[HSF] Anticoagulation after mitral repair

[Prasanna Simha M]

This was a reply to an email nearly 2 years ago !!
Prasanna

On Thu, Mar 20, 2008 at 8:01 AM, Tea Acuff <tacuff at swbell.net> wrote:
> "Should I toss umpteen years of
>  >practice protocol out the window for this type of result?"
>
>  Only if you envision a different and better world.
>
>  "Are there analogies in other
>  >human endeavors that can help light the way to truth?"
>
>  Ever talked with someone that lost a child?
>
>  Sorry for your loss.
>
>  tea
>
>  ----- Original Message ----
>  From: Ben Bidstrup <benjamin.bidstrup at bigpond.com>
>  To: OpenHeart-L at lists.hsforum.com
>  Sent: Friday, May 26, 2006 2:15:56 PM
>  Subject: Re: [HSF] Anticoagulation after mitral repair
>
>  >Last week I did a mitral repair on a 73 year old male. He had LVEF
>  >70%, normal sinus rhythm, no coronary disease, normal or slightly
>  >elevated PA pressures.  I performed a quadarangular resection of a
>  >P2 flail, a classic plication of the posterior annulus and placement
>  >of a CG future band.  No MR or complications post op.  No a-fib or
>  >other arrhythmias.  On post-op day 5, I was sitting and talking to
>  >him about discharge instructions and his medications when right
>  >before my eyes he has a huge right hemispheric CVA.  Two minutes
>  >previously he was talking normally, and suddenly he has dense left
>  >hemiplegia with difficult to understand speech.  Normal carotid
>  >arteries and immediate echo shows no thrombus and no MR with good EF
>  >and sinus rhythm.  I did use one pledgeted stitch for the annulus.
>  >I have not been anticoagulating these types of patients post-op and
>  >have never had a CVA in this type of patient either.  Should these
>  >folks be anticoagulated for a period of time post-op?  Incidentally,
>  >one of my partners (whose routine it is to anticoagulate for 6 weeks
>  >after mitral repair) had a patient with an INR of 2 on Coumadin have
>  >a MASSIVE retroperitoneal bleed on post-op day 4.
>  >
>  >Is there a right or wrong approach.  Should I toss umpteen years of
>  >practice protocol out the window for this type of result?  I know we
>  >have had this type of discussion before, but how should one case
>  >influence a previous body of work?  Are there analogies in other
>  >human endeavors that can help light the way to truth?
>  >
>  >Signed a very frustrated
>  >Ed Bender, MD
>  >_______________________________________________
>  Every thing we do has a risk and a benefit. We quote mortalities of
>  <1% but that means that somewhere along the line 1 in say 200 will
>  die for no apparent cause. We will agonise over what we have done and
>  come up with maybe some suggestions. The same applies to stroke,
>  renal failure, GI Bleeds etc. At the STS Eric Jamieson reported on
>  anticoagulation in AVR (IMHO not too dissimilar a situation). I try
>  and avoid warfarin as I see more complications related to that than
>  to not using it. It will be perhaps easier in a year or 2 when some
>  of the newer oral agents (Factor Xa inhibitors oral once daily) or
>  direct thrombin inhibitors become available. Xemilgatran
>  unfortunately was a fizzer.
>  I do not anticoagulate AVRs or MV repairs with warfarin. ASA alone.
>  There is no evidence to support the addition of clopidogrel unless
>  there is aspirin resistance, and I would suggest that the risks of
>  using it would be higher than not.
>  --
>  Ben Bidstrup FRACS FRCSEd FEBCTS
>  Consultant Cardiothoracic Surgeon
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-- 
Prasanna Simha M