AVR options

[Steve__0__0]

  I'm a 47 year old, very active male, diagnosed with severe aortic stenosis. I found
  out about this is 9/98 when visiting Dr. for checkup. I'm told that because I'm asymptomatic
  we are holding off on the valve replacement and the cardiologist will monitor me every 3 months for
  changes in the dopplar echochardiogram baseline, etc. Based on this I have some time to decide
  a valve option.
  I have read the many postings on this forum regarding the options and I have some
  questions:
  - If I chose the prosthetic valve option with the requisite coumadin use,
  is it true that alchohol consumption is prohibited?
  - Just how problematic and restrictive is the use of coumadin,
  I'm hearing and reading that this is a nasty drug to be on.
  I would like to find out as much as possible about being on coumadin before
  I decide to rule out a homograph replacement.
  - I just saw CCF's statistics for 1997 quoting 4500 open heart surgeries
  with about 1450 of these being valve replacements, how many of these 1450
  where done using the Ross procedure?
  Thanks
---------------------------------------------------------------------------------------------------------------------  
Dear Steve,
Thank you for your question.
Q: If I chose the prosthetic valve option with the requisite coumadin use,
is it true that alchohol consumption is prohibited?
A: Alcohol use is discouraged because of the potential interaction between alcohol and coumadin in patients with liver disease and due to the increased risks of bleeding if one was to fall after having a bit too much.  An occasional glass of wine would probably be ok with your doctor.
Q: Just how problematic and restrictive is the use of coumadin,
I'm hearing and reading that this is a nasty drug to be on. I would like to find out as much as possible about being on coumadin before I decide to rule out a homograph replacement.
A: This is a personal decision that must be made in conjunction with the surgeon.  Many people tolerate coumadin with no problems.  I have attached additional information about coumadin for your information.
Coumadin (generic name Warfarin) is a anticoagulant (blood thinner) that is used for a variety of conditions.  Common reasons for coumadin use are in atrial fibrillation to reduce the risk of stroke, in persons with clotting disorders, in persons with mechanical heart valves, and sometimes in people with severe heart failure.  The usual dosage is somewhere between 1 and 15 mg a day.  Potential side effects include bleeding, hair loss, nausea, vomiting, stomach cramps, diarrhea and leukopenia (low blood cell count).  The half life (amount of time for half the drug to be cleared from the body is 42 hours but varies widely depending on the individual).  
Many drugs interact with coumadin and may cause more anticoagulation effect (clofibrate, diazoxide, ethacrynic acid, nalidixic acid, phenylbutazone, salicylates, aspirin, sulfonamides, alcohol, allopurinol, amiodarone, cimetidind, phenytoin, erythromycin, gemfibrozil, propranolol, thyroid drugs) or decreased anticoagulation effect (smoking, estrogens, vitamin K, aluminum hydroxide - antiacids, cholestipol, spironolactone).  See complete list below.  The effects of coumadin must be carefully monitored by a blood test called an INR.  Usually this is checked more often at the onset of taking the drug and less often once a steady state has been reached.  Therapeutic INR is usually 2 to 3 depending on the condition being treated.
Pregnant women and those with a hypersensitivity to coumadin should not take this medication.  
The medication should not be taken with food and any signs of bleeding should be reported to your doctor.  Use a soft toothbrush, avoid hazardous activities, carry Medi-Alert ID identifying drug useage and notify your doctor if you have any dark brown urine or red or tarry black stools.
Known Drug interactions with Warfarin
Increased Effect :
                       Highly Probable
                            Alcohol (if concomitant liver disease)
                            Amiodarone
                            Cimetadine
                            Clofibrate
                            Cotrimoxazole
                            Erythromycin
                            Fluconazole
                            Isoniazid
                            Metronidazole
                            Miconazole
                            Omeprazole
                            Phenylbutazone
                            Piroxicam
                            Propafenone
                            Propanolol
                            Sulfinpyrazone
                       Probable
                            Acetaminophen (Tylenol®)
                            Anabolic steroids
                            Aspirin
                            Chloral Hydrate
                            Ciprofloxacin
                            Dextropropoxyphene
                            Disulriam
                            Quinidine
                            Phenytoin (Dilantin®)
                            Simvastatin
                            Tamoxifen
                            Tetracycline
                            Influenza vaccine
                       Possible
                            Disopyramide
                            5-Fluorouracil
                            Ifosphamide
                            Lovastatin
                            Metolazone
                            Nalidixic Acid
                            Norfloxacin
                            Ofloxacin
                            Topical salicylates
                            Sulindac
                            Tometin
                       Doubtful
                            Cefamandole
                            Cefazolin
                            Gemfibrozil
                            Heparin
                            Indomethacin
                            Sulfisoxazole
Decreased Effect
                        
                       Highly Probably
                            Barbiturates
                            Carbamazepine
                            Chlorodiazepoxide
                            Cholestyramine
                            Griseofulvin
                            Nafcillin
                            Rifampin
                            Sucralfate
                       Probable
                            Dicloxacillin
                       Possible
                            Azathioprine
                            Cyclosporine
                            Etrelinate
                            Trazodone

No Effect
                    
                       Highly Probable
                            Alcohol (if no liver disease)
                            Antacids
                            Atenolol
                            Bumetanide
                            Diflunisal
                            Enoxacin
                            Famotidine
                            Felodipine
                            Fluoxetine
                            Ketorolac
                            Metoprolol
                            Moricizine
                            Naproxen
                            Nitrazepam
                            Nizatidine
                            Psyllium
                            Ranitidine
                       Probable
                            Ibuprofen
                            Ketoconazole
                            Ketoprofen
                       Doubtful
                            Diltiazem
                            Tobacco
                            Vancomycin

Other Web Sites:
http://search.excite.com/search.gw?c=web&s=coumadin+or+warfarin&showSummary=false&start=20&perPage=20&prev=Previous+Results
Package insert and patient information:
http://www.dupontmerck.com/coumadin/cnsmindx.htm
Food interactions with coumadin:
http://www.rncentral.com/library/health/warfarin.html
Patient information and links:
http://www.hsforum.com/HeartSurgery/TLC/Coumadin/Coumadin.hsf

Q: I just saw CCF's statistics for 1997 quoting 4500 open heart surgeries
with about 1450 of these being valve replacements, how many of these 1450
where done using the Ross procedure?
A: I don't believe we are doing any Ross procedures due to the high complication rate of the procedure.
I hope you find this information useful.  Information provided in the heart forum is for general purposes only.  Only your physician can provide specific diagnoses and therapies.  Please feel free to write back with additional questions.
If you would like to make an appointment at the Cleveland Clinic Heart Center, please call 1-800-CCF-CARE or inquire online by using the Heart Center website at www.ccf.org/heartcenter.  The Heart Center website contains a directory of the cardiology staff that can be used to select the physician best suited to address your cardiac problem.