Surgery after Valve Replacement

[scrappy]

I unfortunately get to go under the knife again. It is nothing major, but, I guess once you are on coumadin everything is major (or at least seems that there are many more precautions). Well, anyway, I have to have a sphincterectomy because I developed anal fissures. I have tried everything under the sun to correct the problem without surgery. But, everything has failed. So, hopefully I do this and everything will be fine and I will be done with the constant bleeding when I have a bowel movement.

So, among others, here is my issue... For this procedure is it completely necessary to be on lovenox? The idea of being off coumadin and starting the injections scares me. And, to further complicate the issue, my cardiologist tells me one thing and the coumadin clinic tells me another. Cardiologist: I was told to stop taking coumadin for two days before starting lovenox, then to take the lovenox until the day before surgery and not to take it the day of surgery. Then take the coumadin the day of surgery and keep the lovenox going until INR is stabilized. Coumadin Clinic: Start taking lovenox on the same day I stop coumadin. Take it up until the night before surgery, do not take it before surgery, and them take it later that night along with restarting coumadin. Surgeon: Stop taking coumadin and start lovenox. Stop taking lovenox for 24 hrs before surgery and not start again until 48 hrs after surgery, then continue coumadin. (I had an AVR, root, and ascending aortic aneurysm replaced last May.) Any advice from the REAL experts would be helpful. It seems like many of those in the medical field have no clue on coumadin management. :confused2: Thanks, Jason

 

[Lionheart]

Jason,
I say put the ball back in their court. Send a copy of the above to all of the doctors and point out the differences and tell them to get together and figure out what is right and come to a medical consensus about exactly what you should do prior to surgery. They should all be on the same page or at least admit that none of the above options are harmful. The Cardio and Coumadin clinic are fairly similar and appear reasonable considering the half-life of coumadin.

I also bet there are Guidelines published by medical societies that provide a standard for the process of going off Coumadin and starting Lovenox prior to surgery. Maybe ask each of them for a copy of those guidelines to support their recommendations. If they provide it then you know the right action.
Best,
John

 

[ALCapshaw2]

I've written on the subject of Bridging with Lovenox a few times in the past.

Bottom Line: I asked 3 surgeons about their philosophy of Bridging and got 3 different answers.

After stopping Coumadin, it 'usually' takes a couple of days for your INR to drop below 2.0
so starting Lovenox ONE day after you stop Coumadin is a reasonable 'intermediate' approach IMO.

Coumadin takes around 4 days to become fully metabolized so starting back the night following surgery is pretty safe.

When (and some surgeons would say IF) to start taking taking Lovenox after another surgical procedure is a Balancing Act between the Risk of Bleeding and the Risk of Stroke. It would be wise for you to have your Surgeon confer with your Cardiologist on this issue. In my non-professional opinion, holding Lovenox for 24 to 48 hours after surgery is not a bad idea if there is a risk of bleeding.

I once fussed at a Nurse for not starting me on Lovenox after a different type of invasive procedure.
The nurse finally contacted my Cardio who ordered them to restart the Lovenox (24 hours later).
It worked out OK...

Some surgeons seem to think it is OK to NOT use Lovenox after other surgeries and just let the Coumadin return to your stable range in 4 days or so. I'm more comfortable with the 48 hour hold for Lovenox.

You can probably find my other posts by doing a Search for keyword "bridging" under my screen name.

'AL Capshaw'