Aa
bioprosthetic or mechanical
For a 50 year old female, which has the higher risk a bioprosthetic mitral valve that may need to be replaced in 15 years, or a mechanical valve that requires long term coumadin use. I have had colon cancer that requires colonoscopies every 3 years to monitor & I need bunion surgery within the next year. Would the risk for developing a clot while off coumadin for these procedures be higher than the risk of another valve replacement? Surgery in 1 week & trying to make a highly informed decision, but very confused with the risks of one against the other.
This discussion is related to Re: 12 years after AVR, still no coumadin.
This discussion is related to Re: 12 years after AVR, still no coumadin.
"So, you can either opt for the best solution today, or opt for the option which gives you much lower risk in the near future". .Well said. That is exactly how I wanted to say it :)
I think Kenkeith is wise here with looking not at availability now, but what will soon be available. Many valves in europe are successfully replaced with very little invasion, and the US will soon follow, seeing the years of this success in Europe. I don't believe this option would be available if you have a mechanical valve. New synthetics are constantly being developed and tested in research and I'm sure it won't be too long before a valve is developed which will require no medication. So, you can either opt for the best solution today, or opt for the option which gives you much lower risk in the near future.
On the horizon, and possibly something you and your doctors may consider, is a new valve without cracking the chest. There are two competing types of these transcatheter valves already sold in Europe...and manufacturer Edwards Lifesciences Corp. hopes to win U.S. Food and Drug Administration"s approval to sell its version for patients in about a year.
If you go for the bio valve now, replacement in the future may be a minimal risk. Given you age is now 50 and if and when you may require another valve in 15 years, your overall health may be an issue at that time and under current interventional procedure may put one at a hgh risk. But if, and I am sure it will occur, there can be a replacement or repair with very little risk for an elderly, frail patient...if that is a health issue at the time. Take care.
If you go for the bio valve now, replacement in the future may be a minimal risk. Given you age is now 50 and if and when you may require another valve in 15 years, your overall health may be an issue at that time and under current interventional procedure may put one at a hgh risk. But if, and I am sure it will occur, there can be a replacement or repair with very little risk for an elderly, frail patient...if that is a health issue at the time. Take care.
Well to be blunt, you'd be an idiot, a complete idiot to get a tissue valve as it will wear out necessitating at least 2 open heart surgeries before the age of 80. And 15 years is optimistic, think 10 years in terms of this.
Long term the risk of bleeding goes up. But coupled against the risk of multiple open heart surgeries with neurological damage factored in. The overwhelming advice is mechanical.
There are exceptions to the rule, but at your age and since you stated no obvious exception, then your choice is mechanical as I am certain your cardiologist and surgeon indicated
Long term the risk of bleeding goes up. But coupled against the risk of multiple open heart surgeries with neurological damage factored in. The overwhelming advice is mechanical.
There are exceptions to the rule, but at your age and since you stated no obvious exception, then your choice is mechanical as I am certain your cardiologist and surgeon indicated
Correction. "Your interest with the medication and a prosthetic heart valves pose a particular problem" s/b medication and mechanical valve.
Coumadin pre-operatively, as you state one considers the risks of hemorrhage or thromboembolism versus the benefit from the operation. When considering noncardiac surgery, these factors and the need to weigh the risk of hemorrhage against that of thromboembolism must analyzed on an individual patient basis.
Certain procedures such as a bunion that are not procedure that threatens limb or life are easy analysis.
The approach options for a patient can be one of the following:
continue warfarin therapy, withhold warfarin therapy for a period of time before and after the procedure, or temporarily withhold warfarin therapy and also provide a "heparin bridge" during the perioperative period. Which management option to follow is primarily determined by the characteristics of the patient and by the nature of the procedure.
There are guidelines with American College of Chest Physicians that have proposed guidelines for antithrombotic prophylaxis in patients with different risk factors, and it recommends that if the risk for thromboembolism is low, warfarin therapy can be withheld for 4-5 days before the procedure without bridging.
Your interest with the medication and a prosthetic heart valves pose a particular problem. "Arterial thromboembolism from the heart often results in death (40% of events) or major disability (20% of events)". The greatest problem encountered is that no consensus exists regarding the optimal pre-operative management of anticoagulation for patients who have been receiving long-term warfarin therapy. "Some prospective studies have suggested that patients on long-term warfarin therapy who undergo minor invasive procedures and are taken off their oral anticoagulation for up to 5 days have a less than 1% risk of experiencing a thromboembolic event".
Heparin bridging: It has been suggested that patients on long-term warfarin therapy (including those with mechanical heart valves or atrial fibrillation) who are undergoing minor elective invasive outpatient procedures (eg, colonoscopy, dental procedures) may have a slightly increased risk of perioperative bleeding if placed in some form of heparin therapy (eg, heparin bridge) than those who have their oral anticoagulation withheld for 4-5 days (major hemorrhage 3.7% vs 0.2% and significant nonmajor hemorrhage 9% vs 0.6%, respectively).
Cleveland Clinic: " Some prospective studies have suggested that patients on long-term warfarin therapy who undergo minor invasive procedures and are taken off their oral anticoagulation for up to 5 days have a less than 1% risk of experiencing a thromboembolic event."
The American College of Chest Physicians proposed guidelines for antithrombotic prophylaxis in patients with different risk factors, and it recommends that if the annual risk for thromboembolism is low, warfarin therapy can be withheld for 4-5 days before the procedure without bridging.
High risk patients only is bridge therapy, "the warfarin is discontinued and when the INR drops below the therapeutic level, heparin (usually low molecular weight heparin which may be easier administered at home) is instituted. The heparin is discontinued on the day of the procedure (or the day before depending upon the timing and the planned procedure) and resumed later that day, or the next day. This protects the patient from developing a blood clot while off anticoagulant therapy as the blood is thinned by the heparin until the warfarin is therapeutic in the body".
Usually, a younger patient goes with the mechanical valve to avoid a replacement risk. Also, one does not know what the future may be for replacement...less risk, different procedure, etc. There is no easy answer, but you may find the stats helpful for clots, etc. Take care and thanks for sharing.
Certain procedures such as a bunion that are not procedure that threatens limb or life are easy analysis.
The approach options for a patient can be one of the following:
continue warfarin therapy, withhold warfarin therapy for a period of time before and after the procedure, or temporarily withhold warfarin therapy and also provide a "heparin bridge" during the perioperative period. Which management option to follow is primarily determined by the characteristics of the patient and by the nature of the procedure.
There are guidelines with American College of Chest Physicians that have proposed guidelines for antithrombotic prophylaxis in patients with different risk factors, and it recommends that if the risk for thromboembolism is low, warfarin therapy can be withheld for 4-5 days before the procedure without bridging.
Your interest with the medication and a prosthetic heart valves pose a particular problem. "Arterial thromboembolism from the heart often results in death (40% of events) or major disability (20% of events)". The greatest problem encountered is that no consensus exists regarding the optimal pre-operative management of anticoagulation for patients who have been receiving long-term warfarin therapy. "Some prospective studies have suggested that patients on long-term warfarin therapy who undergo minor invasive procedures and are taken off their oral anticoagulation for up to 5 days have a less than 1% risk of experiencing a thromboembolic event".
Heparin bridging: It has been suggested that patients on long-term warfarin therapy (including those with mechanical heart valves or atrial fibrillation) who are undergoing minor elective invasive outpatient procedures (eg, colonoscopy, dental procedures) may have a slightly increased risk of perioperative bleeding if placed in some form of heparin therapy (eg, heparin bridge) than those who have their oral anticoagulation withheld for 4-5 days (major hemorrhage 3.7% vs 0.2% and significant nonmajor hemorrhage 9% vs 0.6%, respectively).
Cleveland Clinic: " Some prospective studies have suggested that patients on long-term warfarin therapy who undergo minor invasive procedures and are taken off their oral anticoagulation for up to 5 days have a less than 1% risk of experiencing a thromboembolic event."
The American College of Chest Physicians proposed guidelines for antithrombotic prophylaxis in patients with different risk factors, and it recommends that if the annual risk for thromboembolism is low, warfarin therapy can be withheld for 4-5 days before the procedure without bridging.
High risk patients only is bridge therapy, "the warfarin is discontinued and when the INR drops below the therapeutic level, heparin (usually low molecular weight heparin which may be easier administered at home) is instituted. The heparin is discontinued on the day of the procedure (or the day before depending upon the timing and the planned procedure) and resumed later that day, or the next day. This protects the patient from developing a blood clot while off anticoagulant therapy as the blood is thinned by the heparin until the warfarin is therapeutic in the body".
Usually, a younger patient goes with the mechanical valve to avoid a replacement risk. Also, one does not know what the future may be for replacement...less risk, different procedure, etc. There is no easy answer, but you may find the stats helpful for clots, etc. Take care and thanks for sharing.
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