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From the Publishers of Surgery with a Prosthetic ValveWhat about the Warfarin? COPYRIGHT © 2014, ALL RIGHTS RESERVED Terms of Use The Consult Guys® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the Consult Guys® slide sets constitutes copyright infringement. Copyright © 2014 Copyright © 2014 Case Mechanical prosthetic aortic valve Laparoscopic cholecystectomy “Cleared” for surgery Perioperative anticoagulation management Copyright © 2014 ACC / AHA Guideline 2002 Philosophy “… the concept of ‘medical clearance’ for surgery is short sighted.” Goals of the preoperative consult: Evaluate current medical status Advise on disease management in the periop period At times recommend preventive measures for future Define your role in care (Co-manager, subspecialty consultant) Copyright © 2014 Clearance 2007 The consultant should not use phrases such as “clear for surgery”. --ACC / AHA 2007 Guidelines on Perioperative cardiovascular Evaluation and Care for Noncardiac Surgery Copyright © 2014 Case Options for our Patient: A. Perform the surgery while INR Therapeutic Discontinue warfarin 5 days prior to surgery and admit to hospital for continuous heparin infusion. Discontinue heparin 8-12 hours before surgery C. Discontinue warfarin 5 days prior to surgery and begin low molecular weight heparin during the period of subtherapeutic INR D. Discontinue warfarin 72 hours prior to procedure and restart warfarin within 24 hours after the procedure B. Copyright © 2014 Antithrombotic Therapy in Patients with Mechanical Valves who Require Interruption of Warfarin Therapy for Noncardiac Surgery Continue antithrombotic therapy for procedures where bleeding inconsequential: Skin Eye surgery Dental Copyright © 2014 Cleaning Caries Journal of the American Dental Association, November 2003 Review of Clinical Studies: anticoagulants and dental procedures Warfarin and Low dose Aspirin (100 mg/d) Copyright © 2014 J Canadian Dental Assn, February 2009 Copyright © 2014 J. Canadian Dental Assn, February 2009 Copyright © 2014 Copyright © 2014 Low risk of valve thrombosis Bileaflet aortic valve Normal LV function Sinus rhythm Stop warfarin 48-72 hours before procedure Restart warfarin within 24 hours after Copyright © 2014 High risk of valve thrombosis: mitral valve tricuspid valve Aortic valve AND atrial fibrillation prior thromboembolism hypercoagulable older generation valve LVEF < 30% a second mechanical valve Therapeutic unfractionated heparin when INR < 2.0 Restart as soon as possible Copyright © 2014 Copyright © 2014 Bridge Therapy Copyright © 2014 Copyright © 2014 Mechanical valve: Bridge anticoag ACCP 9th ed Thromboembolic risk Low Moderate High Copyright © 2014 Bridge None Maybe Yes High Risk for thromboembolism Mitral prosthesis Older aortic prosthesis Recent TIA, stroke Moderate Risk for thromboembolism Bileaflet aortic valve AND atrial fibrillation prior stroke, TIA CHADS2 pts Low Risk for thromboembolism Bileaflet aortic valve Copyright © 2014 Copyright © 2014 Laparoscopic cholecystectomy and anticoagulation 44 patients chronic oral anticoagulation Protocol Stop OAC 5 days preop Bridge (LMWH) start 3 days preop Postop LMWH and oral anticoagulant 25% postoperative bleed vs. 1.5% control group Copyright © 2014 The Guys replies Do not use “cleared” for surgery The patient is at low risk for thrombosis of his prosthetic aortic valve Discontinue warfarin 72 hours prior to this procedure and resume warfarin within 24 hours following the surgery Copyright © 2014 Produced by and COPYRIGHT © 2014, ALL RIGHTS RESERVED