[HSF] Anticoagulation after mitral repair

Michael Firstenberg msfirst at gmail.com
Thu Mar 20 17:40:20 EDT 2008 

so in the past 1-2 years has the answer changed?

-michael



On 3/20/08, Tea Acuff <tacuff at swbell.net> wrote:
>
> 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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