[HSF] Anticoagulation after mitral repair

Tea Acuff tacuff at swbell.net
Thu Mar 20 13:00:13 EDT 2008 

I am not a technophile. Maybe Ed is still in mourning. Anyway (at my age?) anything that happened more than 2 weeks ago is open for brand new experience.

tea



----- Original Message ----
From: Prasanna Simha M <prasannasimha at gmail.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Thursday, March 20, 2008 3:12:19 AM
Subject: Re: [HSF] Anticoagulation after mitral repair

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
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