[HSF] Anticoagulation after mitral repair

Ben Bidstrup benjamin.bidstrup at bigpond.com
Thu Mar 20 22:57:43 EDT 2008 

Tea spent a bit of time thinking about that one!

>Tea I was saying that you have replied to an email posted by Ed 
>Bender in 2006.
>Prasanna
>
>On Thu, Mar 20, 2008 at 9:19 AM, Tea Acuff <tacuff at swbell.net> wrote:
>>  Surely you can show us, Prasanna, so I can give proper credit.
>>
>>   tea
>>
>>
>>
>>
>>   ----- Original Message ----
>>   From: Prasanna Simha M <prasannasimha at gmail.com>
>>   To: OpenHeart-L at lists.hsforum.com
>>
>>
>>  Sent: Wednesday, March 19, 2008 9:55:07 PM
>>   Subject: Re: [HSF] Anticoagulation after mitral repair
>>
>>   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
>>   _______________________________________________
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>
>
>
>--
>Prasanna Simha M
>_______________________________________________
>OpenHeart-L mailing list
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-- 
Ben Bidstrup FRACS FRCSEd FEBCTS
Consultant Cardiothoracic Surgeon

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