[HSF] Anticoagulation after mitral repair

Tea Acuff tacuff at swbell.net
Thu Mar 20 21:48:03 EDT 2008 

Does anyone have any good data that platlet inhibitors are best for arterial clotting and coumadin/ heparin for venous. It seems a little too artifical a divide from the clotting system perspective to me. Sounds like a surgeon explanation perhaps?

tea



----- Original Message ----
From: Michael Firstenberg <msfirst at gmail.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Thursday, March 20, 2008 9:00:33 PM
Subject: Re: [HSF] Anticoagulation after mitral repair

but ACC/AHA guidelines from the Cardiologists say coumadin.

-michael


On 3/20/08, Prasanna Simha M <prasannasimha at gmail.com> wrote:
>
> Nope
> Still only Aspirin.
> Prasanna
>
> On Fri, Mar 21, 2008 at 2:10 AM, Michael Firstenberg <msfirst at gmail.com>
> wrote:
> > 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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> --
> Prasanna Simha M
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