[HSF] Anticoagulation after biological valve or repair

[Michael Firstenberg]

Rat Poison, I say, rat poison...... good luck!
(not to wish this on anyone, but how do you know this is not a leaking
pseudo-aneurysm or suture line problem... i.e. reinfection or some other
problem)

My philosophy is that patients on coumadin or who need coumadin get 1 life
threatening bleeding complication then I discuss with them and their
families coming off of it (unless they really really need it - like for a
mechanical valve - when I was general surgery resident and saw a lot of
trauma, I was amazed at how many patients were on coumadin/plavix/both for
very vague reasons).  Coumadin for afib is the worse - 6-20% risk of a
stroke (minor TIA to death) per year vs. a major bleeding complication (like
GI bleeding, scopes, hematomas, etc)..... Most patients after they have a
complication will opt for no coumadin.


-michael


On 5/3/08, DukeB60 at aol.com <DukeB60 at aol.com> wrote:
>
> I just got a call from the ED and a  cardiologist regarding a post-op.
> third
> time redo aortic valve who  presented today with hypotension.  He had a
> previous AVR a few years ago  with subsequent prosthetic endocarditis and
> got a
> tissue valve replacement only  to develop a large perivalvular leak and
> subvalvular aneurysm for which I was  consulted.  He has very, very severe
> bullous
> emphysema with his lungs  touching in the midline for six inches before
> you could
> even get to the heart by  preop CT.  I did his redo, redo AVR a couple of
> weeks
> ago and by some  miracle was able to dissect down to the heart and aorta
> without a hint of an air  leak and replaced his valve and repaired a
> subvalvular
> aneurysm bulging into the  LA due to a disruption of the Aorto-Mitral
> continuity.  He remarkably did  very well and was discharged only to
> return today with
> hypotension and a CT  showing a large mediastinal hematoma causing
> tampanode.
> Oh by the way, his  INR is 6.  I'm waiting right now to get some FFP
> infused
> then evacuate the  hematoma and deal with those lungs again.  I'm not sure
> why
> he is on  Coumadin.  It only reinforces the points made previously that
> the
> morbidity  of the coumadin outweight the risk of CNS events but the cards
> do
> love  coumadin.
>
>
>                              Ed
>
> Edward P. Raines, M.D., J.D.
> BryanLGH  Cardiothoracic Surgery
> BryanLGH Medical Center East
> 1600 South 48th  Str.
> Lincoln, Nebraska 68506
> Office: 402-481-8430
> Cell:  402-730-9242
> Fax: 402-481-8429
>
>
>
>
>
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