1. Surgery with a Prosthetic Valve- What about the Warfarin? COPYRIGHT © 2014, ALL RIGHTS RESERVED From the Publishers of

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3. Copyright © 2014 Dear Consult Guys; I need your advice with this one. One of my patients needs cholecystectomy and has a prosthetic aortic valve. My question relates to his preoperative warfarin management. He is 70 years old and underwent aortic valve replacement (bileaflet mechanical valve) as treatment of aortic stenosis five years ago. He has no history of atrial fibrillation, hypertension, diabetes, TIA or stroke. A recent echocardiogram demonstrated normal left ventricular function. He has been maintained on warfarin anticoagulation with INR 2.5 – 3.0 I received a call from a surgeon today and was told that as treatment of chronic cholecystitis he is scheduled to undergo laparoscopic surgery in 10 days. I’ve “cleared” him for surgery but I’m not exactly sure what to do about his need for anticoagulation in the perioperative period. Can you guys give me your thoughts? Dear Consult Guys; I need your advice with this one. One of my patients needs cholecystectomy and has a prosthetic aortic valve. My question relates to his preoperative warfarin management. He is 70 years old and underwent aortic valve replacement (bileaflet mechanical valve) as treatment of aortic stenosis five years ago. He has no history of atrial fibrillation, hypertension, diabetes, TIA or stroke. A recent echocardiogram demonstrated normal left ventricular function. He has been maintained on warfarin anticoagulation with INR 2.5 – 3.0 I received a call from a surgeon today and was told that as treatment of chronic cholecystitis he is scheduled to undergo laparoscopic surgery in 10 days. I’ve “cleared” him for surgery but I’m not exactly sure what to do about his need for anticoagulation in the perioperative period. Can you guys give me your thoughts?

4. Copyright © 2014 Mechanical prosthetic aortic valve Laparoscopic cholecystectomy “Cleared” for surgery Perioperative anticoagulation management Case

5. Copyright © 2014 “… 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) ACC / AHA Guideline 2002 Philosophy

6. Copyright © 2014 The consultant should not use phrases such as “clear for surgery”. --ACC / AHA 2007 Guidelines on Perioperative cardiovascular Evaluation and Care for Noncardiac Surgery Clearance 2007

7. Copyright © 2014 Options for our Patient: A. Perform the surgery while INR Therapeutic B. 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 Case

8. 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  Cleaning  Caries

9. Copyright © 2014 Journal of the American Dental Association, November 2003 Review of Clinical Studies: anticoagulants and dental procedures Warfarin and Low dose Aspirin (100 mg/d)

10. Copyright © 2014 J Canadian Dental Assn, February 2009

11. Copyright © 2014 J. Canadian Dental Assn, February 2009

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13. 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

14. 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

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16. Bridge Therapy

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18. Mechanical valve: Bridge anticoag ACCP 9 th ed Thromboembolic risk Bridge LowNone ModerateMaybe HighYes

19. Copyright © 2014 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

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21. 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

22. 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

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