Ross
Well-known member
Exactly unless it was an emergency, then plasma or vit K by IV.mtkayak said:
Society of Thoracic Surgeons Risk Calculator
- Thread starter StretchL
- Start date
Help Support Valve Replacement Forums:
M
Mary
Ross said:
It's not a situation I would want to face, and I'm glad I don't have to.
Ross
Well-known member
But the point being, it's not as big a deal as it may seem to be on Coumadin.Mary said:
Lets not let the Afib folks out of the picture too. They sure weren't presented this by choice. Who knows, perhaps one day you will be on it too.
M
Mary
Ross said:But the point being, it's not as big a deal as it may seem to be on Coumadin.
You're right, Ross, perhaps I will be. But it won't be by choice.
And my wish for you is that any future medical procedures you might encounter turn out to be less of a big deal than what you've anticipated.
StretchL
Well-known member
Ross said:They wouldn't remove it until they've given you either plasma or Vit K, in any event, you would be coagulated before they would attempt it. Either of these will bring INR down to zelch in no time. If they use Vit K, it's difficult to get back in range for a long time afterwards, so plasma is the choice in most circumstances. This was even true for my recent GI bleed. Right away, 2 units of fresh frozen plasma, followed with whole blood and fluids.
Ross, wasn't there a danger of embolism once the INR was down that far? Also, isn't it kind of scary being out of the hospital release range for those 3 days?
Ross
Well-known member
It is a risk, but it's a very small one. Some people, believe it or not, have walked around with a mechanical valve for years without anticoagulation. Don't think I'm going to try that, but it has been done. Al Lodwick has the case specifics on that deal. Not at all sure percentage wise what the risk is, but it's tiny. Plus to answer your question a little better, I was on a Heparin drip, which is the anticoagulant until the Coumadin is back in range. The only time I was on nothing was when I first entered the hospital and they gave me the plasma and checked for further bleeding. It was still about 3 days total with no anticoagulation of any sort.StretchL said:
Found some info: www.warfarinfo.com and:
PATIENTS WITH MECHANICAL HEART VALVES
A wide variation in the risk of thromboembolism exists for patients with mechanical heart valves. Older style, such as caged-ball and Bjork Shiley valves and any valve in the mitral position have increased risk over newer valves such as St. Jude and Medtronics and any valve it the atrial position. If a person has the warfarin stopped two to three days before a procedure and it takes two to three days to have the INR reach a therapeutic level after the procedure, then the approximate risk of stroke during the time the warfarin is discontinued is 0.02% to 0.06%. To put this in another perspective, imagine that there were 10,000 people in the world who had mechanical heart valves and their warfarin was stopped for a procedure today. Among those 10,000 people somewhere between 2 and 6 would have a stroke. For every day over six that the INR remains below the desired range, the number of people having a stroke will increase. You will then have to consider the risk of bleeding. Routine dental procedures, cataract surgery, and most skin surgery present little risk of serious bleeding. For these, the risk of stroke ordinarily outweighs the risk of bleeding so they should be performed without stopping warfarin. As the risk of bleeding increases, the need for stopping warfarin increases. However, the risk of stroke remains the same. Therefore, the use of bridge therapy with low-molecular weight heparin increases in importance.
MANAGING WARFARIN WHEN A PATIENT REQUIRES A PROCEDURE
This editorial relies heavily on the article The Management of Anticoagulation Before and After Procedures by John Spandorfer, M.D. in Medical Clinics of North America, Postoperative Medical Complications, 2001;85: 1109-1116.
M
Mary
This article doesn't minimize the risk of stopping anticoagulation during surgery, and it differentiates the risk between a tissue or mechanical valve.
http://www.australianprescriber.com/magazine/23/1/13/6/
http://www.australianprescriber.com/magazine/23/1/13/6/
Ross
Well-known member
Now for the wrench. How many other things influence clotting during an operation, bypass machine, clamping, etc. All in all, I'm willing to bet that there is less risk from stopping anticoagulation then there is of one of these other influencing factors. Nonetheless, stressing over this isnt worth it. It's miniscule compared to reops.
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.3 These figures are calculated by assuming an average thromboembolic rate of 8% per year in patients with mechanical heart valves, an anticoagulation-free period of four days and a 3% risk of major postoperative bleeding with intravenous heparin. In light of these calculations, a risk-benefit analysis would preclude the use of full dose anticoagulation during the perioperative period in patients with mechanical valves, except in patients with very recent arterial embolism who have a high risk of recurrence in the absence of anticoagulation. In the absence of recent embolism, the authors recommend, for hospitalised patients, the use of subcutaneous low dose unfractionated or low molecular weight heparin at doses used for prophylaxis against venous thromboembolism, with no prophylaxis for outpatients.
There are limited prospective data to support or contradict these recommendations. The available literature consists mainly of small, non-randomised trials from which no definitive conclusions can be drawn. In one of the few prospective studies, 45 patients with mechanical heart valves underwent non-cardiac surgical procedures.4 No thromboembolic events were seen in 26 patients with aortic prostheses in whom warfarin was withheld for a total of 6-10 days perioperatively. In 19 patients with mitral prostheses, the warfarin effect was reversed with vitamin K on the day of surgery. A heparin infusion was started 12 hours after the operation and warfarin was resumed on the third postoperative day. No thromboembolic events were observed in this group.
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.3 These figures are calculated by assuming an average thromboembolic rate of 8% per year in patients with mechanical heart valves, an anticoagulation-free period of four days and a 3% risk of major postoperative bleeding with intravenous heparin. In light of these calculations, a risk-benefit analysis would preclude the use of full dose anticoagulation during the perioperative period in patients with mechanical valves, except in patients with very recent arterial embolism who have a high risk of recurrence in the absence of anticoagulation. In the absence of recent embolism, the authors recommend, for hospitalised patients, the use of subcutaneous low dose unfractionated or low molecular weight heparin at doses used for prophylaxis against venous thromboembolism, with no prophylaxis for outpatients.
There are limited prospective data to support or contradict these recommendations. The available literature consists mainly of small, non-randomised trials from which no definitive conclusions can be drawn. In one of the few prospective studies, 45 patients with mechanical heart valves underwent non-cardiac surgical procedures.4 No thromboembolic events were seen in 26 patients with aortic prostheses in whom warfarin was withheld for a total of 6-10 days perioperatively. In 19 patients with mitral prostheses, the warfarin effect was reversed with vitamin K on the day of surgery. A heparin infusion was started 12 hours after the operation and warfarin was resumed on the third postoperative day. No thromboembolic events were observed in this group.
C
CathyK.
I guess it all boils down to preference no matter what. I, myself would be more comfortable with reops then coumadin for life. However, my surgeon stated that less harsh anticoagulants are on their way and I might change my mind at that time. I was also told that the second time the surgeon goes in to replace the valve is not a real big worry for the surgeon, but the third time and so on, the surgeon starts to get a bit nervous. Maybe by my second reop there will be other options for me. At least that is where my thinking is at this point. However, haven't been in surgery yet! I might have a different outlook post-op!
Cathy
Cathy
twinmaker
Well-known member
Stretch, concerning your last question...that's why they give you a Heparin drip. It covers you while the INR is coming back up or going down depending what situation you are in. Lovenox does the same thing. LINDA
K
Karlynn
CathyK. said:
First let me say Cathy - I agree with your perspective of it being an individual thing, so my quote of your above isn't a criticism of your view in the slightest. It does all boil down to preferance because we keep seeing that statistically, the playing field is even.
Your quote above inadvertently highlights what I've felt for a long time. "Not a big worry for the surgeon". Surgeons usually don't stick around to see what the long-term affects of operations are (even 1st ones) on patients. Particularly the Big Guns. I think that all some of us are trying to say is long-term physical outcome also needs to be considered. It is not followed by "So one should choose mechanical." What we are saying is simply - This also needs to be understood and considered if the choice is to be the most informed.
I've got a granddaughter arriving - I need that royalty check I get everytime someone chooses a St. Jude.
StretchL
Well-known member
Karlynn, you've probably mentioned it before somewhere, but... how often do you home test?
Have you travelled extensively since beginning the home test? If so, how did you deal with that?
Have you done any international travel during that time?
Thanks!
Have you travelled extensively since beginning the home test? If so, how did you deal with that?
Have you done any international travel during that time?
Thanks!
Ross
Well-known member
I've stated my opinion over and over. I'm for anything that is going to keep your from getting on the table again. No matter your choice, it's still possible that whatever your choose, may have to be replaced for one reason or another. Statistically you can have many operations. Realistically, you may die on your first or things may go very badly and you may end up being on Coumadin, have a pace maker and then suddenly, the prospects of getting back on that table don't look so good. It has happened, granted to only a few, but it has happened. The problem is, no one knows who it's going to happen to next. I'm not saying this to scare anyone which I'm often accused of, but if the truth hurts, so be it.
R
RandyL
Coumadin
Coumadin
I am sorry but I really don't see the big deal with taking Coumadin. It is just like taking any other pill daily whether it be aspirin,cholesterol,anti acid, etc. You have to test once a week or once every 2 weeks or once a month. It's not like Coumadin is in charge of your life. You can do anything your body is physically up to doing. The only thing that requires a little extra effort on your part is doing some extra things if you require some kind of invasive medical procedure. If the only reason you don't want a mechanical valve is because of Coumadin then you are making a decision based on the wrong factors. I am not touting mechanical or tissue just stating the fact that taking Coumadin should not effect your decision.
Coumadin
I am sorry but I really don't see the big deal with taking Coumadin. It is just like taking any other pill daily whether it be aspirin,cholesterol,anti acid, etc. You have to test once a week or once every 2 weeks or once a month. It's not like Coumadin is in charge of your life. You can do anything your body is physically up to doing. The only thing that requires a little extra effort on your part is doing some extra things if you require some kind of invasive medical procedure. If the only reason you don't want a mechanical valve is because of Coumadin then you are making a decision based on the wrong factors. I am not touting mechanical or tissue just stating the fact that taking Coumadin should not effect your decision.
K
Karlynn
StretchL said:
I test every week. But thinking of going to once every 2 weeks.
I've traveled to Europe twice. Once since home testing. We went to Paris for 10 days. I took my machine along just in case, but didn't end up testing. Too distracted by The City of Lights!
Now that I have the INRatio - traveling with it will take up much less space and less weight, plus all I'll need to take is AA batteries. My ProTime required me to take my heavy charger, plus a Euro adapter. (And then I didn't test.
) My daughter may be teaching in France for a year starting in the Fall of '07 and I plan on a few trips over there to see her.For someone who travels extensively (and I wouldn't consider my 2 trips to Europe extensive.) and they are on warfarin, I'd highly recommend the INRatio. It would literally fit in a shaving kit. You don't have to refrigerate your strips. And the machine runs off of AA batteries. I've had my INRatio for ~20 weeks. I test weekly and I still haven't had to replace the batteries yet.
K
Karlynn
RandyL said:
Like reeling in big, honkin' sea creatures!
StretchL
Well-known member
RandyL said:
Y'know... just when I start to reconsider the possibility of a mechanical valve I read the kind of hyperbole quoted above and it suddenly jolts me back to reality.
Here is a link to the "situational safety" page on PTINR.com, a site connected to the very one you're now reading by a big ole hyperlink right up there in the upper right hand corner. http://www.ptinr.com/data/pages/search.aspx?search=Situational Safety:
Here are a few quotes from that page:
"Few patients think of the hazards of a simple box of plastic wrap..."
"Hidden dangers lurk in every dishwasher."
"Pick up a few tips on how to reduce your risk of a blood clot while gardening..."
"Car doors present one of the greatest risks for patients on warfarin on any given day" [Jeez and Pres. Bush had me thinking it was the "evildoers"... (sorry, couldn't resist that one...)]
"Stubbing one's toe not only hurts - it represents and internal bleeding risk..."
It would be comical if it weren't so damned serious.
K
Karlynn
This site is about sharing our experiences.
This site is about sharing our experiences.
Just my luck to have a break waiting for my latest media file to download to my church program and I come on 5 minutes after Stretch posts. All I can say is "Oh, lordy, now do people see why we get so darned frustrated?" Even sites that supposedly are "go to" places for information, sites that VR teams up with, and we still are inundated by really ridiculous information. And then people come on that have no personal experience and tell us that we are walking dead people because of all these "dangers". If that's the point, then please just come out and say it and we'll move on. I don't know whether to laugh or cry.
First of and foremost, in Randy's defense, if he is a warfarin user and if he looks upon it like that, then who is to tell him he's wrong? It is HIS life and HIS experience. It applies to him and his life and he has had a complicated several months. So to say he's using hyperbole is saying that his life is a hyperbole. Nice compliment. No disrespect intended Stretch, but you have no personal experience yet with either valve surgery or warfarin so to tell Randy he's wrong, is ludicrous. Post all the links you want to all the papers you want. But wait until you?ve had personal experience to tell someone else that their view is exaggerated. Rain hates warfarin and she is a warfarin user. My experience makes me disagree with Rain, but telling her she?s wrong for her view, someone who uses the drug, would be highly arrogant of me. I can report what my experiences are, but to say she?s exaggerating, I would never do that.
Secondly, many of PTINR's situational safety articles are just plain ridiculous and something we continue to battle. I will give them some credit and say a few of their articles may be important in this area, but come on!!!!!!! Opening cans? Easy open tops? Dangers that lurk in your dishwasher? Sharp foods???????????? I half expected to read one on Green Jello!!! And you reading this makes Randy's personal experience all wrong???? Maybe someone who shares Randy's experiences can debate him on his position. Kind of like Ross and Mary do at times.
Oh, and I just stubbed my 2nd toe big time a few weeks ago. It may have even broken. Yet, I didn't spend a minute in the hospital for it. It didn't even turn purple, just a little discolored.
The next thing that will happen is that someone will come on and give their personal experience on reoperations and someone with no personal experience is going to come on and tell them they're wrong. . Someone can come on and post that their reoperation was successful, they felt even better than before their 1st operation and that they even danced a jig 12 hours after and tell people not to be afraid of reoperation. I am certainly not going to come on and tell them that I had been considering tissue, but that now their report on their experience was so outlandish I had decided not to. I may question to myself, whether their experience is the exception and not the rule, and may even respectfully ask that, but I certainly wouldn't be insulting to them or their personal experience. I would be very happy they had that experience.
Someone please tell me what the end point is here? For all of us to acknowledge that anticoagulation therapy is going to kill us?
If I sound angry - I am. Discussion and debate is fine and healthy and informative, but when we begin denigrating people who tell their personal views based on their own personal experience - not papers, not what doctors have told them, not what clinics have published, we have gone to the dark side. This site is about sharing our personal experiences.
This site is about sharing our experiences.
Just my luck to have a break waiting for my latest media file to download to my church program and I come on 5 minutes after Stretch posts. All I can say is "Oh, lordy, now do people see why we get so darned frustrated?" Even sites that supposedly are "go to" places for information, sites that VR teams up with, and we still are inundated by really ridiculous information. And then people come on that have no personal experience and tell us that we are walking dead people because of all these "dangers". If that's the point, then please just come out and say it and we'll move on. I don't know whether to laugh or cry.
First of and foremost, in Randy's defense, if he is a warfarin user and if he looks upon it like that, then who is to tell him he's wrong? It is HIS life and HIS experience. It applies to him and his life and he has had a complicated several months. So to say he's using hyperbole is saying that his life is a hyperbole. Nice compliment. No disrespect intended Stretch, but you have no personal experience yet with either valve surgery or warfarin so to tell Randy he's wrong, is ludicrous. Post all the links you want to all the papers you want. But wait until you?ve had personal experience to tell someone else that their view is exaggerated. Rain hates warfarin and she is a warfarin user. My experience makes me disagree with Rain, but telling her she?s wrong for her view, someone who uses the drug, would be highly arrogant of me. I can report what my experiences are, but to say she?s exaggerating, I would never do that.
Secondly, many of PTINR's situational safety articles are just plain ridiculous and something we continue to battle. I will give them some credit and say a few of their articles may be important in this area, but come on!!!!!!! Opening cans? Easy open tops? Dangers that lurk in your dishwasher? Sharp foods???????????? I half expected to read one on Green Jello!!! And you reading this makes Randy's personal experience all wrong???? Maybe someone who shares Randy's experiences can debate him on his position. Kind of like Ross and Mary do at times.
Oh, and I just stubbed my 2nd toe big time a few weeks ago. It may have even broken. Yet, I didn't spend a minute in the hospital for it. It didn't even turn purple, just a little discolored.
The next thing that will happen is that someone will come on and give their personal experience on reoperations and someone with no personal experience is going to come on and tell them they're wrong. . Someone can come on and post that their reoperation was successful, they felt even better than before their 1st operation and that they even danced a jig 12 hours after and tell people not to be afraid of reoperation. I am certainly not going to come on and tell them that I had been considering tissue, but that now their report on their experience was so outlandish I had decided not to. I may question to myself, whether their experience is the exception and not the rule, and may even respectfully ask that, but I certainly wouldn't be insulting to them or their personal experience. I would be very happy they had that experience.
Someone please tell me what the end point is here? For all of us to acknowledge that anticoagulation therapy is going to kill us?
If I sound angry - I am. Discussion and debate is fine and healthy and informative, but when we begin denigrating people who tell their personal views based on their own personal experience - not papers, not what doctors have told them, not what clinics have published, we have gone to the dark side. This site is about sharing our personal experiences.
R
RandyL
StretchL said:
I guess you are talking about my statement being Hyperbole, meaning I exagerated the truth. I am not saying that Coumadin is a drug similiar to the ones I mentioned,what I am saying is it is easy to take right along with those other drugs that I take daily.You certainly have to be educated on the use of Coumadin or be under the direct care of someone who is.My personal use of the drug produces no side effects that I know of for ME. Again meaning I don't even know I am taking it just like the other drugs I mentioned. I read the hyperlink you posted for the first time and it reads just like an OSHA report. I like the diswasher one the best. Let's discuss it for a minute.
If anyone reaches into a dishwasher's utility holder carelessly they will probably get stabbed or cut. If they are not taking Coumadin they will bleed until their blood clots off. If they are taking Coumadin they bleed till their blood clots off which could take longer but not always. I have cut myself numerous times while on Coumadin and I would say it bleeds a little longer than normal but not anything that would put me in the panic mode. I have even gashed my leg and yes it took a little longer to stop the bleeding but again it wasn't anything that made me nervous. I would compare a bleed while on coumadin similiar to cut while shaving, they tend to bleed a little longer than a cut in your finger for instanceand are harder to stop.
I am not worried in the least about a superficial cut while on Coumadin. There is a risk of a blow to the body creating an internal bleed that could be very dangerous if not attended to. I do wear a Medical ID chain to let someone know if I am in an accident so as to warn them that I will bleed longer than most people before I clot. I think if I read that link you posted before I read any other material I would of been scared to death of taking Coumadin and would of definately picked a tissue valve and hoped everything went well so Coumadin would not be a part of my life.
I think all you can do is read everything you can and make the best decision based on what you believe. BTW I had to look up Hyperbole to see what you meant. Believe me when I tell you I am not on any side here tissue or mechanical but I still believe that Coumadin is not the villain it is being made out to be.IMHO
StretchL
Well-known member
Karlynn:
You're right... it is Randy's life and his experience. But, if you'll re-read his post, it says, "If the only reason you don't want a mechanical valve is because of Coumadin then you are making a decision based on the wrong factors."
The operative word being "you."
Randy is telling me why my decision making process is flawed, and you're right, who is he to tell me that I'm wrong? That's exactly what got my dander up about his post. We're ALL welcome to our opinions, and you'll notice that I'm asking you and Ross about your experiences on warfarin. I'm interested. But I don't like someone telling me that I'm making a decision "based on the wrong factors." I'll venture to guess that Randy knows very little about my life or lifestyle, that he doesn't know what it's like to leave home on a days notice and fly to an isolated region devastated by a tsunami or hurricane, and that he spent no more time researching his surgery than I am spending researching mine. In Banda Aceh last year I fell amidst the rubble of what was once a city and nearly got a piece of rebar stuck through my shoulder. Would I have survived if it had gone through me? Possibly. Would I have survived if I had been on warfarin and it had gone through me? Probably not. And I can tell you that it would have been one helluva way to go... bleeding to death literally as far away from home as one can go and still be on the planet, with only my assistant and our Indonesian guide to hold my hand while I slowly expired.
So if someone doesn't want a visceral reaction from me, then let them tell me about THEIR experiences and refrain from telling me what's right or wrong for me.
With regard to PTINR, if "many of PTINR's situational safety articles are just plain ridiculous," then what in the hell are they doing linked to this site? Are visitors here supposed to just know that you and Ross and whomever else is on warfarin therapy are right, but ptinr is wrong? If the infomation there is wrong then someone needs to get that link off line or put a huge disclaimer somewhere on THIS site saying that vr.com is for social purposes only and that the information contained herein should not be taken seriously as one considers his/her surgical or therapeutic options.
What indeed is the end point? I never said that anticoagulation therapy is going to kill anyone. This whole argument started when someone took issue with the opinion of a Cleveland Clinic surgeon, A CCF SURGEON FOR GOD'S SAKE, when the surgeon gave HIS profesional opinions in an e-mail to me about the risks of re-op v. warfarin therapy.
Frankly, this site is beginning to feel like a soapbox for the anticoagulated to tell us how wonderful life is on Coumadin while leaving precious little room for anyone, even those who are about to have surgery, to question whether the opinions and experiences of the anticoagulated are EXAMPLES or EXCEPTIONS.
You're right... it is Randy's life and his experience. But, if you'll re-read his post, it says, "If the only reason you don't want a mechanical valve is because of Coumadin then you are making a decision based on the wrong factors."
The operative word being "you."
Randy is telling me why my decision making process is flawed, and you're right, who is he to tell me that I'm wrong? That's exactly what got my dander up about his post. We're ALL welcome to our opinions, and you'll notice that I'm asking you and Ross about your experiences on warfarin. I'm interested. But I don't like someone telling me that I'm making a decision "based on the wrong factors." I'll venture to guess that Randy knows very little about my life or lifestyle, that he doesn't know what it's like to leave home on a days notice and fly to an isolated region devastated by a tsunami or hurricane, and that he spent no more time researching his surgery than I am spending researching mine. In Banda Aceh last year I fell amidst the rubble of what was once a city and nearly got a piece of rebar stuck through my shoulder. Would I have survived if it had gone through me? Possibly. Would I have survived if I had been on warfarin and it had gone through me? Probably not. And I can tell you that it would have been one helluva way to go... bleeding to death literally as far away from home as one can go and still be on the planet, with only my assistant and our Indonesian guide to hold my hand while I slowly expired.
So if someone doesn't want a visceral reaction from me, then let them tell me about THEIR experiences and refrain from telling me what's right or wrong for me.
With regard to PTINR, if "many of PTINR's situational safety articles are just plain ridiculous," then what in the hell are they doing linked to this site? Are visitors here supposed to just know that you and Ross and whomever else is on warfarin therapy are right, but ptinr is wrong? If the infomation there is wrong then someone needs to get that link off line or put a huge disclaimer somewhere on THIS site saying that vr.com is for social purposes only and that the information contained herein should not be taken seriously as one considers his/her surgical or therapeutic options.
What indeed is the end point? I never said that anticoagulation therapy is going to kill anyone. This whole argument started when someone took issue with the opinion of a Cleveland Clinic surgeon, A CCF SURGEON FOR GOD'S SAKE, when the surgeon gave HIS profesional opinions in an e-mail to me about the risks of re-op v. warfarin therapy.
Frankly, this site is beginning to feel like a soapbox for the anticoagulated to tell us how wonderful life is on Coumadin while leaving precious little room for anyone, even those who are about to have surgery, to question whether the opinions and experiences of the anticoagulated are EXAMPLES or EXCEPTIONS.
