[HSF] Anticoagulation after biological valve or repair

[Edward P Raines]

After four units of FFP and Vit. K his INR was 1.7.  Took him to the  
OR on 15 mic. of dopa. and prepped and draped prior to induction of  
anesthesia.  Removed 1200 cc of clot and blood with not obvious source  
of bleeding.  Lungs intact again.  Off dpopa near extubation in ICU.   
He is in NSR, EF okay so not sure why he is on coumadin.


             Ed

Sent from my iPod

On May 3, 2008, at 1:47 PM, "Michael Firstenberg" <msfirst at gmail.com>  
wrote:

> 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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