In: Mechanical Heart18 Sep 2014
In patients with a mechanical heart valve who are receiving long-term oral anticoagulant therapy and are undergoing elective surgery, the management of perioperative anticoagulation therapy is problematic. Temporary discontinuation of anticoagulants increases the risk of valve thrombosis and systemic embolism. On the other hand, continuing anticoagulants perioperatively, or stopping and restarting anticoagulants too soon after surgery, can cause life-threatening bleeding.- The optimal anticoagulation strategy would minimize the risk of thromboembolism (TE), without causing excessive postoperative bleeding. anti allergy drugs
To date, there is no consensus about the management of perioperative anticoagulation therapy in patients with a mechanical heart valve who are undergoing elective surgery, largely because of a lack of clinical trials investigating different anticoagulation strategies. The traditional management approach has been to hospitalize patients 3 to 4 days before surgery to discontinue warfarin or other oral anticoagulants and to start IV heparin, which is stopped 3 h before surgery. After surgery, IV heparin and warfarin are restarted when surgical hemostasis has been achieved, and heparin is continued until the anticoagulant effect of warfarin is within the therapeutic range. However, some authors have suggested that the risk of perioperative TE has been exaggerated,- and that perioperative IV heparin should be reserved for patients at highest risk for TE, eg, previous TE.> A less aggressive management approach involves temporary discontinuation of warfarin and the use of low-dose subcutaneous heparin postoperatively until patients are discharged from the hospital. Another approach, which is appealing for patients undergoing a surgical procedure that does not require overnight hospitalization, involves outpatient perioperative anticoagulant therapy with full-dose subcutaneous heparin or low-molecular-weight heparin (LMWH).
As a first step in designing prospective studies to investigate different perioperative anticoagulation strategies, we performed a survey to determine physicians’ anticoagulation preferences in patients with a mechanical heart valve who are undergoing elective surgery and to determine the effect of different risks of TE and postoperative bleeding on anticoagulation preferences.
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