Valves and Anticoagulation

[DrMetal]

Can somebody check me here to make sure I have this right (I was going through the ACC guidelines):

• Aortic Mechanical Valve , AC = Coumadin(lifelong) + ASA 81mg(lifelong) , goal INR 2.5
• Aortic Mechanical Valve + other comorbids (AF, low EF, previous clots), AC is same as above, goal INR 3.0
• Mitral Mechanical Valve, AC = Coumadin(lifelong) + ASA 81mg(lifelong) , goal INR 3.0 (always).
• Aortic/Mitral BIOPROSTHETIC Valve, AC = +/- Coumadin for first 3-6 months post-op, then can DC it. While on coumadin, goal INR 2.5/3.0 for aortic/mitral respectively. Aspiring 81 mg Lifelong

----So even in the case of Mitral Bioprosthetic Valve, you can DC the coumadin after 3-6 months post op (if you started the coumadin at all) and go with just ASA 81mg monotherapy for AC, right? (and assuming no other comorbids)


To Bridge or not bridge for a major surgery: I've seen some make a distinction between Aortic and Mitral valves (the former not requiring bridging, you can just just turn off the coumadin...the mitral always requiring bridging). That distinction doesn't quit make sense to me.

It makes more senses to me, that if you have the patient on outpatient coumadin (for any reason....you're trying to keep the patient in a "higher level" of AC for some protective benefit), wouldn't you always want to bridge with heparin gtt (irrespective of aortic vs mitral valve)?

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[ROBINHO]

Can somebody check me here to make sure I have this right (I was going through the ACC guidelines):

• Aortic Mechanical Valve , AC = Coumadin(lifelong) + ASA 81mg(lifelong) , goal INR 2.5
• Aortic Mechanical Valve + other comorbids (AF, low EF, previous clots), AC is same as above, goal INR 3.0
• Mitral Mechanical Valve, AC = Coumadin(lifelong) + ASA 81mg(lifelong) , goal INR 3.0 (always).
• Aortic/Mitral BIOPROSTHETIC Valve, AC = +/- Coumadin for first 3-6 months post-op, then can DC it. While on coumadin, goal INR 2.5/3.0 for aortic/mitral respectively. Aspiring 81 mg Lifelong

----So even in the case of Mitral Bioprosthetic Valve, you can DC the coumadin after 3-6 months post op (if you started the coumadin at all) and go with just ASA 81mg monotherapy for AC, right? (and assuming no other comorbids)


To Bridge or not bridge for a major surgery: I've seen some make a distinction between Aortic and Mitral valves (the former not requiring bridging, you can just just turn off the coumadin...the mitral always requiring bridging). That distinction doesn't quit make sense to me.

It makes more senses to me, that if you have the patient on outpatient coumadin (for any reason....you're trying to keep the patient in a "higher level" of AC for some protective benefit), wouldn't you always want to bridge with heparin gtt (irrespective of aortic vs mitral valve)?

1. Your algorithm per ACC guideline is right

2. Bioprosthetic after 3-6 months stop anticoagulation irrespective of mitral. The whole idea of the 3-6 months is to allow the valve to endothelize

3. Your bridging information is a bit off . Look at the 2017 updated guidelines on valvular heart disease. Concise delineation of bridging in valvular disease

There is a quite a difference between aortic and mitral valves. When you eject blood from the left ventricle, it goes through aortic valve. There is always a high flow in that valve so lower risk of thrombosis. Mitral valve has a lower flow so the risk of thrombosis is higher (that is why people distinguish them). However, the distinction does stop at just mitral versus aortic. When it comes to bridging you gotta treat aortic + Afib, aortic + any thromboembolic risk, ball and cage aortic valve etc just like how you treat mitral valve.

Aortic valve WITHOUT RISK FACTOR= yes you can turn down anticoagulation temporarily

 

[DrMetal]

Aortic valve WITHOUT RISK FACTOR= yes you can turn down anticoagulation temporarily

And this is true, irrespective of the type of Aortic valve? Aortic mechanical or Aortic bioprosthetic , if no risk factors, does not require bridging for major surgeries? (you just turn off the coumadin 2-3 days before, have the surgery, restart coumadin once surgically safe to do so?).

Thanks for the reply!

 

[francisco84]

And this is true, irrespective of the type of Aortic valve? Aortic mechanical or Aortic bioprosthetic , if no risk factors, does not require bridging for major surgeries? (you just turn off the coumadin 2-3 days before, have the surgery, restart coumadin once surgically safe to do so?).

Thanks for the reply!

Well, bio-avr don't need long term AC. But yes, mechanical avr with no risk factors can go without bridging. And if you need to bridge, you can do so with LMWH.