Duke Medicine Ambulatory Division, titled "Clinical Practice Guidelines for the Management of Anticoagulation Therapy in the Ambulatory Setting" gives guidelines for managing INRs at all ranges. Appendix A of the paper recommends an increase in warfarin dosage on DAY ONE of 10-20% of the weekly dose. It also recommends an increase in the weekly dosing. The protocol does not include bridging. Here's the link to the article: http://www.gme.duke.edu/newsletters/200901January/Coag Binder 1-09.pdf.

Regarding bridging, the Duke paper said "Bridging should be considered if a patient is on Coumadin, and will be having a procedure or surgery." In other words, if your INR is low - but you're not having a procedure or surgery - you probably don't need to bridge. It also says that the "Last dose of Lovenox should be at least 24 hours prior to the scheduled procedure." This suggests that if you are self-medicating with Lovenox too close to the actual procedure, this may not be good. Unfortunately, the paper doesn't describe 'procedure.' (Is tooth cleaning a 'procedure' that may require bridging?)

The risk of a clot forming on a heart valve probably varies from individual to individual, and is also related to the type of valve. Although bridging is probably not a bad thing to do when the INR is below range, if the Duke protocol is to be believed, it may be that, for short periods below 2.0, just increasing the dosage of warfarin may be adequate protection.

 

[hook]

Thanks all for the feedback

 

[catwoman]

I had the lovely over 50 test, gastro doc wanted me off of coumadin 7 days, I told her NO WAY and she agreed to 5. Same plan, once I hit 2 I started lovenox that evening, withheld the night before and morning of. Resumed both after procedure. I know folks wait until they fall below their range but with this all new to me post op, I felt comfortable with my decisions, with guidance from the Coumadin Clinic (mine knows what they are doing). Good thing I was bridging, had 4 polyps removed.

I refused to go off warfarin for my most recent colonoscopy. I did agree to lower my INR to 2.5. I estimated the dosage change needed to get it to 2.5. I seldom bring my INR diaries to work, but today I did so I could test at work instead of home.
I got my INR down to 2.5 this way:
My colonoscopy was on 12/1/2008. I had been taking 5.5X3 + 5.0X4. I took 5mg Nov. 23-26, when I tested at 3.4, then dropped to 4mg for Nov. 27-30. I was still on a downward swing Nov. 23-26, so that 3.4 didn't reflect a "final" INR. I tested at 2.5 on Sunday, Nov. 30. Procedure was done Dec. 1. No polyps found; I had had polyps removed during the previous colonoscopy.
We have had other folks here have colonoscopies while anticoagulated and at least one had some polyps removed, no problem.
FYI: Lovenox & other LMWH products carry a risk of inducing bleeding.

 

[njean]

I have had four major surgeries, not related to my heart, in my lifetime. Each time, the surgeon performing the surgery(s) kept in close communication with my cardiologist. One time, when I had my hysterectomy, my cardiologist was there in the operating room w/the surgeon to make sure all progressed well. Each time I was bridged with Lovenox and had no significant problems. I've also been bridged whenever I've had to undergo a right-heart cath.

I think the key for a successful surgery or procedure without anticoagulants, is for both your surgeon and cardiologist to keep in close contact with one another.

Best of luck to you!

 

[Guest]

I refused to go off warfarin for my most recent colonoscopy. I did agree to lower my INR to 2.5. I estimated the dosage change needed to get it to 2.5.

We have had other folks here have colonoscopies while anticoagulated and at least one had some polyps removed, no problem.
FYI: Lovenox & other LMWH products carry a risk of inducing bleeding.

I tried to discuss with her about the coagulation and others who have had theirs fully coagulated, but she was adamant. My range is 2 - 3. If I was coagulated and she found polyps, I'd have to have a second procedure and bridge then. Soooo, with a family history of colon cancer, I agreed but only to the 5 days. She's a great doctor and I really like her so I have to trust her reasoning....I get to do it again in 3 years.

Yes, I know lovenox carries risk of inducing bleeding, I remember what Ross went through when he had his oral surgery.

 

[catwoman]

I tried to discuss with her about the coagulation and others who have had theirs fully coagulated, but she was adamant. My range is 2 - 3. If I was coagulated and she found polyps, I'd have to have a second procedure and bridge then. Soooo, with a family history of colon cancer, I agreed but only to the 5 days. She's a great doctor and I really like her so I have to trust her reasoning....I get to do it again in 3 years.

I understand your predicament.
My mother had colon cancer surgery in December 1977, at age 50. Her mother had colon cancer surgery in 1963 or perhaps 1964, at age 61 or 62.

My valve is in the mitral position. That's why I'm less agreeable to going off warfarin for a colonoscopy. My GI doc said if he found a small polyp, he'd remove it. Otherwise, I'd win a return trip. :eek2: I gambled on that, and won. We'll see what happens in 2 years when I get to enjoy my next one.

When I had my first colonoscopy, in about 2000 or 2001, I think, I was told I should have had one at age 40 -- 10 years before my mother was DXed with colon cancer. That's the rule of thumb if you have a family history of colon cancer -- 10 years before the relative's age at diagnosis.
Both my mother & her mom had no further problems with colon cancer.

 

[hook]

Here are a couple general questions for the masses.
1) Are mitral valve clots considered more dangerous that throwing a clot from another valve?
2) Do newer bi-leaflet valves have less risk of forming a clot

I had a final meeting with the surgeon yesterday, and he seemed very concerned about the risk of surgery with the valve. I am not sure if it is because the valve is not his area of expertise, or if my risk is that much elevated over someone with a normal valve. He kind of scared me off a bit.

 

[Protimenow]

I don't know about the clot issue. From what I've read, the mitral valve is more likely to throw a clot than an aortic valve. As far as I can tell, a clot is a clot wherever it comes from. From what I've read, the bi-leaflet valves are less likely to form a clot than the other valves. Then, too, the risk appears to drop 3 months post-op (which looks like a week or so, in your case).

 

[catwoman]

1. A clot is a clot is a clot.
The mitral and tricuspid valves have a lower blood flow; therefore, there is a higher risk of a clot forming (my guess from more stagnant blood, but I'm not a medical professional). I was reading something by the CCF about this earlier this morning.
2. I don't know. The On-X has been highly touted for its hemodynamics.
I have a St. Jude. If I had to have a re-op, I would not hesitate to go with another St. Jude. I'm 8 years out and have had no problems.
But valve choices -- whether tissue or mechanical -- are personal ones. I liken choosing a valve to shopping for a car. Some people agonize more over valve choices than a car. You can always sell the car in a year or two, but you don't willingly choose to go back in just to get a "new and improved" valve model.

 

[Protimenow]

Marsha is absolutely right. When the St. Jude came out, they said something about a 45 year servicable life (or something). I've had mine for 20 years (minus a few days), and it's still ticking (and I think it's ticking in a way that it should).

By the time I need to have my valve replaced (if my other parts don't wear out first), perhaps they'll be able to do it less invasively -- perhaps just a couple slits in my chest and arthroscopic leaflet repair or something). I didn't agonize with my choice (actually, my surgeon made it fairly easy for me), I manage my INR, and I suspect that I'll have this St. Jude Aortic valve as long as I last.

 

[Bina]

I don't know about the clot issue. From what I've read, the mitral valve is more likely to throw a clot than an aortic valve. As far as I can tell, a clot is a clot wherever it comes from. From what I've read, the bi-leaflet valves are less likely to form a clot than the other valves. Then, too, the risk appears to drop 3 months after post-op (which looks like a week or so, in your case).

Todd's surgery was last year...May 2010