Tissue Regrets??

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LondonAndy

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I don't know what the factors are affecting what dose of warfarin /coumadin we need, but if helpful to mention my dose is 8mg one day, 7mg the next, and repeat. I am an overweight 53yo male diabetic, if that is a factor, and eat small amounts of broccoli and other vitamin K rich vegetables most days and drink moderate amounts of alcohol probably twice a week. But as many have commented on this site, I don't find alcohol has much effect on my INR.

It DID take a while after surgery to get my INR right, and I was on Heparin (Lovenox) injections too during that period. I was in hospital about 18 days after surgery, but I did also have to have a pacemaker inserted as they accidentally damaged my heart's electrics during the op.
 

pellicle

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I finally hit 1.4 this morning so am headed in good direction.
also, while you're in there with time to read stuff, this article explains why they are "easing you in" to warfarin...

https://www.dermnetnz.org/topics/warfarin-induced-skin-necrosis/

What is warfarin-induced skin necrosis?
Warfarin is an anticoagulant medicine (blood thinner). Warfarin-induced skin necrosis refers to a rare condition in which there is paradoxical blood clotting. Blood clots block the blood vessels and cause necrosis, where an area of skin is destroyed. Warfarin-induced skin necrosis affects one in every 10,000 patients prescribed warfarin.

The onset is usually within the first 2 to 5 days of warfarin therapy when the blood tends to clot more than is normal. Skin necrosis affects areas of the body with a high fat content.




old chinese saying "beginnings are a delicate time"

stick with it and be patient (which is your name while you're in a hospital ... ; -)
 

Keithl

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Well they backed down to 7.5mg today since my INR is now 1.7. If it hits 1.8 they will discharge me and let Coumadin clinic deal with it. I drink some organic vegetable juices and cold pressed juices that have Vit. k in them that I have stopped and will phase them back in with my local testing. The advantages of those juices is high potassium as well. Hopefully being discharged within 24 hours and itching to get home.

I love Cleveland Clinic, but after the first few days the only communication is with Nurse Practitioner and not my medical, that has been extremely disappointing. They might have a word, class medical facility, but communication and logistics (case management) they suck at.
 

Keithl

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But as you are on heparin that won't happen. INR measurements are different to heparin and their specific action on coagulation is different.

They did not have me on enough Heparin until early today, even my wife overheard a doctor saying I was finally out of stroke risk. It is a shame that once you start to stabilize you are handed off to surgeon's fellows and they are a mixed bag. They had me on 5ml/hr for 2 days and never tested me, then tested me and started bumping it up landing on 18ml/hr. Also once my insurance pre-approval ran out they still have not called to get my extended stay covered. So basically I was a high stroke rick unmonitored for almost 5 days and they are not managing my insurance. Great medical attendings, but weak in other areas.
 

pellicle

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They did not have me on enough Heparin until early today, even my wife overheard a doctor saying I was finally out of stroke risk.
I recall you mentioning that before ... I asked how you knew 5ml/h was insufficient and raised the issue of the need to stabilize the wound and the valve VS the risks of clots causing problems. I don't recall you commenting on that. Also while you're in hospital stroke can be dealt with swiftly with tPA treatment.

Such major surgery is risky, I'm just saying that perhaps both of us don't know enough to be canning the hospital just yet.

... So basically I was a high stroke rick unmonitored for almost 5 days and they are not managing my insurance.
this does seem poor, but what do you mean unmonitored?

Anyway, I hope that you get your INR up to 2.5 soon, even if 7.5mg is your dose (for now, and it will increase again in time after surgery) it will take a few more days to have it rise.

I assume that they would prefer to keep you in and monitor your INR carefully than release you into the wild and run greater risks of stroke (for there you will likely be unmonitored ... probably for weeks at a time
 

Keithl

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I recall you mentioning that before ... I asked how you knew 5ml/h was insufficient and raised the issue of the need to stabilize the wound and the valve VS the risks of clots causing problems. I don't recall you commenting on that. Also while you're in hospital stroke can be dealt with swiftly with tPA treatment.

Such major surgery is risky, I'm just saying that perhaps both of us don't know enough to be canning the hospital just yet.



this does seem poor, but what do you mean unmonitored?

Anyway, I hope that you get your INR up to 2.5 soon, even if 7.5mg is your dose (for now, and it will increase again in time after surgery) it will take a few more days to have it rise.

I assume that they would prefer to keep you in and monitor your INR carefully than release you into the wild and run greater risks of stroke (for there you will likely be unmonitored ... probably for weeks at a time

There are some articles I found that show they should have started the heparin at 10ml/hr based on my weight. They used 5ml/hr for 2 days without drawing blood to check it’s effectiveness. Now they pulled blood every 6 hours until my number got where they wanted it which wound up being 18 ml/hr. Last night my INR also finally got to 1.7 with a goal of 1.8 to release me and a range of 2-3 for first 3 months.

My surgeon was great, but the post operative care here leaves something to be desired as the surgeon's fellows huddle every day in secret and determine your care and tell nurses what to do. No one comes and communicates anything to me. And the fellows are a bunch of Cleveland Clinic “want a be” god complex ego maniacs too good to talk to patients.

The only reason I know I was stroke risk is they huddle in an area my wife’s sets up to work from hospital every day and she over hears them.
 

pellicle

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Hi

There are some articles I found that show they should have started the heparin at 10ml/hr based on my weight. They used 5ml/hr for 2 days without drawing blood to check it’s effectiveness.
well I'm no expert, but I'd say that the delivery rate would also depend on the concentration of heparin and the type of heparin (more than one). Myself I'm always cautious about "speed learning" on the internet.

Now they pulled blood every 6 hours until my number got where they wanted it which wound up being 18 ml/hr.
interesting ...
Last night my INR also finally got to 1.7 with a goal of 1.8 to release me and a range of 2-3 for first 3 months.
that's good ... glad to see that's moving in the right direction. I guess now you'll need to ensure that they don't overshoot it.


And the fellows are a bunch of Cleveland Clinic “want a be” god complex ego maniacs too good to talk to patients.
you don't paint a good picture of the place.

Anyway, I hope that you have a smooth ride from here on in
 
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Keithl

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On the contrary, the fellows are the only issue, the front line staff excellent. I also fall into the small scope of patients that are in better shape than most which I think hurts in that there are so many others that need more help. My understanding is most hospitals delegate the post surgical care to lower lever “doctors in training” or “attendee wanna bes”. There is no mistaking this hospital is a big business and as with any big business there is political processes and a machine in place.

I am very disappointed in the lack of collaboration on my care, my surgeon was here 3 times the first 2 days I assume until all
was good then it appears he hands it off to his fellows. That to me is the issue, as most of them cycle through here with lofty ambitions, they are here to make a name for themselves and either get an attending position or have “Cleveland Clinic” on their resumes. Several of the nurses have shared with me some of the concerns with the fellows and how they act as the guard rails.

Most people are not actively involved in their own health care, so I am an anomaly that they clearly do not know how to deal with. My nurse teams have been great at providing me info, but they only have access to what they do.
 

LondonAndy

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I was on Heparin in hospital after the valve surgery as they waited for my blood "to get right" before inserting a pacemaker as a result of surgical complication. I well remember the regular blood taking! The veins in my arm basically collapsed with the frequency of visits from the vampires, and finally an anesthetist kindly took the bloods but even he ended up taking it from my foot! They gave me a blood transfusion in the end, as they were running out of time for the temporary pacemaker cable life expectancy.

About six months after I left hospital, about 4 years ago, I was again on Heparin for a few days when I went out of range. The dose was indeed weight related (something like below 80kg give a small injection, above 80kg give a large one, but I am guessing the weight). Obviously as Pellicle says, if it comes in different strengths the actual amount of the injection will vary.
 

Gail in Ca

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If repeat open heart surgeries weren't so risky, I think we all would choose a tissue valve each time. I had porcine at age 34, told it would last 15 yrs, ha! I got 11 yrs and that was considered really good. Then, mechanical at age 45, and boy was it tempting to get a tissue (homograft) when I got BE and needed another surgery at age 54. But, I chose another mechanical and I'm good with that. It took 3 hours for my surgeon to cut thru the scar tissue from my previous surgeries. You just appreciate the years you get with those quiet tissue valves!
 

LondonAndy

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If repeat open heart surgeries weren't so risky, I think we all would choose a tissue valve each time. I had porcine at age 34, told it would last 15 yrs, ha! I got 11 yrs and that was considered really good. Then, mechanical at age 45, and boy was it tempting to get a tissue (homograft) when I got BE and needed another surgery at age 54. But, I chose another mechanical and I'm good with that. It took 3 hours for my surgeon to cut thru the scar tissue from my previous surgeries. You just appreciate the years you get with those quiet tissue valves!
I don't know if it is because I am a gadget enthusiast, or perhaps because I am an insulin dependent diabetic used to taking tablets every day, but a mechanical valve was never something I was worried about. Even if we take away the risks associated with open heart surgery, there is still the period when a tissue valve gets close to the end of its life potentially causing problems, and then a minimum 6 week recovery period when you are unlikely to be able to work or do much - a significant disruption to life.

Going back to reality and factoring in the risks of surgery, which as Gail says increases with redos, and for me when I was 48 years old the decision to try and avoid redo was my number one priority. Yes, i was concerned about ticking, but for me that turned out to not be an issue. And as a diabetic, used to pricking a finger several times a day, a once-a-week prick for the INR check didn't bother me at all. I manage my own INR and am in range 95% of the time
 

Keithl

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If repeat open heart surgeries weren't so risky, I think we all would choose a tissue valve each time. I had porcine at age 34, told it would last 15 yrs, ha! I got 11 yrs and that was considered really good. Then, mechanical at age 45, and boy was it tempting to get a tissue (homograft) when I got BE and needed another surgery at age 54. But, I chose another mechanical and I'm good with that. It took 3 hours for my surgeon to cut thru the scar tissue from my previous surgeries. You just appreciate the years you get with those quiet tissue valves!

I am not sure I agree. I had my local,surgeon and cardio push tissue valve and even the surgeon in Cleveland offered tissue (but he did not push it) and my thing was one and done and while there is no guarantee that this will be trouble free forever it is likely I will never need another OHS and while my recovery has been great I still would not wish this on anyone. Every surgery has risk so I am not willing to roll the dice more than I have too. As I dial in my warfarin it is not a big deal as I take several supplements every day anyway. The big thing for me will be moving the dose from evening to morning as I take my morning pills very religiously.
 

pellicle

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The big thing for me will be moving the dose from evening to morning as I take my morning pills very religiously.
It's no biggie, just do it. You probably won't even notice the INR change.

I've done it a few times when moving from one side of the planet to the other.
 

NealR

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Just had my 2nd ohs in 10 years. Was a rough one and @ 3 weeks post, still a bit to go. I can do 6000 steps a day, but still raw and wobbly. At 59, I will eventually need a third. Hoping to go the transcatheter route (both aortic and mittral). Let's hope tech in 10 years has this miracle procedure better perfected
 

Gazza01

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Let's not forget guys and gals that it's not all about tissue and mechanical any more there is a breakthrough on polymer valves. There is an engineer who has devised a way of making a polymer that will bend one way but not the other. So a valve can be made to open oneway but not leak back. The valves are already being tested at high speeds so they can get a 1/2 a million beats in a 6 month period. They are also running many of these at the same time so as to get a clear picture of how the valves will fare over a long period. The engineer in charge is expecting these to be used within a few years rather than decades. No blood thinners needed either. I had my large bovine done 18 months ago and I am hoping by the time I am in need of a new one that there is a valve that will last 30 years and can be fitted and forgotten that is not mechanicaI. I really dread having ohs again although it saved my life. ( I collapsed while exercising age 53 and was told it was bicuspid from birth. It was so blocked I was held in hospital until it was done. Thanks to the Royal Brompton.) I'm only just coming to terms with it all mentally really, which I believe will also be a lot easier in the future decades, when surgery will be minimally invasive and a valve popped in place that needs no drugs or further work barring something extraordinary. It will come.
 

DaveEM

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I just had an aortic valve redo last year (Feb 2018) replacing a porcine valve with a new bovine. The unique thing about the new bovine is that it has a hard-ish ring that will enable a TAVR installation that will sit solidly and securely against the ring, eliminating many of the current issues regarding leakage and regurgitation. So, even though I'll likely need a replacement of the new valve in 10-15 years, the TAVR replacement will obviate the need for an additional OHS. But I like the idea of a new polymer valve and would even consider another OHS to get one. My redo went fine and I feel the greatest I've felt in years. I'm 62 y.o. by the way and expect to live forever...
 

dick0236

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Let's not forget guys and gals that it's not all about tissue and mechanical any more there is a breakthrough on polymer valves................. valves are already being tested at high speeds so they can get a 1/2 a million beats in a 6 month period. ................... It will come.
You are right that it will come......but this Polymer valve has a long way to go. 1/2 million beats (500,000) in six months is no big deal. A heart valve, beating at 80 bpm, beats over 115,000 per day. If surgical decision must be made today don't bet on what might be in the future......or when.

FWIW, my valve has completed over 2 billion beats (2,186,496,000)........and there are a lot of folks that are right behind me.......so we KNOW mechanical valves have stood the test of time already.
 
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arkiebelle

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I don't regret my tissue valve at all but it hasn't been easy. I was 36 when I had my first OHS and chose a tissue valve because I wanted to have a child. I knew the price for that is another surgery in the future. Fast forward 11 years, that precious baby that I had prayed for is almost 8. I had my stenoic bovine mitral valve replaced with a mechanical one on Halloween 2018. The surgery was risky and recovery has been slow and difficult. I also developed a-fib, and have had 3 cardioversions, a MAZE, and now a cryoablation.
 
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