warfarin and Postoperative-Complications

The aim of this study was to evaluate the efficacy and safety of the anticoagulants for the prevention of portal vein system thrombosis (PVST) in patients with cirrhosis after splenectomy and explore the optimal time of anticoagulant administration.. A systematic literature search was performed using PubMed, Embase and China Biology Medicine disc (CBM)databases, so as to screen out studies comparing the prognoses between cirrhotic post-splenectomy patients treated with and without anticoagulants. The parameters that were analyzed included the incidence of PVST and postoperative bleeding.. With a total of 592 subjects, we included 8 studies (6 observational and 2 randomized trials) that fulfilled the inclusion criteria. We found that the incidence of PVST was significantly lower in the anticoagulation group during the first 6 months of anticoagulant administration. And the largest difference in the incidence of PVST between the anticoagulation and control groups was observed at 3 months (odds ratio 0.17(0.11~0.27); P = 0.767; I2 = 0.0%) and 6 months (OR = 0.21(0.11~0.40); P = 0.714; I2 = 0.0%) postoperatively. The incidence of bleeding was not significantly higher in the anticoagulation group (odds ratio 0.71 (0.30~1.71); P = 0.580; I2 = 0.0%).. Low-molecular weight heparin (LMWH) and warfarin can decrease the incidence of PVST in post-splenectomy cirrhotic patients without an increased risk of bleeding. And the optimal use time of warfarin is 6 months after splenectomy.

Topics: Anticoagulants; Heparin, Low-Molecular-Weight; Humans; Liver Cirrhosis; Portal Vein; Postoperative Complications; Splenectomy; Venous Thrombosis; Warfarin

Aspirin is increasingly recognised as an efficacious thromboprophylactic agent with a superior safety profile compared to alternatives. Following our institution's previously published experience we implemented a risk-stratified protocol utilising aspirin as standard. We now present retrospective review of standard use of aspirin on fatal pulmonary embolism, all-cause mortality, and venous thromboembolism (VTE) following total hip arthroplasty (THA).. A consecutive series of elective THAs was identified. Prospectively maintained databases were analysed to yield demographic data and identify deaths or readmission data. Patients who died within 90 postoperative days underwent review of the complete medical record.. 4204 THAs were included in the study cohort. VTE prophylaxis prescription was available in 3805. 2560 received aspirin (67.3%), 1049 enoxaparin (27.6%) and 193 warfarin (5.1%); there were no differences in 90-day all-cause mortality (. Our large series continues to demonstrate that aspirin for thromboprophylaxis following THA is effective in risk-stratified patients. Furthermore, we demonstrate that introduction of a departmental protocol establishing aspirin as standard practice was not associated with increased mortality or incidence of thromboembolism. Taken in conjunction with our previous cohort our series encompasses 11,420 consecutive THAs. There has been a single death following fatal PE in the aspirin group (0.02%) compared to 5 in the LMWH group (0.2%) and 1 in the warfarin group (0.06%). We join calls for large-scale randomised controlled trials to elucidate the place of aspirin in VTE prevention following hip arthroplasty.

Topics: Anticoagulants; Arthroplasty, Replacement, Hip; Aspirin; Heparin, Low-Molecular-Weight; Humans; Postoperative Complications; Venous Thromboembolism; Warfarin

Graft thrombosis is a well-recognised complication of solid organ transplantation and is one of the leading causes of graft failure. Currently there are no standardised protocols for thromboprophylaxis. Many transplant units use unfractionated heparin (UFH) and fractionated heparins (low molecular weight heparin; LMWH) as prophylaxis for thrombosis. Antiplatelet agents such as aspirin are routinely used as prophylaxis of other thrombotic conditions and may have a role in preventing graft thrombosis. However, any pharmacological thromboprophylaxis comes with the theoretical risk of increasing the risk of major blood loss following transplant. This review looks at benefits and harms of thromboprophylaxis in patients undergoing solid organ transplantation.. To assess the benefits and harms of instituting thromboprophylaxis to patients undergoing solid organ transplantation.. We searched the Cochrane Kidney and Transplant Register of Studies up to 10 November 2020 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.. We included all randomised controlled trials (RCTs) and quasi-RCTs designed to examine interventions to prevent thrombosis in solid organ transplant recipients. All donor types were included (donor after circulatory (DCD) and brainstem death (DBD) and live transplantation). There was no upper age limit for recipients in our search.. The results of the literature search were screened and data collected by two independent authors. Dichotomous outcome results were expressed as risk ratio (RR) with 95% confidence intervals (CI). Random effects models were used for data analysis. Risk of bias was independently assessed by two authors using the risk of bias assessment tool. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.. We identified nine studies (712 participants). Seven studies (544 participants) included kidney transplant recipients, and studies included liver transplant recipients. We did not identify any study enrolling heart, lung, pancreas, bowel, or any other solid organ transplant recipient. Selection bias was high or unclear in eight of the nine studies; five studies were at high risk of bias for performance and/or detection bias; while attrition and reporting biases were in general low or unclear. Three studies (180 participants) primarily investigated heparinisation in kidney transplantation. Only two studies reported on graft vessel thrombosis in kidney transplantation (144 participants). These small studies were at high risk of bias in several domains and reported only two graft thromboses between them; it therefore remains unclear whether heparin decreases the risk of early graft thrombosis or non-graft thrombosis (very low certainty). UFH may make little or no difference versus placebo to the rate of major bleeding events in kidney transplantation (3 studies, 155 participants: RR 2.92, 95% CI 0.89 to 9.56; I² = 0%; low certainty evidence). Sensitivity analysis using a fixed-effect model suggested that UFH may increase the risk of haemorrhagic events compared to placebo (RR 3.33, 95% CI 1.04 to 10.67, P = 0.04). Compared to control, any heparin (including LMWH) may make little or no difference to the number of major bleeding events (3 studies, 180 participants: RR 2.70, 95% CI 0.89 to 8.19; I² = 0%; low certainty evidence) and had an unclear effect on risk of readmission to intensive care (3 studies, 180 participants: RR 0.68, 95% CI 0.12 to 3.90, I² = 45%; very low certainty evidence). The effect of heparin on our other outcomes (including death, patient and graft survival, transfusion requirements) remains unclear (very low certainty evidence). Three studies (144 participants) investigated antiplatelet interventions in kidney transplantation: aspirin versus dipyridamole (1), and Lipo-PGE. Overall, there is a paucity of research in the field of graft thrombosis prevention. Due to a lack of high quality evidence, it remains unclear whether any therapy is able to reduce the rate of early graft thrombosis in any type of solid organ transplant. UFH may increase the risk of major bleeding in kidney transplant recipients, however this is based on low certainty evidence. There is no evidence from RCTs to guide anti-thrombotic strategies in liver, heart, lung, or other solid organ transplants. Further studies are required in comparing anticoagulants, antiplatelets to placebo in solid organ transplantation. These should focus on outcomes such as early graft thrombosis, major haemorrhagic complications, return to theatre, and patient/graft survival.

Topics: Anticoagulants; Aspirin; Bias; Dipyridamole; Hemorrhage; Heparin; Heparin, Low-Molecular-Weight; Humans; Kidney Transplantation; Liver Transplantation; Placebos; Platelet Aggregation Inhibitors; Postoperative Complications; Randomized Controlled Trials as Topic; Thrombosis; Transplant Recipients; Warfarin

Decisions surrounding periprocedural anticoagulation management must balance thromboembolic and procedural bleed risk. The interruption of both warfarin and DOACs requires consideration of anticoagulant pharmacokinetics, procedural bleed risk and patient characteristics. There is a diminishing role for periprocedural bridging LMWH overall and no role for bridging LMWH for the procedural interruption of DOACs. A clinical approach to perioperative DOAC management based on operative bleeding risk and renal function is safe and effective, and at present, is preferred over preprocedural DOAC levels testing. Clear communication of the anticoagulation interruption plan to both the patient and the patient's care team is essential.

Topics: Administration, Oral; Anticoagulants; Atrial Fibrillation; Dabigatran; Hemorrhage; Heparin, Low-Molecular-Weight; Humans; Perioperative Care; Postoperative Complications; Pyrazoles; Pyridones; Randomized Controlled Trials as Topic; Risk Assessment; Risk Factors; Rivaroxaban; Stroke; Surgical Procedures, Operative; Warfarin

Oral anticoagulants (OACs) are a class of medications commonly used in the long-term management of patients at risk of thrombosis. They include warfarin and direct oral anticoagulants (DOACs). The aging of the population and improvements in perioperative care have led to an increase in the number of patients on OACs and presenting for different types of elective and emergency surgery. Perioperative management of OACs constitutes a unique challenge. It is based on the quantification of a patient's individual hemorrhagic and thrombotic risk together with the intrinsic surgical bleeding risk. We reviewed current guidelines to define effective discontinuation of OACs, the need for bridging with different anticoagulants, and post-surgery OACs re-initiation. We also discussed the option for acute reversal of anticoagulation.

Topics: Anticoagulants; Blood Coagulation; Factor Xa Inhibitors; Hemorrhage; Humans; Postoperative Complications; Practice Guidelines as Topic; Preoperative Care; Risk Factors; Thrombosis; Warfarin

To assess the incremental benefit of uninterrupted direct oral anticoagulants (DOACs) vs. uninterrupted vitamin K antagonists (VKA) for catheter ablation (CA) of non-valvular atrial fibrillation (NVAF) on three primary outcomes: major bleeding, thrombo-embolic events, and minor bleeding. A secondary outcome was post-procedural silent cerebral infarction (SCI) as detected by brain magnetic resonance imaging.. A systematic review of Medline, Cochrane, and Embase was done to find all randomized controlled trials (RCTs) in which uninterrupted DOACs were compared against uninterrupted VKA for CA of NVAF. A fixed-effect model was used, with the exception of the analysis regarding major bleeding events (I2 > 25), for which a random effects model was used. The benefit of uninterrupted DOACs over VKA was analysed from four RCTs that enrolled a total of 1716 patients (male: 71.2%) with NVAF. Of these, 1100 patients (64.1%) had paroxysmal atrial fibrillation. No significant benefit was seen in major bleeding events [risk ratio (RR) 0.54, 95% confidence interval (95% CI) 0.29-1.00; P = 0.05]. No significant differences were found in minor bleeding events (RR 1.11, 95% CI 0.82-1.52; P = 0.50), thrombo-embolic events (RR 0.74, 95% CI 0.26-2.11; P = 0.57), or post-procedural SCI (RR 1.06, 95% CI 0.74-1.53; P = 0.74).. An uninterrupted DOACs strategy for CA of NVAF appears to be as safe as uninterrupted VKA without a significantly increased risk of minor or major bleeding events. There was a trend favouring DOACs in terms of major bleeding. Given their ease of use, fewer drug interactions and a similar security and effectiveness profile, DOACs should be considered first line therapy in patients undergoing CA for NVAF.

Topics: Anticoagulants; Antithrombins; Atrial Fibrillation; Catheter Ablation; Cerebral Infarction; Dabigatran; Drug Administration Schedule; Factor Xa Inhibitors; Hemorrhage; Humans; Postoperative Complications; Postoperative Hemorrhage; Risk Factors; Rivaroxaban; Severity of Illness Index; Thromboembolism; Warfarin

Atrial fibrillation (AF) is a known complication of many cardiac procedures, including those undergoing surgical aortic valve replacement (SAVR). In the transcatheter aortic valve replacement (TAVR) era, AF has been noted not only to be present in these patients but also associated with morbidity and mortality. In this article, we first outline the significance of AF in general and then more specifically in patients undergoing cardiac surgery. We then compare and contrast specific clinical issues related to AF in patients with aortic stenosis undergoing aortic valve replacement, traditionally with SAVR, but now increasingly more common with TAVR.

Topics: Aged; Aged, 80 and over; Anticoagulants; Aortic Valve Stenosis; Atrial Fibrillation; Heart Valve Prosthesis Implantation; Humans; Male; Middle Aged; Postoperative Complications; Risk Factors; Stroke; Transcatheter Aortic Valve Replacement; Warfarin

After arthroplasty treatment, some complications commonly occur, such as early revision, infection/dislocation, and venous thromboembolism (VTE). This study aims to use a network meta-analysis to compare effects of 9 anticoagulant drugs (edoxaban, dabigatan, apixaban, rivaroxaban, warfarin, heparin, bemiparin, ximelagatran, and enoxaparin) in preventing postoperative complications in arthroplasty patients.. After retrieving PubMed, Embase, and Cochrane Library database from the inception to November 2016, randomized controlled trials were enrolled. The integration of direct and indirect evidences was performed to calculate odd ratios and the surface under the cumulative ranking curves. Nineteen eligible randomized controlled trials were included.. The network meta-analysis results showed that compared with warfarin, edoxaban, apixaban, and rivaroxaban had a lower incidence rate in asymptomatic deep venous thrombosis, which indicated that edoxaban, apixaban, and rivaroxaban had better effects on prevention. Similarly, in comparison to enoxaparin, edoxaban and rivaroxaban had better effect; rivaroxaban was better than ximelagatran in preventive effects. Compared with apixaban, edoxaban, dabigatan, rivaroxaban, and enoxaparin had a higher incidence rate in clinically relevant non-major bleeding, which showed that preventive effects were relatively poor. In addition, the results of the surface under the cumulative ranking curves showed that rivaroxaban and bemiparin worked best on symptomatic deep venous thrombosis and pulmonary embolism. In terms of bleeding, apixaban and warfarin had better preventive effects.. Our findings suggested that rivaroxaban may work better in terms of symptomatic deep venous thrombosis and pulmonary embolism, whereas apixaban had better preventive effects in bleeding.

Topics: Anticoagulants; Arthroplasty; Azetidines; Benzylamines; Dabigatran; Enoxaparin; Heparin; Heparin, Low-Molecular-Weight; Humans; Network Meta-Analysis; Postoperative Complications; Pulmonary Embolism; Pyrazoles; Pyridines; Pyridones; Rivaroxaban; Thiazoles; Treatment Outcome; Venous Thromboembolism; Warfarin

A best evidence topic was written according to a structured protocol. The question addressed was 'In patients requiring an implanted cardiac rhythm device, do novel oral anticoagulant agents lead to increased rates of peri-procedural complications?' Altogether 1228 papers were found using the reported search, of which 5 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The novel oral anticoagulant agents (NOACs) assessed in the included studies were dabigatran (a direct thrombin inhibitor) and rivaroxaban (a Factor Xa inhibitor). Dabigatran was included in all five studies and showed bleeding complication rates of 0-4%. Rivaroxaban was included in one study and had bleeding complication rates of 4%. Warfarin was a comparator agent in three studies and had bleeding complication rates of 4.6-8%. The incidence rate of thromboembolic complications was 0-1% with dabigatran and 0% with rivaroxaban and warfarin in all studies. Based on the available studies, there is no evidence of significantly increased risk of bleeding or thromboembolic events with NOACs compared with warfarin when used at the time of cardiac rhythm device implantation. However, not all patients in the studies were actually receiving the specified NOAC at the time of device implantation, thereby limiting the available evidence.

Topics: Aged, 80 and over; Anticoagulants; Cardiac Surgical Procedures; Dabigatran; Defibrillators, Implantable; Humans; Intraoperative Complications; Male; Pacemaker, Artificial; Postoperative Complications; Rivaroxaban; Thromboembolism; Warfarin

New oral anticoagulants (NOACs) have been shown to be comparable to warfarin in patients with non-valvular atrial fibrillation (AF). This meta-analysis was performed to evaluate the efficacy and safety of NOACs for perioperative anticoagulation of AF catheter ablation.. PubMed, Embase, the Cochrane Library, CNKI, VIP, and SinoMed were searched for articles published up to August 30, 2015. The data were calculated with RevMan 5.2 using a fixed-effects model.. Nineteen studies with a total of 7996 patients were included in this meta-analysis. NOAC treatment was associated with fewer overall bleeding events than continuous warfarin treatment (RR = 0.78, 95% CI = 0.64-0.95, P = 0.01); similarly, there were fewer overall bleeding events with NOAC treatment than interrupted warfarin treatment (RR = 0.58, 95% CI = 0.44-0.77, P = 0.0002). In the subgroup analyses, the incidence of overall bleeding events (RR = 0.67, 95% CI = 0.48-0.92, P = 0.01) and minor bleeding events (RR = 0.56, 95% CI = 0.37-0.86, P = 0.007) in the interrupted NOAC group was lower than that in the continuous warfarin group. NOAC treatment did not increase the risk of thromboembolic complications compared with warfarin treatment (P > 0.05).. The findings of this meta-analysis suggested that periprocedural NOAC therapy was as effective as continuous warfarin therapy for preventing thromboembolism and had a lower incidence of bleeding complications. Interrupted NOAC therapy during the periprocedural period might result in a lower incidence of bleeding complications compared with continuous NOAC therapy.

Topics: Administration, Oral; Anticoagulants; Atrial Fibrillation; Catheter Ablation; Causality; Comorbidity; Female; Hemorrhage; Humans; Male; Middle Aged; Perioperative Care; Postoperative Complications; Prevalence; Risk Factors; Warfarin

Topics: Abdominal Pain; Adult; Anticoagulants; Colectomy; Colitis, Ulcerative; Enoxaparin; Fibrinolysis; Humans; Ileostomy; Male; Mesenteric Ischemia; Postoperative Complications; Prognosis; Risk Factors; Thrombectomy; Thrombophilia; Tomography, X-Ray Computed; Warfarin

To perform a systematic review and meta-analysis of studies evaluating anticoagulation during the early postoperative period following mechanical heart valve implantation.. Five literature databases were searched to assess the rates of bleeding and thromboembolic events among patients receiving oral anticoagulation (OAC), both with and without bridging anticoagulation therapy with unfractionated heparin (UFH) or subcutaneous low molecular weight heparin (LMWH). The studies' results were pooled via a mixed effects meta-analysis. Heterogeneity (I(2) ) and publication bias were both evaluated.. Twenty-three studies including 9534 patients were included. The bleeding rates were 1.8% (95% confidence interval CI 1.0-3.3) in the group receiving OAC, 2.2% (95% CI 0.9-5.3) in the OAC + UFH group, and 5.5% (95% CI 2.9-10.4) in the OAC + LMWH group (P = 0.042). The thromboembolic event rate was 2.1% (95% CI 1.5-2.9) in the group receiving OAC, as compared with 1.1% (95% CI 0.7-1.8) when the bridging therapy groups were combined as follows: OAC + UFH and OAC + LMWH (P = 0.035). Most of the analyses showed moderate heterogeneity and negative test results for publication bias.. Bridging therapy following cardiac valve surgery was associated with a lower thromboembolic event rate, although the difference was small, with considerable overlap of the CIs. Direct comparisons are missing. Bridging therapy with UFH appears to be safe; however, this observation has a risk of bias. Early bridging therapy with LMWH appears to be associated with consistently high bleeding rates across multiple analyses. On the basis of the quality of the included studies, more trials are necessary to establish the clinical relevance of bridging therapy and the safety of LMWH.

Topics: Administration, Oral; Anticoagulants; Case-Control Studies; Cohort Studies; Equipment Design; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Hemorrhage; Heparin; Heparin, Low-Molecular-Weight; Hospital Mortality; Humans; Postoperative Complications; Postoperative Period; Publication Bias; Thromboembolism; Thrombophilia; Treatment Outcome; Warfarin

The Fontan circulation is associated with an increased risk of thromboembolic events (TEs). As many as 25% of these thrombotic events result in fatality. More subtle adverse effects on the pulmonary circulation from embolic thrombi may further impair adequate functioning of the circuit. Despite these well-documented phenomena, the most optimal approaches to thromboprophylaxis are still not clearly defined.. A meta-analysis of published trials in English on PubMed and Cochrane libraries that evaluated the role of using TE prophylaxis in patients who underwent the Fontan procedure was conducted.. 10 studies with a total number of 1200 patients with an average follow-up time of 7.1 years were identified. A random effect model was used.. The incidence of TE was significantly less in patients who received TE prophylaxis (using either aspirin or warfarin) compared with patients who did not receive TE prophylaxis (OR 0.425, 95% CI 0.194 to 0.929, p<0.01, I(2)=37%). The incidence of TE was significantly lower in patients who received aspirin compared with no TE prophylaxis (OR 0.363, 95% CI 0.177 to 0.744, p<0.01, I(2)=0%) and who received warfarin compared with no TE prophylaxis (OR 0.327, 95% CI 0.168 to 0.634, p<0.01, I(2)=2.5%). There was no significant difference in incidence of TE between warfarin and aspirin (OR 0.936, 95% CI 0.609 to 1.438, p=0.54, I(2)=0%). Furthermore, there was no significant difference in incidence of early TE (within 6 months of the operation) or late TE (>6 months) between patients receiving warfarin and aspirin (OR 0.784, 95% CI 0.310 to 1.982, p=0.37, I(2)=8%) and (OR 0.776, 95% CI 0.249 to 2.42, p=0.3, I(2)=45%), respectively. When only total cavopulmonary connection patients were included, there was again no difference between warfarin and aspirin in the incidence of TE (OR 0.813, 95% CI 0.471 to 1.401, p=0.34, I(2)=11%).. This study shows a significantly lower incidence of TE after Fontan procedure if either aspirin or warfarin is used. This meta-analysis suggests no significant difference in incidence of early or late TE in patients receiving aspirin compared with warfarin.

Topics: Anticoagulants; Aspirin; Chemoprevention; Comparative Effectiveness Research; Fontan Procedure; Humans; Incidence; Postoperative Complications; Thromboembolism; Warfarin

Perioperative pulmonary thromboembolism (PTE) occurred in 2.93 per 10,000 cases and mortality of PTE was 14% in Japan according to the surveillance of Japanese Society of Anesthesiologists from 2009 to 2011. Anesthesiologists have to evaluate perioperative venous thromboembolism (VTE) risk carefully and take adequate measures to prevent PTE. The first step is the assessment of the preoperative probability of VTE and the next step is the assessment of the risk for VTE during and after operation. If a patient has moderate probability of VTE preoperatively, diagnostic procedures are recommended. If the d-dimer is positive, whole-leg ultrasound is recommended. If DVT is positive in proximal vein, further investigation or anticoagulant therapy are considered. Primary preventions of VTE during and after surgeries are as follows. In patients with low or moderate risks for VTE, intermittent pneumatic compression is recommended. In patients with high risks for VTE, pharmacologic prophylaxes are recommended. In recent years newly developed anticoagulants can be available other than low-dose unfractionated heparin. However, the incidence of VTE in Japanese populations is different from western countries. Moreover our own evidence has not fully been accumulated yet. Therefore further investigations for prevention of perioperative VTE in Japan are expected for our own new guidelines.

Topics: Anesthesia, Epidural; Anticoagulants; Biomarkers; Diagnostic Imaging; Fibrin Fibrinogen Degradation Products; Heparin; Humans; Intraoperative Complications; Perioperative Care; Postoperative Complications; Practice Guidelines as Topic; Pulmonary Embolism; Pyridines; Risk Factors; Thiazoles; Venous Thromboembolism; Venous Thrombosis; Warfarin

Topics: Administration, Oral; Aged; Anticoagulants; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Atrial Fibrillation; Benzimidazoles; beta-Alanine; Cerebral Hemorrhage; Dabigatran; Gastrointestinal Hemorrhage; Humans; Intracranial Embolism; Morpholines; Postoperative Complications; Pyrazoles; Pyridones; Risk Factors; Rivaroxaban; Thiophenes; Thrombosis; Vitamin K; Warfarin

Optimal antithrombotic recommendations for patients following bioprosthetic aortic valve replacement have yet to be decided. Current guidelines present conflicting opinions and are based on historical studies, which are limited by their design. We review comparative studies investigating differing thromboprophylactic regimes and outcomes for bioprosthetic aortic valve replacement.

Topics: Administration, Oral; Aged; Anticoagulants; Aortic Valve; Aortic Valve Stenosis; Aspirin; Bioprosthesis; Fibrinolytic Agents; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Male; Meta-Analysis as Topic; Postoperative Complications; Practice Guidelines as Topic; Prosthesis Failure; Reoperation; Thrombosis; Time Factors; Treatment Outcome; Warfarin

In the perioperative period, patients who are under anti-thrombotic therapy should be managed with care, although there is no clear consensus on this matter. For hand surgery, several authors have advocated no interruption of the anti-thrombotic therapy, but the choice differs between institutes according to protocols and surgeons' preference. We report a case of massive pulmonary embolism after stopping warfarin for carpal tunnel release in a patient with a previous history of pulmonary embolism. Although the patient recovered after thrombolytic therapy and intensive care unit (ICU) care, this case has struck the authors as a valuable lesson. In managing anti-thrombotic therapy, we should weigh the risks and benefits of the patients carefully before making a decision.

Topics: Anticoagulants; Carpal Tunnel Syndrome; Female; Follow-Up Studies; Heparin; Humans; Middle Aged; Postoperative Complications; Preoperative Care; Pulmonary Embolism; Radiography; Recovery of Function; Recurrence; Retreatment; Thrombolytic Therapy; Warfarin; Withholding Treatment; Wound Healing

Guidelines for the prevention of venous thromboembolism (VTE) after elective total hip or knee arthroplasty (THA/TKA) have been developed separately by the American Academy of Orthopaedic Surgeons (AAOS) and the American College of Chest Physicians (ACCP). Differences exist in approaches to preventing postoperative VTE through prophylaxis.. To compare trials using vitamin K antagonists (VKAs) and differences in guidelines to determine the benefits and drawbacks of warfarin for VTE prophylaxis following THA/TKA.. Guidelines from the AAOS published in 2009 and revised in 2011 and from the ACCP published in 2008 were compared for recommendations on the use of VKAs. A MEDLINE search from 1960 to November 2009 was conducted to identify pertinent articles on the use of warfarin or VKAs for VTE prophylaxis following THA/TKA. Search terms included warfarin, vitamin K antagonist, total hip or total knee replacement, and total hip or total knee arthroplasty.. Only clinical trials in which warfarin was the primary agent for prophylaxis compared to other anticoagulants were included.. Data on differences between guideline recommendations for the use of VKAs and the importance of a deep vein thrombosis or asymptomatic events were extracted. Thirteen comparative trials using VKAs for VTE prophylaxis and international normalized ratio (INR) targets were assessed. Overall, the incidence of bleeding tended to be lower with the use of VKAs, but thrombosis when including asymptomatic events was numerically higher when comparing INR targets. However, INR targets varied, with no comparative trials assessing the AAOS 2009 recommended INR target of 1.5-2.0. The AAOS guidelines initially recommended a longer duration of therapy and expressed stronger support for the use of aspirin for prophylaxis; however, in 2011, its guidelines were revised, with no specific recommendations as to agent, dose, or INR target goal.. Warfarin is an effective agent to prevent VTE after elective THA/TKA. The most effective approach, including extended warfarin use up to 4 weeks or longer, has not been determined.

Topics: Anticoagulants; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Clinical Trials as Topic; Humans; Postoperative Complications; Practice Guidelines as Topic; Venous Thromboembolism; Warfarin

Topics: Anticoagulants; Heparin, Low-Molecular-Weight; Humans; Postoperative Complications; Preoperative Care; Randomized Controlled Trials as Topic; Time Factors; Warfarin

We consider in this review traditional and novel approaches to drug prevention of pulmonary embolism (PE) which in predominant number of cases is related to deep vein thrombosis of lower extremities. Risk of PE development is especially high in patients after orthopedic hip or knee surgery. Modern recommendations contemplate use of unfractionated and low molecular weight heparins, vitamin K antagonists (warfarin in the first place), fondaparinux. Oral direct anticoagulants related to selective inhibitors of blood coagulation factors IIa (thrombin) and Xa have appeared recently and proved their preventive efficacy and safety in randomized controlled studies. Preventive efficacy and safety of dabigatran among direct selective factor IIa (thrombin) inhibitors and of rivaroxaban, apixaban, and edoxaban among direct selective factor IIa inhibitors have been studied best.

Topics: Anticoagulants; Drug Administration Routes; Drug Substitution; Factor Xa Inhibitors; Heparin; Heparin, Low-Molecular-Weight; Humans; International Normalized Ratio; Lower Extremity; Orthopedic Procedures; Postoperative Complications; Pulmonary Embolism; Randomized Controlled Trials as Topic; Risk Factors; Secondary Prevention; Therapies, Investigational; Thrombin; Venous Thrombosis; Warfarin

Deep venous thrombosis (DVT) is the end result of a complex interaction of events including the activation of the clotting cascade in conjunction with platelet aggregation. Patients undergoing major lower extremity orthopedic surgery, especially total joint arthroplasty (TJA), are at high risk for developing a postoperative DVT or a subsequent pulmonary embolus. Venous thromboembolic (VTE) prophylaxis, most commonly pharmacologic prophylaxis, has become the standard of care for patients undergoing elective TJA. However, the controversy between the efficacy of VTE prophylaxis and the increased risk for bleeding in the postoperative period continues to exist. This review addresses the controversy underlying VTE prophylaxis by outlining 2 guidelines and demonstrating the pros and cons of different DVT prophylaxis regimens based on the available evidence-based literature.

Topics: Anticoagulants; Arthroplasty, Replacement; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Aspirin; Drug Interactions; Humans; International Normalized Ratio; Postoperative Complications; Practice Guidelines as Topic; Venous Thrombosis; Warfarin

An increasing number of preoperative patients are receiving therapy with an oral anticoagulant (warfarin) or antiplatelet drugs to prevent thromboembolic complications. Because of its irreversible inhibition on hepatic synthesis of vitamin K-dependent coagulation factors, warfarin must be stopped 3 to 4 (ideally 4 to 5) days prior to the planned major operation. Normal PT-INR is mandatory prior for neuraxial block. Rapid reversal of warfarin in emergency settings with FFP rather than vitamin K is advocated. More reliable and prompt reversal is possible with PCCs and rFVIIa, but this approach is off-label use in Japan as well as in the US. Antiplatelet drugs have different mechanisms to suppress platelet aggregation. Ticlopidine and clopidogrel should be stopped 7 days prior to the major surgery because of their irreversible inhibition on ADP receptors of platelets. Although it is recommended to stop aspirin 7 days prior to the planned major surgery in some guidelines, low dose oral aspirin (75-300 mg day(-1)) alone is accepted in another guideline because it does not create a level of risk that will interfere with the performance of neuraxial blocks.

Topics: Anticoagulants; Humans; Platelet Aggregation Inhibitors; Postoperative Complications; Preoperative Care; Thromboembolism; Warfarin

Life-threatening in the short term and leading to a high level of morbidity in the long term, venous thromboembolism (VTE) is the most fearful complication following lower limb arthroplasty. With advances in surgical procedure, anesthetic management and postoperative convalescence have altered the risks of venous thromboembolism after total joint arthroplasty in the lower extremity. The pathogenesis of VTE is multifactorial and includes the well-known Virchow's triad of hypercoagulability, venous stasis and endothelial damage. Therefore, it is appropriate to use a multimodal approach to thromboprophylaxis. Despite extensive research, the ideal multimodal prophylaxis against venous thrombolism has not been identified. So this article reviews the recent developments in multimodal prophylaxis for thromboembolism after total joint arthroplasty.

Topics: Anesthesia, Epidural; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Aspirin; Factor Xa Inhibitors; Heparin, Low-Molecular-Weight; Humans; Postoperative Complications; Venous Thromboembolism; Warfarin

Deep vein thrombosis (DVT) is a cause of preventable morbidity and mortality in hospitalized surgical patients. The occurrence of the disease is related to presence of risk factors, which are related primarily to trauma, venous stasis and hyper-coagulability. DVT seems not to be taken seriously by many surgeons in Nigeria. This is despite comprehensive studies that show no real differences in racial demography of the disease.. To highlight the importance of physician awareness about DVT especially its risks and prevention methods.. A detailed literature search was completed to extrapolate articles that described DVT risks and prevention. This involved hand and online searches. Specific search terms used included DVT/risk factors/prevention. The searches generated 468 papers. Of these 57 papers were included in the review.. Predominant risk factors for DVT include middle or old age, prolonged surgery, trauma, confinement, presence of malignancy and insertion of deep venous catheters. In women, contraceptive use, hormone replacement therapy, pregnancy and the puepernum are a additional risk factors. Prophylactic measures include those directed at eliminating venous stasis and those directed at changes in blood coagulability.. Deep Venous Thrombosis is a common disease with fatal and serious long term burdensome complications. We must target primary and secondary prophylaxis to improve survival and reduce morbidity from this preventable disease.

Topics: Anticoagulants; Aspirin; Awareness; Clinical Competence; Cyclooxygenase Inhibitors; Dextrans; Dihydroergotamine; Fibrinolytic Agents; Heparin; Humans; Nigeria; Postoperative Complications; Risk Factors; Vasoconstrictor Agents; Venous Thrombosis; Warfarin

There is a perception in the orthopaedic and thromboembolism community that the incidence of deep vein thrombosis (DVT) has decreased in patients undergoing total knee arthroplasty (TKA) or total hip arthroplasty (THA).. To assess the incidence of DVT with warfarin thromboprophylaxis over time in patients undergoing elective TKA or THA.. The MEDLINE, EMBASE, and Cochrane Library databases were searched to October 2006, supplemented by a manual search of reference lists. Two reviewers independently extracted data on study characteristics, quality and the frequency of total, symptomatic and proximal DVT.. Fourteen studies (4,423 patients) were included. Total and proximal DVT after TKA declined over time (r=-0.75, p=0.031; r=-0.86, p=0.007 respectively). Total and proximal DVT after THA did not change. The risk of developing DVT after TKA was significantly higher than after THA (OR 1.85, 95% CI 1.6-2.14; p<0.0001). The risk of developing symptomatic DVT after THA was significantly higher than after TKA (OR 2.18, 95% CI 1.11-4.27; p=0.012).. The incidence of DVT in patients undergoing elective TKA appears to have declined in patients receiving warfarin thromboprophylaxis.

Topics: Adult; Age Factors; Aged; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Humans; Incidence; Middle Aged; Postoperative Complications; Randomized Controlled Trials as Topic; Time Factors; Venous Thrombosis; Warfarin

Temporary interruption of long-term anticoagulation and antiplatelet therapy during surgical procedures exposes patients to thrombotic risk. Continuation of these agents, however, is associated with an increased risk of bleeding. Managing anticoagulation can be a particular challenge in the emergency setting.. A literature review of published articles sourced using the keywords heparin, warfarin, perioperative, antiplatelet, aspirin and surgery was undertaken. A management plan for all likely situations was developed.. Based on an individual assessment of risk factors for arterial or venous thromboembolism and the risk of perioperative bleeding, it is possible to form an anticoagulant and antiplatelet management plan likely to achieve a low incidence of bleeding and thrombosis. A multidisciplinary approach is desirable.

Topics: Anticoagulants; Aspirin; Emergency Treatment; Heparin; Humans; Intraoperative Care; Platelet Aggregation Inhibitors; Postoperative Care; Postoperative Complications; Risk Assessment; Risk Factors; Thrombosis; Warfarin

Rivaroxaban is the first oral anticoagulant with a direct anti-Xa activity to be registered (approval). As for all first comers in a class, it should be assessed both for itself and for the class. The targeting of factor-Xa factor, key component in the coagulation cascade, has the theoretical benefit of being an effective antithrombotic and a potential risk for hemorrhage, both highly dose-dependent. Experience has shown us that the representativeness and predictiveness of in vitro tests and preclinical models are only partial and sometimes even misleading. This is why the responses can only come from clinical trials and rigorous research testing doses, which should be conducted specifically in all the indications foreseen, with no extrapolations. The oral anticoagulant drugs are developed in the prevention of arterial thromboembolic events caused by atrial fibrillation too, where the vitamin K antagonists (VKAs) are the current standard of care. The well-known problems of monitoring and adaptation doses with VKAs have led to developing new replacement classes without the need for control or biological adaptation. However, in certain conditions there is a need to monitor the patient. The advantage for the direct anti-Xa inhibitors such as rivaroxaban is that the prothrombin time, a routine test is sensitive and provides a prolonged response that is proportional to the plasma concentration within a wide range of concentrations. This test is potentially usable provided that the indispensable standardization is forthcoming.

Topics: Administration, Oral; Anticoagulants; Clinical Trials as Topic; Drug Administration Schedule; Drug Monitoring; Factor Xa Inhibitors; Fibrinolytic Agents; Hemorrhage; Heparin; Heparin, Low-Molecular-Weight; Humans; Molecular Structure; Morpholines; Postoperative Complications; Preanesthetic Medication; Prothrombin Time; Rivaroxaban; Thiophenes; Thrombin; Thromboembolism; Vitamin K; Warfarin

Rivaroxaban is a small molecule, direct Factor Xa inhibitor and may be a potentially attractive alternative to vitamin K antagonists. Rivaroxaban is being investigated for the prevention and treatment of venous and arterial thrombosis. A broad search of Medline, clinicaltrials.gov and the annual proceedings of the American Society of Hematology and the International Society on Thrombosis and Hemostasis was conducted. This review addresses the findings of this systematic search, including the need for new oral anticoagulants, the development and pharmacology of rivaroxaban, and the results of completed as well as ongoing trials with rivaroxaban. At present, the safety and efficacy of rivaroxaban for the prophylaxis and treatment of venous thromboembolism has been evaluated in Phase II and Phase III trials involving over 24,000 patients. Additionally, rivaroxaban is being evaluated for the treatment of pulmonary embolism, secondary prevention after acute coronary syndromes and the prevention of stroke and non-central nervous system embolism in patients with non-valvular atrial fibrillation. The drug may have its greatest impact in providing a much-needed and attractive alternative to warfarin. Further data (especially large Phase III trials) are required.

Topics: Acute Coronary Syndrome; Administration, Oral; Aged; Aged, 80 and over; Animals; Anticoagulants; Atrial Fibrillation; Binding Sites; Clinical Trials as Topic; Comorbidity; Drug Evaluation, Preclinical; Factor Xa; Factor Xa Inhibitors; Fibrinolytic Agents; Hemorrhage; Humans; Male; Middle Aged; Morpholines; Postoperative Complications; Rats; Rivaroxaban; Stroke; Thiophenes; Thrombosis; Warfarin

Patients undergoing major orthopedic surgery--hip or knee arthroplasty, or hip fracture repair--are in the highest risk category for venous thromboembolism (VTE) solely on the basis of the orthopedic procedure itself. Despite this, nearly half of patients undergoing these procedures do not receive appropriate prophylaxis against VTE, often due to a disproportionate fear of bleeding complications in this population. Guidelines from the American College of Chest Physicians (ACCP) provide evidence-based recommendations for many aspects of VTE risk reduction in the setting of orthopedic surgery, as detailed in this review. The ACCP recommends the use of either low-molecular-weight heparin (LMWH), fondaparinux, or adjusted-dose warfarin as preferred VTE prophylaxis in patients undergoing either hip or knee arthroplasty. Fondaparinux is the preferred recommendation for patients undergoing hip fracture repair, followed by LMWH, unfractionated heparin, and adjusted-dose warfarin as alternative options. Extended-duration prophylaxis (for 4 to 5 weeks) is now recommended for patients undergoing hip arthroplasty or hip fracture repair. Patients undergoing knee arthroscopy do not require routine pharmacologic VTE prophylaxis.

Topics: Anticoagulants; Fondaparinux; Heparin, Low-Molecular-Weight; Humans; Orthopedic Procedures; Polysaccharides; Postoperative Complications; Risk Assessment; Risk Factors; Risk Reduction Behavior; Venous Thromboembolism; Warfarin

Cancer patients, especially those undergoing surgery for cancer, are at extremely high risk for developing venous thromboembolism (VTE), even with appropriate thromboprophylaxis. Anticoagulant prophylaxis in cancer surgery patients has reduced the incidence of VTE events by approximately one-half in placebo-controlled trials, and extended prophylaxis (for up to 1 month) has also significantly reduced out-of-hospital VTE events in clinical trials in this population. Clinical trials show no difference between low-molecular-weight heparin (LMWH) and unfractionated heparin in VTE prophylaxis efficacy or bleeding risk in this population, although the incidence of heparin-induced thrombocytopenia is lower with LMWH. The risk-benefit profile of low-dose anticoagulant prophylaxis appears to be favorable even in many cancer patients undergoing neurosurgery, for whom pharmacologic VTE prophylaxis has been controversial because of bleeding risks.

Topics: Fondaparinux; Heparin, Low-Molecular-Weight; Humans; Neoplasms; Polysaccharides; Postoperative Complications; Risk Assessment; Risk Factors; Risk Reduction Behavior; Venous Thromboembolism; Warfarin

Improvements in the performance and longevity of biological valve prostheses have steadily increased their rates of implantation in recent years. Aortic bioprostheses, which are commonly used in the elderly or when the risks of anticoagulating are high, have generally been associated with low rates of long-term complications. Freedom from anticoagulation, therefore, represents the main theoretical advantage of biological, compared with mechanical, aortic prostheses. While a variety of anticoagulant and antiplatelet drug regimens have been described, a precise antithrombotic protocol for the early postoperative period after bioprosthetic aortic valve replacement has not been developed. There are also important differences between the international guidelines published. This review examines the clinical evidence concerning the use of vitamin K antagonist and antiplatelet therapy in the early management of the antithrombotic complications after bioprosthetic aortic valve replacement.

Topics: Anticoagulants; Aortic Valve; Aspirin; Bioprosthesis; Heart Valve Prosthesis; Humans; Platelet Aggregation Inhibitors; Postoperative Complications; Practice Guidelines as Topic; Risk Factors; Thromboembolism; Warfarin

The aim of this study was to report our experience and review the published data on argatroban administration during adult cardiac surgery.. The information on all reported cases of argatroban use in adults, during cardiac surgery was reviewed, including that of the patient described here. This analysis focused on patient characteristics, type of surgery, argatroban dosing schedule, monitoring of anticoagulation and outcomes.. Twenty-one cases have been reported. Fifteen patients underwent off-pump surgical procedures with the argatroban dose adjusted to maintain an activated clotting time (ACT) range between 200 and 300 s. Three intraoperative thrombi occurred in two patients when the ACT was <280 s. None had coagulopathy. Six cases reported the use of argatroban during on-pump cardiac surgery dosed to keep the ACT >400 s. Intraoperative thrombotic complications were not reported in this group; however, one clot in the pump was noted after the procedure when the ACT was between 300 and 350 s. All six cases required larger volumes of perioperative blood products and three had severe coagulopathy. Of the 21 cases, seven had an indication for continued anticoagulation following surgery. Four cases did not report further use of argatroban after surgery. Three patients received argatroban after surgery without complications. Recommendations for how to use argatroban during cardiac surgery are proposed.. Argatroban, with ACT monitoring, might be safely used for anticoagulation during cardiac surgery.

Topics: Adult; Aged; Anticoagulants; Arginine; Cardiac Surgical Procedures; Coronary Artery Bypass; Coronary Artery Bypass, Off-Pump; Drug Monitoring; Endocarditis, Bacterial; Female; Heart Valve Prosthesis Implantation; Heparin; Humans; Intra-Aortic Balloon Pumping; Intraoperative Complications; Male; Middle Aged; Mitral Valve; Pipecolic Acids; Postoperative Complications; Retrospective Studies; Staphylococcal Infections; Subclavian Vein; Sulfonamides; Thrombosis; Venous Thrombosis; Warfarin; Whole Blood Coagulation Time

The use of bioprosthetic heart valves has dramatically increased over the last decade. In 2004, the ratio was 52% for mechanical and 48% for bioprosthetic valves in a survey by the Japanese Association for Thoracic Surgery. This increase in the use of bioprosthetic valves is related to evidence demonstrating the durability of such valves over the last 20 years. The guidelines of the Japanese Circulation Society recommend selection of prosthetic heart valves by considering the patient's age. In patients who received a mechanical valve in previous cardiac surgery, selection of another mechanical valve is inevitable. The age of 65 years is when patients are separated into groups receiving either mechanical (<64 years) or bioprosthetic (> or =65 years) valves. However, the evidence that a bioprosthetic valve is better for patients in their 60s is somewhat questionable, particularly in Japanese with a long life expectancy. Anticoagulation with warfarin in patients with mechanical valves leads to a higher incidence of hemorrhagic complications compared with bioprosthetic valves, although the incidence of thromboembolism is the same. Thus patients with contraindications to warfarin or a low risk of thromboembolism who are more than 65 years old are reasonable candidates for a bioprosthetic valve. It is also recommended that women of childbearing age receive bioprosthetic valves after being informed of the possibility and risks of reoperation. In addition to the information in the guidelines and physicians' preference for valve selection, factors such as the patient's lifestyle, wishes, cardiac function, other complications, and longevity must always be considered when selecting a valve prosthesis.

Topics: Adult; Age Factors; Aged; Anticoagulants; Aortic Valve; Bioprosthesis; Contraindications; Female; Heart Valve Diseases; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Male; Middle Aged; Postoperative Complications; Prognosis; Prosthesis Failure; Reoperation; Risk; Warfarin

Venous thromboembolism, including deep vein thrombosis and pulmonary thromboembolism, is a common illness during postoperative period. Pharmacological antithrombotic therapy is the cornerstone for the treatment of venous thromboembolism. However, management of venous thromboembolism during postoperative period can be challenging, because of increased risk of bleeding associated with antithrombotic agents. Therefore, we should devise a strategy with mechanical support such as catheter intervention, inferior vena cava filter and percutaneous cardiopulmonary support during the period with increased bleeding risk.

Topics: Anticoagulants; Catheterization; Extracorporeal Membrane Oxygenation; Heparin; Humans; Perioperative Care; Postoperative Complications; Practice Guidelines as Topic; Pulmonary Embolism; Vena Cava Filters; Venous Thrombosis; Warfarin

The reported overall risk of deep venous thrombosis in gynaecological surgery ranges from 7 to 45%. Fatal pulmonary embolism is estimated to occur in nearly 1% of these women. Pharmaceutical interventions are one possible prophylactic measure for preventing emboli in women undergoing major gynaecological surgery. Agents include unfractionated heparin (low -dose and adjusted-dose), low-molecular-weight heparins, heparinoids and warfarin.. The objective of this review was to evaluate the effectiveness of warfarin, heparin and aspirin in preventing thromboembolism after major gynaecological surgery.. We searched the Cochrane Menstrual Disorders and Subfertility Group trials register (searched 15 August 2003), the Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library issue 2, 2003), MEDLINE (1966 to April 2003), EMBASE (1985 to April 2003), and CINAHL (1982 to April 2003). References from relevant articles were searched and authors contacted where necessary. In addition we contacted experts in the field for unpublished works.. Randomised controlled trials of heparins, warfarin or aspirin to prevent thromboembolism after major gynaecological surgery were eligible for inclusion.. Thirty-three trials were identified in the initial search. On careful inspection only eight of these met the inclusion criteria. Trials were data extracted and assessed for quality by at least two reviewers. Data were combined for meta-analysis using odds ratios for dichotomous data or weighted mean difference for continuous data. A random effects statistical model was used.. The meta-analysis of heparin versus placebo found a statistically significant decrease in the number of DVTs in both the all women group (including those with and without malignancy) (OR 0.30, 95% CI 0.12 to 0.76) and the subgroup of only women with malignancy (OR 0.30, 95% CI 0.10 to 0.89). There was no significant difference in the incidence of PE. Oral warfarin reduced DVT when compared to placebo in all women (OR 0.22, 95% CI 0.06 to 0.86) and in women with malignancy (OR 0.18, 95% CI 0.04 to 0.87). Meta-analyses of UH and LMWH showed no statistical difference in any comparison. No studies compared aspirin alone to placebo, heparin or warfarin. There was a statistically significant increase in injection site haematomas associated with heparin compared to placebo (OR 0.30, 95% CI 0.10 to 0.89).. Women, undergoing major gynaecological surgery and without contraindications to anticoagulants should be offered thromboprophylaxis. Evidence suggests that UH and LMWH are equally as effective in preventing DVT and the one trial available suggests that warfarin is as effective as UH. There is no evidence as yet to suggest that warfarin, heparin or aspirin reduce incidence of PE.

Topics: Anticoagulants; Aspirin; Female; Gynecologic Surgical Procedures; Heparin; Humans; Postoperative Complications; Pulmonary Embolism; Venous Thrombosis; Warfarin

Without prophylaxis, rates of deep vein thrombosis (DVT) after major orthopedic surgery range from 40% to 60%. Randomized clinical trials over the past 30 years have provided evidence that primary thromboprophylaxis reduces DVT, pulmonary embolism (PE), and fatal PE, and prophylaxis to prevent venous thromboembolism (VTE) in patients at risk has been ranked as the highest safety practice for hospitalized patients. Since 1986, some type of prophylaxis has been recommended for total knee arthroplasty (TKA), total hip arthroplasty (THA), and hip fracture surgery. Orthopedic guidelines published in Chest provide a current evidence-based guide for prophylaxis for TKA, THA, and hip fracture surgery. In addition to following these recommendations for routine prophylaxis, surgeons should assess patients for additional VTE risk. Patients at higher risk may need more intense prophylaxis. Data from meta-analyses and placebo-controlled, blinded, randomized clinical trials have demonstrated little or no increase in rates of clinically important bleeding with prophylaxis.

Topics: Anticoagulants; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Hip Fractures; Humans; Postoperative Complications; Practice Guidelines as Topic; Pulmonary Embolism; Risk Factors; Venous Thrombosis; Warfarin

The optimal approach to early postoperative anticoagulation after mechanical valve implantation remains controversial. This review article examines the pathogenesis of thrombus formation and the different strategies for early postoperative anticoagulation. The most commonly reported anticoagulation regimens had the after estimates of early postoperative thromboembolism and hemorrhage: oral anticoagulation alone (0.9%, 3.3%); oral anticoagulation with intravenous unfractionated heparin (1.1%, 7.2%); and oral anticoagulation with low molecular weight heparin (0.6%, 4.8%). Although intravenous heparin may be associated with a higher incidence of hemorrhage, a randomized trial is needed to provide the best evidence regarding early postoperative anticoagulation after mechanical valve implantation. Nearly four decades have passed since the first mechanical prosthetic valves were implanted. Frequent thromboembolic complications with the first mechanical valves led to recommendations of universal anticoagulation for these patients. Since then, several design changes and modifications have been made to improve the longevity, hemodynamics, and thrombogenicity of newer generation mechanical valves. With improved blood flow, less stasis, and less thrombogenic materials, lower rates of thromboembolism have been reported. Despite these advances however, thromboembolism and anticoagulant-related bleeding continue to account for 75% of all complications after mechanical valve replacement. Occurring most commonly within six months after implantation, these complications can adversely affect mortality and quality of life. Furthermore, the threat of their occurrence creates a psychological burden for each patient with a mechanical valve. The need for life-long anticoagulation in patients with mechanical valves is not in dispute, and the perioperative management of anticoagulation during non-cardiac surgery has been reviewed extensively. However, the approach to early postoperative anticoagulation after mechanical valve implantation is still a matter of debate. The optimal intensity and timing of anticoagulation to prevent early thromboembolism after valve replacement surgery without postoperative bleeding complications is unknown. Hence, many anticoagulation protocols have been proposed, but a lack of consensus remains. The objectives of this study were (1) to reexamine the pathogenesis of thrombus formation and the need for anticoagulation; (2) to critically review the lit

Topics: Administration, Oral; Anticoagulants; Drug Therapy, Combination; Heart Valve Prosthesis Implantation; Hemorrhage; Heparin; Humans; Platelet Aggregation Inhibitors; Postoperative Care; Postoperative Complications; Risk Factors; Thromboembolism; Warfarin

Venous thromboembolic disease (VTD), which consists primarily of deep venous thrombosis (DVT) and pulmonary embolism (PE), is of significant concern to orthopedic surgeons who perform total hip and total knee arthroplasties. DVT and PE can be prevented in multiple ways; each method or combination of methods has its benefits and drawbacks. Seemingly, the more efficacious a medication or method for preventing VTD, the higher the associated risk for adverse events such as bleeding and wound complications. For each patient, then, the balance or homeostasis between significant clotting event and bleeding must be determined. Examining this balance and understanding the benefits and risks associated with each medication or intervention may allow surgeons to make educated decisions about prophylaxis for their patients. Furthermore, risk stratification and multimodal management may prove to be the safest and most effective way to manage VTD prevention.

Topics: Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Aspirin; Dose-Response Relationship, Drug; Drug Administration Schedule; Female; Heparin; Humans; Male; Phlebography; Platelet Aggregation Inhibitors; Postoperative Complications; Pulmonary Embolism; Reoperation; Risk Assessment; Venous Thrombosis; Warfarin

Venous thromboembolism (VTE), which is manifested as deep vein thrombosis (DVT) and pulmonary embolism (PE), represents a significant cause of death, disability, and discomfort. They are frequent complications of various surgical procedures. The aging population and the survival of more severely injured patients may suggest an increasing risk of thromboembolism in the trauma patients. Expanded understanding of the population at risk challenges physicians to carefully examine risk factors for VTE to identify high-risk patients who can benefit from prophylaxis. An accurate knowledge of evidence-based risk factors is important in predicting and preventing postoperative DVT, and can be incorporated into a decision support system for appropriate thromboprophylaxis use. Standard use of DVT prophylaxis in a high-risk trauma population leads to a low incidence of DVT. The incidence of VTE is common in Asia. The evaluation includes laboratory tests, Doppler test and phlebography. Screening Doppler sonography should be performed for surveillance on all critically injured patients to identify DVT. D-Dimer is a useful marker to monitor prophylaxis in trauma surgery patients. The optimal time to start prophylaxis is between 2 hours before and 10 hours after surgery, but the risk of PE continues for several weeks. Thromboprophylaxis includes graduated compression stockings and anticoagulants for prophylaxis. Anticoagulants include Warfarin, which belongs to Vitamin K antagonists, unfractionated heparin, low molecular weight heparins, factor Xa indirect inhibitor Fondaparinux, and the oral IIa inhibitor Melagatran and ximelagatran. Recombinant human soluble thrombomodulin is a new and highly effective antithrombotic agent. Prophylactic placement of vena caval filters in selected trauma patients may decrease the incidence of PE. The indications for prophylactic inferior vena cava filter insertion include prolonged immobilization with multiple injuries, closed head injury, pelvic fracture, spine fracture, multiple long bone fracture, and attending discretion. Multiple-trauma patients are at increased risk for DVT but are also at increased risk of bleeding, and the use of heparin may be contraindicated. Serial compression devices (SCDs) are an alternative for DVT prophylaxis. Compression devices provide adequate DVT prophylaxis with a low failure rate and no device-related complications. Immobilization is one of important reasons of VTE. The ambulant patient is far less li

Topics: Anticoagulants; Factor Xa Inhibitors; Heparin; Heparin, Low-Molecular-Weight; Humans; Orthopedic Procedures; Postoperative Complications; Pulmonary Embolism; Recombinant Proteins; Risk Factors; Thrombomodulin; Vena Cava Filters; Venous Thrombosis; Vitamin K; Warfarin

Topics: Anti-Inflammatory Agents, Non-Steroidal; Anticoagulants; Aspirin; Atrial Fibrillation; Brain Damage, Chronic; Case Management; Contraindications; Craniotomy; Decompression, Surgical; Diabetes Complications; Evidence-Based Medicine; Facial Neoplasms; Fibrin Tissue Adhesive; Hemorrhage; Heparin; Heparin, Low-Molecular-Weight; Humans; Hypercholesterolemia; Hypertension; Infarction, Middle Cerebral Artery; International Normalized Ratio; Intracranial Embolism; Male; Melanoma; Middle Aged; Mohs Surgery; Paresis; Postoperative Complications; Preoperative Care; Prospective Studies; Retrospective Studies; Skin Neoplasms; Skin Transplantation; Thrombolytic Therapy; Warfarin

Topics: Abdomen; Anticoagulants; Aspirin; Heparin; Humans; Pelvis; Postoperative Complications; Venous Thrombosis; Warfarin

Patients undergoing general surgery present an inherent risk of deep vein thrombosis (DVT). Evidence-based strategies for prevention and treatment of DVT should be continuously upgraded on the basis of good-quality recent trials.. Articles were identified using MEDLINE, EMBASE, and the Cochrane Library databases (January 1980 to July 2003). Randomized clinical trials and meta-analyses in which different prophylactic and treatment methods were compared for general surgery patients were selected.. In general surgery, low-molecular weight heparins (LMWHs) are relied upon more and more for prophylaxis and initial anticoagulant treatment of DVT, because of their multiple advantages in efficacy, safety, and convenience in handling. For cost-effective reasons, full-dose vitamin K antagonists are still preferred as the standard long-term anticoagulation method, while LMWHs represent the exception. Long-term use of low-intensity warfarin should be considered a new standard of care for the management of venous thrombosis. Compared to LMWH, the new anticoagulant molecules fondaparinux and ximelagatran seem to have similar efficacy in the treatment of venous thromboembolism, but they have a 2-fold increased efficacy in its prophylaxis. Clinical implementation of these new anticoagulant molecules depends on their cost-effectiveness; however, they have the potential to become the treatment of choice in the next decade. Thrombolysis has an unacceptable risk of hemorrhagic complications when used in the treatment of postoperative DVT. Furthermore, there are no data to prove that thrombolysis reduces the incidence of postthrombotic syndrome (PTS), despite early and complete recanalization achieved by thrombolysis. Surgical thrombectomy is only meant to decompress the venous hypertension consecutive to massive thrombosis (phlegmasia cerulea dolens) and thus to avoid venous gangrene. Other mechanical percutaneous thrombectomy devices are under evaluation. In selected cases, a combination treatment consisting of locoregional thrombolysis of the crurofemoral venous axis and mechanical thrombectomy of the pelvic venous axis achieves high rates of complete desobliteration.

Topics: Anticoagulants; Heparin, Low-Molecular-Weight; Humans; Postoperative Complications; Risk Assessment; Surgical Procedures, Operative; Thrombectomy; Thrombolytic Therapy; Venous Thrombosis; Vitamin K; Warfarin

Topics: Administration, Oral; Anticoagulants; Comorbidity; Drug Administration Schedule; Drug Interactions; Drug Monitoring; Hemorrhage; Humans; International Normalized Ratio; Patient Selection; Perioperative Care; Point-of-Care Systems; Postoperative Complications; Practice Guidelines as Topic; Risk Assessment; Risk Factors; Thromboembolism; Time Factors; Warfarin

Thromboembolism affects many patients with solid tumors and clonal hematologic malignancies. Thromboprophylaxis with low-molecular-weight heparin (LMWH) is indicated for surgery and other high-risk situations, but not routinely for central venous catheters or nonsurgical, ambulatory management. Thrombotic events require full anticoagulation for the duration of active disease and/or the prothrombotic stimulus. LMWHs are safe and more effective than both unfractionated heparin for initial therapy and warfarin for secondary prevention. Anti-inflammatory and antiangiogenic properties might account for this advantage and for a survival benefit of chronic LMWH in subgroups of cancer patients. Ongoing studies are characterizing the cost-effectiveness and antitumor mechanisms of LMWHs, the potential utility of newer anticoagulants, and the ability of predictive models to identify high-risk candidates for thromboprophylaxis.

Topics: Anticoagulants; Dose-Response Relationship, Drug; Drug Administration Schedule; Female; Heparin, Low-Molecular-Weight; Humans; Male; Neoplasms; Postoperative Complications; Preoperative Care; Prognosis; Randomized Controlled Trials as Topic; Risk Assessment; Surgical Procedures, Operative; Survival Analysis; Thromboembolism; Thrombolytic Therapy; Treatment Outcome; Warfarin

Topics: Chemoprevention; Heparin, Low-Molecular-Weight; Humans; Perioperative Care; Postoperative Complications; Pulmonary Embolism; Risk Assessment; Risk Factors; Venous Thrombosis; Warfarin

The hemostatic properties of recombinant activated factor VII (rFVIIa) are established in patients with inherited or acquired hemophilia with inhibitors and in patients with congenital factor VII deficiencies. Emerging clinical evidence suggests that there may be a wider role for rFVIIa in the management of hemorrhage associated with traumatic injury/accident and severe bleeding associated with critical surgery. This article considers recent data from studies in which rFVIIa was used in an attempt to control bleeding in clinical situations as diverse as coagulopathy associated with chronic liver disease, massive perioperative bleeding and bleeding during prostatectomy, organ transplantation and orthopedic surgery, uncontrollable obstetric hemorrhage, and intracerebral hemorrhage. In nontrauma settings involving acute and potentially life threatening bleeding, there may be a place for rFVIIa as adjunctive therapy in the control of hemostasis.

Topics: Anticoagulants; Factor VII; Factor VIIa; Hemophilia A; Hemorrhage; Humans; Liver Transplantation; Postoperative Complications; Randomized Controlled Trials as Topic; Recombinant Proteins; Warfarin

Venous thromboembolism (VTE) is a serious disorder and a major cause of morbidity and mortality among acutely ill medical patients. However, despite the growing number of patients with acute medical illnesses who have an associated risk of VTE, the widespread use of VTE prophylaxis does not yet occur for both surgical and nonsurgical patients. Although individuals at greatest risk for VTE include patients undergoing major orthopedic surgery and those with medical conditions that require prolonged immobilization, all patients who have acute medical illnesses should be considered for VTE prophylaxis. Several strategies, including various mechanical and pharmacologic approaches, are currently used for VTE prophylaxis. Increased awareness about the full range of options for VTE prophylaxis can help health care providers select the appropriate course of action to help reduce the incidence of VTE among patients with acute medical illnesses.

Topics: Anticoagulants; Aspirin; Bandages; Combined Modality Therapy; Heparin, Low-Molecular-Weight; Intermittent Pneumatic Compression Devices; Platelet Aggregation Inhibitors; Postoperative Complications; Randomized Controlled Trials as Topic; Thromboembolism; Vena Cava Filters; Venous Thrombosis; Warfarin

All patients with neurologic diseases should receive perioperative VTE prophylaxis. The choice of mechanical, pharmacologic, or combined modalities of prophylaxis depends on both the underlying risk factors and surgical VTE risks. Prophylaxis and treatment options must be individualized to the patient. Prevention of VTE will help minimize the need for therapeutic treatment. Options for treatment include both inpatient and outpatient regimens using UFH or LMWH. In patients with an absolute or relative contraindication to anticoagulation, an IVC filter is an appropriate management strategy. Perioperative bridging therapy should be considered in patients with high or moderate risks for recurrent VTE.

Topics: Anti-Inflammatory Agents, Non-Steroidal; Anticoagulants; Aspirin; Brain Diseases; Chondroitin Sulfates; Dermatan Sulfate; Dose-Response Relationship, Drug; Drug Combinations; Fibrinolytic Agents; Heparin; Heparitin Sulfate; Humans; Postoperative Complications; Venous Thrombosis; Warfarin

Every year, approximately 2 million people experience a deep venous thrombosis (DVT). Approximately 600,000 of these people are diagnosed with a pulmonary embolism and about 10% of these die. It has been established that surgery, anesthesia, and bed rest increase the risk of DVT, and therefore, patients who undergo a major lower-extremity procedure should receive prophylaxis. During the past 10 years, the choices of pharmacological and mechanical prophylaxis have increased greatly. Warfarin is probably the most widely used prophylactic method in the U.S., but low-molecular-weight heparin (LMWH) use has increased. Also available is a synthetic pentasaccharide that acts as an anti-Xa inhibitor to decrease DVT without increase in bleeding. All but warfarin are given by subcutaneous injection and require no laboratory management to adjust the medication. Another drug in clinical trials is a direct thrombin inhibitor taken orally in a fixed dose that does not require monitoring. Non-pharmacological prophylaxis and/or stacked modalities, although used, have not shown the efficacy of pharmacological prophylaxis. With the incidence of DVT reported in the range of 41% to 85% without prophylaxis in joint replacement and hip-fracture surgery, prophylaxis is warranted in all lower-extremity joint replacement and hip-fracture patients.

Topics: Anticoagulants; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Azetidines; Benzylamines; Fondaparinux; Heparin, Low-Molecular-Weight; Humans; Polysaccharides; Postoperative Complications; Pulmonary Embolism; Venous Thrombosis; Warfarin

Topics: Anticoagulants; Aortic Valve Insufficiency; Arginine; Autoantibodies; Autoimmune Diseases; Female; Fingers; Heart Valve Prosthesis Implantation; Heparin; Hirudins; Humans; Ischemia; Middle Aged; Necrosis; Pipecolic Acids; Platelet Activation; Platelet Factor 4; Postoperative Complications; Raynaud Disease; Recombinant Proteins; Sulfonamides; Thrombocytopenia; Thrombosis; Toes; Warfarin

Topics: Activities of Daily Living; Anticoagulants; Bandages; Female; Heparin; Humans; Massage; Perioperative Care; Postoperative Complications; Posture; Pulmonary Embolism; Risk Factors; Vena Cava Filters; Venous Thrombosis; Warfarin

To elucidate predisposing factors for enlargement of intracerebral hematoma (ICH) during warfarin therapy, we reviewed 47 patients on warfarin who developed acute ICH and determined relationships among ICH enlargement, INR reversal and clinical data. Among 36 patients treated to counteract the effects of warfarin within 24 h of onset, ICH increased in 10 patients (enlarged group), but remained unchanged in the remaining 26 (unchanged group), while ICH remained unchanged in another 11 patients in whom the effect of warfarin was reversed after 24 h. The international normalized ratio (INR) was counteracted immediately in 11 patients treated with prothrombin complex concentrate (PCC) but gradually in the other 36 treated by reducing the dose of warfarin, or by administering vitamin K or fresh frozen plasma. Multivariate analysis with a logistic regression model showed an INR value <2.0 at admission or for 24 h after immediate INR correction with PCC prevented ICH enlargement (OR 0.069, 95%CI 0.006-0.789, p = 0.031). An INR value of >2.0 within 24 h of ICH seems an important predisposing factor for ICH enlargement.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anticoagulants; Cerebral Hemorrhage; Comorbidity; Diabetes Mellitus; Disease Progression; Female; Humans; Hypercholesterolemia; Hypertension; International Normalized Ratio; Liver Diseases; Male; Middle Aged; Platelet Aggregation Inhibitors; Postoperative Complications; Retrospective Studies; Risk Factors; Tomography, X-Ray Computed; Vitamin K; Warfarin

A 12-year-old girl underwent laparoscopy-assisted splenectomy and cholecystectomy with removal of her spleen through a small Pfannenstiel incision. She had an unremarkable postoperative course but returned 16 days later because of increasing right-sided abdominal pain. The pain was constant, sharp, and stabbing without radiation. Abdominal examination showed diffuse right upper quadrant and epigastric tenderness without peritoneal irritation. Laboratory test results included white blood cell count, 14.4 x 10(9)/mm3; hemoglobin, 8.5 g/dL; platelets, 1,483,000; and normal values for lipase, amylase, aspartate transaminase, and alanine transaminase. Evaluation with ultrasonography and vessel Doppler studies showed an occlusive thrombus throughout the portal and splenic veins. The patient underwent intravenous heparin anticoagulation therapy. Her symptoms resolved completely over the next 2 days. The patient is currently receiving warfarin and anagrelide as an outpatient (international normalized ratio, 2). There were no long-term complications caused by portal vein thrombosis. This is the first reported case of portal vein thrombosis after laparoscopic splenectomy in the pediatric population.

Topics: Anemia, Hemolytic, Autoimmune; Anticoagulants; Child; Cholecystectomy, Laparoscopic; Cholelithiasis; Drug Therapy, Combination; Female; Humans; Hypersplenism; Laparoscopy; Portal Vein; Postoperative Complications; Quinazolines; Splenectomy; Splenic Vein; Venous Thrombosis; Warfarin

Topics: Anticoagulants; Drug Interactions; Humans; Intraoperative Complications; Nursing Assessment; Perioperative Nursing; Phytotherapy; Postoperative Complications; Warfarin

Venous thromboembolism has been a common illness even in Japan and gets increased social as well as medical attention, especially during postoperative period. The most effective way of reducing unexpected death from postoperative venous thromboembolism is to institute a comprehensive institutional policy of primary prophylaxis in patients at risk. Since the clinical experience has shown that there are ethnic differences between Japanese and westerners in coagulability, it will be inappropriate to assume that the results of western studies are fully applicable to the clinical situation in Japan. Although it is difficult to prepare the guideline for prophylaxis of venous thromboembolism based on reliable evidence for Japanese currently, available epidemiologic information has been obtained in orthopedic or gynecologic fields.

Topics: Anticoagulants; Heparin; Humans; Japan; Postoperative Complications; Prognosis; Pulmonary Embolism; Risk; Surgical Procedures, Operative; Warfarin

The reported overall risk of deep venous thrombosis in gynaecological surgery ranges from 7 to 45%. Fatal pulmonary embolism is estimated to occur in nearly 1% of these women. Pharmaceutical interventions are one possible prophylactic measure for preventing emboli in women undergoing major gynaecological surgery. Agents include unfractionated heparin (low -dose and adjusted-dose), low-molecular-weight heparins, heparinoids and warfarin.. The objective of this review was to evaluate the effectiveness of warfarin, heparin and aspirin in preventing thromboembolism after major gynaecological surgery.. We searched the Cochrane Menstrual Disorders and Subfertility Group trials register (searched 15 August 2003), the Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library issue 2, 2003), MEDLINE (1966 to April 2003), EMBASE (1985 to April 2003), and CINAHL (1982 to April 2003). References from relevant articles were searched and authors contacted where necessary. In addition we contacted experts in the field for unpublished works.. Randomised controlled trials of heparins, warfarin or aspirin to prevent thromboembolism after major gynaecological surgery were eligible for inclusion.. Thirty-three trials were identified in the initial search. On careful inspection only eight of these met the inclusion criteria. Trials were data extracted and assessed for quality by at least two reviewers. Data were combined for meta-analysis using odds ratios for dichotomous data or weighted mean difference for continuous data. A random effects statistical model was used.. The meta-analysis of heparin versus placebo found a statistically significant decrease in the number of DVTs in both the all women group (including those with and without malignancy) (OR 0.30, 95% CI 0.12 to 0.76) and the subgroup of only women with malignancy (OR 0.30, 95% CI 0.10 to 0.89). There was no significant difference in the incidence of PE. Oral warfarin reduced DVT when compared to placebo in all women (OR 0.22, 95% CI 0.06 to 0.86) and in women with malignancy (OR 0.18, 95% CI 0.04 to 0.87). Meta-analyses of UH and LMWH showed no statistical difference in any comparison. No studies compared aspirin alone to placebo, heparin or warfarin. There was a statistically significant increase in injection site haematomas associated with heparin compared to placebo (OR 0.30, 95% CI 0.10 to 0.89).. Women, undergoing major gynaecological surgery and without contraindications to anticoagulants should be offered thromboprophylaxis. Evidence suggests that UH and LMWH are equally as effective in preventing DVT and the one trial available suggests that warfarin is as effective as UH. There is no evidence as yet to suggest that warfarin, heparin or aspirin reduce incidence of PE.

Topics: Anticoagulants; Aspirin; Female; Gynecologic Surgical Procedures; Heparin; Humans; Postoperative Complications; Pulmonary Embolism; Venous Thrombosis; Warfarin

Adjusted doses of oral warfarin sodium or fixed doses of subcutaneous low-molecular-weight heparin (LMWH) are the standard approaches for preventing venous thromboembolism following major orthopedic surgery of the legs. In recent years, new anticoagulants have been compared with either LMWH or warfarin. The optimal timing for the first dose of LMWH prophylaxis and of the new anticoagulants is controversial. Recent clinical trials of LMWH and of newer anticoagulants have provided new information on the relationship between the timing of the first anticoagulant dose and the efficacy and safety of thromboprophylaxis after major orthopedic surgery. These data on the optimal timing of initiating prophylaxis come from limited direct randomized comparisons of different timing with the same anticoagulant, subgroup analysis of large studies with a single anticoagulant, indirect comparisons across studies in systematic reviews, and single randomized trials comparing different anticoagulants. In the direct comparison of the same anticoagulant, preoperative initiation of the same regimen of LMWH (dalteparin) increased major bleeding, without improved antithrombotic efficacy compared to the early postoperative regimen. Fondaparinux, 2.5 mg, begun 6 h postoperatively is more effective and as safe as the currently approved regimens of enoxaparin begun either 12 h preoperatively, or 12 to 24 h postoperatively, in patients undergoing major orthopedic surgery. In a subgroup analysis of several large randomized trials, fondaparinux, 2.5 mg, begun < 6 h postoperatively was associated with increased major bleeding, without improved efficacy. The results of indirect comparisons also favor the use of a 6-h postoperative starting time for the first dose, while the single randomized trials comparing different anticoagulants performed to date are not helpful in establishing an optimal time for the first dose. The aggregate clinical research evidence supports the following general conclusions about the relationship between the timing of the first anticoagulant dose and the efficacy and safety of prophylaxis: (1) preoperative initiation is not required for good efficacy and, when begun within 2 h of surgery, increases major bleeding; (2) initiation at 6 h postoperatively is effective and not associated with increased major bleeding; (3) initiation < 6 h postoperatively increases major bleeding, without improved efficacy; thus, 6 h appears to be the threshold for early postoperative

Topics: Anticoagulants; Drug Administration Schedule; Fondaparinux; Heparin, Low-Molecular-Weight; Humans; Leg; Polysaccharides; Postoperative Complications; Randomized Controlled Trials as Topic; Time Factors; Venous Thrombosis; Warfarin

Venous thromboembolism (VTE) prophylaxis is indicated while in the hospital after major surgery. There is evidence that the prevalence of asymptomatic deep-vein thrombosis, detected by routine venography after major orthopedic surgery, is lower at hospital discharge in patients who have received 10 days rather than 5 days of prophylaxis. This observation supports the current American College of Chest Physicians (ACCP) recommendation for a minimum of 7 to 10 days of prophylaxis after hip and knee replacement, even if patients are discharged from the hospital within 7 days of surgery. As risk of VTE persists for up to 3 months after surgery, patients at high risk for postoperative VTE may benefit from extended prophylaxis (eg, an additional 3 weeks after the first 7 to 10 days). Extended prophylaxis with low-molecular-weight heparin (LMWH) reduces the frequency of postdischarge VTE by approximately two thirds after hip replacement; however, the resultant absolute reduction in the frequency of fatal pulmonary embolism is small (ie, estimated at 1 per 2,500 patients). Indirect evidence suggests that, compared with LMWH, efficacy of extended prophylaxis after hip replacement is greater with fondaparinux, similar with warfarin, and less with aspirin. Extended prophylaxis is expected to be of less benefit after knee than after hip replacement. In keeping with current ACCP recommendations, at a minimum, extended prophylaxis should be used after major orthopedic surgery in patients who have additional risk factors for VTE (eg, previous VTE, cancer). If anticoagulant drug therapy is stopped after 7 to 10 days, an additional month of prophylaxis with aspirin should be considered.

Topics: Anticoagulants; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Aspirin; Drug Administration Schedule; Fondaparinux; Hemorrhage; Heparin; Humans; Polysaccharides; Postoperative Complications; Prevalence; Radiography; Risk Factors; Time Factors; Venous Thrombosis; Warfarin

To compare the cost-effectiveness of warfarin or enoxaparin with no prophylaxis for prevention of venous thromboembolism in patients undergoing total knee replacement (TKR) or knee arthroplasty.. Literature search and retrospective database analysis.. Cohort of 42,692 patients over 40 years old who underwent TKR or knee arthroplasty, with a subsequent length of stay of at least 1 day, and who did not die postoperatively.. Both warfarin and enoxaparin were superior to no prophylaxis with regard to costs and clinical outcomes. Enoxaparin was associated with medical charges of $26,455/patient and prevented 194 deaths/10,000 patients. Warfarin was associated with medical charges of $27,360/patient and prevented 124 deaths/10,000 patients.. A wide range of model estimates and assumptions identify enoxaparin as the prophylaxis modality of choice for preventing venous thromboembolism and subsequent clinical complications following total knee replacement surgery.

Topics: Adult; Anticoagulants; Arthroplasty, Replacement, Knee; Cost-Benefit Analysis; Enoxaparin; Health Care Costs; Humans; MEDLINE; Postoperative Complications; Premedication; Thromboembolism; Warfarin

Venous thromboembolism (VTE) and particularly idiopathic VTE may be paraneoplastic phenomena. The merits of screening patients with idiopathic VTE for occult cancer are still under debate, and randomized studies are required to establish its potential cost-effectiveness. Cancer and its related surgery greatly increase the risk of VTE. Thromboprophylaxis using agents such as low-molecular-weight heparin (LMWH) has proved to be safe and effective in reducing the incidence of postoperative VTE. The ENOXACAN II study has shown that prolonging the standard 1-week regimen of the LMWH enoxaparin to 4 weeks may further reduce the incidence of postoperative VTE. Enoxaparin has also shown potential benefits in the secondary prevention of VTE and the reduction of bleeding complications. Emerging data indicate that LMWH may improve survival rates in cancer patients with VTE, making this a very important area for future research.

Topics: Antineoplastic Agents; Double-Blind Method; Enoxaparin; Fibrinolytic Agents; Heparin, Low-Molecular-Weight; Humans; Meta-Analysis as Topic; Multicenter Studies as Topic; Neoplasms; Paraneoplastic Syndromes; Postoperative Complications; Prospective Studies; Randomized Controlled Trials as Topic; Risk; Thromboembolism; Thrombophilia; Treatment Outcome; Venous Thrombosis; Warfarin

Thrombosis is the most common cause of mortality in the United States, resulting in more than 2 million deaths per year. Almost an equal number of individuals are affected each year by nonfatal thrombosis, including deep vein thrombosis and nonfatal pulmonary embolism. A large proportion of thrombotic episodes can be prevented by the appropriate selection of prophylactic therapy--a clinical decision that figures greatly in numerous clinical conditions associated with an increased risk of thrombosis, including major orthopedic surgery. Orthopedic surgeons are well aware of the risks for complications inherent in total hip arthroplasty and total knee arthroplasty in particular. However, determining which protocols are optimal for thromboprophylaxis remains a matter of contention, and the choice of prophylactic therapy is a critical factor in the successful completion of any major orthopedic surgical procedure. Although there are key differences between total hip and knee arthroplasty in terms of the measures available for thromboprophylaxis and the data documenting their relative degree of effectiveness, the two procedures share many similarities in these respects as well as in their surgical protocols. By reviewing the data and practice guidelines on thromboprophylaxis in total hip and knee arthroplasty together, orthopedic surgeons can more clearly see the implications for clinical success that the choice of prophylactic therapy has on their management of these two vitally important procedures.

Topics: Anticoagulants; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Heparin, Low-Molecular-Weight; Humans; Incidence; Postoperative Complications; Prevalence; Risk Factors; Syndrome; Venous Thrombosis; Warfarin

Topics: Anticoagulants; Arthroplasty, Replacement; Humans; Postoperative Complications; Postoperative Hemorrhage; Venous Thrombosis; Warfarin

Although pharmacologic prophylaxis against venous thromboembolism has become the standard of care following total hip and knee replacement, prophylaxis among patients undergoing surgery for hip fracture and other lower extremity trauma remains underutilized. Available experience consistently supports the view that low-molecular-weight heparins are more effective than unfractionated heparin for prevention of proximal deep vein thrombosis (DVT) with no additional hemorrhagic risk and more effective than oral anticoagulants for prevention of in-hospital (mostly distal) venous thrombosis at the price of a higher surgical site bleeding and wound hematoma. The choice between low-molecular-weight heparin and warfarin should be tailored to the individual patients based on the clinical assessment of postoperative thrombosis and bleeding risk as well as the prophylaxis-specific cost and convenience. Whether thromboprophylaxis should be continued for a few additional weeks after hospital discharge is controversial. The overall incidence of postoperative DVT in patients with cancer is about twice as high as that of patients free of malignancy. Accordingly, they require prophylactic measures comparable with those usually recommended for major orthopedic surgery. In this setting, dermatan sulfate shows promise. In contrast to surgical patients, prevention of venous thromboembolism is less well studied in hospitalized medical patients. In a recent controlled randomized trial, enoxaparin in high prophylactic doses was an effective and safe measure of thromboprophylaxis in ordinary bedridden patients.

Topics: Anesthesia, Conduction; Anticoagulants; Arthroplasty, Replacement, Hip; Comorbidity; Heart Diseases; Heparin, Low-Molecular-Weight; Hospitalization; Humans; Neoplasms; Postoperative Complications; Spinal Cord Injuries; Venous Thrombosis; Warfarin

Deep venous thrombosis (DVT) is common in total knee arthroplasty (TKA). Because of the rarity of the most serious outcomes, most randomized controlled trials lack the power to analyze these outcomes. A meta-analysis was performed for agents used in DVT prophylaxis in TKA employing a Medline literature search. Study inclusion criteria were randomized controlled trials comparing prophylactic agents in elective TKA with mandatory screening for DVT by venography. Fourteen studies (3,482 patients) met inclusion criteria. For total DVT, all agents except dextran and aspirin protected significantly better than placebo (P < .0001). For proximal DVT rates, low-molecular-weight heparin was significantly better than warfarin (P = .0002). There was a trend that aspirin was better than warfarin (P = .0106). No significant difference was found for symptomatic pulmonary embolism, fatal pulmonary embolism, major hemorrhage, or total mortality.

Topics: Aged; Arthroplasty, Replacement, Knee; Aspirin; Female; Heparin, Low-Molecular-Weight; Humans; Male; Postoperative Complications; Randomized Controlled Trials as Topic; Venous Thrombosis; Warfarin

Patients undergoing total hip replacement are at high risk of developing venous thromboembolism. The 6th ACCP Consensus Conference on Antithrombotic Therapy identified two effective prophylactic methods; low molecular weight heparins (LMWH) and oral anticoagulants. However, two key issues remain controversial. The relative efficacy and safety of prophylaxis initiated pre operatively and post operatively and the optimum duration of prophylaxis. Clinical practice has diverged in North America and Europe as to the appropriate time to administer prophylaxis. This treatment is given pre-operatively in Europe and post-operatively in North America. A number of recent studies have demonstrated that an effective antithrombotic agent administered either immediately before or after surgery may be more effective than current practice. The use of LMWH for extended thromboprophylaxis is supported by convincing data. Clinical trials have demonstrated a significant benefit of pentasaccharide in the prevention of venous thromboembolism in major orthopaedic surgery. A direct thrombin inhibitor given sc. followed by oral administration was found to be as effective and safe as LMWH for the prophylaxis of deep vein thrombosis (DVT) following major hip or knee surgery.

Topics: Anticoagulants; Arthroplasty, Replacement, Hip; Clinical Trials as Topic; Fibrinolytic Agents; Heparin, Low-Molecular-Weight; Humans; Intraoperative Complications; Postoperative Complications; Thromboembolism; Warfarin

It is well-known that peri-operative and post-operative venous thrombosis are common. Trials in Europe have shown that extended out-of-hospital prophylaxis with a low-molecular-weight heparin reduces the rate of deep vein thrombosis in patients undergoing elective hip surgery. North American investigators of limited-outcome descriptive studies, however, have suggested that out-of-hospital prophylaxis is not necessary. To resolve this uncertainty, NAFT (North American Fragmin Trial) was conducted, the results of which are summarized in this paper. The findings of NAFT support the favourable findings of the European studies on extended prophylaxis. Furthermore, European data have shown extended out-of-hospital prophylaxis to be cost-effective. On the basis of the aggregate data, it is felt that the A2 recommendation made by the Fifth American College of Chest Physicians consensus conference for extended prophylaxis should be changed to an A1 recommendation.

Topics: Anticoagulants; Arthroplasty, Replacement, Hip; Cost-Benefit Analysis; Dalteparin; Decision Making; Double-Blind Method; Drug Administration Schedule; Drug Costs; Elective Surgical Procedures; Follow-Up Studies; Hematoma; Humans; North America; Postoperative Complications; Postoperative Period; Practice Guidelines as Topic; Safety; Treatment Outcome; Venous Thrombosis; Warfarin

Post-surgical deep vein thrombosis (DVT) is often underdiagnosed by clinical assessment alone. Subclinical DVT is a major source of pulmonary embolism, which is an important cause of death, particularly following total hip replacement surgery. Results from pathophysiological studies and recently conducted, prospective double-blind venographic studies in Europe and North America suggest that, in patients undergoing total hip replacement surgery, thromboprophylaxis with a low-molecular-weight heparin should be continued for at least 5 weeks post-operatively to minimize this serious complication.

Topics: Anticoagulants; Arthroplasty, Replacement, Hip; Double-Blind Method; Europe; Heparin, Low-Molecular-Weight; Humans; Leg; Multicenter Studies as Topic; North America; Outpatients; Phlebography; Postoperative Complications; Postoperative Period; Prevalence; Prospective Studies; Pulmonary Embolism; Randomized Controlled Trials as Topic; Regional Blood Flow; Risk Factors; Thromboembolism; Thromboplastin; Venous Thrombosis; Warfarin

Postoperative thromboembolic events are a major cost factor for every healthcare system. Although thromboprophylaxis carries its own costs, the application of a thromboprophylactic regimen is cost-effective in most instances, at least in high-risk patients. A regimen of general postoperative prevention of deep vein thrombosis is always more cost-effective than surveillance programmes with treatment after diagnosis, and is almost always more cost-effective than no prophylaxis. For patients with a high risk of postoperative thromboembolism, such as after orthopaedic surgery, low-molecular-weight heparins have a rather clear advantage over prophylaxis with unfractionated heparin and warfarin, also in terms of cost- effectiveness. With regard to moderate-risk patients, such as after general surgery, the economic benefits are less clear. However, since the results of economic analyses are heavily dependent on the healthcare system, and since there are methodological difficulties and uncertainties connected with the analyses, the implications are difficult -- if not impossible -- to generalize. There is an urgent need for further prospective studies, which should be performed with defined economic variables a priori and in close cooperation with health economists.

Topics: Anticoagulants; Arthroplasty, Replacement, Hip; Clinical Trials as Topic; Cohort Studies; Cost of Illness; Cost-Benefit Analysis; Drug Costs; Heparin, Low-Molecular-Weight; Hospitalization; Humans; Incidence; Postoperative Complications; Randomized Controlled Trials as Topic; Research Design; Retrospective Studies; Risk; Venous Thrombosis; Warfarin

Two patients developed catastrophic multicentric skin necrosis while receiving warfarin to treat venous thromboembolism complicated by immune-mediated heparin-induced thrombocytopenia (HIT). Patient 1 developed skin necrosis involving the breasts, thighs, and face, as well as venous limb gangrene and bilateral hemorrhagic necrosis of the adrenal glands, resulting in death. The second patient developed bilateral mammary necrosis necessitating mastectomies, as well as skin necrosis involving the thigh. Neither patient had an identifiable hypercoagulable syndrome, other than HIT. HIT may represent a risk factor for the development of multicentric warfarin-induced skin necrosis (WISN).

Topics: Adrenal Gland Diseases; Aged; Amputation, Surgical; Anticoagulants; Antigens, Human Platelet; Autoantibodies; Autoimmune Diseases; Databases, Factual; Disseminated Intravascular Coagulation; Ecchymosis; Fatal Outcome; Female; Gangrene; Hemorrhage; Heparin; Humans; Mastectomy; Middle Aged; Multiple Organ Failure; Necrosis; Postoperative Complications; Pulmonary Embolism; Skin; Skin Diseases; Thigh; Thrombin; Thrombocytopenia; Thrombophilia; Thrombophlebitis; Vena Cava Filters; Warfarin

Atrial fibrillation is a common condition and carries a risk of thromboembolism. There is general acceptance that those patients with atrial fibrillation secondary to valvular (and in particular mitral) heart disease or following valve replacement require anticoagulation. Since patients with non-valvular causes of atrial fibrillation are a more heterogeneous group, the indications for anticoagulation have been less clear. A number of benchmark studies clearly indicate that the risk of stroke can be reduced by up to 70% in those treated with warfarin, but only by a variable 30% with aspirin. Problems with interpretation of the results of these studies relate to the younger age range included and a low recruitment rate, leading to a possible under-estimate of the bleeding risk. Subgroup analysis provides risk stratification for patients with non-valvular atrial fibrillation so that those with three or more of any of the five following risk factors: congestive heart failure, hypertension, previous stroke, left atrial enlargement or left ventricular hypertrophy, have an 18% chance of new thromboembolic events, whereas this falls to one third of this with only one or two risk factors, and 1% with none. Those with so-called lone atrial fibrillation aged < 60 years have a very low incidence of atrial fibrillation and can be considered for aspirin alone. The trials supporting in these statements are presented.

Topics: Aged; Anticoagulants; Aspirin; Atrial Fibrillation; Clinical Trials as Topic; Heart Valve Diseases; Heart Valve Prosthesis; Humans; Intracranial Embolism and Thrombosis; Platelet Aggregation Inhibitors; Postoperative Complications; Risk Factors; Warfarin

Left atrial appendage obliteration was historically ineffective for the prevention of postoperative stroke in patients with rheumatic atrial fibrillation who underwent operative mitral valvotomy. It is, however, a routine part of modern "curative" operations for nonrheumatic atrial fibrillation, such as the maze and corridor procedures.. To assess the potential of left atrial appendage obliteration to prevent stroke in nonrheumatic atrial fibrillation patients, we reviewed previous reports that identified the etiology of atrial fibrillation and evaluated the presence and location of left atrial thrombus by transesophageal echocardiography, autopsy, or operation.. Twenty-three separate studies were reviewed, and 446 of 3,504 (13%) rheumatic atrial fibrillation patients, and 222 of 1,288 (17%) nonrheumatic atrial fibrillation patients had a documented left atrial thrombus. Anticoagulation status was variable and not controlled for. Thrombi were localized to, or were present in the left atrial appendage and extended into the left atrial cavity in 254 of 446 (57%) of patients with rheumatic atrial fibrillation. In contrast, 201 of 222 (91%) of nonrheumatic atrial fibrillation-related left atrial thrombi were isolated to, or originated in the left atrial appendage (p < 0.0001).. These data suggest that left atrial appendage obliteration is a strategy of potential value for stroke prophylaxis in nonrheumatic atrial fibrillation.

Topics: Aged; Atrial Fibrillation; Cerebrovascular Disorders; Contraindications; Heart Atria; Heart Diseases; Humans; Mitral Valve Stenosis; Postoperative Complications; Thrombosis; Warfarin

All patients at moderate to high risk for the development of venous thromboembolism should receive prophylaxis. The approaches of proven value include low dose heparin, low molecular weight heparin, oral anticoagulants and intermittent pneumatic compression. The use of one of the cited heparin nomograms will ensure that all patients are rapidly brought within the therapeutic range. Because of the varying sensitivities of thromboplastins, each laboratory should establish a therapeutic range using the activated partial thromboplastin time (APTT) which will correspond to 0.2 to 0.4 U/ml of heparin. Constant vigilance and a high level of suspicion are necessary to establish the clinical diagnosis of heparin-induced thrombocytopenia, and to institute appropriate therapy. Physicians should be aware of the sensitivity of the thromboplastin being used in the performance of the International Normalised Ratio (INR). Care must be taken to ensure that patients are maintained within the target therapeutic range for INR (in most cases 2 to 3) by frequent determination of the INR and appropriate adjustments of warfarin dosage. Low molecular weight heparin is the recommended approach to the initial management of venous thromboembolism where these agents are available. Patients with an acute episode of venous thromboembolism should receive warfarin therapy for at least 3 months. At the present time it is reasonable to treat the first recurrence with oral anticoagulants for a period of 12 months and indefinitely for more than 1 recurrence. For selected patients with acute massive pulmonary embolism, thrombolytic therapy with one of the available agents is recommended. However, the role of thrombolytic therapy in patients with proximal venous thrombosis remains unclear. In selected patients with acute venous thromboembolism who have contraindications to anticoagulant therapy or who-have objectively documented recurrent disease while on adequate therapy, the insertion of an inferior vena cava filter is recommended.

Topics: Anticoagulants; Bandages; Clinical Trials as Topic; Heparin; Heparin, Low-Molecular-Weight; Humans; Postoperative Complications; Risk Factors; Thromboembolism; Warfarin

Use of low molecular weight heparins (LMWHs) is now generally accepted as an ideal method of prophylaxis against postoperative venous thromboembolism. However, the long-term effects on the development of postthrombotic deep vein insufficiency are not known. Every patient developing such complications consumes a vast amount of resources, in terms of both direct and indirect costs. Our cost-effective analysis indicates that LMWH (reviparin sodium) is most cost-saving for both direct and indirect costs, particularly in high risk patients undergoing major surgery.

Topics: Anticoagulants; Cost-Benefit Analysis; Heparin, Low-Molecular-Weight; Humans; Postoperative Complications; Thrombosis; Warfarin

Topics: Aspirin; Bandages; Dextrans; Heparin; Humans; Pelvis; Postoperative Complications; Thromboembolism; Time Factors; Urologic Diseases; Warfarin

Topics: Adult; Aged; Animals; Anticoagulants; Blood Coagulation; Clinical Trials as Topic; Dihydroergotamine; Drug Combinations; Hemorrhage; Heparin, Low-Molecular-Weight; Humans; Middle Aged; Monitoring, Physiologic; Postoperative Complications; Prothrombin Time; Rabbits; Reference Standards; Thrombelastography; Thromboembolism; Warfarin

Topics: Animals; Anticoagulants; Antithrombin III; Antithrombin III Deficiency; Aprotinin; Blood Coagulation Tests; Cardiopulmonary Bypass; Heparin; Hirudin Therapy; Hirudins; Humans; Intraoperative Complications; Peptide Fragments; Postoperative Complications; Recombinant Proteins; Thrombin; Thrombosis; Warfarin

While several methods of prophylaxis have been shown to reduce the risk of venous thromboembolism following total hip replacement, the safest and most effective agent is unclear. To clarify this issue, we performed a meta-analysis of the randomized trials of methods used to prevent venous thromboembolism following total hip replacement.. English-language human studies articles from 1966 through 1993 were obtained from a MEDLINE database search with indexing terms including thromboembolism, hip replacement or hip prosthesis, and randomized controlled trials. Additional references were obtained from study bibliographies.. The following criteria were used to select studies for inclusion: study design--randomized clinical trial; study population--patients undergoing elective total hip replacement; interventions--aspirin, warfarin, dextran, heparin, low-molecular-weight heparin, compression stockings; and outcomes--venous thromboembolism, major hemorrhage.. Methodological and descriptive data from each study were abstracted by one author who was blinded to quantitative outcomes data.. Ninety-one treatment groups and 25 control groups were identified from 56 trials. Four treatment groups were excluded because of rarely used combinations. Trial populations were clinically homogeneous. When compared with the control arm, all treatments except aspirin reduced the risk of all deep venous thromboses (risk differences range, 0.18 to 0.31; all P values < .05). All treatments except aspirin reduced the risk of proximal venous thrombosis (risk differences range, 0.09 to 0.18; all P values < .05). Only low-molecular-weight heparin and stockings reduced the risk of pulmonary embolism, both with risk differences equal to 0.02. The crude risks of clinically important bleeding as defined by the individual trials were 0% for stockings, 0.3% for controls, and 1.8% for low-molecular-weight heparin.. The results suggest that low-molecular-weight heparin and compression stockings have the greatest relative efficacy in preventing venous thromboembolism following total hip replacement. Low-molecular-weight heparin may be more effective, though at a small risk of clinically important bleeding.

Topics: Aspirin; Bandages; Dextrans; Heparin; Heparin, Low-Molecular-Weight; Hip Prosthesis; Humans; Postoperative Complications; Randomized Controlled Trials as Topic; Research Design; Thromboembolism; Warfarin

Topics: Anesthesia; Cost-Benefit Analysis; Heparin; Heparin, Low-Molecular-Weight; Hip Prosthesis; Humans; Knee Prosthesis; Postoperative Complications; Thromboembolism; Thrombolytic Therapy; Warfarin

To compare the efficacy and cost-effectiveness of enoxaparin, a low-molecular-weight heparin derivative, with that of low-dose warfarin in the prevention of deep-vein thrombosis (DVT) after total hip replacement.. English-language articles on enoxaparin and warfarin prophylaxis is patients undergoing total hip replacement published from January 1982 to December 1992.. Four trials of enoxaparin (involving 567 patients) and six trials of warfarin (involving 630) met the following criteria: randomized controlled trial, prophylaxis started no later than 24 hours after surgery and continued for at least 7 days, warfarin dose monitored and adjusted appropriately, enoxaparin dosage 30 mg twice daily, and DVT confirmed by bilateral venography.. Rates of DVT, cost of prophylaxis, diagnosis and treatment per patient, rate of pulmonary embolism (PE), number of deaths and incremental cost-effectiveness (cost per life-year gained).. The pooled rate of DVT was 13.6% with enoxaparin (95% confidence interval [CI] 10.9% to 16.3%) and 20.6% with warfarin (95% CI 17.4% to 23.8%). At a cost of $19.55 per day for enoxaparin the total cost per patient, including prophylaxis and management of DVT, exceeded that per patient receiving warfarin by about $121. For every 10,000 patients treated the use of enoxaparin will prevent 47 cases of DVT, 3 cases of PE and 4 deaths. Thus, the estimated incremental cost-effectiveness of enoxaparin is $29 120 per life-year gained.. On the basis of current Canadian cost-effectiveness guidelines the results of this study would be considered moderate to strong evidence to adopt enoxaparin prophylaxis against DVT after total hip replacement. However, because of the limited data the estimates are uncertain. Future trials should compare enoxaparin and warfarin and incorporate a prospective economic appraisal.

Topics: Cost-Benefit Analysis; Enoxaparin; Hip Prosthesis; Humans; Postoperative Complications; Thrombophlebitis; Warfarin

Internal jugular vein thrombosis (IJVT) is an uncommon condition, which is often not correctly diagnosed clinically. Diagnosis is readily made by duplex scan, computerized tomography with contrast or magnetic resonance imaging. A case of IJVT following carotid endarterectomy with intra-operative retraction of the internal jugular vein is reported.

Topics: Blindness; Carotid Artery, Internal; Carotid Stenosis; Drug Therapy, Combination; Endarterectomy, Carotid; Heparin; Humans; Jugular Veins; Male; Middle Aged; Postoperative Complications; Radiography; Recurrence; Thrombosis; Ultrasonography; Warfarin

To evaluate the role of antithrombotic therapy, on preserving graft patency, we performed a meta-analysis of randomized clinical trials involving aspirin (ASA), dipyridamole (D), anticoagulants (AC) and placebo or nontreatment controls (P). Manual literature searches were performed supplemented by computerized MEDLINE listings complete to July 1991. Saphenous vein graft occlusion was determined by angiography (patients with > or = 1 distal anastomotic occlusion). The trial data were aggregated with the methods of Mantel and Haenszel. The results are reported as odds ratios (OR) +/- 95% confidence intervals (CI). Seventeen trials were evaluated. Aspirin strongly influenced graft occlusion [ASA +/- D vs P: OR 0.60, 95% CI 0.51, 0.71, P < 0.0001], but dipyridamole provided no additional benefit [ASA+D vs ASA: OR 0.94, 95% CI 0.72, 1.24, P = 0.71]. Anticoagulants reduced graft occlusion [AC vs P: OR 0.56, 95% CI 0.33, 0.93, P = 0.025] and the results were similar to that achieved with aspirin [ASA vs AC: OR 0.95, 95% CI 0.62, 1.44, P = 0.87]. The combination of aspirin and anticoagulants was superior to anticoagulants alone in two limited trials [ASA+AC vs AC: OR 0.55, 95% CI 0.33, 0.88, P = 0.01]. A low (100 mg) to medium (325 mg) daily aspirin dosage was more effective than a high dose (975 mg). Early postoperative treatment (< or = 6 h) strongly influenced graft occlusion while preoperative administration provided no additional benefit. No mortality advantage was identified for any antithrombotic therapy. Aspirin or anticoagulants enhance saphenous vein graft patency following aortocoronary bypass surgery, and a combination thereof deserves further investigation in a trial large enough to detect the effects of these treatments with respect to clinical events.

Topics: Anticoagulants; Aspirin; Coronary Artery Bypass; Dipyridamole; Drug Therapy, Combination; Graft Occlusion, Vascular; Logistic Models; Postoperative Complications; Randomized Controlled Trials as Topic; Risk; Treatment Outcome; Warfarin

Postarthroplasty patients develop venous thromboembolic disease because of venous stasis, hypercoaguability, and vessel wall injury. However, most venous thrombi are nonocclusive or small and elicit few symptoms; pulmonary emboli also tend to be asymptomatic. Noninvasive techniques to detect deep vein thrombosis do not appear to be reliable in this population, so venography may be required. Postoperative perfusion lung scans, with comparison to preoperative perfusion scans, are the best screen for asymptomatic pulmonary emboli. Heparin infusion, followed by oral warfarin, is indicated for symptomatic thromboembolic disease as well as for asymptomatic patients with substantial proximal deep venous thrombosis or large pulmonary emboli.

Topics: Contraindications; Heparin; Humans; Joint Prosthesis; Phlebography; Plethysmography, Impedance; Postoperative Complications; Pulmonary Embolism; Radionuclide Angiography; Ultrasonography; Warfarin

Warfarin is a very effective anticoagulant when used in the standard dose; however, the definition of standard dose has become ambiguous as the importance of the thromboplastin used in the measure of the prothrombin times has been demonstrated. Full or "standard" anticoagulation with warfarin imposes a hemorrhagic risk that can be avoided using lower doses. The premise has now been established that less than standard doses are efficacious. What is yet to be determined, however, is how low the dose of warfarin may be while maintaining efficacy and in which clinical settings. These conclusions must be established cautiously in clinical settings before being advocated generally. More complete discussions of this topic as well as safer means of using warfarin in general are available.

Topics: Atrial Fibrillation; Coronary Disease; Feasibility Studies; Humans; Postoperative Complications; Prospective Studies; Prothrombin Time; Thrombophlebitis; Thrombosis; Warfarin

The sudden development of cyanotic lesions on the feet may be a result of atheroembolic disease or a number of medical conditions. A careful history and physical examination, basic laboratory tests, and noninvasive vascular assessment usually distinguish between medical and surgical causes and direct the choice of further investigations. Specific therapy is often available for medical conditions causing this syndrome. The management of atheroembolic disease is more controversial. In particular, further research is necessary to determine which patients need surgical intervention and which patients can be managed safely by medical therapy.

Topics: Adrenal Cortex Hormones; Blood Coagulation Disorders; Calcinosis; Cyanosis; Embolism; Humans; Ischemia; Postoperative Complications; Skin Diseases; Syndrome; Toes; Vasculitis; Warfarin

Topics: Cholecystectomy; Cost-Benefit Analysis; Costs and Cost Analysis; France; Heparin; Humans; Orthopedics; Postoperative Complications; Thromboembolism; Warfarin

Cardiac disorders associated with cerebral embolism including cardiac surgery, myocardial infarction, endocarditis and non-valvular atrial fibrillation (NVAF) are reviewed along with methods to detect cardioembolic sources. Warfarin and aspirin are effective in the primary prevention of stroke in NVAF but the relative efficacy remains to be determined.

Topics: Cerebrovascular Disorders; Heart Diseases; Humans; Intracranial Embolism and Thrombosis; Postoperative Complications; Risk Factors; Warfarin

Topics: Aspirin; Bandages; Dextrans; Dihydroergotamine; Drug Combinations; Heparin; Heparin, Low-Molecular-Weight; Hip Prosthesis; Humans; Male; Postoperative Complications; Risk Factors; Thromboembolism; Warfarin

Orthopedic surgery patients are at high risk of developing thromboembolic disease simply by the very nature of the procedures they undergo even if no other risk factor is present. In unprotected total hip replacement patients, the incidence of fatal pulmonary embolism is at least 2% and the incidence of deep vein thrombosis reaches 50%. Noninvasive screening methods for deep vein thrombosis such as cuff impedance phlebography and fibrinogen scanning have been proved accurate in patients with suspected symptomatic deep vein thrombosis. In asymptomatic but high-risk total hip replacement patients, however, these methods have a combined sensitivity of only 23%. Radiological venography still remains the screening method of choice in these patients. Low-dose warfarin prophylaxis reduces the incidence of deep vein thrombosis to 16% and lowers the risk of major bleeding complications tenfold over the traditional higher dose warfarin. It also enhances protection against proximal thrombi compared to dextran, aspirin, or external pneumatic compression. When low-dose warfarin is used for 12 weeks after total hip replacement without routine venography, it drastically reduces fatal pulmonary embolism (no cases in 268 consecutive patients). This prophylactic regimen is also safe in terms of bleeding complications before and after patient discharge. Finally, it is very cost effective: a saving of $176,000 in treating 268 patients compared with routine venography.

Topics: Adult; Female; Hip; Humans; Male; Middle Aged; Postoperative Complications; Pulmonary Embolism; Thrombophlebitis; Warfarin

Topics: Cost-Benefit Analysis; Hemorrhage; Hip Prosthesis; Humans; Postoperative Complications; Pulmonary Embolism; Thromboembolism; Thrombophlebitis; Warfarin

Oral anticoagulants are used extensively, although their risks are not always fully recognized. The prophylaxis of venous thrombosis after hip surgery, the prevention of deep venous thrombosis and pulmonary emboli after an acute episode of these, the prevention of arterial emboli from the heart in patients at risk, and the prophylaxis of thrombosis in patients with congenital deficiency of antithrombin III, protein C, or protein S are some of the indications for oral anticoagulant use. Warfarin sodium is contraindicated in pregnancy, however. The recommended prothrombin time is 1 1/2 to two times control, lower than previously. The major risk of oral anticoagulant therapy, bleeding, is treated with vitamin K or plasma, depending on its severity. Warfarin necrosis and the "purple-toe" syndrome are seen more frequently than realized.

Topics: Absorption; Administration, Oral; Biological Availability; Drug Interactions; Hemorrhage; Hip Fractures; Humans; Myocardial Infarction; Necrosis; Postoperative Complications; Protein Binding; Prothrombin Time; Pulmonary Embolism; Thrombophlebitis; Thrombosis; Vitamin K; Warfarin

Routine prophylaxis of deep vein thrombosis and pulmonary embolism is justified by the importance of these complications as sources of major morbidity and mortality in otherwise healthy patients more than 40 years old undergoing extensive elective operations. As no one prophylactic technique is ideal, the continuing controversy is over the choice of technique for each patient. Appropriate selection of a prophylactic technique requires a careful preoperative assessment based upon the relative risk of thromboembolism due to associated disease, the risk of bleeding complications secondary to an underlying bleeding diathesis, the possibility of major morbidity from unexpected postoperative bleeding determined by the anatomic site of surgical procedure and the risk of thromboembolism imposed by the surgical procedure itself (57). For patients at high risk, warfarin remains the prophylactic agent of choice. To date, the available data on combinations of mechanical and chemical techniques are incomplete and contradictory, but future studies may identify synergistic combinations. In patients at high risk who also greatly risk having bleeding complications, vena caval interruption should be considered. In patients undergoing operation at moderate risk, low dose heparin, dextran and external pneumatic compression devices are beneficial. In patients undergoing elective hip and knee operation at moderate risk, aspirin appears especially safe and effective. When major morbidity may result from anticoagulation in patients at moderate risk for deep vein thrombosis and pulmonary embolism, external pneumatic compression devices, gradient elastic stockings or elevation of the leg should be used. Further carefully controlled clinical trials are needed to identify even better options for prophylaxis.

Topics: Adult; Age Factors; Anticoagulants; Aspirin; Clothing; Dextrans; Early Ambulation; Heparin; Hip Joint; Humans; Knee Joint; Physical Exertion; Postoperative Complications; Posture; Pulmonary Embolism; Risk; Thrombophlebitis; Warfarin

Approximately 20,000 heart valve prostheses are inserted yearly in the United States. Even after successful heart operations, the patients who receive them cannot be regarded as healthy individuals but are a special group with special problems who need close medical attention for the rest of their lives. They are susceptible to many unusual complications because of their implanted foreign body, and it is a challenge to all physicians in contact with them to be aware of their peculiar problems in order to prevent complications if possible and to treat them immediately if they occur. General therapy, surgical complications, infection, and mechanical problems are reviewed, with means for management outlined. These difficulties can be dealt with only by careful follow-up and well-coordinated teamwork between the family physician and the institution where the operation was performed.

Topics: Activities of Daily Living; Anti-Arrhythmia Agents; Diet, Sodium-Restricted; Digitalis Glycosides; Diuretics; Embolism; Endocarditis, Bacterial; Heart Valve Prosthesis; Humans; Postoperative Care; Postoperative Complications; Thrombosis; Time Factors; Warfarin

Topics: Acute Disease; Anticoagulants; Atrial Fibrillation; Cell Transformation, Neoplastic; Disseminated Intravascular Coagulation; Dose-Response Relationship, Drug; Embolization, Therapeutic; Female; Hemorrhage; Heparin; Humans; Mitral Valve; Postoperative Complications; Pregnancy; Pulmonary Embolism; Thrombocytopenia; Thromboembolism; Thrombophlebitis; Vitamin K; Warfarin

Topics: Anti-Arrhythmia Agents; Cardiac Catheterization; Diet, Sodium-Restricted; Digitalis Glycosides; Diuretics; Endocarditis, Bacterial; Fluoroscopy; Heart Valve Prosthesis; Humans; Phonocardiography; Postoperative Complications; Postpericardiotomy Syndrome; Surgical Wound Infection; Thromboembolism; Warfarin

Topics: Administration, Oral; Anticoagulants; Dextrans; Fibrinogen; Heparin; Humans; Physical Therapy Modalities; Postoperative Complications; Pulmonary Embolism; Radionuclide Imaging; Thromboembolism; Thrombophlebitis; Warfarin

Topics: Aged; Anticoagulants; Aspirin; Bandages; Coumarins; Dextrans; Exercise Therapy; Femoral Neck Fractures; Fibrinogen; Fractures, Bone; Hemorrhage; Hip Injuries; Humans; Iodine Isotopes; Physical Exertion; Postoperative Care; Postoperative Complications; Pulmonary Embolism; Thromboembolism; Thrombophlebitis; Warfarin

Topics: Anemia, Hemolytic; Anemia, Hemolytic, Autoimmune; Animals; Anticoagulants; Aortic Valve Insufficiency; Aortic Valve Stenosis; Cardiology; Cattle; Child; Dipyridamole; Dogs; Endocarditis, Bacterial; Extracorporeal Circulation; Female; Heart Valve Prosthesis; History, 15th Century; History, 16th Century; History, 19th Century; History, 20th Century; Humans; Postoperative Complications; Pregnancy; Prosthesis Design; Thromboembolism; Vascular Surgical Procedures; Venoms; Warfarin

Background The long-term impact of new-onset postoperative atrial fibrillation (POAF) after coronary artery bypass grafting and the benefit of early-initiated oral anticoagulation (OAC) in patients with POAF are uncertain. Methods and Results All patients who underwent coronary artery bypass grafting without preoperative atrial fibrillation in Sweden from 2007 to 2015 were included in a population-based study using data from 4 national registries: SWEDEHEART (Swedish Web System for Enhancement and Development of Evidence-based Care in Heart Disease Evaluated According to Recommended Therapies), National Patient Registry, Dispensed Drug Registry, and Cause of Death Registry. POAF was defined as any new-onset atrial fibrillation during the first 30 postoperative days. Cox regression models (adjusted for age, sex, comorbidity, and medication) were used to assess long-term outcome in patients with and without POAF, and potential associations between early-initiated OAC and outcome. In a cohort of 24 523 patients with coronary artery bypass grafting, POAF occurred in 7368 patients (30.0%), and 1770 (24.0%) of them were prescribed OAC within 30 days after surgery. During follow-up (median 4.5 years, range 0‒9 years), POAF was associated with increased risk of ischemic stroke (adjusted hazard ratio [aHR] 1.18 [95% CI, 1.05‒1.32]), any thromboembolism (ischemic stroke, transient ischemic attack, or peripheral arterial embolism) (aHR 1.16, 1.05‒1.28), heart failure hospitalization (aHR 1.35, 1.21‒1.51), and recurrent atrial fibrillation (aHR 4.16, 3.76‒4.60), but not with all-cause mortality (aHR 1.08, 0.98‒1.18). Early initiation of OAC was not associated with reduced risk of ischemic stroke or any thromboembolism but with increased risk for major bleeding (aHR 1.40, 1.08‒1.82). Conclusions POAF after coronary artery bypass grafting is associated with negative prognostic impact. The role of early OAC therapy remains unclear. Studies aiming at reducing the occurrence of POAF and its consequences are warranted.

Topics: Aged; Aspirin; Atrial Fibrillation; Coronary Artery Bypass; Coronary Artery Disease; Factor Xa Inhibitors; Female; Humans; Long Term Adverse Effects; Male; Outcome Assessment, Health Care; Platelet Aggregation Inhibitors; Postoperative Complications; Sweden; Thromboembolism; Time-to-Treatment; Warfarin

Vitamin K antagonists are the only approved oral anticoagulants for long-term prophylaxis against valve thrombosis and thromboembolism in patients with a mechanical heart valve. Despite the proven efficacy and safety of anticoagulation with the oral direct factor Xa inhibitor apixaban compared with warfarin in high-risk populations including subjects with atrial fibrillation or with venous thromboembolism, it remains unknown whether patients with a mechanical heart valve can be safely managed with apixaban. The On-X Aortic Heart Valve and On-X Ascending Aortic Prosthesis with the Vascutek Gelweave Valsalva Graft may have lower rates of valve thrombosis and thromboembolism than conventional bileaflet and tilting disc valves due its unique pyrolytic carbon composition and flared inlet design. DESIGN: PROACT Xa is a randomized, multicenter, open-label, active-controlled trial comparing apixaban with warfarin in patients with an On-X Aortic Heart Valve or On-X Ascending Aortic Prosthesis with the Vascutek Gelweave Valsalva Graft. The study will randomize approximately 1,000 patients from approximately 60 sites in North America who underwent aortic valve replacement at least 3 months prior. Patients will be randomized 1:1 to receiving apixaban 5 mg twice daily or warfarin with a target international normalized ratio of 2.0-3.0. The last randomized participant will be followed for at least 2 years. The primary efficacy outcome is the composite of valve thrombosis and valve-related thromboembolism, and the primary safety outcome is major bleeding. Assuming the primary outcome occurs in warfarin-anticoagulated patients at a rate of 1.75%/patient-year, the study has more than 90% power to assess noninferiority of apixaban treatment with an absolute noninferiority margin of 1.75%/patient-year. A second co-primary analysis is to compare the hazard rate for the apixaban arm to twice the objective performance criterion for thromboembolism and valve thrombosis, that is, 3.4%/patient-year. SUMMARY: PROACT Xa will determine whether patients with an On-X Aortic Heart Valve can be anticoagulated with apixaban as an alternative to warfarin.

Topics: Anticoagulants; Aortic Valve; Factor Xa Inhibitors; Heart Valve Prosthesis; Humans; Multicenter Studies as Topic; Postoperative Complications; Prosthesis Design; Pyrazoles; Pyridones; Randomized Controlled Trials as Topic; Thromboembolism; Thrombosis; Treatment Outcome; Warfarin

Portal vein system thrombosis (PVST) is a common, potentially life-threatening complication after splenectomy. The optimal recognized anticoagulation drugs for preventing PVST in cirrhotic patients after splenectomy remain unclear. The aim of this study is to evaluate the safety and efficacy of warfarin in preventing PVST after laparoscopic splenectomy and azygoportal disconnection (LSD).. In this randomized controlled single-center study, 80 cirrhotic patients who underwent LSD were randomly assigned to 2 years of treatment with either warfarin (n = 40) or aspirin (n = 40). The primary outcome was prevention of PVST. Sonographers and radiologists who assessed outcomes were blinded to group assignments. Intention-to-treat analysis was performed.. During the first year, excluding two patients withdrawing from the study, 15 of the 39 warfarin-treated patients (38.5%) and five of the 39 aspirin-treated patients (12.8%) did not develop PVST (P = 0.010). The incidence of PVST in the first 2 postoperative years was significantly lower in the warfarin group than in the aspirin group (F = 7.360, P = 0.008). The warfarin group in paired within-group comparisons had significantly greater improvements in total bilirubin and albumin levels at baseline versus at 6 months postoperatively and in creatinine levels at baseline versus at 12, 18, and 24 months postoperatively respectively (all P < 0.05). In contrast, those paired comparisons of the aspirin group showed no significant differences (all P > 0.05).. Warfarin therapy was safe and effective and significantly reduced the risk of PVST after LSD, compared with aspirin treatment. Warfarin treatment was associated with better liver function protection and renal function improvement than aspirin treatment.

Topics: Aged; Aged, 80 and over; Aspirin; Female; Humans; Incidence; Laparoscopy; Liver Cirrhosis; Male; Middle Aged; Portal Vein; Postoperative Complications; Splenectomy; Venous Thrombosis; Warfarin

The present work is a controlled, blinded, and randomized clinical trial comparing hemostatic measures for the control of post-tooth extraction hemorrhage in patients on anticoagulation therapy with warfarin.. The sample consisted of 37 patients (37.8% male and 62.2% female) with a mean age of 45.5 years. After randomization, 20 patients were allocated to the control group (conventional hemostasis measures) and 17 to the study group (addition of local tranexamic acid). All variables that could influence the outcome were similar between the groups and no significant difference was seen (p > 0.05).. In the assessment of immediate hemostasis, for the control group, the time to achieve cessation of bleeding was 9.1 (± 3.6) minutes. For the study group this was much lower, and this difference (6.018 / confidence interval of 95%, 4.677 to 7.359) was statistically significant (p < 0.001). In evaluating the control of intermediate hemorrhage, the use of tranexamic acid was more significantly associated with the absence of bleeding, especially in the first 24 h.. Thus, this measure of local hemostasis in topical form with gauze compression and irrigation was shown to be more effective in reducing the time to attain immediate hemostasis, and in preventing intermediate hemorrhage.

Topics: Anticoagulants; Antifibrinolytic Agents; Female; Hemostatics; Humans; Male; Middle Aged; Oral Hemorrhage; Postoperative Complications; Tooth Extraction; Tranexamic Acid; Treatment Outcome; Warfarin

We assessed antiplatelet therapy use and outcomes in patients undergoing percutaneous coronary intervention (PCI) during the ARISTOTLE trial.. Patients were categorized based on the occurrence of PCI during follow-up (median 1.8 years); PCI details and outcomes post-PCI are reported. Of the 18,201 trial participants, 316 (1.7%) underwent PCI (152 in apixaban group, 164 in warfarin group).. PCI occurred infrequently during follow-up. Most patients on study drug at the time of PCI remained on study drug in the peri-PCI period; 19% continued the study drug without interruption. Antiplatelet therapy use post-PCI was variable, although most patients received DAPT. Additional data are needed to guide the use of antithrombotics in patients undergoing PCI.

Topics: Aged; Anticoagulants; Aspirin; Atrial Fibrillation; Coronary Artery Disease; Drug Monitoring; Female; Hemorrhage; Humans; International Normalized Ratio; Male; Middle Aged; Myocardial Infarction; Outcome Assessment, Health Care; Percutaneous Coronary Intervention; Platelet Aggregation Inhibitors; Postoperative Complications; Proportional Hazards Models; Pyrazoles; Pyridones; Stroke; Warfarin

Peri-operative management of anticoagulated patients with atrial fibrillation (AF) is challenging. To gain information on the peri-operative management of edoxaban, we compared outcomes in patients on warfarin or edoxaban enrolled in ENGAGE AF-TIMI 48 who underwent a surgery or invasive procedure.. Data from patients undergoing their first surgery/procedure were analysed and results compared by anticoagulant (warfarin vs. higher- or lower-dose edoxaban regimen [HDER and LDER, respectively]). Patients were classified by procedural management: anticoagulant interrupted (last dose 4-10 days pre-procedure) or anticoagulant continued (last dose ≤ 3 days pre-procedure). Stroke/systemic embolism (SSE), major bleeding (MB), MB or clinically relevant non-MB (CRNMB) and death were assessed from 7 days pre- until 30 days post-procedure. The chi-square test was used to compare outcomes across treatment groups.. In patients requiring surgery/procedure in ENGAGE AF-TIMI 48, peri-operative rates of SSE, MB and death were not significantly different in patients who received edoxaban or warfarin.

Topics: Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Blood Coagulation; Cardiac Surgical Procedures; Double-Blind Method; Female; Hemorrhage; Humans; Male; Perioperative Care; Postoperative Complications; Pyridines; Stroke; Thiazoles; Treatment Outcome; United States; Warfarin

The burden oral anticoagulation is a limitation of mechanical valve prostheses.. The aim of this study was to test whether patients could be safely managed with dual-antiplatelet therapy (DAPT) (aspirin 325 mg and clopidogrel 75 mg) or lower warfarin after On-X mechanical aortic valve replacement (mAVR).. PROACT (Prospective Randomized On-X Anticoagulation Trial) (n = 576) is a multicenter (41 sites) noninferiority trial. From June 2006 through February 2014, 201 patients ≥18 years of age without thromboembolic risk factors undergoing mAVR were randomized to receive DAPT (n = 99) or standard warfarin plus aspirin (n = 102) 3 months after mAVR (low-risk arm). From June 2006 through October 2009, 375 patients with 1 or more thromboembolic risk factors were also randomized to lower intensity warfarin plus aspirin (international normalized ratio 1.5 to 2.0; n = 185) or standard warfarin plus aspirin (international normalized ratio 2.0 to 3.0; n = 190) 3 months after mAVR (high-risk arm).. The low-risk arm was terminated for excess cerebral thromboembolic events (3.12% per patient-year vs. 0.29% per patient-year, p = 0.02) in the DAPT group at up to 8.8-year follow-up (631.6 patient-years), with no differences in bleeding or all-cause mortality. High-risk arm patients experienced significantly lower major (1.59% per patient-year vs. 3.94% per patient-year, p = 0.002) and minor (1.27% per patient-year vs. 3.49% per patient-year, p = 0.002) bleeding up to 8.7-year follow-up (2,035.2 patient-years), with no differences in thromboembolism (0.42% per patient-year vs. 0.09% per patient-year, p = 0.20) and all-cause mortality.. DAPT was associated with higher rates of thromboembolism and valve thrombosis compared with control in the low-risk arm. International normalized ratios were safely maintained at 1.5 to 2.0 in high-risk patients, without differences in mortality or thromboembolic complications. (Randomized On-X Anticoagulation Trial [PROACT]; NCT00291525).

Topics: Adult; Aged; Anticoagulants; Aortic Valve; Aspirin; Clopidogrel; Female; Heart Valve Prosthesis Implantation; Humans; Male; Middle Aged; Platelet Aggregation Inhibitors; Postoperative Complications; Prospective Studies; Thromboembolism; Warfarin

Catheter ablation of atrial fibrillation is typically performed with uninterrupted anticoagulation with warfarin or interrupted non-vitamin K antagonist oral anticoagulant therapy. Uninterrupted anticoagulation with a non-vitamin K antagonist oral anticoagulant, such as dabigatran, may be safer; however, controlled data are lacking. We investigated the safety of uninterrupted dabigatran versus warfarin in patients undergoing ablation of atrial fibrillation.. In this randomized, open-label, multicenter, controlled trial with blinded adjudicated end-point assessments, we randomly assigned patients scheduled for catheter ablation of paroxysmal or persistent atrial fibrillation to receive either dabigatran (150 mg twice daily) or warfarin (target international normalized ratio, 2.0 to 3.0). Ablation was performed after 4 to 8 weeks of uninterrupted anticoagulation, which was continued during and for 8 weeks after ablation. The primary end point was the incidence of major bleeding events during and up to 8 weeks after ablation; secondary end points included thromboembolic and other bleeding events.. The trial enrolled 704 patients across 104 sites; 635 patients underwent ablation. Baseline characteristics were balanced between treatment groups. The incidence of major bleeding events during and up to 8 weeks after ablation was lower with dabigatran than with warfarin (5 patients [1.6%] vs. 22 patients [6.9%]; absolute risk difference, -5.3 percentage points; 95% confidence interval, -8.4 to -2.2; P<0.001). Dabigatran was associated with fewer periprocedural pericardial tamponades and groin hematomas than warfarin. The two treatment groups had a similar incidence of minor bleeding events. One thromboembolic event occurred in the warfarin group.. In patients undergoing ablation for atrial fibrillation, anticoagulation with uninterrupted dabigatran was associated with fewer bleeding complications than uninterrupted warfarin. (Funded by Boehringer Ingelheim; RE-CIRCUIT ClinicalTrials.gov number, NCT02348723 .).

Topics: Aged; Anticoagulants; Atrial Fibrillation; Catheter Ablation; Dabigatran; Female; Hemorrhage; Humans; Incidence; Kaplan-Meier Estimate; Male; Middle Aged; Postoperative Complications; Stroke; Warfarin

Fontan patients managed with warfarin are at risk not only for thrombotic events, but also for bleeding episodes as a consequence of anticoagulation treatment. The aim of this study was to determine whether time spent in patient specified therapeutic range (TTR), when managed in a cardiology-based pharmacist managed anticoagulation clinic (PMAC), is a useful target metric for monitoring, as well as improving outcomes. A single center retrospective review was conducted evaluating TTR of all Fontan patients (n = 45) on warfarin managed in our outpatient cardiology pharmacist managed anticoagulation clinic (PMAC) during a 19 month time frame. The primary outcome was time spent within, above, and below therapeutic range. Secondary outcomes were thrombotic event (TE) incidence pre- and post PMAC enrollment and bleeding event incidence during PMAC management. Of the Fontan patients included, 55.6% were male and the median age at latest anticoagulation clinic follow-up was 19 years (IQR 13, 29). A composite 52.9 patient years of warfarin therapy was evaluated during the study time frame. The mean TTR for patients was 84.1 ± 5.2%. The most frequent reasons for non-therapeutic INRs were diet changes (42.8%), medication non-compliance (13.7%), and drug interactions (8.8%). Only one TE occurred during the study time frame. The incidence of TE in this population was decreased after PMAC enrollment (1 per 52.9 patient year versus 1 event per 17.4 patient year; p < 0.0002). Two major bleeds that required emergency department visit occurred during this time, none were cerebral or gastrointestinal. In Fontan patients anticoagulated with warfarin, a greater than 80% TTR can be achieved in a PMAC. Such high time in therapeutic range was associated with excellent outcomes, despite the obvious complexity of this population.

Topics: Biomarkers; Child; Child, Preschool; Female; Follow-Up Studies; Fontan Procedure; Hemorrhage; Humans; Male; Postoperative Complications; Retrospective Studies; Thrombosis; Time Factors; Warfarin

Warfarin discontinuation with heparin bridging is a common practice in patients receiving warfarin prior to elective coronary angiography (CAG). The uninterrupted warfarin strategy has been suggested to be alternative option for patients with high thromboembolic risk. Therefore, we aimed to assess the safety of elective transfemoral CAG during uninterrupted warfarin therapy compared to heparin bridging.. This study was a randomized open-label design with blinded event evaluation. The 110 consecutive patients (age ≥ 18 years) receiving warfarin before the planned transfemoral CAG were randomly assigned to either heparin bridging or uninterrupted warfarin with targeted INR (2.0-3.0). The primary outcome was the incidence of major vascular access site complications.. The baseline characteristics were comparable between two groups (mean age was 60.1 ± 7.8 years, 49 males). The mean INR on the day of CAG of heparin bridging and uninterrupted warfarin groups was 1.2 ± 0.3 and 2.2 ± 0.5 (P < 0.001). The major vascular access site complications occurred in 3 of 55 (5.5%) heparin-bridging patients and in none of 55 uninterrupted warfarin patients (P = 0.243). The total vascular access site complications occurred in 6 (10.9%) heparin-bridging and one (1.8%) uninterrupted warfarin patients (P = 0.113). No patient developed either other bleeding or thromboembolic events during 7 days after CAG.. We demonstrated that an uninterrupted warfarin strategy did not increase vascular access site complications in patients undergoing transfemoral CAG compared to heparin bridging therapy. Due to the safety and the ease of uninterrupted warfarin strategy, this approach should be encouraged in patients receiving long-term warfarin who undergo elective transfemoral CAG.

Topics: Aged; Anticoagulants; Coronary Angiography; Female; Femoral Artery; Heparin; Humans; Incidence; Male; Middle Aged; Postoperative Complications; Thromboembolism; Warfarin

The optimal medical strategy for prevention of thromboembolic events after surgical bioprosthetic aortic valve replacement (BAVR) is still debated. The objective of this study was to compare warfarin therapy (target INR of 2.0 to 3.0) with aspirin 150mg daily as antithrombotic therapy for the first three months after BAVR with or without concomitant coronary artery bypass grafting (CABG). The aim was to evaluate thromboembolic complications, major bleeding complications and death.. Prospective, single-centre, open-label, randomized controlled trial. 370 patients were enrolled, 328 were available for data analysis.. At baseline the warfarin and aspirin groups were comparable. Thromboembolic events were comparable between groups 11 (6.6%) vs. 12 (7.5%), p=0.83. Major bleeding events occurred numerically more often in warfarin patients 9 (5.4%) vs. 3 (1.9%), p=0.14. Warfarin was in multivariate analysis significantly associated with major bleeding OR 5.18 (CI 1.06-25.43), p=0.043. 90-day mortality was comparable between groups 8 (4.7%) vs. 6 (3.7%), p=0.79.. Our results suggest that aspirin might be equally effective as warfarin in preventing thromboembolic events after BAVR, but with less major bleedings. Although this is numerically the largest trial testing this hypothesis in a prospective randomized trial, further adequately powered studies are warranted.

Topics: Aged; Aged, 80 and over; Anticoagulants; Aortic Valve; Aspirin; Bioprosthesis; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Hemorrhage; Humans; Postoperative Complications; Prospective Studies; Thromboembolism; Thrombosis; Warfarin

To investigate the feasibility, effectiveness, and complications of catheter-directed thrombolysis (CDT) using three different approaches for acute lower-extremity deep venous thrombosis (DVT).. A total of 106 patients with acute DVT were enrolled in this study. Forty-one patients received CDT through the small saphenous vein (Group A), 35 through the great saphenous vein (Group B), and 30 through the popliteal vein (Group C). Iliac vein balloon dilation and stenting was performed in 65 cases.. The vascular approach route was not statistically related to limb edema reduction rates (Groups A, B, and C: 82.3 ± 7.6% vs. 81.6 ± 6.0% vs. 83.9 ± 6.1%), nor to thrombolysis rates (63.5 ± 7.7% vs. 66.9 ± 8.4% vs. 66.1 ± 2.7%). The procedure was significantly shorter for Groups B and C. No significant difference was found between Groups B and C. Most complications occurred in Group A. The complication rate in Group B was the lowest. Eighty-eight patients were followed up for 7-24 months. Of these, 78 were pain-free and without limb edema; six showed rethrombosis.. CDT is an effective method to manage acute DVT. Of the three routes tested, the small saphenous vein route was associated with more frequent complications. Great saphenous vein catheterization was more effective because of its lower complication rate.

Topics: Adolescent; Adult; Aged; Anticoagulants; Catheterization, Peripheral; China; Female; Fibrinolytic Agents; Follow-Up Studies; Humans; Iliac Vein; Lower Extremity; Male; Middle Aged; Operative Time; Popliteal Vein; Postoperative Complications; Saphenous Vein; Stents; Thrombolytic Therapy; Venous Thrombosis; Warfarin; Young Adult

Portal vein system thrombosis (PVST) is a frequent and potentially life-threatening complication after laparoscopic splenectomy and azygoportal disconnection (LSD) in patients with cirrhotic portal hypertension. The objective of this study was to investigate the safety and effectiveness of warfarin with a target international normalized ratio (INR) of 2.0-2.5 for the prevention of PVST after LSD. Hitherto, this is the first study to assess the use of warfarin in this field.. We retrospectively analyzed a database of 73 consecutive patients who underwent LSD from January 2013 to September 2014. Patients were categorized into the warfarin group (34 patients) and the aspirin group (39 patients). The INR and incidence of PSVT were monitored for 90 days.. Compared with the aspirin group, the warfarin group had a lower incidence of PVST on postoperative day (POD) 30 [17/34 (50.0%) versus 29/39 (74.4%); P = .032] and POD 90 [8/34 (23.5%) versus 30/39 (76.9%); P < .0001] and main portal vein thrombosis (MPVT) on POD 90 [3 (8.8%) versus 13 (33.3%); P = .012]. From POD 30 to 90, the warfarin group achieved more complete recanalization of PVST [9/17 (52.9%) versus 3/29 (10.3%), P = .005] and MPVT [9/12 (75.0%) versus 3/12 (25.0%), P = .039]. Multiple logistic regression analysis revealed that warfarin was an independent protective factor for PVST at POD 90 (relative risk, 0.027; 95% confidence interval, 0.004-0.168; P < .001). No patients developed bleeding complications.. Anticoagulation therapy with warfarin is safe and effective for the prevention of PVST in cirrhotic patients with portal hypertension after LSD.

Topics: Adolescent; Adult; Aged; Anticoagulants; Aspirin; Azygos Vein; Female; Heparin, Low-Molecular-Weight; Humans; Liver Cirrhosis; Male; Middle Aged; Portal Vein; Postoperative Complications; Retrospective Studies; Splenectomy; Treatment Outcome; Venous Thrombosis; Warfarin; Young Adult

This study examines makers of activation of clotting following three chemoprophylactic regimens used for prevention of postoperative venous thromboembolic disease (TED) following high-risk surgery for TED.. Patients having elective primary knee or hip replacement surgery received variable dose warfarin (target international normalized ratios 2.0-2.5), 1 mg warfarin daily starting 7 days preoperatively or aspirin 325 mg daily starting on the day of surgery. Twelve patients in each group were treated for 28 ± 2 days. Thrombin-antithrombin (T-AT) and prothrombin fragment F1 + 2 were measured at baseline and postoperative days 3 and 28 ± 2.. Thrombin-antithrombin and F1 + 2 on postoperative day 3 were equal for the study groups. By days 28 ± 2, variable dose warfarin therapy group suppressed production of F1 + 2 (P = 0.002) with no difference in the T-AT accumulation. F1 + 2 for other patients overlapped the normal range.. The signals of activated clotting following surgery did not differentiate the three regimens on postoperative day 3. Variable dose warfarin was associated with suppression of F1 + 2 after 1 month of therapy, with no effect on accumulation of T-AT. Fixed low-dose warfarin started 7 days prior to surgery and aspirin are not inferior on postoperative day 3, but appear to be inferior over a longer treatment.

Topics: Aged; Anticoagulants; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Biomarkers; Blood Coagulation; Female; Hospitalization; Humans; International Normalized Ratio; Male; Middle Aged; Orthopedic Procedures; Postoperative Complications; Venous Thromboembolism; Warfarin

It is uncertain whether bridging anticoagulation is necessary for patients with atrial fibrillation who need an interruption in warfarin treatment for an elective operation or other elective invasive procedure. We hypothesized that forgoing bridging anticoagulation would be noninferior to bridging with low-molecular-weight heparin for the prevention of perioperative arterial thromboembolism and would be superior to bridging with respect to major bleeding.. We performed a randomized, double-blind, placebo-controlled trial in which, after perioperative interruption of warfarin therapy, patients were randomly assigned to receive bridging anticoagulation therapy with low-molecular-weight heparin (100 IU of dalteparin per kilogram of body weight) or matching placebo administered subcutaneously twice daily, from 3 days before the procedure until 24 hours before the procedure and then for 5 to 10 days after the procedure. Warfarin treatment was stopped 5 days before the procedure and was resumed within 24 hours after the procedure. Follow-up of patients continued for 30 days after the procedure. The primary outcomes were arterial thromboembolism (stroke, systemic embolism, or transient ischemic attack) and major bleeding.. In total, 1884 patients were enrolled, with 950 assigned to receive no bridging therapy and 934 assigned to receive bridging therapy. The incidence of arterial thromboembolism was 0.4% in the no-bridging group and 0.3% in the bridging group (risk difference, 0.1 percentage points; 95% confidence interval [CI], -0.6 to 0.8; P=0.01 for noninferiority). The incidence of major bleeding was 1.3% in the no-bridging group and 3.2% in the bridging group (relative risk, 0.41; 95% CI, 0.20 to 0.78; P=0.005 for superiority).. In patients with atrial fibrillation who had warfarin treatment interrupted for an elective operation or other elective invasive procedure, forgoing bridging anticoagulation was noninferior to perioperative bridging with low-molecular-weight heparin for the prevention of arterial thromboembolism and decreased the risk of major bleeding. (Funded by the National Heart, Lung, and Blood Institute of the National Institutes of Health; BRIDGE ClinicalTrials.gov number, NCT00786474.).

Topics: Adult; Anticoagulants; Atrial Fibrillation; Double-Blind Method; Elective Surgical Procedures; Female; Hemorrhage; Heparin, Low-Molecular-Weight; Humans; Male; Perioperative Period; Postoperative Complications; Thromboembolism; Warfarin

Results of reconstructive operations, performed on the main arteries of the lower extremities (LE) in 63 patients, suffering obliterating atherosclerosis were analyzed with the objective to analyze the causes of thrombotic complications occurrence. There was established, that common clinical screening tests, applied for control of the hemostasis system state, do not permit completely to reveal thrombophylic changes in early postoperative period timely and to prevent the occurrence of the reconstructed segments thrombosis. Direct correlation connection between the ischemia stage of the LE tissues, the reperfusion changes signs and hyperaggregation severity, occurring due to deficiency of the blood serum natural anticoagulants in patients, suffering obliterating atherosclerosis, was established.

Topics: Aged; Anticoagulants; Arteriosclerosis Obliterans; Blood Coagulation; Enoxaparin; Female; Humans; Ischemia; Male; Microcirculation; Plastic Surgery Procedures; Postoperative Complications; Severity of Illness Index; Thrombosis; Treatment Outcome; Warfarin

Decreased antithrombin III (ATIII) activity and large splenic vein diameter (SVD) are risk factors for portal vein thrombosis (PVT) after splenectomy in liver cirrhosis with portal hypertension. Antithrombin III concentrates can prevent PVT. This study was designed to stratify risks for PVT after splenectomy in cirrhotic patients and to develop prophylactic protocols for PVT.. In 53 patients (testing cohort), the cutoff level of preoperative ATIII activity (≤60%) was evaluated for administration of ATIII concentrates. Antithrombin III activity and SVD were re-evaluated as criteria for prophylaxis of PVT. In 57 patients (validation cohort), the risk stratification of PVT and prophylactic protocols were validated.. In the testing cohort, 10 (19%) of 53 patients had PVT. Risk level of PVT was stratified and prophylactic protocols were developed. Patients at low risk (ATIII activity ≥70% and SVD <10 mm) were not treated; those at high risk (ATIII activity <70% or SVD ≥10 mm) received ATIII concentrates (1,500 U/day) for 3 days; and those at highest risk (SVD ≥15 mm) received ATIII concentrates for 3 days, followed by danaparoid sodium (2,500 U/day) for 14 days and warfarin. In the validation cohort, 0 of 14 low-risk and 2 of 32 high-risk patients had PVT. Although 8 of 11 patients at highest risk had temporary PVT, it disappeared within 3 months postoperatively. Finally, only 2 (3.5%) of 57 patients had PVT.. Risk stratification of PVT after splenectomy and prophylaxis with ATIII concentrates and danaparoid sodium dramatically reduced the incidence of PVT.

Topics: Adult; Aged; Anticoagulants; Antithrombin III; Chondroitin Sulfates; Clinical Protocols; Decision Support Techniques; Dermatan Sulfate; Drug Therapy, Combination; Female; Fibrinolytic Agents; Heparitin Sulfate; Humans; Hypertension, Portal; Laparoscopy; Liver Cirrhosis; Male; Middle Aged; Portal Vein; Postoperative Complications; Prospective Studies; Risk Assessment; Risk Factors; ROC Curve; Splenectomy; Venous Thrombosis; Warfarin

Using data from ARISTOTLE, we describe the periprocedural management of anticoagulation and rates of subsequent clinical outcomes among patients chronically anticoagulated with warfarin or apixaban. We recorded whether (and for how long) anticoagulant therapy was interrupted preprocedure, whether bridging therapy was used, and the proportion of patients who experienced important clinical outcomes during the 30 days postprocedure. Of 10 674 procedures performed during follow-up in 5924 patients, 9260 were included in this analysis. Anticoagulant treatment was not interrupted preprocedure 37.5% of the time. During the 30 days postprocedure, stroke or systemic embolism occurred after 16/4624 (0.35%) procedures among apixaban-treated patients and 26/4530 (0.57%) procedures among warfarin-treated patients (odds ratio [OR] 0.601; 95% confidence interval [CI] 0.322-1.120). Major bleeding occurred in 74/4560 (1.62%) procedures in the apixaban arm and 86/4454 (1.93%) in the warfarin arm (OR 0.846; 95% CI 0.614-1.166). The risk of death was similar with apixaban (54/4624 [1.17%]) and warfarin (49/4530 [1.08%]) (OR 1.082; 95% CI 0.733-1.598). Among patients in ARISTOTLE, the 30-day postprocedure stroke, death, and major bleeding rates were low and similar in apixaban- and warfarin-treated patients, regardless of whether anticoagulation was stopped beforehand. Our findings suggest that many patients on chronic anticoagulation can safely undergo procedures; some will not require a preprocedure interruption of anticoagulation. ARISTOTLE was registered at www.clinicaltrials.gov as #NCT00412984.

Topics: Aged; Anticoagulants; Atrial Fibrillation; Double-Blind Method; Embolism; Factor Xa Inhibitors; Female; Humans; Male; Postoperative Complications; Pyrazoles; Pyridones; Stroke; Treatment Outcome; Warfarin

The safety and efficacy of combined low dose aspirin and warfarin therapy in patients with atrial fibrillation after mechanical heart valve replacement were evaluated. A total of 1016 patients (620 females, mean age of 36.8±7.7 years) admitted for cardiac valve replacement and complicated with atrial fibrillation after surgery were randomly divided into study (warfarin plus 75-100 mg aspirin) or control (warfarin only) groups. International normalized ratio (INR) and prothrombin time were maintained at 1.8-2.5 and 1.5-2.0 times the normal values, respectively. Thromboembolic events and major bleedings were registered during the follow-up period. Patients were followed up for 24±9 months. The average dose of warfarin in the study and control groups was 2.91±0.83 mg and 2.88±0.76 mg, respectively (P>0.05). The incidence of overall thromboembolic events in study group was lower than that in control group (2.16% vs. 4.35%, P=0.049). No statistically significant differences were found in hemorrhage events (3.53% vs. 3.95%, P=0.722) or mortality (0.20% vs. 0.40%, P=0.559) between the two groups. Combined low dose aspirin and warfarin therapy in the patients with atrial fibrillation following mechanical heart valve replacement significantly decreased thromboembolic events as compared with warfarin therapy alone. This combined treatment was not associated with an increase in the risk of major bleeding or mortality.

Topics: Adult; Anticoagulants; Aspirin; Atrial Fibrillation; Female; Fibrinolytic Agents; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; International Normalized Ratio; Male; Postoperative Complications; Prothrombin Time; Warfarin

To our knowledge, this is the first study to describe the correlation of anterior chamber bleeding after laser peripheral iridotomy (LPI) and antiplatelet therapy.. To determine the incidence and amount of anterior chamber bleeding after laser peripheral iridotomy in patients whose condition is suggestive of primary angle-closure glaucoma (PACS) who continued their antiplatelet or anticoagulant treatment before undergoing LPI compared with when they discontinued treatment.. A prospective controlled trial.. Patients with suspected bilateral primary angle-closure and no other ocular disease who take antiplatelet or anticoagulant medications regularly (from January 2010-October 2011) were enrolled.. The incidence of anterior chamber bleeding with and without antiplatelet and anticoagulant therapy.. A total of 104 patients (208 eyes) participated in the study. Thirty-six eyes (34.6%) in the treated and untreated arms bled. The amount of bleeding did not differ significantly when the patient was on or off antiplatelet or anticoagulant treatment, nor did the immediate postprocedure mean intraocular pressure (P = .13). The type of antiplatelet or anticoagulant, total laser energy, age, sex, or color of irides were not risk factors for increased bleeding (P = .156 for all parameters).. No indication was noted for discontinuing these medications before a high-powered pulsed laser peripheral iridotomy.

Topics: Adult; Aged; Aged, 80 and over; Anterior Chamber; Anticoagulants; Aspirin; Clopidogrel; Eye Color; Female; Glaucoma, Angle-Closure; Gonioscopy; Humans; Hyphema; Incidence; Intraocular Pressure; Iridectomy; Iris; Laser Therapy; Lasers, Solid-State; Male; Middle Aged; Platelet Aggregation Inhibitors; Postoperative Complications; Prospective Studies; Risk Factors; Ticlopidine; Tonometry, Ocular; Warfarin

According to the current guidelines, substitution of warfarin with heparin is recommended as perioperative management in patients with high risk of thromboembolism. Optimal management of oral anticoagulation in patients undergoing implantable cardioverter defibrillator (ICD) implantation, however, remains controversial.. Bleeding complications among 273 consecutive patients undergoing initial ICD implantation were retrospectively analyzed. Patients were grouped according to medication at the time of device implantation: neither antiplatelet nor anticoagulation (N group, n=121); antiplatelet only (AP group, n=59); warfarin (W group, n=59); and heparin bridging (H group, n=34). The rate of the major bleeding complications, defined as hematoma requiring reoperation, cardiac tamponade, and pericardial effusion requiring additional hospital stay, was 1.7% in the N group, 0% in the AP group, 5.1% in the W group, and 17.6% in the H group (P<0.001, N group vs. H group). After multivariate adjustment, heparin bridging was a significant predictor of major bleeding complications (odds ratio, 7.44; 95% confidence interval: 2.06-26.89; P=0.0022). The international normalized ratio of 3 patients in the W group with major bleeding complications was 1.98 ± 0.10, and was significantly higher than in patients without them (1.31 ± 0.05, n=26, P<0.001).. Heparin bridging increased the risk of bleeding complications at the time of ICD implantation.

Topics: Aged; Anticoagulants; Defibrillators, Implantable; Female; Hemorrhage; Heparin; Humans; International Normalized Ratio; Male; Middle Aged; Perioperative Care; Postoperative Complications; Retrospective Studies; Warfarin

Systemic thromboembolism and bleeding remain the two most common and serious complications of catheter ablation of atrial fibrillation. A variety of periprocedure anticoagulation strategies have been proposed to mitigate these risks. Although operators are now routinely administering dabigatran for anticoagulation in this setting, its relative safety and effectiveness compared to warfarin are unknown.. A total of 202 patients received dabigatran as part of their periprocedural anticoagulation regimen at the time of initial or redo catheter ablation for symptomatic atrial fibrillation. A comparison group of 202 patients treated with warfarin was randomly selected from patients undergoing atrial fibrillation (AF) ablation during the same time period. AF types were paroxysmal in 223 patients, persistent in 158 patients, and longstanding persistent in 13 patients. Mean age was 60.0 ± 10.5 years, 55 % had a history of hypertension, and mean CHADS-VASc score was 1.7 ± 1.3. "Continuous" warfarin or dabigatran was administered in 80 and 32 % of patients, respectively. Time to first dose of dabigatran post-procedure was 12.2 ± 10.3 h. Two dabigatran and no warfarin-treated patients had systemic thromboembolism (p = NS); five dabigatran and three warfarin-treated patients had bleeding complications (p = NS, combined endpoint p = 0.116). One dabigatran patient had severe pericardial bleeding (3 L blood loss).. In a retrospective pilot trial comparing the risks of systemic thromboembolism or bleeding complications in patients treated with warfarin or dabigatran anticoagulation, the outcomes were similar. A prospective trial is warranted.

Topics: Anticoagulants; Atrial Fibrillation; Benzimidazoles; beta-Alanine; Canada; Catheter Ablation; Comorbidity; Dabigatran; Decision Making; Drug-Related Side Effects and Adverse Reactions; Evidence-Based Medicine; Humans; Postoperative Complications; Premedication; Risk Factors; Thromboembolism; Treatment Outcome; United States; Warfarin

Total knee arthroplasty (TKA) and total hip arthroplasty (THA) are associated with high rates of venous thromboembolism (VTE). Anticoagulants, such as warfarin, are commonly used to prevent VTE in such patients. The practice and effectiveness of warfarin in real world populations is not well documented. 595 TKA and THA patients treated with warfarin were followed by two anticoagulation clinics in the Michigan Anticoagulation Quality Improvement Initiative. Length of prescribed anticoagulation, percent time in therapeutic range (%TTR) and time to first therapeutic INR were calculated for each surgical group. For THA, all 300 patients received at least ten days with a 28-day median length of anticoagulation therapy. For TKA, all 295 patients received at least 10 days with a 28-day median length of anticoagulation therapy. For THA patients, time to first therapeutic INR was on average 12.0 ± 8.0 days with a mean %TTR of 36.6 ± 26.8% for goal INR 2.0-3.0. For THA patients, 39 (13%) never reached target INR. For TKA patients, time to first therapeutic INR was on average 12.8 ± 10.3 days with a mean %TTR of 36.0 ± 28.3% for goal INR 2.0-3.0. For TKA patients, 44 (14.9%) never reached target INR. Many orthopaedic surgeons who use warfarin for post-arthroplasty VTE prophylaxis do so in accordance with national guidelines. The time to first therapeutic INR is strikingly long and %TTR markedly low for these patients, raising questions about the efficacy of warfarin therapy in the first 1-2 post-operative weeks. Further studies to investigate the best target INR for warfarin prophylaxis, as well as the composite rates of VTE and clinically relevant bleeding from treatment with warfarin, LMWH and newer anticoagulants are needed.

Topics: Anticoagulants; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Female; Humans; International Normalized Ratio; Male; Michigan; Middle Aged; Postoperative Complications; Practice Guidelines as Topic; Time Factors; Venous Thromboembolism; Warfarin

The study sought to identify factors associated with increased risk of thrombosis after Fontan.. The Fontan procedure is the culmination of staged palliation for patients with univentricular physiology. Thrombosis is an important complication after this procedure.. An international multicenter randomized controlled trial of acetylsalicylic acid versus warfarin for thromboprophylaxis after the Fontan procedure was conducted in 111 patients, and did not show a significant difference regarding thrombotic complications. We performed a secondary analysis of this previously published manuscript to identify factors associated with thrombosis in this population. Standardized prospective data collection included independent adjudication of all events.. At 2.5 years after randomization, time-related freedom from thrombosis was 69% (all venous, no arterial events), with 28% of thrombosis presenting with clinical signs or events. Hazard of thrombosis was highest immediately after Fontan with a gradual increase in risk during late follow-up. In multivariable models, factors associated with higher risk of thrombosis were pulmonary atresia with intact ventricular septum (hazard ratio [HR]: 3.64, 95% confidence interval [CI]: 1.04 to 12.70, p = 0.04), pulmonary artery distortion (HR: 2.35, 95% CI: 0.96 to 5.73, p = 0.06), lower pre-operative unconjugated bilirubin (HR: 0.84 μmol/l, 95% CI: 0.72 to 0.99, p = 0.04), use of central venous lines for >10 days or until hospital discharge (HR: 17.8, 95% CI: 3.97 to 79.30, p < 0.001), and lower FiO(2) 24 h after the procedure (HR: 0.67/10%, 95% CI: 0.45 to 1.00, p = 0.06). Patients on warfarin who consistently achieved minimum target international normalized ratio levels or those on acetylsalicylic acid had a decrease in risk of thrombosis compared with patients who often failed to meet target international normalized ratio level (HR: 3.53, 95% CI: 1.35 to 9.20, p = 0.01).. More favorable thromboprophylaxis strategies are needed in light of the difficulties in controlling warfarin therapy and the high prevalence of thrombosis in this population.

Topics: Anticoagulants; Aspirin; Child; Child, Preschool; Female; Fontan Procedure; Humans; Male; Postoperative Complications; Thrombosis; Tricuspid Atresia; Warfarin

No data are available regarding the management of cancer patients requiring interruption of long-term vitamin-K antagonist (VKA) therapy. For this purpose, we tested the efficacy and safety of fixed doses of low-molecular weight heparin (LMWH) in substitution of VKA because of invasive procedures or chemotherapy-induced thrombocytopenia. In cancer patients on VKA, therapy was discontinued 5 ± 1 days before surgery or chemotherapy. Heparin was given at prophylactic dosage in patients at low risk and at fixed subtherapeutic doses (3,800 or 4,000 UI anti-FXa, b.i.d.) in those at high-risk for thrombosis. LMWH was reinitiated 12 hr after surgery and VKA the day after. In patients receiving chemotherapy, LMWH was reinitiated 12/24 hr after obtaining a stable platelet count ≥ 30,000 mmc(3) and VKA after a stable platelet count ≥ 50,000 mmc(3) . Thromboembolism and major bleeding events were recorded from the time of VKA suspension to 30 ± 2 days postprocedure or until the next chemotherapy. Overall, 156 patients (56.4% at low risk and 43.5% at high risk for thrombosis) were enrolled; 34.6% underwent major surgery, 40.4% nonmajor surgery, and 25% chemotherapy. Thrombotic events occurred in five patients [3.2%, 95% confidence interval (CI): 1.41-7.27], four belonging to the high-risk and one to the low-risk group. Major bleeding occurred in five patients (3.2%, 95 CI: 1.41-7.27), all belonging to the high-risk group (three during major surgery and two during chemotherapy). In conclusion, LMWH given at fixed subtherapeutic is a feasible and relatively safe approach for bridging therapy in cancer patients on long-term VKA.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Antineoplastic Agents; Atrial Fibrillation; Female; Heart Valve Prosthesis; Hemorrhage; Heparin, Low-Molecular-Weight; Humans; Incidence; Male; Middle Aged; Neoplasms; Postoperative Complications; Prospective Studies; Risk; Thrombocytopenia; Thromboembolism; Thrombophilia; Warfarin

The prevalence of patent foramen ovale among patients with cryptogenic stroke is higher than that in the general population. Closure with a percutaneous device is often recommended in such patients, but it is not known whether this intervention reduces the risk of recurrent stroke.. We conducted a multicenter, randomized, open-label trial of closure with a percutaneous device, as compared with medical therapy alone, in patients between 18 and 60 years of age who presented with a cryptogenic stroke or transient ischemic attack (TIA) and had a patent foramen ovale. The primary end point was a composite of stroke or transient ischemic attack during 2 years of follow-up, death from any cause during the first 30 days, or death from neurologic causes between 31 days and 2 years.. A total of 909 patients were enrolled in the trial. The cumulative incidence (Kaplan-Meier estimate) of the primary end point was 5.5% in the closure group (447 patients) as compared with 6.8% in the medical-therapy group (462 patients) (adjusted hazard ratio, 0.78; 95% confidence interval, 0.45 to 1.35; P=0.37). The respective rates were 2.9% and 3.1% for stroke (P=0.79) and 3.1% and 4.1% for TIA (P=0.44). No deaths occurred by 30 days in either group, and there were no deaths from neurologic causes during the 2-year follow-up period. A cause other than paradoxical embolism was usually apparent in patients with recurrent neurologic events.. In patients with cryptogenic stroke or TIA who had a patent foramen ovale, closure with a device did not offer a greater benefit than medical therapy alone for the prevention of recurrent stroke or TIA. (Funded by NMT Medical; ClinicalTrials.gov number, NCT00201461.).

Topics: Adolescent; Adult; Anticoagulants; Aspirin; Clopidogrel; Combined Modality Therapy; Drug Therapy, Combination; Embolism, Paradoxical; Female; Foramen Ovale, Patent; Humans; Ischemic Attack, Transient; Kaplan-Meier Estimate; Male; Middle Aged; Platelet Aggregation Inhibitors; Postoperative Complications; Prostheses and Implants; Secondary Prevention; Stroke; Ticlopidine; Warfarin; Young Adult

Dabigatran reduces ischemic stroke in comparison with warfarin; however, given the lack of antidote, there is concern that it might increase bleeding when surgery or invasive procedures are required.. The current analysis was undertaken to compare the periprocedural bleeding risk of patients in the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) trial treated with dabigatran and warfarin. Bleeding rates were evaluated from 7 days before until 30 days after invasive procedures, considering only the first procedure for each patient. A total of 4591 patients underwent at least 1 invasive procedure: 24.7% of patients received dabigatran 110 mg, 25.4% received dabigatran 150 mg, and 25.9% received warfarin, P=0.34. Procedures included: pacemaker/defibrillator insertion (10.3%), dental procedures (10.0%), diagnostic procedures (10.0%), cataract removal (9.3%), colonoscopy (8.6%), and joint replacement (6.2%). Among patients assigned to either dabigatran dose, the last dose of study drug was given 49 (35-85) hours before the procedure on comparison with 114 (87-144) hours in patients receiving warfarin, P<0.001. There was no significant difference in the rates of periprocedural major bleeding between patients receiving dabigatran 110 mg (3.8%) or dabigatran 150 mg (5.1%) or warfarin (4.6%); dabigatran 110 mg versus warfarin: relative risk, 0.83; 95% CI, 0.59 to 1.17; P=0.28; dabigatran 150 mg versus warfarin: relative risk, 1.09; 95% CI, 0.80 to 1.49; P=0.58. Among patients having urgent surgery, major bleeding occurred in 17.8% with dabigatran 110 mg, 17.7% with dabigatran 150 mg, and 21.6% with warfarin: dabigatran 110 mg; relative risk, 0.82; 95% CI, 0.48 to 1.41; P=0.47; dabigatran 150 mg: relative risk, 0.82; 95% CI, 0.50 to 1.35; P=0.44.. Dabigatran and warfarin were associated with similar rates of periprocedural bleeding, including patients having urgent surgery. Dabigatran facilitated a shorter interruption of oral anticoagulation.. URL: http://www.clinicaltrials.gov. Unique identifier: NCT00262600.

Topics: Aged; Aged, 80 and over; Anticoagulants; Benzimidazoles; beta-Alanine; Blood Loss, Surgical; Brain Ischemia; Cardiac Pacing, Artificial; Cataract Extraction; Dabigatran; Female; Follow-Up Studies; Hemorrhage; Humans; Incidence; Male; Middle Aged; Postoperative Complications; Risk Factors; Stroke; Thromboembolism; Warfarin

No human physiological data exists on whether aspirin only is as effective as warfarin plus aspirin in preventing cerebral microembolization in the early postoperative period after bioprosthetic aortic valve replacement (bAVR).. We prospectively enrolled 56 patients who had no other indication for oral anticoagulation, who underwent bAVR and received, in an open-label fashion, either daily warfarin (for INR 2.0-3.0) plus 81 mg of aspirin (n=28) or 325 mg of aspirin only (n=28). Cerebral microembolization was quantified at 4 hours (baseline) and at 1 month postoperatively, by recording 1-hour bilateral middle cerebral artery (MCA) microembolic signals (MES). Platelet-function analysis (PFA) of closure times (CT) on collagen was also used as a marker of platelet-dependent activation. Follow-up to 1 year was complete. Preoperative demographics and baseline platelet function were equivalent in both groups. There was no mortality, stroke, or transient ischemic attack at 1 year in either group. No significant differences were found in the proportion of patients with MES among those receiving warfarin plus aspirin versus aspirin only, at baseline (68% versus 82%, respectively; P=0.4) and at 1 month (46% versus 43%; P=1.0) after bAVR. The total MES and PFA were also equivalent between groups, at baseline and follow-up.. Early after bAVR, the effects of these 2 antithrombotic regimens on cerebral microembolization and platelet function are equivalent. These data bring new mechanistic support to the premise that aspirin only may safely be used early after bAVR in patients who have no other indication for oral anticoagulation.

Topics: Aged; Aged, 80 and over; Anticoagulants; Aortic Valve Stenosis; Aspirin; Bioprosthesis; Collagen; Coronary Artery Bypass; Drug Synergism; Drug Therapy, Combination; Female; Follow-Up Studies; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Hemorrhage; Humans; Infarction, Middle Cerebral Artery; Male; Middle Aged; P-Selectin; Platelet Activation; Postoperative Complications; Prospective Studies; Ultrasonography, Doppler, Transcranial; Warfarin

Using two antithrombotic treatment (clopidogrel vs. clopidogrel combined warfarin) strategies after femoral-popliteal artery angioplasty prospectively, to evaluate which strategy is more effective for the restenosis prevention.. Totally 50 patients referred for endovascular treatment (including the percutaneous transluminal angioplasty (PTA) and stent implantation) of the superficial femoral artery and popliteal artery from January 2008 to May 2009 were randomly divided into clopidogrel group (group A, 25 cases, 30 limbs) and clopidogrel plus warfarin group (group B, 25 cases, 33 limbs) before operation. Clinical outcomes and restenosis rate of the target lesions were evaluated at 3, 6 and 12 months after operation.. Totally 88 patients were screened for participation in the study, 56 patients were included after the follow-up of 12 months. At 3 months, the rates of restenosis were 16.7% in group A and 18.2% in group B (χ² = 0.025, P = 0.874). At 6 months, the accumulated restenosis rates were 36.7% in group A and 36.4% in group B (χ² = 0.001, P = 0.98). At 12 months, the accumulated restenosis rates were 53.3% in group A and 42.4% in group B (χ² = 0.75, P = 0.387). Analysis for the critical limb ischemia sub-group showed that follow-up of 12 months, the accumulated restenosis rate was 8/10 in group A and 6/12 in group B (χ² = 1.023, P = 0.312).. The clopidogrel alone treatment for PTA or PTA plus stent implantation of femoral popliteal artery has no statistically significant difference in comparison with the clopidogrel combined warfarin treatment in terms of the cumulative vascular restenosis rate at 3, 6, 12 months postoperatively.

Topics: Adult; Aged; Aged, 80 and over; Angioplasty, Balloon; Arterial Occlusive Diseases; Clopidogrel; Female; Femoral Artery; Humans; Male; Middle Aged; Popliteal Artery; Postoperative Complications; Prospective Studies; Ticlopidine; Warfarin

Thrombin generation has a key role in the pathophysiology of hemostasis. Research has focused on the intraoperative course of hemostasis, while little is known about postoperative hemostatic activation. Thrombin generation assays quantify the potential for thrombin generation ex vivo and may be useful for determining hypercoagulability. The thrombin dynamics test (TDT) assesses the initial kinetics of thrombin formation. We hypothesized that there would be an increase in thrombin generation as well as thrombin capacity after cardiac surgery.. Two hundred twenty patients undergoing primary coronary artery bypass grafting or aortic valve replacement (AVR) surgery were prospectively enrolled. Patients undergoing AVR received warfarin beginning on the second postoperative day. In addition to prothrombin fragment (F(1+2)), TDT, d-dimer, and troponin T were assessed. Blood samples were obtained preoperatively, at the end of the operation, 4 hours postoperatively, and the morning of postoperative days (PODs) 1, 3, and 5. The primary end point was the change of thrombin dynamics on POD 1.. In all patients, F(1+2) peaked at the end of the operation and remained significantly elevated until POD 5. Compared with baseline and after an initial decrease, TDT was found to be significantly elevated on POD 1. After coronary artery bypass graft, TDT remained significantly elevated, whereas in AVR patients with warfarin treatment, TDT was significantly reduced on PODs 3 and 5.. After cardiac surgery, thrombin generation continues, accompanied by a high thrombin-generating capacity and elevated fibrinogen levels. This constellation suggests a marked procoagulopathic state in the postoperative period with the potential to aggravate the risk of thromboembolic complications. Warfarin treatment after AVR significantly reduced thrombin-generating capacity.

Topics: Aged; Blood Coagulation; Cardiopulmonary Bypass; Female; Humans; Male; Middle Aged; Postoperative Complications; Prospective Studies; Thrombin; Warfarin

Management of oral anticoagulation in patients undergoing pacemaker (PPM) or implantable cardioverter-defibrillator (ICD) implantation remains controversial. Prior studies demonstrate that continuation of warfarin may be safer when compared with strategies requiring interruption and/or heparin bridging. Limited data from randomized trials exist.. We conducted a randomized trial to determine whether warfarin continuation is superior to warfarin interruption during PPM or ICD implantation.. Patients on oral anticoagulation referred for PPM or ICD implantation were randomized to warfarin continuation versus interruption. Patients randomized to warfarin interruption were further stratified into two groups based on their risk for thromboembolic events in the absence of warfarin. Moderate-risk patients were randomized to warfarin continuation versus warfarin interruption. High-risk patients were randomized to warfarin continuation versus warfarin interruption with heparin bridging. The primary combined outcome included thromboembolic events, anticoagulant-related complications, or any significant bleeding necessitating additional intervention or discontinuation of anticoagulation.. We studied 100 patients (average age 70.8 years, 21% female, mean body mass index 28.4) who underwent 64 ICD and 36 PPM implantations. Fifty patients were assigned to continue warfarin. The randomized groups were well matched. Among patients randomized to warfarin interruption, there were two pocket hematomas, one pericardial effusion, one transient ischemic attack, and one patient who developed heparin-induced thrombocytopenia. No events were noted among patients continuing warfarin (P = .056).. While the results were not statistically significant, there was a trend toward reduced complications in patients randomized to warfarin continuation. This strategy should be considered in patients undergoing PPM or ICD implantation.

Topics: Aged; Anticoagulants; Arrhythmias, Cardiac; Defibrillators, Implantable; Dose-Response Relationship, Drug; Female; Follow-Up Studies; Humans; Intraoperative Care; Male; Pacemaker, Artificial; Postoperative Complications; Prospective Studies; Prosthesis Implantation; Stroke; Treatment Outcome; Warfarin

Current guidelines recommend discontinuation of oral anticoagulation treatment (OAT) and switch to heparin 2-5 days before catheter ablation of atrial fibrillation (AF). However, increasing evidence leans against the 'bridge therapy' and support continuation of OAT during the procedure.. We evaluated the safety of AF ablation among patients with therapeutic OAT. The study population comprised 193 consecutive patients who underwent 228 AF ablation procedures guided by electroanatomical mapping. Periprocedural international normalized ratio was <2 (1.6 ± 0.3) in 103 cases (Group 1) and ≥2 (2.4 ± 0.4) in 125 cases (Group 2). Heparin (5000 IU bolus followed by continuous infusion through an open-irrigated ablation catheter) was used in both groups. No intracardiac echocardiographic guidance was used and activated clotting time (ACT) was not monitored. The incidence of major (intracranial bleeding, tamponade, bleeding that required surgical intervention, or blood transfusion) and minor bleeding complications and all thrombo-embolic events were registered during the 3-month follow-up. There was no statistical difference in major (P = 1.0) and minor complications (P = 0.74) between the groups. The bleeding complications included one surgically corrected groin haematoma in both groups (0.9%), 25 small haematomas at the puncture site (11 in Group 1 (10.7%) and 14 in Group 2 (11.2%), P = 0.90), and two minor pericardial effusions in Group 1. In Group 2, one patient had ischaemic stroke 16 days after the procedure.. Transseptal puncture and AF ablation can be performed safely in patients with ongoing OAT without intracardiac echocardiographic guidance and ACT monitoring.

Topics: Administration, Oral; Anticoagulants; Atrial Fibrillation; Catheter Ablation; Female; Follow-Up Studies; Hemorrhage; Heparin; Humans; Incidence; Male; Middle Aged; Postoperative Complications; Thrombosis; Treatment Outcome; Warfarin

The ideal management of oral anticoagulation (OAC) before and after catheter ablation for atrial fibrillation (AF) is still controversial.. To compare two anticoagulation strategies for catheter ablation for AF: warfarin withholding and use of low-molecular-weight heparin (LMWH); and maintenance of warfarin and therapeutic INR (between 2.0 and 3.0).. 140 patients (pt) with persistent/permanent AF undergoing catheter ablation for AF were divided into two groups: Group I (70 pt), in which warfarin was withheld five days prior to the procedure and transition to LMWH was used (enoxaparin: 1 mg/kg 2x/day before ablation, and 0.5 mg/kg 2x/day after ablation); Group II (70 pt), in which warfarin was not withheld and the procedure was performed with therapeutic INR. Both groups received intravenous heparin (ACT > 350 seconds) during ablation.. In Group I, one pt (1.4%) had a major hemorrhagic complication and four pts (5.7%) had minor hemorrhagic complications. In Group II, two pts (2.8%) had minor hemorrhagic complications and one pt had a major bleeding, which occurred after using LMWH due to INR < 2.0. None of the groups had thromboembolic complications or cardiovascular death over a period of 16 ± 8 months.. Catheter ablation for AF without withholding OAC and with therapeutic INR is a strategy that has similar safety and efficacy when compared with the traditional transition to LMWH, avoiding the potentially inadequate anticoagulation of the initial post-ablation period.

Topics: Aged; Anticoagulants; Atrial Fibrillation; Catheter Ablation; Chi-Square Distribution; Dose-Response Relationship, Drug; Female; Hemorrhage; Heparin, Low-Molecular-Weight; Humans; International Normalized Ratio; Male; Postoperative Complications; Preoperative Care; Warfarin

The recently published HRS/EHRA/ECAS AF Ablation Consensus Statement recommended that warfarin should be used for at least 2 months following an AF ablation in all patients regardless of stroke risk factors. The objective of the study was to assess outcomes based upon anticoagulation practice after atrial fibrillation (AF) ablation to determine relative risk of a strategy of aspirin only in low-risk patients.. A total of 630 consecutive patients who underwent 934 ablation procedures using an open irrigated tip catheter for symptomatic AF were evaluated. Outcomes were compared between patients treated with warfarin (goal INR: 2-3) versus aspirin only (325 mg/day) in CHADS2 0-1 patients after ablation.. Of the 690 patients, 123 (20%) were treated with aspirin and 507 (80%) with warfarin. Prevalences of the CHADS2 scores of patients on aspirin were (0: 40.7%, 1: 59.3%) and on warfarin (0: 13.6%, 1: 31.6%, > or = 2: 54.8%), P < 0.0001. Patients in the warfarin group were older, had on average a lower ejection fraction, and had higher rates persistent/permanent AF, repeat ablations, hypertension, prior stroke/TIA, and diabetes. The 1-year survival free of AF for the total study population was 71.6%. There were no strokes/TIA in the aspirin group and 4 events (4 strokes, 0 TIAs) in the warfarin group. Two patients in the warfarin group died of fatal hemorrhage (1 intracranial, 1 gastrointestinal).. Select low-risk patients with a low CHADS2 (0-1) score who undergo left atrial ablation with an aggressive anticoagulation strategy with heparin and use of an open irrigated tip catheter with low CHADS2 scores can safely be discharged following their procedure on aspirin alone.

Topics: Aged; Anticoagulants; Atrial Fibrillation; Catheter Ablation; Comorbidity; Female; Humans; Incidence; Male; Middle Aged; Postoperative Complications; Risk Assessment; Risk Factors; Stroke; Survival Analysis; Survival Rate; Therapeutics; Warfarin

The purpose of this study is to address the safety and efficacy of a warfarin dosing nomogram. Patients undergoing hip or knee arthroplasty were randomized to warfarin dosed by nomogram (n = 106) or by house staff (n = 110) during their hospital stay. The average daily dose of warfarin was 4.14 mg for the nomogram group and 4.18 mg for the house staff group. On postoperative day 4, the average international normalized ratio was 1.55 in the nomogram group compared with 1.59 in the house staff group. On postoperative day 4, 19.1% of the patients in the nomogram group had a therapeutic international normalized ratio, compared with 14.7% in the house staff group. There were no differences in bleeding or thrombotic complications in the 2 groups. This nomogram appears to be both safe and effective.

Topics: Aged; Anticoagulants; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Female; Humans; International Normalized Ratio; Internship and Residency; Male; Postoperative Complications; Statistics, Nonparametric; Venous Thrombosis; Warfarin

The dosage requirement of warfarin to achieve a given international normalized ratio (INR) often varies considerably between the immediate postoperative period and long-term follow-up in patients with prosthetic heart valves, leading to INR instability.. To document the extent of warfarin sensitivity in a prospective study of patients receiving heart valve replacements.. Clinical and laboratory data regarding anticoagulation for 111 patients who received warfarin following heart valve replacement were collected during their hospital stay (induction period) and between 1 and 3 months after surgery (follow-up period).. Mean patient age was 65.39 +/- 10.55 years (range 29-85), with 66 men. The mean INR value during the follow-up period was, on average, 0.21 higher than the induction period (2.81 +/- 0.5 vs 2.6 +/- 0.6; p = 0.007). The mean follow-up warfarin dose was 1.54 mg higher than the mean induction warfarin dose (5.09 +/- 2.03 vs 3.55 +/- 1.94 mg; p < 0.001). The warfarin dose index, which indicates relative sensitivity of warfarin, decreased from 1.16 to 0.65 (p < 0.001). Although the INR values during the induction and follow-up periods were similar, the dose requirement in the follow-up period was, on average, 43% higher than that of the induction period.. Immediately after heart valve replacement, patients are more sensitive to warfarin and should receive a lower warfarin dose during the initial phase of oral anticoagulation treatment. This enhanced sensitivity decreases with time. Patients require frequent monitoring and are likely to need an increase in the warfarin dose to avoid insufficient anticoagulation during the early follow-up period.

Topics: Adult; Aged; Anticoagulants; Female; Follow-Up Studies; Heart Valve Prosthesis Implantation; Humans; International Normalized Ratio; Male; Middle Aged; Partial Thromboplastin Time; Postoperative Complications; Prospective Studies; Warfarin

Warfarin dosing with a target international normalized ratio (INR) range of 1.5-2.5 has not been reported as adequate for venous thromboembolism (VTE) prophylaxis after total knee (TKR) and total hip replacement (THR) surgery.. To evaluate the rate of symptomatic VTE after TKR and THR surgery using a low-dose (INR 1.5-2.5) warfarin protocol started the evening before surgery compared with a literature cohort treated with enoxaparin.. TKR/THR patients treated with a 21-day low-dose warfarin protocol were followed via a consecutive observational design. Main outcome measures were symptomatic VTE and pulmonary embolism (PE), with major bleeds and death as secondary outcomes. Low-dose warfarin was compared with a literature cohort of patients treated with enoxaparin who received enoxaparin for a similar length of time and was evaluated for the same outcomes. Cohort event rates were derived as a weighted average using the DerSimonian model.. VTE, PE, bleeds, and deaths in the low-dose warfarin group were 8 (1.04%), 4 (0.52%), 8 (1.04%), and 4 (0.52%), respectively. The cohort weighted average values were 35 (1.33%), 19 (0.72%), 65 (2.46%), and 18 (0.67%), respectively. Odds ratios for low-dose warfarin for VTE, PE, and VTE plus PE were 0.778 (95% CI 0.36 to 1.68), 0.717 (0.24 to 2.11), and 0.754 (0.41 to 1.42), respectively, all nonsignificant. Odds ratios for bleeds and death were 0.420 (0.20 to 0.87; p = 0.02) and 0.756 (0.26 to 2.24; NS), respectively.. For this evaluation, low-dose warfarin was comparable to the enoxaparin cohort for development of VTE, PE, and VTE+PE. Incidences of bleeds in the enoxaparin cohort were significantly higher than in patients receiving low-dose warfarin.

Topics: Angiography; Anticoagulants; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Cohort Studies; Dose-Response Relationship, Drug; Enoxaparin; Female; Hemorrhage; Hospital Mortality; Humans; International Normalized Ratio; Male; Odds Ratio; Orthopedics; Phlebography; Postoperative Complications; Prospective Studies; Pulmonary Embolism; Thromboembolism; Treatment Outcome; Venous Thrombosis; Warfarin

Venous thromboembolic disease remains the most common reason for readmission after total hip arthroplasty. Prospective analysis of screening contrast venography was done from 1984 to 2003 in 1972 patients having elective total hip arthroplasty. Patients with deep venous thrombosis or pulmonary embolism received warfarin therapy; those with negative venograms received no further anticoagulation. From 1984 to 1992, patients not completing venography were discharged without warfarin; since 1993, patients without venography received warfarin for 6 weeks. Readmission for deep venous thrombosis, pulmonary embolism, or bleeding was tracked for 6 months. Venograms were completed in 1032 patients; 175 (16.9%) had deep venous thrombosis. Deep venous thrombosis was reduced by a clinical pathway that included continuous epidural anesthesia (14.2% versus 22.5%). The overall readmission rate for venous thromboembolic disease was 1.62%, including 14 pulmonary emboli (three fatal) and 18 femoral deep venous thrombosis. Readmission occurred in 0.27% (1 of 360) patients on continued warfarin, compared with 2.2% (19 of 880) with negative venograms discharged without further anticoagulation. Three patients (0.15%) suffered fatal pulmonary emboli; all had negative venograms and received no outpatient prophylaxis. Extended outpatient warfarin therapy provided effective protection against venous thromboembolic disease readmission. Surveillance venography was a poor predictor of need for continued prophylaxis; all patients should have extended anticoagulation after total hip arthroplasty.. Therapeutic study, Level I-1 (high-quality randomized trial with statistically significant difference or no statistically significant difference but narrow confidence intervals). See the Guidelines for Authors for a complete description of levels of evidence.

Topics: Anticoagulants; Arthroplasty, Replacement, Hip; Hemorrhage; Humans; Patient Readmission; Phlebography; Postoperative Complications; Predictive Value of Tests; Prevalence; Pulmonary Embolism; Risk Factors; Venous Thrombosis; Warfarin

Patients with prosthetic heart valves have a higher risk of developing valve thrombosis and arterial thromboembolism. Antithrombotic therapy in the early postoperative period after biological aortic valve replacement (BAVR) is controversial. The American College of Cardiology/American Heart Association and European Society of Cardiology guidelines recommend the use of warfarin for the first 3 months after BAVR, although the American College Chest Physician guidelines suggest that the recommendations are very weak and that the risk/benefit is unclear. This prospective study investigated the efficacy of postoperative warfarin compared with aspirin in patients after aortic valve replacement.. Patients undergoing BAVR between 2001 and 2002 received 2 antithrombotic therapies: 141 patients received warfarin for the first 3 months, and 108 patients received only aspirin. The major end points evaluated were the rate of cerebral ischemic events, bleeding, and survival. There were 3 and 5 postoperative cerebral ischemic events between 24 hours and 3 months for patients treated with aspirin and warfarin, respectively. After 3 months, the incidence of cerebral ischemic events did not differ between the 2 groups. The rate of major bleeding events, the stroke-free survival, and the overall survival rates were not statistically significant between the warfarin and aspirin groups.. There seem to be no advantages in performing early anticoagulation therapy compared with a low-antiplatelet regimen with regard to early cerebral ischemic events, bleeding, and survival. Currently there is no evidence to support the fact that warfarin is more effective than aspirin.

Topics: Aged; Anticoagulants; Aspirin; Bioprosthesis; Brain Ischemia; Disease-Free Survival; Female; Heart Valve Prosthesis; Hemorrhage; Humans; Incidence; Life Tables; Male; Middle Aged; Postoperative Complications; Prospective Studies; Survival Analysis; Thromboembolism; Warfarin

When warfarin is interrupted for surgery, low-molecular-weight heparin is often used as bridging therapy. However, this practice has never been evaluated in a large prospective study. This study was designed to assess the efficacy and safety of bridging therapy with low-molecular-weight heparin initiated out of hospital.. This was a prospective, multicenter, single-arm cohort study of patients at high risk of arterial embolism (prosthetic valves and atrial fibrillation with a major risk factor). Warfarin was held for 5 days preoperatively. Low-molecular-weight heparin was given 3 days preoperatively and at least 4 days postoperatively. Patients were followed up for 3 months for thromboembolism and bleeding. Eleven Canadian tertiary care academic centers participated; 224 patients were enrolled. Eight patients (3.6%; 95% CI, 1.8 to 6.9) had an episode of thromboembolism, of which 2 (0.9%; 95% CI, 0.2 to 3.2) were judged to be due to cardioembolism. Of these 8 episodes of thromboembolism, 6 occurred in patients who had warfarin deferred or withdrawn because of bleeding. There were 15 episodes of major bleeding (6.7%; 95% CI, 4.1 to 10.8): 8 occurred intraoperatively or early postoperatively before low-molecular-weight heparin was restarted, 5 occurred in the first postoperative week after low-molecular-weight heparin was restarted, and 2 occurred well after low-molecular-weight heparin was stopped. There were no deaths.. Bridging therapy with subcutaneous low-molecular-weight heparin is feasible; however, the optimal approach for the management of patients who require temporary interruption of warfarin to have invasive procedures is uncertain.

Topics: Anticoagulants; Arterial Occlusive Diseases; Aspirin; Atrial Fibrillation; Blood Loss, Surgical; Cohort Studies; Dalteparin; Elective Surgical Procedures; Feasibility Studies; Heart Valve Prosthesis Implantation; Humans; International Normalized Ratio; Intraoperative Complications; Postoperative Complications; Postoperative Hemorrhage; Premedication; Preoperative Care; Prospective Studies; Risk; Thromboembolism; Treatment Outcome; Vitamin K; Warfarin

After coronary endarterectomy, patients have an increased incidence of perioperative myocardial infarction. This study was undertaken to evaluate the possible reduction of perioperative myocardial damage after coronary endarterectomy by intravenous utilization of prostacyclin.. Elective coronary artery bypass grafting was performed in 1,190 patients with diffuse and distal coronary artery disease, in whom endarterectomy of one or more vessels was used as a treatment. All procedures were done with cardiopulmonary bypass. There were 584 patients in the prostacyclin-treated group, and 606 patients in the control group. Prostacyclin (10 ng x kg(-1) x min(-1)) was started 20 minutes before the cross-clamp removal, or at the time of rewarming, and was continued during the first 24 hours after surgery. The incidence of perioperative myocardial damage was detected by creatine kinase-MB enzyme measurement, and electrocardiographic and left ventricular function changes.. A significant decrease in perioperative myocardial damage was detected in the group treated with prostacyclin with respect to the control group.. Prostacyclin infusion initiated during revascularization and continued in the early postoperative course could be successfully employed for the prevention of thrombocyte aggregation and potentially decrease the overall incidence of significant myocardial damage after coronary endarterectomy.

Topics: Anticoagulants; Biomarkers; Coronary Artery Bypass; Coronary Artery Disease; Creatine Kinase; Creatine Kinase, MB Form; Drug Therapy, Combination; Elective Surgical Procedures; Electrocardiography; Endarterectomy; Epoprostenol; Female; Heparin; Humans; Incidence; Infusions, Intravenous; Isoenzymes; Male; Middle Aged; Myocardial Infarction; Platelet Aggregation Inhibitors; Postoperative Complications; Prospective Studies; Treatment Outcome; Ventricular Function, Left; Warfarin

The full homograft root replacement has been regarded as the 'gold standard' for aortic valve replacement (AVR). Xenograft full root AVR may offer similar theoretical advantages, but no prospective randomized trials to compare the two valve substitutes have been reported to date.. A total of 147 patients (mean age 66.2 years; range: 40-82 years) was randomized to undergo either Medtronic Freestyle (group F; n = 80) or homograft (group H; n = 67) root AVR. Coronary artery bypass grafting was associated with root AVR in 55 patients (37.4%). Follow up included routine clinical and echocardiographic assessments.. Overall, there were seven early deaths (4.8%). The early mortality rate for isolated root AVR was 2.1% in group F (1/47) and 2.2% in group H (1/45) (p = NS). There were four late deaths in group F, and two in group H. Actuarial survival was 83+/-5% and 84+/-4% (p = NS) at five years, in groups F and H, respectively. No patient required reoperation on the aortic valve. Overall, there were eight thromboembolic events and six anticoagulant-related bleeding events; these were equally divided between the two groups. After a median follow up of 45 months, most patients in both groups were in NYHA class I, and the mean trans-aortic gradient was 6+/-1 mmHg in group F and 5+/-2 mmHg in group H (p = NS). Mild aortic regurgitation was recorded in 1/26 patients (4%) of group F, and in 1/16 (6%) of group H.. The Medtronic Freestyle porcine xenograft appears to be a good alternative to homografts for full aortic root replacement, at least in the mid term.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Aortic Valve Insufficiency; Aortic Valve Stenosis; Atrial Fibrillation; Bioprosthesis; Female; Follow-Up Studies; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Hemodynamics; Humans; Male; Middle Aged; Postoperative Complications; Prospective Studies; Survival Analysis; Transplantation, Homologous; Treatment Outcome; Warfarin

Mitral valve surgery seldom suppresses atrial fibrillation (AF), present prior to surgery. Maze III surgery eliminates AF in >80% of cases, the reason why combining this procedure with mitral valve surgery in patients with AF seems worthwhile. We prospectively studied the outcome of combining the Maze III procedure with mitral valve surgery.. Thirty-five patients with AF and a mean age of 64 years undergoing mitral valve surgery were prospectively randomized according to a 2.5:1 ratio to surgery with (n=25), or without (n=10) maze III and followed for at least 1 year.. At discharge and after 12 months freedom from AF was 56% and 92%, respectively, in the maze group, and 0% and 20%, respectively, in patients without maze (group differences at discharge p=0.002, after 12 months p=0.0007). Sinus node incompetence was seen in 1 of 25 maze patients requiring pacing. No in-hospital or late death occurred; stroke was observed in 1 patient (without maze). Quality of life markedly improved after surgery, but did not differ between patients with or without maze surgery.. This first prospective randomized study shows that combining maze III with mitral valve surgery resulted in a significantly better elimination of preoperative AF than mitral valve surgery alone. As the quality of life did not differ between patients with, or without maze surgery, additional maze surgery is primarily recommended in patients in whom anticoagulation therapy can be avoided after surgery, specifically in patients with scheduled mitral valve plasty.

Topics: Anti-Arrhythmia Agents; Anticoagulants; Atrial Fibrillation; Cardiac Surgical Procedures; Echocardiography, Doppler; Electric Countershock; Electrocardiography, Ambulatory; Endpoint Determination; Exercise Test; Female; Heart Valve Diseases; Humans; Male; Middle Aged; Mitral Valve; Postoperative Complications; Prospective Studies; Quality of Life; Treatment Outcome; Warfarin

In 80 consecutive, anticoagulated patients scheduled for minor surgery, we reduced warfarin daily dosage by 50% on days 4, 3 and 2 before the surgery, restoring the original dose the day immediately before surgery. The evening after surgery, patients took a double warfarin dose, and then the usual maintenance dose was reintroduced. The mean International Normalized Ratio (INR) value assessed 1 week before surgery was 2.63 (range 1.88-3.87); it decreased at the moment of performing surgery to 1.68 (range 1.42-2.20; P < 0.05 with respect to the preoperative value), and returned to 2.43 7 days after (range 1.96-3.51, P = ns with respect to the preoperative value). No significant difference was found comparing prothrombin fragment 1.2 (F1.2) levels 1 week before surgery and on the morning of surgery (0.49 ng/ml vs 0.67 ng/ml, P = ns), suggesting that no activation of blood coagulation had taken place following the reduction of anticoagulant therapy. Patients developed neither major nor minor bleeding, nor thromboembolism during the procedures or up to 1 month after surgery. In our experience, this method for the management of anticoagulation before minor surgery has been shown to be safe and useful, avoiding the cumbersome shift to either intravenous or subcutaneous heparin.

Topics: Administration, Oral; Adult; Aged; Anticoagulants; Cohort Studies; Dose-Response Relationship, Drug; Female; Humans; International Normalized Ratio; Male; Middle Aged; Postoperative Complications; Surgical Procedures, Operative; Thromboembolism; Time Factors; Warfarin

The optimal duration of thromboprophylaxis after major orthopedic surgery is controversial. Although oral anticoagulants are still widely used for the prevention of venous thromboembolism after hip replacement, to our knowledge no study has assessed the benefit of prolonging anticoagulation beyond the hospital stay.. Consecutive patients who had received warfarin sodium prophylaxis after total hip arthroplasty were randomized to stop taking the drug at the time of hospital discharge or to continue taking it for 4 more weeks. The rate of symptomatic and asymptomatic venous thromboembolic events (as shown by compression ultrasonography of the proximal-vein system) occurring during the study period was compared between the 2 groups. The study was prematurely terminated after the inclusion of the first 360 patients because a statistically significant and clinically relevant superiority of extended over short-term thromboprophylaxis was observed.. Objectively confirmed venous thromboembolic complications were recorded in 10 patients: 9 (5.1%) in the group of 176 control patients, and 1 (0.5%) in the group of 184 patients who continued the warfarin treatment. The absolute difference in the incidence of events was 4.57% (95% confidence interval [CI], 1.15-7.99). The relative risk of venous thromboembolism developing in control patients compared with patients assigned to extended thromboprophylaxis was 9.4 (95% CI, 1.2-73.5). The number needed to treat was 22. Major bleeding developed in 1 patient who was randomized to the extended prophylaxis group (0.5%; 95% CI, 0.02-3.0) compared with none in the control group.. Extending prophylaxis with warfarin for a few more weeks beyond the hospital stay has the potential to considerably improve the outcome of patients who undergo hip arthroplasty.

Topics: Administration, Oral; Adult; Aged; Aged, 80 and over; Anticoagulants; Arthroplasty, Replacement, Hip; Female; Follow-Up Studies; Hemorrhage; Humans; International Normalized Ratio; Italy; Male; Middle Aged; Postoperative Complications; Prospective Studies; Time Factors; Treatment Outcome; Venous Thrombosis; Warfarin

To determine the coagulation status of patients receiving postoperative warfarin and epidural analgesia using thromboelastography (TEG(R)).Prospective, observational, clinical study.Orthopedic postoperative division at a university hospital.52 ASA physical status II and III patients undergoing knee arthroplasty and receiving prophylactic warfarin and epidural analgesia.Patients' preoperative and postoperative coagulation status was determined by TEG(R). Daily TEG(R) parameters were obtained until the epidural catheter was removed. TEG(R) parameters include reaction time (R-time or time until the first significant levels of detectable clot formation), K-time (clot firmness), maximum amplitude (MA-clot strength), alpha angle (clot development), and coagulation index (overall coagulation). In addition, daily international normalized ratios (INRs) were obtained as per our routine practice. On the day of catheter removal reaction time was significantly increased compared with preoperative values (p < 0.0001), but it remained within normal ranges. There was no change in the coagulation index. However, INR was abnormal and significantly increased (INR = 1.48+/-0.3; p < 0.0001), compared with preoperative values, on the day when the epidural catheter was removed. When the epidural catheters are removed, overall coagulation status, as measured by TEG(R), and despite an elevated INR (mean INR <1.5), remained within normal limits in patients receiving low-dose warfarin prophylaxis.

Topics: Aged; Analgesia, Epidural; Anticoagulants; Arthroplasty, Replacement, Knee; Blood Coagulation; Device Removal; Humans; International Normalized Ratio; Pain, Postoperative; Postoperative Complications; Prospective Studies; Thrombelastography; Thrombosis; Warfarin

The benefits of the long-term administration of oral anticoagulant therapy remain unclear in patients with lower extremity arterial bypass surgery. We studied the effect of warfarin plus aspirin therapy (WASA) versus aspirin therapy alone (ASA) on patient mortality, morbidity and bypass patency rates in a randomized clinical trial.. In a multicenter, prospective, nonmasked clinical trial, 831 patients who underwent peripheral arterial bypass surgery were compared in a long-term treatment program of WASA (target international normalized ratio of 1.4 to 2.8; 325 mg/day) with ASA (325 mg/day). The primary end point was bypass patency, and mortality and morbidity were the secondary endpoints.. There were 133 deaths in the WASA group (31.8%) and 95 deaths in the ASA group (23.0%; risk ratio, 1.41; 95% confidence interval, 1.09 to 1.84; P =.0001). Major hemorrhagic events occurred more frequently in the WASA group (WASA, n = 35; ASA, n = 15; P =.02). In the prosthetic bypass group, there was no significant difference in patency rate in the 8-mm bypass subgroup, but there was a significant difference in patency rate in the 6-mm bypass subgroup (femoral-popliteal; 71.4% in the WASA group versus 57.9% in the ASA group; P =.02). In the vein bypass group, patency rate was unaffected (75.3% in the WASA group versus 74.9% in the ASA group).. The long-term administration of warfarin therapy when combined with aspirin therapy has only a few selected indications for improvement of bypass patency and is associated with an increased risk of morbidity and mortality.

Topics: Administration, Oral; Aged; Anticoagulants; Aspirin; Blood Vessel Prosthesis; Boston; Combined Modality Therapy; Dose-Response Relationship, Drug; Drug Therapy, Combination; Extremities; Femoral Artery; Follow-Up Studies; Hemorrhage; Humans; International Normalized Ratio; Maryland; Middle Aged; Morbidity; Peripheral Vascular Diseases; Popliteal Artery; Postoperative Complications; Prospective Studies; Time; Treatment Outcome; Vascular Patency; Vascular Surgical Procedures; Warfarin

Several studies have suggested that after hip replacement the risk of deep vein thrombosis and subsequent pulmonary embolism (PE) may persist for some weeks. Antithrombotic prophylaxis, however, is generally stopped at hospital discharge. Using a Markov-based decision analysis, we measured the clinical and economical consequences of extending prophylaxis after hospital discharge up to 4 weeks and 6 weeks, using either low-molecular-weight heparin (LMWH), warfarin, or aspirin. In the reference strategy, antithrombotic prophylaxis was stopped at hospital discharge. Outcome measures included the number of PE prevented, major haemorrhages induced, overall costs in Euro (EUR) and specific costs generated by each PE prevented for all strategies. Extending prophylaxis up to 4 weeks after discharge was safe and cost saving for all prophylactic regimens, although LMWH was the most effective strategy. Our results were most sensitive to the rate of haemorrhages, the efficacy of treatment and its costs. Specifically, the number of PEs prevented exceeded that of haemorrhages induced if the efficacy of antithrombotic prophylaxis was > or = 40% (assuming a low rate of haemorrhages of 0.1% per week), and > or = 70% (assuming a high rate of haemorrhages of 0.25% per week). LMWH and warfarin remained cost saving unless their costs were more than doubled compared to that of baseline value. Although less effective than LMWH and warfarin, prophylaxis with aspirin was cost saving in all scenarios tested. Extending prophylaxis up to 6 weeks was also effective (the number of PEs prevented overwhelmed that of major haemorrhages induced), but only for the scenario of a low bleeding risk (0.1%/week). In this strategy, aspirin remained cost saving, while the costs for each PE prevented became high (EUR 10,000 to EUR 20,000) if the costs of LMWH and warfarin increased. After hip replacement, extending antithrombotic prophylaxis up to 4 weeks after hospital discharge is effective and cost saving. Although LMWH is the most effective strategy, warfarin, and to a lesser extent aspirin may be alternate options if ressources are a major concern. Extending prophylaxis up to 6 weeks is more risky in patients at high bleeding risk, and generates additional costs.

Topics: Ambulatory Care; Anticoagulants; Arthroplasty, Replacement, Hip; Aspirin; Cost-Benefit Analysis; Dalteparin; Decision Support Techniques; Drug Costs; Elective Surgical Procedures; Enoxaparin; Fibrinolytic Agents; Hemorrhage; Humans; Markov Chains; Models, Theoretical; Postoperative Complications; Postoperative Period; Recurrence; Thrombosis; Warfarin

Since coronary artery bypass graft patients remain at risk of coronary artery and bypass graft occlusion after successful surgery, adjunct treatment regimens are under investigation. In a study of the patients of the multicenter Post Coronary Artery Bypass Graft (Post CABG) Trial, 1 mg warfarin was found to have no important effect on coagulation parameters.. The effects of 1, 2 and 3 mg warfarin were evaluated at six-week intervals in 20 Post CABG Trial patients receiving titrated dose increases in comparison to 20 patients of similar age, gender and time from CABG treated with placebo.. International normalized ratio (INR) values increased with warfarin dose increments for 1, 2, and 3 mg, respectively (0.95+/-0.16, 1.08+/-0.19, and 1.34+/-0.39) and in comparison to placebo treated patients (dosextreatment p<0.001). Factor VII coagulant activity decreased with warfarin titration (1 mg, 119.0+/-18.3 %; 2 mg, 100.6+/-32.8 %; 3 mg, 95.0+/-27.8 %) and in comparison to placebo (dosextreatment p=0.008). Levels of prothrombin fragment F1.2, tissue plasminogen activator, fibrinogen and von Willebrand factor were unchanged with warfarin dose increments and in comparison to placebo.. At doses up to 3 mg, warfarin acts on the INR through a reduction of factor VII with no effect on the fibrinolytic system, fibrinogen or von Willebrand factor. At these doses F1.2 did not document reduced coagulation activity. The observations of this study were consistent with the decision in the Post CABG Trial to increase the warfarin dose above 1 mg to achieve a distinct effect of warfarin that was less than full anticoagulation.

Topics: Adult; Aged; Anticoagulants; Aspirin; Coronary Artery Bypass; Coronary Disease; Dose-Response Relationship, Drug; Drug Therapy, Combination; Factor VII; Female; Fibrinogen; Graft Occlusion, Vascular; Humans; International Normalized Ratio; Male; Middle Aged; Peptide Fragments; Postoperative Complications; Postoperative Hemorrhage; Prothrombin; Recurrence; Saphenous Vein; Thrombosis; Tissue Plasminogen Activator; Treatment Outcome; von Willebrand Factor; Warfarin

Patients treated with total knee arthroplasty are at high risk for the development of venous thromboembolism postoperatively. This study compared the efficacy and safety of two common thromboprophylactic agents, enoxaparin (a low-molecular-weight heparin) and warfarin.. Three hundred and forty-nine patients were included in a prospective, randomized, multicenter, open-label, parallel-group clinical trial. Treatment with enoxaparin (30 mg, administered subcutaneously twice daily) or warfarin (adjusted to an international normalized ratio of 2 to 3) was initiated during the immediate postoperative period, within eight hours after the surgery, and was continued for four to fourteen days. Venous thromboembolism was defined as deep-vein thrombosis documented by contrast venography, symptomatic deep-vein thrombosis documented by lower-extremity ultrasonography, or symptomatic pulmonary embolism confirmed by a positive lung scan or pulmonary angiography.. In the all-treated-patients group, eighty (45%) of the 176 warfarin-treated patients had venous thromboembolism: fifty-nine (34%) had distal deep-vein thrombosis; twenty (11%), proximal deep-vein thrombosis; and one (0.6%), pulmonary embolism. Venous thromboembolism developed in significantly fewer (p = 0.0001) enoxaparin-treated patients (forty-four of 173; 25%): forty-one (24%) had distal deep-vein thrombosis, three (2%) had proximal deep-vein thrombosis, and none had pulmonary embolism. The enoxaparin-treated patients also had a significantly lower prevalence of proximal deep-vein thrombosis (p = 0.002). The estimated odds for the development of venous thromboembolism were 2.52 times greater (95% confidence interval, 2.00 to 3.19) with warfarin than they were with enoxaparin. Major hemorrhage occurred in four warfarin-treated patients and nine enoxaparin-treated patients; with the numbers available, this difference was not significant (p = 0.17). Clinically important operative-site hemorrhage occurred in six (3%) of the warfarin-treated patients and twelve (7%) of the enoxaparin-treated patients (p = 0.15).. A fixed 30-mg subcutaneous dose of enoxaparin, administered twice daily, with the first dose administered within eight hours after the completion of surgery, was significantly more effective than adjusted-dose warfarin in reducing the occurrence of asymptomatic venous thromboembolism, including proximal deep-vein thrombosis, in patients undergoing total knee arthroplasty. With the numbers available, there was no significant difference between groups with regard to the occurrence of major hemorrhagic complications; however, the rate of overall hemorrhagic complications was higher in the enoxaparin group.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Arthroplasty, Replacement, Knee; Enoxaparin; Female; Hemorrhage; Humans; Male; Middle Aged; Postoperative Complications; Prospective Studies; Pulmonary Embolism; Treatment Outcome; Venous Thrombosis; Warfarin

Patients taking warfarin and at high risk for thromboembolic complications have traditionally been hospitalized for two to three days to receive standard treatment with intravenous heparin both prior to and following procedures while their international normalized ratio (INR) is subtherapeutic.. To assess the feasibility of protocol implementation for outpatient anticoagulation with low-molecular-weight heparin to eliminate or reduce the length of hospital admission needed solely for anticoagulation.. Patients included were receiving warfarin for a prosthetic heart valve, mitral valve disease with atrial fibrillation, or recent episode of venous thromboembolism. Warfarin was discontinued four days prior to the procedure. Subcutaneous dalteparin 200 units/kg was given on the two mornings prior to the procedure and restarted 12-24 hours after the procedure until the INR was in the therapeutic range. Warfarin was reinitiated on the evening of surgery.. Twenty-four patients underwent 26 procedures. There were two minor bleeding complications, and one patient experienced a transient ischemic attack. Patients received a median of five days of dalteparin. The INR returned to the therapeutic range on the median postoperative day 4. All patients avoided two days of hospitalization prior to the procedure (i.e., no patients needed to be admitted preoperatively for anticoagulation). A median of four days would have been required for the sole purpose of postoperative anticoagulation.. Outpatient perioperative anticoagulation with dalteparin for high-risk patients requiring long-term oral anticoagulation appears feasible and warrants further study.

Topics: Adult; Aged; Anticoagulants; Dalteparin; Feasibility Studies; Female; Hemorrhage; Hospitalization; Humans; Male; Middle Aged; Perioperative Care; Postoperative Complications; Prospective Studies; Thrombosis; Warfarin

Widespread use of adjusted low-dose warfarin has been limited by the inconvenience of outpatient laboratory monitoring and the perceived risk of bleeding complications. We sought to determine if the dose of warfarin could be lowered safely even further, eliminating the need for laboratory monitoring and lowering the complication rate. Two hundred forty-five Patients undergoing primary total joint arthroplasty (n = 245) were randomized prospectively to adjusted low-dose warfarin (international normalized ratio [INR], 1.4-1.8) or fixed minidose warfarin (2 mg daily, regardless of INR) before hospital discharge. Prophylaxis continued for 6 weeks, with twice-weekly laboratory monitoring. Patients were followed for bleeding, thromboembolic events, and minor reported complications of warfarin therapy. With the numbers available, the rates of thromboembolic and bleeding events were not significantly different using equivalence analysis. Of patients in the fixed group, 8% had INRs >3.1, necessitating a decrease in dosage to 1 mg. Although such a fixed-dose protocol may simplify outpatient prophylaxis, intermittent monitoring still would be required because a subset of patients achieve a moderate level of anticoagulation and would be at risk for bleeding complications.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Arthroplasty, Replacement; Chi-Square Distribution; Female; Humans; International Normalized Ratio; Male; Middle Aged; Postoperative Complications; Prospective Studies; Prothrombin Time; Pulmonary Embolism; Treatment Outcome; Venous Thrombosis; Warfarin

It is well-known that peri-operative and post-operative venous thrombosis are common. Trials in Europe have shown that extended out-of-hospital prophylaxis with a low-molecular-weight heparin reduces the rate of deep vein thrombosis in patients undergoing elective hip surgery. North American investigators of limited-outcome descriptive studies, however, have suggested that out-of-hospital prophylaxis is not necessary. To resolve this uncertainty, NAFT (North American Fragmin Trial) was conducted, the results of which are summarized in this paper. The findings of NAFT support the favourable findings of the European studies on extended prophylaxis. Furthermore, European data have shown extended out-of-hospital prophylaxis to be cost-effective. On the basis of the aggregate data, it is felt that the A2 recommendation made by the Fifth American College of Chest Physicians consensus conference for extended prophylaxis should be changed to an A1 recommendation.

Topics: Anticoagulants; Arthroplasty, Replacement, Hip; Cost-Benefit Analysis; Dalteparin; Decision Making; Double-Blind Method; Drug Administration Schedule; Drug Costs; Elective Surgical Procedures; Follow-Up Studies; Hematoma; Humans; North America; Postoperative Complications; Postoperative Period; Practice Guidelines as Topic; Safety; Treatment Outcome; Venous Thrombosis; Warfarin

The minimal effective dose of aprotinin on hemostasis under normothermic perfusion, the influence of anticoagulant therapy on graft patency, and the thromboembolic and hemorrhagic events were investigated after aortocoronary bypass graft operation (CABG). One hundred CABG patients under normothermic perfusion were randomly divided into the following groups: (1) coumadin plus acetylsalicylic acid (ASA) (n=32); no aprotinin used during cardiopulmonary bypass (CPB); (2) minimal-dose, 10(6) KIU during CPB, aprotinin used, followed by ASA and coumadin (n=36); and (3) very low-dose, total of 2x10(6) KIU before CPB and during CPB; aprotinin used; anticoagulation therapy with heparin early after surgery and followed by replacement with ASA and coumadin (n=32). The patency of arterial grafts was 100% in all groups. The patency of vein grafts was 95-98% and there was no difference among the groups. The blood loss was significantly reduced in both aprotinin groups (groups 2 and 3) compared to the coumadin plus ASA group, although no difference existed between the 2 aprotinin groups. Postoperative thrombotic and hemorrhagic events were not observed in any group. From this study, it was concluded that 10(6) KIU aprotinin in pump-prime-only followed by oral ASA and coumadin was the recommendation from the benefit/cost consideration.

Topics: Adult; Anticoagulants; Aprotinin; Aspirin; Coronary Artery Bypass; Drug Administration Schedule; Hemostasis; Hemostatics; Heparin; Humans; Middle Aged; Postoperative Complications; Postoperative Hemorrhage; Thromboembolism; Vascular Patency; Warfarin

Venous thromboembolic disease in the form of deep venous thrombosis and pulmonary embolism is a major risk after a total hip arthroplasty. Enoxaparin, a low-molecular-weight heparin, has been shown to reduce the prevalence of deep venous thrombosis after total hip arthroplasty. Warfarin, an orally administered anticoagulant, has been used historically to reduce the risk of deep venous thrombosis after total hip arthroplasty.. We compared enoxaparin and adjusted-dose warfarin with respect to their safety and their efficacy in the prevention of clinically important venous thromboembolic disease, defined as distal or proximal deep venous thrombosis or pulmonary embolism, or both, during hospitalization after total hip arthroplasty. We also evaluated the prevalence of complications and mortality from venous thromboembolic disease within three months after discharge.. Three thousand and eleven patients at 156 centers were randomly assigned to prophylactic treatment with injection of enoxaparin or oral administration of adjusted-dose warfarin during hospitalization. During the study, fifty-five (3.6 percent) of the 1516 patients who were managed with enoxaparin and fifty-six (3.7 percent) of the 1495 patients who were managed with warfarin had venous thromboembolic disease. Twenty-one patients (0.7 percent), which included four (0.3 percent) of those managed with enoxaparin and seventeen (1.1 percent) of those managed with warfarin (p = 0.0083), had venous thromboembolic disease during hospitalization. After discharge from the hospital, venous thromboembolic disease developed in ninety patients (3.0 percent): fifty-one (3.4 percent) of those managed with enoxaparin and thirty-nine (2.6 percent) of those managed with warfarin. One patient who had been managed with enoxaparin died because of a pulmonary embolism, which was confirmed at autopsy. Three additional patients (one who had been managed with enoxaparin and two who had been managed with warfarin) died, and the deaths were attributed to venous thromboembolic disease; however, no autopsies were performed. Twenty-six patients (0.9 percent) (eighteen managed with enoxaparin and eight managed with warfarin) had clinically important bleeding.. Inpatient programs providing treatment with either enoxaparin (thirty milligrams every twelve hours) or adjusted-dose warfarin for a mean of 7.3 days afforded protection against venous thromboembolic disease, with overall rates of morbidity and mortality of 3.7 and 0.6 percent, respectively, and a very low rate of major bleeding complications (0.9 percent) for three months after total hip arthroplasty. During hospitalization, the patients managed with enoxaparin had a lower rate of venous thromboembolic disease than those managed with adjusted-dose warfarin (p = 0.0083). This benefit was lost after the medication was discontinued, with no difference in the prevalences of venous thromboembolic disease between the two groups at three months after discharge from the hospital.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anticoagulants; Dose-Response Relationship, Drug; Drug Administration Schedule; Enoxaparin; Female; Humans; Male; Middle Aged; Postoperative Complications; Pulmonary Embolism; Risk Factors; Thromboembolism; Thrombophlebitis; Treatment Outcome; Warfarin

The purpose of this study was to assess the rate of postoperative deep vein thrombosis (DVT) as a function of oral anticoagulation therapy after total hip replacement surgery.. A total of 125 patients completed the study. All the patients received sequential gradient pneumatic compression over elastic stockings until hospital discharge. In addition, all the patients underwent postoperative heparin therapy followed by oral warfarin therapy, adjusted in dose to maintain a goal international normalized ratio (INR) level of 2.0 to 3.0. Warfarin therapy and compression stockings were continued for 1 month after surgery. Bilateral duplex scanning was performed 1 and 4 weeks after surgery to assess the rate of DVT.. Nineteen of the 125 patients had DVT develop (15.2%). Of those thromboses, six (31.6%) and 13 (68%) were detected 1 week and 1 month after surgery, respectively. The rate of proximal DVT was 2.4% (3 of 125) 1 week after surgery and rose to 8.2% (10 of 122) 1 month after surgery. Most DVT cases (64%; 12 of 19) were asymptomatic. The patients in whom DVT developed had significantly lower INR values during the second to fourth postoperative weeks than did those patients without thrombosis, and no differences in INR values were found during the first postoperative week.. The risk of the development of DVT extends beyond hospital discharge in patients who undergo total hip replacement, despite a regimen of prolonged oral anticoagulation therapy. This is particularly true in patients whose INR values did not reach therapeutic range during the first postoperative month. Therefore, thrombosis prophylaxis regimens on the basis of the administration of warfarin should try to maintain INR values within therapeutic range during the entire first postoperative month to minimize the incidence of DVT.

Topics: Administration, Oral; Aged; Anticoagulants; Arthroplasty, Replacement, Hip; Bandages; Case-Control Studies; Female; Humans; Male; Postoperative Care; Postoperative Complications; Postoperative Period; Time Factors; Ultrasonography, Doppler, Duplex; Venous Thrombosis; Warfarin

This study was undertaken to assess optimum anticoagulation control after bileaflet mechanical valve replacement by using the international normalized ratio of prothrombin time (PT-INR). From January to December 1995, 261 patients (pts) underwent mechanical valve replacement in the aortic (n = 95), mitral (n = 126), aortomitral (n = 39) or isolated tricuspid (n = 1) valve position in 8 medical centers in Tokyo, Japan. The St. Jude Medical valves were implanted in 184 pts and the Carbomedics valves in 77. There were 17 valve-related events as follows: 11 thromboembolic events (3.62%/pt-yr) including 10 transient ischemic attacks. 5 non-fatal bleeding events (1.65%/pt-yr), 2 reoperations (0.66%/pt-yr). At 18 postoperative months, free rates from all deaths (actuarial survival) thromboembolism, reoperation and all valve-related events were 95.3%, 95.7%, 98.7% and 88.9%, respectively. Under anticoagulant therapy, thrombin-antithrombin III complex and D-dimmer remained in high levels at 1 month after operation, and both values decreased to the control level at 6 months. In patients with thromboembolic events, PT-INR tended to be less than 2.0. The patients with bleeding events showed some increase of PT-INP or received anti-platelet agents. The 5 to 95 percentile of PT-INR at 6 months was 1.2 to 3.0 in the patients without valve-related events. These results suggested that optimum range of PT-INR might be between 1.2 and 3.0 after bileaflet mechanical valve replacement in patients without high risk of thromboembolism and between 2.0 and 3.0 in patients with the high risk.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anticoagulants; Female; Heart Valve Prosthesis Implantation; Humans; Male; Middle Aged; Postoperative Care; Postoperative Complications; Prospective Studies; Prothrombin Time; Thromboembolism; Warfarin

This study was performed to compare the computer-based and physician-based management of warfarin therapy after total hip arthroplasty (THA). The computer-assisted and control groups of patients were placed on warfarin postoperatively and followed for a 1-month period. A significant difference (P<.05) was found between the mean number of days needed to reach therapeutic anticoagulation in the control group (4.7+/-3.0 days) and the experimental group (2.8+/-1.4 days) and the proportion of patients in each group who were discharged with a subtherapeutic international normalized ratio (INR) (INR <1.5). The computer-based management of warfarin therapy was more efficient than unaided physician-based management and therefore may lead to improved, cost-effective patient care by reducing length of hospital stay and complications attributable to nontherapeutic anticoagulation in THA patients.

Topics: Aged; Anticoagulants; Arthroplasty, Replacement, Hip; Bayes Theorem; Cost-Benefit Analysis; Drug Therapy, Computer-Assisted; Humans; Postoperative Complications; Prospective Studies; Retrospective Studies; Warfarin

Topics: Aged; Anticoagulants; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Double-Blind Method; Female; Humans; Male; Mass Screening; Postoperative Care; Postoperative Complications; Postoperative Hemorrhage; Pulmonary Embolism; Thrombophlebitis; Ultrasonography, Doppler, Color; Warfarin

Patients with marginal venous conduit, poor arterial runoff, and prior failed bypass grafts are at high risk for infrainguinal graft occlusion and limb loss. We sought to evaluate the effects of anticoagulation therapy after autogenous vein infrainguinal revascularization on duration of patency, limb salvage rates, and complication rates in this subset of patients.. This randomized prospective trial was performed in a university tertiary care hospital and in a Veterans Affairs Hospital. Fifty-six patients who were at high risk for graft failure were randomized to receive aspirin (24 patients, 27 bypass grafts) or aspirin and warfarin (WAR; 32 patients, 37 bypass grafts). All patients received 325 mg of aspirin each day, and the patients who were randomized to warfarin underwent anticoagulation therapy with heparin immediately after surgery and then were started on warfarin therapy to maintain an international normalized ratio between 2 and 3. Perioperative blood transfusions and complications were compared with the Student t test or with the chi2 test. Graft patency rates, limb salvage rates, and survival rates were compared with the Kaplan-Meier method and the log-rank test.. Sixty-one of the 64 bypass grafts were performed for rest pain or tissue loss, and 3 were performed for short-distance claudication. There were no differences between the groups in ages, indications, bypass graft types, risk classifications (ie, conduit, runoff, or graft failure), or comorbid conditions (except diabetes mellitus). The cumulative 5-year survival rate was similar between the groups. The incidence rate of postoperative hematoma (32% vs 3.7%; P = .004) was greater in the WAR group, but no differences were seen between the WAR group and the aspirin group in the number of packed red blood cells transfused, in the incidence rate of overall nonhemorrhagic wound complications, or in the overall complication rate (62% vs 52%). The immediate postoperative primary graft patency rates (97.3% vs 85.2%) and limb salvage rates (100% vs 88.9%) were higher in the WAR group as compared with the aspirin group. Furthermore, the cumulative 3-year primary, primary assisted, and secondary patency rates were significantly greater in the WAR group versus the aspirin group (74% vs 51%, P = .04; 77% vs 56%, P = .05; 81% vs 56%, P = .02) and cumulative limb salvage rates were higher in the WAR group (81% vs 31%, P = .01).. Perioperative anticoagulation therapy with heparin increases the incidence rate of wound hematomas, but long-term anticoagulation therapy with warfarin improves the patency rate of autogenous vein infrainguinal bypass grafts and the limb salvage rate for patients at high risk for graft failure.

Topics: Aged; Anticoagulants; Arteries; Aspirin; Female; Hematoma; Heparin; Humans; Inguinal Canal; Leg; Male; Postoperative Complications; Prospective Studies; Survival Rate; Transplantation, Autologous; Treatment Outcome; Vascular Patency; Vascular Surgical Procedures; Veins; Warfarin

Topics: Administration, Oral; Anticoagulants; Drug Monitoring; Heart Valve Prosthesis Implantation; Humans; Postoperative Complications; Software; Warfarin

Orgaran (danaparoid sodium injection) is a novel antithrombotic agent. Early studies suggest that this compound may be beneficial in preventing deep vein thrombosis in predisposed patients. This multicenter, randomized, assessor blinded, clinical trial compared subcutaneous danaparoid with warfarin for the prevention of deep vein thrombosis in patients undergoing hip replacement surgery. Bilateral venography was used to detect thrombi. Patients also underwent follow-up examinations 1, 2, and 3 months after discontinuation of the study to determine the after effects of treatment. Nearly 27% of patients who received warfarin and 14.6% of patients who received danaparoid developed deep vein thrombosis, a risk reduction of 46%. The absolute difference in the incidence of deep vein thrombosis was 12.3% in favor of danaparoid. The incidence of venographically documented proximal deep vein thrombosis was 1.5% for danaparoid and 4.1% for warfarin. These results demonstrate that danaparoid is more effective than warfarin in preventing deep vein thrombosis following hip replacement surgery. The preoperative administration of danaparoid does not increase surgical blood loss compared with warfarin.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Arthroplasty, Replacement, Hip; Blood Loss, Surgical; Chondroitin Sulfates; Dermatan Sulfate; Drug Combinations; Female; Heparitin Sulfate; Humans; Male; Middle Aged; Postoperative Complications; Single-Blind Method; Treatment Outcome; Venous Thrombosis; Warfarin

Opinion differs as to whether anticoagulation is beneficial in preventing ischemic stroke in the early postoperative period after biological aortic valve replacement (AVR). The purpose of this study was to determine whether early anticoagulation with heparin and warfarin confers any significant advantage for patients undergoing such replacement.. Patients undergoing biological AVR between 1987 and 1996 were divided retrospectively into 2 groups based on their postoperative anticoagulation. Group A (109 patients) received heparin followed by warfarin for 3 months (prothrombin time, 20 to 25 seconds). Group B (76 patients) received no postoperative anticoagulation. Patients were followed for cerebral ischemic events, bleeding, repeat operation, hospital stay, and survival. There were 5 (4.6%), 3 (2.8%), and 12 (11%) postoperative cerebral ischemic events for group A at time points of < 24 hours, 24 hours to 3 months, and > 3 months, respectively; for group B patients, 3 (3.9%), 2 (2.6%), and 9 (11.8%) events were seen during the same respective time periods. There were no statistically significant differences for ischemic events during any of these time periods for the 2 groups. Bleeding complications occurred in 10 (9.2%) group A and 7 (9.2%) group B patients. Mean hospital stay was 12 days for both groups. Repeat operative AVR was required in 6 (5.5%) group A and 7 (9.2%) group B patients. A comparison of Kaplan-Meier survival rates between groups A and B (mean follow-up, 47 +/- 26 and 59 +/- 30 months, for groups A and B, respectively) was not statistically significant (P = 0.60). Survival rates were 93%, 84%, and 62% at 1, 5, and 7 years for group A and 87%, 74%, and 67% for group B, respectively.. Early anticoagulation after AVR confers no advantage in the prevention of early cerebral ischemic events after biological AVR. No disadvantage in terms of bleeding or prolonged hospital stay was incurred by early anticoagulation. Long-term valve function and survival were not adversely affected by withholding early anticoagulation. We conclude that early anticoagulation after biological AVR is unnecessary.

Topics: Aged; Anticoagulants; Aortic Valve; Bioprosthesis; Brain Ischemia; Drug Therapy, Combination; Female; Heart Valve Prosthesis Implantation; Hemorrhage; Heparin; Humans; Incidence; Male; Middle Aged; Postoperative Complications; Reoperation; Retrospective Studies; Survival Analysis; Unnecessary Procedures; Warfarin

The clinical significance of asymptomatic deep venous thrombosis that develops after joint arthroplasty and the value of screening tests to detect thrombi are uncertain.. To determine 1) the rate of symptomatic deep venous thrombosis or pulmonary embolism occurring after hospitalization for joint arthroplasty and 2) the value of screening compression ultrasonography.. Double-blind, randomized, controlled trial.. Tertiary care hospital.. 1024 patients undergoing elective total hip or knee arthroplasty who received warfarin prophylaxis.. Patients were randomly assigned to undergo either bilateral compression ultrasonography or a sham procedure before hospital discharge. Patients with a diagnosis of asymptomatic deep venous thrombosis were treated after discharge with standard anticoagulant therapy; other patients had warfarin therapy discontinued at discharge. All patients were followed for 90 days.. In the screening group, asymptomatic proximal deep venous thrombosis was detected in 13 of 518 patients (2.5%). Another 4 patients subsequently developed symptomatic proximal deep venous thrombosis, and 1 patient treated for asymptomatic deep venous thrombosis developed major bleeding, for a total outcome event rate of 1.0% (5 of 518 patients). In the placebo group, 3 patients developed symptomatic proximal deep venous thrombosis and 2 had nonfatal pulmonary embolism, for a total event rate of 1.0% (5 of 506 patients) (difference, 0 percentage points [95% CI, -1.2 to 1.2 percentage points]).. In patients undergoing total hip or knee arthroplasty, the use of warfarin prophylaxis during hospitalization results in a very low rate of symptomatic deep venous thrombosis or pulmonary embolism after hospital discharge. The use of screening compression ultrasonography at hospital discharge does not seem to be justified in this setting.

Topics: Algorithms; Anticoagulants; Double-Blind Method; Follow-Up Studies; Hemorrhage; Hip Prosthesis; Humans; Knee Prosthesis; Patient Discharge; Postoperative Complications; Pulmonary Embolism; Thrombophlebitis; Treatment Outcome; Ultrasonography; Warfarin

The effectiveness and safety of warfarin were compared with those of a low-molecular-weight heparin (dalteparin) for the prevention of deep-vein thrombosis after total hip arthroplasty in a prospective, randomized, multi-institutional trial. Patients who were older than eighteen years of age and were scheduled to have an elective primary or revision total hip arthroplasty were eligible; 580 patients were randomized, 550 had the operation and received prophylaxis, and 382 had evaluable venograms. Prophylaxis was provided either with warfarin beginning the night before the operation or with dalteparin beginning two hours before the operation and was continued until venography was performed. Bleeding was assessed on the basis of intraoperative blood loss, transfusion requirements, a decrease in hematocrit, and clinically identified bleeding complications. The prevalence of deep-vein thrombosis was found to be significantly lower in the patients who had received dalteparin than in those who had received warfarin (twenty-eight [15 per cent] of 192 patients compared with forty-nine [26 per cent] of 190 patients; p = 0.006). Deep-vein thrombosis occurred in the calf veins of twenty-one patients (11 per cent) who had received dalteparin and of forty-three patients (23 per cent) who had received warfarin; this difference was significant (p = 0.003). Proximal deep-vein thrombosis occurred in ten patients (5 per cent) who had received dalteparin and in sixteen patients (8 per cent) who had received warfarin; however, with the numbers available, no significant difference could be detected (p = 0.185). We also could not detect a significant difference with regard to the intraoperative and postoperative blood loss, the decrease in hematocrit, and the prevalence of major bleeding complications between the two groups; however, the patients who had received dalteparin had a significantly higher prevalence of bleeding complications involving the operative site (p = 0.03), and a significantly greater percentage required postoperative transfusions (p = 0.001). We concluded that preoperative prophylaxis with dalteparin is significantly more effective than that with warfarin in preventing deep-vein thrombosis after total hip arthroplasty. The greater effectiveness of dalteparin must be considered, however, in light of an increased need for postoperative transfusions and an increase in the prevalence of wound-related bleeding complications.

Topics: Anticoagulants; Blood Loss, Surgical; Dalteparin; Female; Hemorrhage; Hip Prosthesis; Humans; Male; Middle Aged; Postoperative Complications; Premedication; Prospective Studies; Thrombophlebitis; Warfarin

This study compares the benefits of aspirin and warfarin prophylactic agents for patients with thromboembolic disease after total joint arthroplasty. It is a prospective randomized study of 388 patients having total hip or total knee surgery. All consecutive patients having total hip or total knee surgery were entered into this study and evaluated with preoperative and postoperative ventilation perfusion scans and a postoperative venogram. The aspirin and warfarin treatment groups were compared by size and location of venographically revealed clots and changes in ventilation perfusion scans. The results showed that there was no difference in the size or location of deep venous thrombosis in the aspirin or warfarin treatment groups. The venogram was negative in 44.5% of patients; 28.8% had small ++calf clots, 16% had large calf clots, 3.9% had popliteal clots, and 6.7% had femoral clots. Patients with total knee replacement had a 2.6 times greater incidence of calf deep venous thrombosis than patients with total hip replacement. There was no difference between the aspirin and warfarin groups in the incidence of changes in ventilation perfusion scans (18.9%). There was no difference between the 2 groups in bleeding complications. The results suggest that aspirin and warfarin are equivalent in prophylaxis against thromboembolic disease, as determined by prevention of venographic changes or changes in ventilation perfusion scans.

Topics: Aged; Anticoagulants; Aspirin; Female; Humans; Joint Prosthesis; Male; Platelet Aggregation Inhibitors; Postoperative Complications; Prospective Studies; Pulmonary Embolism; Thromboembolism; Treatment Outcome; Warfarin

To compare the effectiveness and safety of fixed-dose enoxaparin and adjusted dose warfarin in preventing venous thromboembolism after knee arthroplasty.. A randomized, double-blind controlled trial.. 8 university hospitals.. 670 consecutive patients who had knee arthroplasty.. Patients were randomly assigned to receive enoxaparin (30 mg subcutaneously every 12 hours) or adjusted-dose warfarin (international normalized ratio, 2.0 to 3.0). Both regimens were started after surgery.. The primary end point was the incidence of deep venous thrombosis in patients with adequate bilateral venograms; the secondary end point was hemorrhage.. Among the 417 patients with adequate venograms, 109 of 211 warfarin recipients (51.7%) had deep venous thrombosis compared with 76 of 206 enoxaparin recipients (36.9%) (P = 0.003). The absolute risk difference was 14.8% in favor of enoxaparin (95% Cl, 5.3% to 24.1%) Twenty-two warfarin recipients (10.4%) and 24 enoxaparin recipients (11.7%) had proximal venous thrombosis (P>0.2). The absolute risk difference was 1.2% in favor of warfarin (Cl, -7.2% to 4.8%). The incidence of major bleeding was 1.8% (6 of 334 patients) in the warfarin group and 2.1% (7 of 336 patients) in the enoxaparin group (P>0.2). The absolute risk difference was 0.3% in favor of warfarin (Cl, -2.4% to 1.8%).. A postoperative, fixed-dose enoxaparin regimen is more effective than adjusted-dose warfarin in preventing deep venous thrombosis after knee arthroplasty. No differences were seen in the incidence of proximal venous thrombosis or clinically overt hemorrhage.

Topics: Aged; Anticoagulants; Double-Blind Method; Enoxaparin; Female; Follow-Up Studies; Hemorrhage; Humans; Knee Prosthesis; Male; Middle Aged; Postoperative Care; Postoperative Complications; Pulmonary Embolism; Thromboembolism; Warfarin

No controlled studies exist with regard to the risks of continuing therapy with warfarin sodium or platelet inhibitors or the benefits of briefly discontinuing therapy with these agents in patients who are undergoing cutaneous surgical procedures. Our objective was to determine the frequency of complications of cutaneous surgery in patients who were receiving warfarin or platelet inhibitors and to evaluate whether preoperative discontinuation reduces complications. A retrospective, controlled study was performed of complications of excisional and Mohs micrographic surgery in 653 patients who were being treated with warfarin or platelet inhibitors or with their medications being briefly withheld.. Severe complications of cutaneous surgery in patients who are taking warfarin or platelet inhibitors are uncommon, occur in 1.6% of cases, and are not significantly increased compared with complications in control subjects. Furthermore, there was no statistically significant reduction in the rates of severe complications in patients who had their medications preoperatively held.. Cutaneous surgery in patients who receive warfarin or platelet inhibitors is associated with a low risk of severe complications, not significantly reduced by brief preoperative discontinuation.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anti-Inflammatory Agents, Non-Steroidal; Aspirin; Dermatologic Surgical Procedures; Female; Hematoma; Humans; Male; Middle Aged; Mohs Surgery; Postoperative Complications; Postoperative Hemorrhage; Retrospective Studies; Warfarin

A prospective, randomized trial was conducted to compare the effectiveness and safety of warfarin given in two regimens in prevention of venous thrombosis after total knee replacement. Adult patients scheduled for primary or revision total knee replacement were randomly assigned to receive either a "two-step" warfarin regimen beginning 10-14 days pre-operatively or, alternatively, to begin warfarin the night before surgery. Post-operatively, the dose was adjusted in both groups to achieve a target International Normalized Ratio (INR) of 2.2 and prophylaxis was continued until venography on post-operative days five through nine. Bleeding was assessed by surgical blood loss, transfusion requirements, changes in hematocrit, and clinically identified bleeding complications. The occurrence of deep vein thrombosis was nearly the same in the two treatment groups, 39% in patients randomized to the two-step regimen as compared to 38% in those beginning the night before surgery. The occurrence of proximal vein thrombosis was also similar, 5% versus 7% (p = NS). Patients in the two-step group received 1.33 +/- 1.26 transfusions compared to 0.95 +/- 1.22 in the night before group (p < 0.05) and also had a lower nadir post-operative hematocrit of 26.7 +/- 3.1 as compared to 28.5 +/- 3.2 (p < 0.0001). Major bleeding complications were associated with excessively prolonged INRs and occurred in five patients in the two-step group and two in the night before group. Patients in both groups who developed thrombosis had a significantly lower INR on post-operative days two and three compared to those without thrombosis. We conclude that a prophylactic warfarin regimen for prevention of deep vein thrombosis after total knee replacement beginning the night before surgery is more convenient and may be associated with less bleeding than a regimen beginning warfarin 10-14 days pre-operatively. Careful control of anticoagulant intensity is needed to achieve maximum effectiveness and avoidance of bleeding complications.

Topics: Adult; Aged; Anticoagulants; Drug Administration Schedule; Female; Humans; Knee Prosthesis; Male; Middle Aged; Postoperative Complications; Prospective Studies; Thrombophlebitis; Warfarin

Three hundred and twenty-six patients underwent CarboMedics valve implantation (CM) in the aortic (119 patients), mitral (148 patients) or aortic and mitral (59 patients) positions while 371 patients underwent St. Jude Medical valve implantation (SJ) in the aortic (113 patients), mitral (184 patient), or aortic and mitral (74 patients) positions at National Taiwan University Hospital from August 1991 through 1995. All patients received warfarin (Coumadin) anticoagulation with the target international normalized ratio around 1.5. The hospital mortality was 3.7% in the CM group and 4.3% in the SJ group. In the CM group at 5 years, the actuarial freedom from thromboembolism, valve thrombosis, and anticoagulant-related hemorrhage was 89.91 +/- 2.66%, 95. 23 +/- 1.50%, and 99.62 +/- 0.37%, respectively, and the actuarial survival rate was 90.4 +/- 1.6%. In the SJ group at 5 years, the actuarial freedom from thromboembolism, valve thrombosis, and anticoagulant-related hemorrhage was 94.79% +/- 1.70%, 98.80 +/- 0.72%, and 99.68 +/- 0.31%, respectively, and the actuarial survival rate was 91.3 +/- 1.7%. We therefore concluded that a similar survival rate was noted in the CM and SJ groups. With low dose anticoagulation, the complications of thromboembolism, valve thrombosis, and anticoagulant-related hemorrhage were low in the SJ group.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Aortic Valve; Cardiopulmonary Bypass; Child; Child, Preschool; Female; Heart Valve Prosthesis; Humans; Intraoperative Complications; Male; Middle Aged; Mitral Valve; Postoperative Complications; Taiwan; Thromboembolism; Treatment Outcome; Warfarin

Deep vein thrombosis (DVT) following total hip or knee arthroplasty is a frequent complication which can cause fatal pulmonary embolism (PE). Although many different approaches to its prevention have been attempted, low-dose warfarin has become the standard treatment for the prevention of thromboembolic disease following total hip and knee arthroplasty. Although subcutaneous heparin can reduce the incidence of thromboembolic disease, it has been associated with excessive bleeding complications. The introduction of low molecular weight heparins promises fewer bleeding complications with efficacy equal to that of warfarin. We wish to report the results of a randomized, prospective study comparing a low molecular weight heparin with low dose warfarin in the prevention of thromboembolic disease following total knee arthroplasty (TKA).

Topics: Adult; Aged; Anticoagulants; Chemoprevention; Drug Administration Schedule; Enoxaparin; Female; Humans; Knee Prosthesis; Male; Middle Aged; Postoperative Complications; Thrombophlebitis; Warfarin

The Consortium Study is a prospective, randomized research project designed to extend the medical community's understanding of the incidence of thromboembolic disease following hip replacement surgery. The study's methodology of assessing deep vein thrombosis (DVT) and pulmonary embolism (PE) is by clinical symptomatology. Once clinical symptoms occur, diagnostic confirmation includes noninvasive techniques such as duplex ultrasonography, venography, VQ lung scan, and/or lung angiography. The study is designed to recruit a cohort of 4500 patients and will involve 150 medical centers in the United States. The final conclusion and definitive data of the incidence of DVT and PE, when comparing enoxaparin with warfarin, will be available after the full complement of 4500 patients is recruited. This study will demonstrate the incidence of thromboembolic disease during the acute hospital phase and the medium-term phase for the patient undergoing elective hip replacement.

Topics: Aged; Anticoagulants; Chemoprevention; Enoxaparin; Female; Hip Prosthesis; Humans; Male; Middle Aged; Postoperative Complications; Prospective Studies; Thrombophlebitis; Warfarin

We present herein a review of 95 patients who underwent valve replacement with the CarboMedics (CM) valve prosthesis between April 1990 and December 1992. The operative mortality for the entire group was 4.2%: 0% following aortic valve replacement (AVR), 2.7% following double valve replacement (DVR). All patients were prescribed warfarin and bucolome for anticoagulation, and were followed up for a mean period of 29.9 months. Late mortality was 8.4%; 3.1% following AVR, 10.8% following MVR, and 12.5% following DVR. There were no cases of mechanical prosthetic valve failure, significant hemolysis, infective prosthetic valve endocarditis, or bleeding complications. After 44 months of follow-up, the actuarial freedom from complications was calculated as: thromboembolism, 97.8 +/- 1.6%; valve thrombosis, 97.8 +/- 1.1%; paravalvular leak, 96.7 +/- 1.9%; and reoperation, 98.9 +/- 1.1%. The overall survival rate was 84.3 +/- 6.3% and all survivors showed a significant improvement in NYHA functional class, from 81% in classes III and IV preoperatively to 99% in classes I and II postoperatively. The CM valve exhibited no significant differences in hemolytic parameters or hemodynamic performance after isolated AVR or MVR compared with the similar type of St. Jude Medical bileaflet valve. The evidence provided by the present study therefore suggests that the CM valve prosthesis can achieve excellent mid-term clinical results and hemodynamic performance with a low incidence of thromboembolism and valve thrombosis.

Topics: Adolescent; Adult; Aged; Aortic Valve; Barbiturates; Female; Follow-Up Studies; Heart Valve Prosthesis; Hemodynamics; Hemolysis; Humans; Male; Middle Aged; Mitral Valve; Postoperative Complications; Survival Rate; Thromboembolism; Thrombosis; Warfarin

Atheroembolization may cause limb loss or organ failure. Surgical outcome data are limited. We report the largest series of atheroembolization focusing on patterns of disease, surgical treatment and outcome.. One hundred patients (70 men), mean age 62 +/- 11 years, operated on for lower extremity, visceral, or nonthoracic outlet upper extremity atheroemboli were identified prospectively and monitored over a 12-year period. The atheroembolic source was localized by use of a combination of computed tomography scanning (n = 55), arteriography (n = 93), duplex scanning (n = 25), transesophageal echocardiography (n = 6), and magnetic resonance imaging (n = 4). Occlusive aortoiliac disease (47 patients) and small aortic aneurysms (20 patients; mean aneurysm size 3.5 +/- 0.8 cm) were the most common source of atheroemboli. Imaging studies revealed 12 patients with extensive suprarenal aortic thrombus. Correction of the embolic source was achieved with aortic bypass (n = 52), aortoiliac endarterectomy and patch (n = 11), femoral or popliteal endarterectomy and patch (n = 11), infrainguinal bypass (n = 3), extraanatomic reconstruction (n = 6), graft revision (n = 3), upper extremity bypass (n = 11), or upper extremity endarterectomy and patch (n = 3).. All four deaths within 30 days and all seven deaths within the first 6 months after operation were among the 12 patients with suprarenal aortic thrombus. The cumulative survival probabilities for all patients at 1, 3, and 5 years were 89%, 83%, and 73%, respectively. After operation, nine patients required major leg amputations and 10 required toe amputations. Renal atheroemboli led to hemodialysis in 10 patients. Recurrent embolic events occurred in five of 97 patients monitored for a mean of 32 months. All five recurrences occurred in the first 8 months after operation. Three patients with recurrent emboli had suprarenal aortic disease, one of whom had undergone axillofemorofemoral bypass. Four of 15 patients receiving postoperative warfarin anticoagulation had development of recurrent embolism. Only one patient not receiving postoperative warfarin had a recurrent event (p < 0.05 by Fisher exact test).. The atheroembolic source is the aorta or iliac arteries in two thirds of patients who underwent operation. Computed tomography scanning of the aorta is a useful diagnostic technique. The source of the emboli can be eliminated surgically with low mortality or limb loss rates except when the suprarenal aorta is involved.

Topics: Adult; Aged; Aged, 80 and over; Angioplasty; Embolism, Cholesterol; Endarterectomy; Extremities; Female; Follow-Up Studies; Humans; Intraoperative Complications; Male; Middle Aged; Postoperative Complications; Prospective Studies; Recurrence; Survival Rate; Time Factors; Tomography, X-Ray Computed; Warfarin

One hundred and fifty six consecutive cemented total knee arthroplasties (TKA) in 147 patients (39 males, 108 females, mean age: 67) received preoperatively low-dose-warfarin for thromboembolic prophylaxis. Warfarin 10 mg was given the night before surgery and warfarin 5 mg the night of surgery. Thereafter, the dosage was adjusted to maintain a prothrombin time between 1.2-1.5 times control (INR = 2.0-3.0). The screening for any deep vein thrombosis (DVT) in the operated limb was by ascending venography. The reported incidence of DVT after TKA without prophylaxis is superior to 50%, more than 10% of those are proximal DVT. In this study, the overall incidence of DVT is down to 22.4%. Only five patients (3.4%) had a proximal DVT. There were no deaths and no clinical pulmonary embolisms. Patients with venous insufficiency had a significantly higher incidence of DVT (36.7%, p = 0.05). The average blood loss was 406 ml. Three major local bleedings occurred (2.0%). At one year follow-up, there were no infections. Low dose warfarin is efficacious in reducing DVT formation with TKA. It is safe and does not create excessive bleeding in cemented TKA.

Topics: Adult; Aged; Aged, 80 and over; Female; Humans; Knee Prosthesis; Male; Middle Aged; Phlebography; Postoperative Complications; Preoperative Care; Prospective Studies; Pulmonary Embolism; Thrombophlebitis; Warfarin

To identify the optimal use of anticoagulants after Carpentier-Edwards valve replacement, a retrospective study of all patients undergoing Carpentier-Edwards aortic (N = 378) or mitral (N = 370) valve replacement was done.. At the time of hospital discharge, 103 patients were managed with warfarin, 509 with aspirin alone, and 136 with no anticoagulation or antiplatelet therapy. Over the first 90 days after aortic or mitral valve replacement, the linearized rate of hemorrhage was greater for warfarin than for aspirin or no therapy (16.7 +/- 7.6%, 3.4 +/- 1.7%, and 3.1 +/- 3.1% per patient-year, respectively; P = .03). After aortic valve replacement, aspirin provided a low rate of thromboembolism (0.8 +/- 0.2% per patient-year), not significantly different from warfarin or no treatment (2.9 +/- 1.6% and 1.5 +/- 0.6% per patient-year) (P = .07). After mitral valve replacement, no single treatment was most advantageous because the rate of hemorrhage over the first 90 days for warfarin was equivalent to the 90-day rate of thromboembolism with aspirin or no therapy.. Anticoagulation after Carpentier-Edwards mitral valve replacement may be best guided by individual patient characteristics. Within the limits of a retrospective analysis, these data support the routine use of aspirin alone after Carpentier-Edwards aortic valve replacement, both in the first 90 days and long-term.

Topics: Aortic Valve; Aspirin; Atrial Fibrillation; Bioprosthesis; Female; Follow-Up Studies; Heart Valve Prosthesis; Hemorrhage; Humans; Incidence; Male; Mitral Valve; Postoperative Complications; Proportional Hazards Models; Retrospective Studies; Risk Factors; Thromboembolism; Time Factors; Warfarin

Orthopedic patients are at a high risk for developing venous thromboembolism, yet only a fraction of eligible patients receive anticoagulation prophylaxis after hospital discharge. This pilot study compared the efficacy of a fixed 2 mg/d dose of warfarin versus an adjusted higher dose of warfarin for 1 month after discharge to prevent the development of proximal leg deep venous thrombosis among recently discharged orthopedic patients. After standard inhospital treatment with adjusted higher-dose warfarin and a predischarge leg ultrasound to exclude deep venous thrombosis, 96 orthopedic patients were randomized just prior to discharge to either fixed low-dose (n = 49) or adjusted higher-dose warfarin (n = 47). At the 6-week follow-up evaluation, ultrasonographically confirmed, asymptomatic, proximal leg deep venous thrombosis occurred in two patients (4%). Both patients were randomized to the fixed low-dose group, although one remained on adjusted higher-dose warfarin throughout the trial. No patient in either group developed major bleeding complications. Further studies should be undertaken to further test fixed low-dose warfarin for venous thromboembolic prevention in high-risk orthopedic patients.

Topics: Female; Follow-Up Studies; Hip Fractures; Hip Prosthesis; Humans; Knee Prosthesis; Male; Middle Aged; Postoperative Complications; Prospective Studies; Thrombophlebitis; Time Factors; Warfarin

The efficacy and safety of RD heparin, a low-molecular-weight heparin, for the prevention of venous thromboembolic disease among patients managed with an elective total hip or total knee arthroplasty were compared with the efficacy and safety of warfarin in an open-label prospective, multicenter trial. Patients were randomized to receive either a fixed dose of fifty anti-factor-Xa units of RD heparin per kilogram of body weight, administered subcutaneously twice daily, beginning postoperatively; a fixed dose of ninety anti-factor-Xa units of RD heparin per kilogram of body weight, administered subcutaneously once daily, beginning postoperatively; or five milligrams of warfarin, administered orally preoperatively, followed by a daily adjusted dose of warfarin to prolong the prothrombin time ratio to 1.2 to 1.5. The primary measure of efficacy was contrast venography of the treated limb, performed by local radiologists blinded to the type of treatment that had been assigned. Nine hundred and sixty-nine patients had a complete assessment for the presence of deep-vein thrombosis. The over-all rates of venous thromboembolic disease were 16 percent (95 pecent confidence interval, 13 to 21 percent) (fifty-three) for the 328 patients who received RD heparin twice daily, 21 percent (95 percent confidence interval, 17 to 26 percent) (sixty-eight) for the 320 patients who received RD heparin once daily, and 27 percent (95 percent confidence interval, 22 to 32 percent) (eighty-seven) for the 321 patients who received warfarin (p < 0.001 for RD heparin administered twice daily compared with warfarin; p = 0.13 for RD heparin administered once daily compared with warfarin). Compared with warfarin, RD heparin administered twice daily and RD heparin administered once daily reduced the risk of venous thromboembolic disease by 41 percent (95 percent confidence interval, 20 to 56 percent) and 18 percent (95 percent confidence interval, -6 to 37 percent), respectively. The rates of venous thromboembolic disease after 523 total hip arthroplasties were 8, 14, and 14 percent for the patients who received RD heparin twice daily, those who received it once daily, and those who received warfarin (p = 0.07 for RD heparin administered twice daily compared with warfarin; p = 0.82 for RD heparin administered once daily compared with warfarin).(ABSTRACT TRUNCATED AT 400 WORDS)

Topics: Adult; Aged; Aged, 80 and over; Drug Administration Schedule; Female; Heparin, Low-Molecular-Weight; Hip Prosthesis; Humans; Knee Prosthesis; Male; Middle Aged; Postoperative Complications; Prospective Studies; Pulmonary Embolism; Thromboembolism; Warfarin

The clinical effect of combined warfarin and antiplatelet therapy on the incidence of stroke and postoperative complications after mitral (plus aortic) valve replacement was studied and compared with that observed with warfarin therapy alone.. It has been reported that combined warfarin and antiplatelet therapy may be effective but may be associated with an increased hemorrhagic risk. Therefore, definite benefits of the treatment in patients with an implanted prosthetic valve have not been clearly documented.. Between January 1980 and December 1992, 195 patients with a St. Jude Medical valve at the mitral (plus aortic) position were assigned to receive treatment with either warfarin alone (125 patients) or warfarin plus antiplatelet agents (70 patients), such as dipyridamole (150 or 300 mg daily, 14 patients) or ticlopidine (200 or 400 mg daily, 56 patients). A minimal dose of aspirin (10 to 40 mg) was added (29 patients) if the maximal platelet aggregation rate by collagen was not reduced. The target thrombotest level was 10% to 20%.. The two treatment groups were similar with regard to gender and age distribution. The number of patients with atrial fibrillation, left atrial thrombus, history of previous stroke, simultaneous aortic valve operation and previously performed valve procedures were comparable in the two groups. Actuarial survival rate at 10 years was 98.3 +/- 1.7% (mean +/- SD) in the warfarin plus antiplatelet group and 90.3 +/- 3.2% in the warfarin group (p < 0.05 at 1 and 9 to 12 years). The actuarial stroke-free rate at 10 years was 95.3 +/- 3.4% and 84.3 +/- 3.8%, respectively (p < 0.05 by the generalized Wilcoxon test). The actuarial complication-free rate at 10 years was 89.4 +/- 4.3% and 67.9 +/- 4.8%, respectively (p < 0.05 by the generalized Wilcoxon test). No hemorrhagic complications were seen in the warfarin plus antiplatelet group.. The results strongly indicate the effectiveness and safety of combined warfarin plus antiplatelet treatment after St. Jude Medical valve replacement for mitral (plus aortic) valve disease.

Topics: Actuarial Analysis; Aortic Valve; Cerebrovascular Disorders; Drug Therapy, Combination; Female; Heart Valve Prosthesis; Humans; Male; Middle Aged; Mitral Valve; Mitral Valve Insufficiency; Mitral Valve Stenosis; Platelet Aggregation Inhibitors; Postoperative Complications; Prosthesis Design; Warfarin

The incidence of clinically significant pulmonary embolism following total hip arthroplasty is reported in patients with venographically documented deep venous thrombosis. One hundred seventy-four patients who enrolled in a prospective evaluation of deep venous thrombosis prophylaxis underwent contrast venography 7-10 days after operation. Ten patients with proximal and 12 patients with isolated deep calf thrombosis were identified on routine venogram reading and received appropriate anticoagulant therapy, including a 6-12-week course of warfarin. There were no clinically evident embolic events and no bleeding complications in this group. A secondary blinded review of venograms several weeks later identified isolated deep calf thrombi in 13 other patients, none of whom had received warfarin after discharge. Four of the 13 patients (P < .02) subsequently presented with pulmonary embolism at a mean of 33.5 days after operation. Asymptomatic deep calf venous thrombosis following total hip arthroplasty is associated with a significant risk of developing clinically evident pulmonary embolism within the first 8 weeks after operation. Once identified, these thrombi were effectively managed with outpatient warfarin anticoagulation, and both embolic and bleeding complications were avoided. This study documents the need for more prolonged routine prophylaxis against venous thrombosis than has heretofore been the rule, extending beyond the time of discharge from the hospital. Alternatively, the authors' experience supports the use of routine screening venography following total hip arthroplasty to allow detection and selective anticoagulant treatment of deep venous thrombosis in both the thigh and calf.

Topics: Hip Prosthesis; Humans; Incidence; Leg; Middle Aged; Phlebography; Postoperative Complications; Prospective Studies; Pulmonary Embolism; Risk Factors; Thrombosis; Warfarin

Topics: Acenocoumarol; Adult; Aged; Anticoagulants; Aortic Valve; Dose-Response Relationship, Drug; Double-Blind Method; Drug Therapy, Combination; Female; Follow-Up Studies; Germany; Heart Valve Diseases; Heart Valve Prosthesis; Hemorrhage; Humans; Male; Middle Aged; Mitral Valve; Phenprocoumon; Postoperative Complications; Prospective Studies; Survival Rate; Thromboembolism; Warfarin

Deep vein thrombosis (DVT) is the most frequent complication after total hip arthroplasty, and proximal DVT is more likely to produce clinical pulmonary emboli than distal DVT. The authors have assessed the incidence and anatomic location of phlebographically proven fresh DVT following total hip arthroplasty in 855 patients over 39 years of age. Eight different regimens (2 warfarin, 3 aspirin, 1 dextran, 1 external pneumatic compression, and 1 dextran combined with external pneumatic compression) were evaluated and compared with an historical placebo control group from the same institution. No significant difference (P < .05) existed in proximal DVT incidence between the placebo group and any of the three aspirin groups, the dextran group, the external pneumatic compression group, or the dextran combined with external pneumatic compression group. In contrast, warfarin, given both in traditional and low-dose regimens, provided a significant reduction in proximal DVT compared with the placebo group (P < .001; statistical power, 0.84 and 0.99, respectively). The low-dose regimen had 10 times fewer bleeding complications than the traditional regimen. All prophylaxis regimens should be evaluated for both proximal and distal DVT formation, as well as for overall incidence. Low-dose warfarin offers the best protection against proximal thrombi of the agents studied, and it is also safer than traditional dosages of warfarin.

Topics: Adult; Aspirin; Combined Modality Therapy; Dextrans; Female; Gravity Suits; Hemorrhage; Hip Prosthesis; Humans; Incidence; Male; Postoperative Complications; Thrombophlebitis; Warfarin

Two studies evaluating the effect of Orgaran prophylaxis on the incidence of postoperative thrombosis in hip fracture surgery are reported. In one Scandinavian study, dextran was used in the comparative group, and in the US study, warfarin was used. In both, Orgaran was significantly more effective in reducing the frequency of deep vein thrombosis without producing an increase in bleeding complications or other side effects.

Topics: Aged; Aged, 80 and over; Chondroitin Sulfates; Dermatan Sulfate; Dextrans; Female; Glycosaminoglycans; Hemorrhage; Heparinoids; Heparitin Sulfate; Hip Fractures; Humans; Incidence; Male; Postoperative Complications; Pulmonary Embolism; Scandinavian and Nordic Countries; Single-Blind Method; Thrombophlebitis; United States; Warfarin

Warfarin is a very effective anticoagulant when used in the standard dose; however, the definition of standard dose has become ambiguous as the importance of the thromboplastin used in the measure of the prothrombin times has been demonstrated. Full or "standard" anticoagulation with warfarin imposes a hemorrhagic risk that can be avoided using lower doses. The premise has now been established that less than standard doses are efficacious. What is yet to be determined, however, is how low the dose of warfarin may be while maintaining efficacy and in which clinical settings. These conclusions must be established cautiously in clinical settings before being advocated generally. More complete discussions of this topic as well as safer means of using warfarin in general are available.

Topics: Atrial Fibrillation; Coronary Disease; Feasibility Studies; Humans; Postoperative Complications; Prospective Studies; Prothrombin Time; Thrombophlebitis; Thrombosis; Warfarin

To evaluate the ability of color Doppler ultrasound to detect proximal deep venous thrombosis (DVT) in asymptomatic high-risk patients who subsequently underwent contrast venography.. Prospective cohort study using blinded observers, with contrast venography as the comparison standard.. Seven medical centers (university and community hospitals) participating in a clinical trial of low-molecular-weight heparin for prevention of DVT.. A total of 385 consecutive patients undergoing elective unilateral hip or knee replacement.. Ten days after surgery or before hospital discharge (whichever occurred first), patients had bilateral color Doppler ultrasound examinations of the proximal veins of the lower extremities. Subsequently, a contrast venogram of the operated leg was obtained.. Color Doppler ultrasound studies and venograms were both evaluable in 319 of the 385 patients. Deep venous thrombosis was identified by contrast venography in 80 patients (prevalence, 25%; 95% CI, 20% to 30%) and involved the proximal veins in 21 patients (prevalence, 7%; CI, 4% to 10%). For proximal DVT, color Doppler ultrasound showed poor sensitivity (38%; CI, 18% to 62%), moderately good specificity (92%; CI, 89% to 95%), and a poor positive predictive value for this population (26%).. Color Doppler ultrasound examinations are insensitive to proximal DVT in asymptomatic high-risk patients and should not be substituted for venography for identifying proximal DVT in such patients.

Topics: Adolescent; Adult; Color; Heparin; Hip Prosthesis; Humans; Knee Prosthesis; Phlebography; Postoperative Complications; Predictive Value of Tests; Risk Factors; Thrombophlebitis; Ultrasonography; Warfarin

Postoperative deep venous thrombosis and pulmonary embolus remain a major source of morbidity and mortality for the urological surgery patient. We report the results of the first 100 patients in a prospective, randomized trial of low dose warfarin and intermittent pneumatic leg compression for deep venous thrombosis prophylaxis. All patients underwent preoperative and postoperative real-time ultrasound imaging and Doppler flow studies of the popliteal, femoral and iliac veins for the evaluation of deep venous thrombosis. Our results indicate that low dose warfarin is as effective as intermittent pneumatic leg compression for prophylaxis of deep venous thrombosis. Low dose warfarin can be used effectively without any significant bleeding complications. We recommend the use of low dose warfarin as an alternative to intermittent pneumatic leg compression for deep venous thrombosis prophylaxis of the urological patient undergoing a major urological operation.

Topics: Aged; Female; Gravity Suits; Humans; Male; Middle Aged; Postoperative Complications; Prospective Studies; Thrombophlebitis; Urologic Diseases; Warfarin

Venous thrombosis rates were compared in 200 patients undergoing total hip arthroplasty and randomized to receive either fixed mini-dose warfarin (1 mg daily) or adjusted-dose warfarin to maintain an international normalized prothrombin ratio (INR) of 2.0-4.0. Bilateral lower limb venography was performed between days 11 and 13 inclusive. Fixed mini-dose warfarin was associated with a significantly higher rate of total thrombosis (P less than 0.05). General anaesthesia was associated with a significantly higher rate of thrombosis than spinal anaesthesia (P less than 0.05). Adjusted-dose warfarin was associated with more bleeding complications than mini-dose warfarin although these were not attributable to excessive anticoagulation. A single death from pulmonary embolus occurred in the early postoperative period in a patient receiving adjusted-dose warfarin.

Topics: Anesthesia, General; Anesthesia, Spinal; Double-Blind Method; Drug Evaluation; Hip Prosthesis; Humans; Incidence; Postoperative Complications; Radiography; Regression Analysis; Thrombophlebitis; Warfarin

In a randomized, prospective trial, a low-molecular-weight heparinoid (Org 10172 [Lomoparan]) was compared with warfarin for efficacy and safety in preventing deep-vein thrombosis in 263 patients who had an operatively treated fracture of the hip. One group of patients received Org 10172 in a dose of 750 units subcutaneously every twelve hours until the ninth postoperative day; on the seventh postoperative day, warfarin was added to the regimen. The other group received only warfarin. Both drugs were begun preoperatively, immediately after the admission evaluation. In the patients who received warfarin, the desired prothrombin time was one and one-half times the control level. Deep-vein thrombosis was detected by 125I-fibrinogen scanning and impedance plethysmography and was confirmed by phlebography and compression ultrasonography. Deep-vein thrombosis was found in nine (7 per cent) of the 132 patients who received Org 10172 and in twenty-eight (21 per cent) of the 131 patients who received warfarin (p less than 0.001). Adverse reactions were not significantly different in the two groups. Major bleeding complications occurred in eight patients in the Org-10172 group, only four of whom were receiving the drug at the time of bleeding, and in five patients who were receiving warfarin (not significant). There was no difference in intraoperative loss of blood or in requirements for transfusion. We concluded that the low-molecular-weight heparinoid Org 10172 is a safe, convenient, effective antithrombotic agent for the prevention of venous thrombosis after an operation for fracture of the hip.

Topics: Aged; Aged, 80 and over; Blood Loss, Surgical; Chondroitin Sulfates; Dermatan Sulfate; Female; Glycosaminoglycans; Heparinoids; Heparitin Sulfate; Hip Fractures; Humans; Iodine Radioisotopes; Male; Middle Aged; Molecular Weight; Plethysmography; Postoperative Complications; Prevalence; Prospective Studies; Risk Factors; Thrombophlebitis; Warfarin

One hundred forty-nine consecutive patients requiring lower extremity total joint arthroplasty were randomized to either coumadin (52 patients) or intermittent pneumatic compression (48 patients) as prophylaxis against deep vein thrombosis (DVT). Forty-nine patients were excluded. When fully ambulatory, the presence or absence of DVT was diagnosed by ascending venography (90% of patients), nuclear venography, venous dopplers, or impedence plethysmography. The two groups were similar in average age (64 years), indication for arthroplasty (pain because of arthritis in 90%), gender (98% male), and average number of risk factors (2.4). Twenty-five percent of patients on coumadin and 25% of patients on intermittent pneumatic compression (IPC) developed DVT. IPC was more effective than coumadin following primary total hip arthroplasties (THAs) (16% versus 24% incidence DVT); coumadin was more effective than IPC following primary total knee arthroplasties (TKAs) (19% versus 32% incidence of DVT). DVT developed in 36% of patients following revision arthroplasty. Seventy-five percent of all thrombi were proximal. Both IPC and coumadin were found to be safe; there was no increased perioperative bleeding in the coumadin group. Of three postoperative deaths, one was possibly due to pulmonary embolism (PE).

Topics: Adult; Aged; Female; Gravity Suits; Hip Prosthesis; Humans; Incidence; Knee Prosthesis; Male; Middle Aged; Postoperative Complications; Prospective Studies; Random Allocation; Reoperation; Thrombophlebitis; Warfarin

To determine whether a small fixed perioperative dose of warfarin would prevent deep vein thrombosis after total hip replacement.. Prospective, randomised, double blind placebo controlled trial.. Winford Orthopaedic Hospital, Bristol.. 148 patients having primary total hip replacement.. Warfarin 1 mg given daily for one week before and three weeks after surgery.. Deep vein thrombosis diagnosed by the iodine-125 labelled fibrinogen uptake method.. Deep vein thrombosis occurred in 25 (34%) of the patients given warfarin and 19 (26%) of the controls (difference 8%; 95% confidence interval -6.8% to 22.8%).. Fixed minidose warfarin does not prevent deep vein thrombosis after total hip replacement.

Topics: Adult; Aged; Aged, 80 and over; Double-Blind Method; Female; Femoral Vein; Hip Prosthesis; Humans; Intraoperative Period; Iodine Radioisotopes; Male; Popliteal Vein; Postoperative Complications; Radionuclide Imaging; Thrombophlebitis; Thrombosis; Warfarin

A randomized trial was carried out with 194 patients to compare the effectiveness of sodium warfarin or aspirin with that of placebo in the prevention of venous thromboembolism after surgery for fractured hip. Prophylaxis was commenced postoperatively and continued for 21 days or until patient discharge, whichever was earlier. All patients underwent surveillance with iodine 125-fibrinogen leg scanning and impedance plethysmography, with subsequent venography. Venous thromboembolism occurred in 13 patients (20.0%) in the warfarin group, 27 patients (40.9%) in the aspirin group, and 29 patients (46.0%) in the placebo group. Proximal vein thrombosis or pulmonary embolism occurred in 6 patients (9.2%) in the warfarin group, 7 patients (10.6%) in the aspirin group, and 19 patients (30.2%) in the placebo group. The results of this study show that sodium warfarin therapy is safe and effective in preventing thromboembolic complications in patients undergoing surgery for fractured hip, and that aspirin therapy is an equally safe and effective method for preventing proximal vein thrombosis or pulmonary embolism.

Topics: Adult; Aged; Aged, 80 and over; Aspirin; Clinical Trials as Topic; Female; Follow-Up Studies; Hemorrhage; Hip Fractures; Humans; Male; Middle Aged; Phlebography; Postoperative Care; Postoperative Complications; Pulmonary Embolism; Random Allocation; Thrombophlebitis; Warfarin

After tissue heart valve replacement 108 patients were randomised to standard anticoagulant control with rabbit brain thromboplastin (Dade C reagent, therapeutic range 18-24 s; international normalised ratio 2.5-40) and 102 to a less intensive regimen controlled with human brain thromboplastin (Manchester Comparative Reagent, therapeutic range 26-30 s; INR 2.0-2.25). Treatment was continued for three months, outcome measures being major or minor embolism or haemorrhage. 2 patients in each group had major embolic events and 11 in each group had minor embolic events. The 95% confidence intervals on the differences are -3.4% to 3.2% for major embolism and -9.3% to 8.2% for minor embolism. Haemorrhagic complications were significantly more frequent with standard treatment (15 patients) than with the less intensive regimen (6 patients); and of the 5 patients with major haemorrhagic complications, all were in the standard treatment group, again a significant difference. The less intensive regimen is thus no less effective and safer than standard anticoagulant therapy in patients with tissue heart valve replacement.

Topics: Administration, Oral; Adult; Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Clinical Trials as Topic; Drug Evaluation; Embolism; Female; Heart Valves; Hemorrhage; Humans; Male; Middle Aged; Postoperative Complications; Prothrombin Time; Random Allocation; Warfarin

A prospective study was carried out to see whether a small fixed dose of warfarin (1 mg daily) given before operation (mean 20 days) would prevent deep vein thrombosis in patients having major gynaecological surgery. One hundred and four patients were randomised into three groups: fixed minidose warfarin; full dose oral anticoagulation; and no treatment (controls). There was a significantly lower incidence of deep vein thrombosis in the minidose warfarin and full dose anticoagulant treatment groups (9% (3/32) and 3% (1/35) respectively) than in the controls (30%; 11/37) but no significant difference between the two anticoagulant treatment groups. Prothrombin time and the activated partial thromboplastin time were normal on the day of surgery in the warfarin treatment group, whereas times were prolonged in the group given full dose anticoagulation. Mean haemoglobin concentrations fell in all three groups after operation but the fall was significantly less in the minidose warfarin treatment group than after full dose anticoagulation. The benefit from full dose oral anticoagulant prophylaxis, based on a preoperative international normalised ratio of 1.5-2.5 with rabbit brain Manchester reagent, was similar to the protection achieved in an oral anticoagulant treatment group controlled with human brain Manchester comparative reagent at a similar level of anticoagulation. The lack of disturbance of normal haemostasis at the time of operation together with a significant reduction in deep vein thrombosis may encourage surgeons to introduce minidose prophylaxis with warfarin.

Topics: Adult; Clinical Trials as Topic; Female; Humans; Middle Aged; Partial Thromboplastin Time; Postoperative Complications; Premedication; Prospective Studies; Prothrombin Time; Random Allocation; Thrombophlebitis; Warfarin

In a prospective, randomized, parallel study, two regimens of platelet-suppressant therapy (PST)--dipyridamole-aspirin and pentoxifylline-aspirin--were compared with standard oral anticoagulation with warfarin in the prevention of prosthetic heart valve thromboembolism. In the entire group of 254 patients followed for 395.6 patient-years, the thromboembolic rate was significantly less in the warfarin group (warfarin vs dipyridamole-aspirin, p less than .005; warfarin vs pentoxifylline-aspirin, p less than .05). Subgroup analysis disclosed that, in patients with isolated mitral valve replacement, warfarin was superior to both of the PSTs with respect to the prevention of thromboembolism (warfarin vs dipyridamole-aspirin, p = .005; warfarin vs pentoxifylline-aspirin, p less than .05). Furthermore, a significant number of our patients could not tolerate the antiplatelet agents. However, in the rare situation in which repeated significant bleeding occurs despite careful adjustment of the dosage of warfarin, PST may be an acceptable alternate method of thromboembolism prophylaxis.

Topics: Adult; Aspirin; Clinical Trials as Topic; Dipyridamole; Drug Combinations; Female; Heart Valve Prosthesis; Humans; Male; Middle Aged; Pentoxifylline; Postoperative Complications; Prospective Studies; Random Allocation; Theobromine; Thromboembolism; Warfarin

This is a brief review of some of the more important aspects of pharmacology and clinical management of anticoagulant therapy for venous thromboembolism. Some controversial aspects of treatment with respect to drug dosage, laboratory monitoring, and intensity and duration of therapy have been discussed. Thromboembolic complications can be reduced by extending the duration of anticoagulant therapy to a minimum period of 4 months after hospital discharge. Longer periods of treatment may be necessary in patients with recurrent deep venous thrombosis or pulmonary embolism. Hemorrhagic complications can be minimized by proper attention to laboratory monitoring and awareness of drug interactions and side effects.

Topics: Ambulatory Care; Anticoagulants; Blood Coagulation Tests; Clinical Trials as Topic; Drug Therapy, Combination; Heparin; Humans; Postoperative Complications; Random Allocation; Risk; Thrombophlebitis; Time Factors; Warfarin

In a randomized, prospective trial of 100 patients, we have studied the safety and efficacy of warfarin sodium in comparison with that of dextran 40 in the prevention of venous thrombosis in patients at high risk for deep vein thrombosis after elective total hip or knee replacement. Warfarin was given in a new two-step regimen designed to avoid bleeding complications while still preventing venous thrombosis. A low dose of warfarin was started ten to 14 days preoperatively, and the prothrombin time was regulated to between 1.5 and 3 seconds longer than control at the time of surgery; immediately after surgery, the dose was increased to prolong the prothrombin time to 1.5 times control. The overall incidence of venous thrombosis as documented by venography was less in the 53 patients treated with warfarin than in the 37 treated with dextran (21% v 51%), as was the incidence of thrombi in the femoral or popliteal veins (2% v 16%). Objective measures of blood loss showed no difference between patients treated with warfarin or dextran, and excessive postoperative bleeding was infrequent and similar in both treatment groups. This study demonstrates that two-step warfarin therapy provides highly effective prophylaxis of postoperative venous thrombosis after elective hip or knee prosthetic surgery without excessive risk of perioperative bleeding.

Topics: Aged; Clinical Trials as Topic; Dextrans; Female; Hemorrhage; Hip; Humans; Intraoperative Care; Knee; Male; Middle Aged; Postoperative Complications; Preoperative Care; Prospective Studies; Radiography; Random Allocation; Thrombophlebitis; Warfarin

Topics: Adult; Aged; Female; Humans; Male; Middle Aged; Oral Hemorrhage; Postoperative Complications; Tooth Extraction; Warfarin

Topics: Animals; Antithrombin III; Clinical Trials as Topic; Factor X; Hemorrhage; Heparin; Humans; Postoperative Complications; Recurrence; Risk; Thrombophlebitis; Time Factors; Warfarin

Topics: Abdomen; Aspirin; Clinical Trials as Topic; Dextrans; Double-Blind Method; Early Ambulation; Hemorrhage; Heparin; Humans; Injections, Subcutaneous; Lidocaine; Male; Orthopedics; Postoperative Complications; Posture; Prostate; Thoracic Surgery; Thromboembolism; Warfarin

In a randomized, controlled clinical study, dextran-70, warfarin, or low-dose heparin were administered to patients undergoing total hip replacement on one surgical unit in an attempt to prevent deep venous thrombosis and pulmonary embolism. Calf vein thrombosis was detected by the 125I-fibrinogen uptake test. None of the methods prevented calf vein thrombosis (dextran-70, 51%; warfarin, 58-6%; heparin, 52-6%). Pulmonary embolism was completely prevented in patients treated with warfarin but occurred in 4% of patients treated with dextran-70 and 15-5% of those treated with low-dose heparin. The incidence of complications of therapy was small and comparable in each group. It is suggested that calf vein thrombosis is a frequent and in itself a non-serious complication of total hip replacement surgery and that emphasis might be placed more usefully on prevention of pulmonary embolism.

Topics: Aged; Dextrans; Female; Heparin; Hip; Humans; Male; Postoperative Complications; Prostheses and Implants; Pulmonary Embolism; Thrombophlebitis; Warfarin

In a prospective controlled randomised trial, the prophylactic value of warfarin sodium (in doses aimed at maintaining a "Thrombotest" value of 10% and given from the day of admission until independent mobility had been achieved or for 3 mo, whichever was the sooner) was assessed in 160 elderly patients who had sustained a fracture of the femoral neck. Treatment significantly reduced the frequency of deep venous thrombosis (D.V.T.), whether indicated by the 125I-fibrinogen test during life or assessed by detailed post-mortem studies. Pulmonary embolism was eliminated in treated patients, but the difference in mortality between the treatment and control groups was not significant, indicating that causes of death other than pulmonary embolism are of major importance in these elderly patients. A case is made out for prophylactic anticoagulation on a selective basis.

Topics: Aged; Clinical Trials as Topic; Drug Evaluation; Female; Femoral Neck Fractures; Follow-Up Studies; Hemorrhage; Humans; Leg; Male; Middle Aged; Postoperative Complications; Prospective Studies; Pulmonary Embolism; Thrombophlebitis; Warfarin

Warfarin, low-dose heparin, or a combination of low-dose heparin and hydrocortisone was administered to 300 patients undergoing total hip replacement. The lowest incidence of thromboembolic (5 per cent) was attained with Warfarin. Further investigation into the method of administration of low-dose heparin is necessary before it can be used effectively as thromboembolism prophylaxis in total hip replacement patients. The addition of hydrocortisone was not found useful.

Topics: Arthroplasty; Drug Therapy, Combination; Heparin; Hip; Humans; Hydrocortisone; Phlebitis; Postoperative Complications; Pulmonary Embolism; Thromboembolism; Warfarin

Topics: Anticoagulants; Aspirin; Clinical Trials as Topic; Dextrans; Drug Evaluation; Drug Therapy, Combination; Female; Hematocrit; Hip Joint; Humans; Joint Prosthesis; Male; Osteoarthritis; Postoperative Complications; Pulmonary Embolism; Rh-Hr Blood-Group System; Thromboembolism; Thrombophlebitis; Warfarin

Topics: Dextrans; Drug Therapy, Combination; Female; Fibrinogen; Hip Joint; Humans; Infusions, Parenteral; Iodine Radioisotopes; Male; Middle Aged; Osteoarthritis; Postoperative Complications; Thrombophlebitis; Warfarin

Topics: Dextrans; Female; Fibrinogen; Humans; Iodine Radioisotopes; Postoperative Complications; Thrombophlebitis; Warfarin

Topics: Adult; Age Factors; Aged; Dextrans; Evaluation Studies as Topic; Female; Hematocrit; Hip; Hip Joint; Hospitalization; Humans; Injections, Intramuscular; Joint Prosthesis; Length of Stay; Male; Middle Aged; Postoperative Complications; Prospective Studies; Prothrombin Time; Sodium; Thrombophlebitis; Warfarin

Topics: Adult; Aged; Aortic Valve; Clinical Trials as Topic; Dipyridamole; Female; Follow-Up Studies; Heart Valve Prosthesis; Humans; Male; Middle Aged; Mitral Valve; Placebos; Postoperative Complications; Thromboembolism; Warfarin

Topics: Aspirin; Clinical Trials as Topic; Heparin; Hip; Humans; Postoperative Complications; Thromboembolism; Thrombophlebitis; Warfarin

Topics: Adult; Aged; Arthroplasty; Aspirin; Blood Platelets; Chromium Alloys; Dextrans; Dipyridamole; Female; Hemorrhage; Hip; Humans; Joint Prosthesis; Male; Middle Aged; Platelet Adhesiveness; Postoperative Complications; Pulmonary Embolism; Thromboembolism; Thrombophlebitis; Veins; Warfarin

A controlled prospective trial was carried out in a group of 80 women undergoing gynaecological surgery and thought to be at risk of developing postoperative venous thrombosis. The patients, who had been randomly allocated to prophylaxis with either dextran 70 or warfarin, were well matched in age, weight and other predisposing factors.In the warfarin group, 12 out of 40 patients developed deep vein thrombosis, six of these episodes being classified as major and six as minor. In the dextran 70 group, 4 out of 40 patients developed deep vein thrombosis, all of them minor. The protective effect of dextran 70 is significantly better than that of warfarin (P<0.01) as used in the present study.

Topics: Clinical Trials as Topic; Dextrans; Female; Fibrinogen; Genital Diseases, Female; Humans; Iodine Radioisotopes; Middle Aged; Postoperative Complications; Prospective Studies; Thrombophlebitis; Warfarin

Topics: Aged; Female; Hematoma; Hip; Humans; Iodine Radioisotopes; Male; Middle Aged; Phlebography; Postoperative Complications; Thrombophlebitis; Warfarin

Topics: Adult; Aortic Valve; Atrial Fibrillation; Dipyridamole; Embolism; Female; Follow-Up Studies; Heart Valve Prosthesis; Humans; Male; Middle Aged; Mitral Valve; Placebos; Postoperative Complications; Thromboembolism; Warfarin

To evaluate the effect of warfarin on blood transfusion and postoperative complications in a low-energy hip fracture population compared with a non-anticoagulated comparison group.. Multicenter Retrospective Cohort.. Three Urban Level I Academic Trauma Centers.. Acute, low-energy, native hip fractures in patients 55 years of age or older on chronic warfarin anticoagulation, propensity score matched 1:2 to non-anticoagulated hip fracture patients meeting all other inclusion criteria.. Transfusion and postoperative complication rates.. Two hundred ten anticoagulated hip fracture patients were matched to 420 nonanticoagulated patients. A higher proportion of patients required blood transfusion in the warfarin cohort (52.4% vs. 43.3%, P < 0.001), attributable mostly to the subgroup of patients undergoing arthroplasty. Warfarin patients had higher incidence of overall 90-day complications (47% vs. 38%, P = 0.039) and readmissions (31.4% vs. 8.9%, P < 0.001). Day of surgery international normalized ratio (INR) did not influence transfusions or complications among warfarin patients. Warfarin patients undergoing surgery within 24 hours had no difference in transfusions and had fewer complications compared with those undergoing surgery after 24 hours. On multivariable logistic regression analysis, warfarin use and day of surgery INR were not predictors of transfusion or complications.. Patients on warfarin experienced longer time to surgery and higher incidence of overall transfusion and postoperative complications within 90 days of surgery. However, warfarin use and day of surgery INR was not independently associated with transfusions or complications. The reason for poorer outcomes in warfarin patients remains a topic of further investigation.. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Topics: Anticoagulants; Hip Fractures; Humans; Postoperative Complications; Propensity Score; Retrospective Studies; Warfarin

Patients with cancer are at an increased risk of developing atrial fibrillation (AF) and often need to undergo procedures or surgery that requires periprocedural interruption of anticoagulation. Anticoagulated patients with cancer might be at increased risk of postprocedural thromboembolic and bleeding complications. Data on postprocedural outcomes among patients with concurrent active cancer and AF are sparse.. To assess the 30-day risk of postoperative thromboembolic and major bleeding complications after the periprocedural interruption of anticoagulation among patients with AF and active cancer.. We conducted a single-center retrospective cohort study in patients with active cancer and AF who required periprocedural interruption of anticoagulation for invasive procedures between August 2015 and May 2019. The primary endpoints were the 30-day postoperative risks of arterial thromboembolism (ATE) and major bleeding. The secondary endpoints included the 30-day risks of venous thromboembolism, clinically relevant nonmajor bleeding, and overall mortality.. Two hundred sixty-four patients undergoing 302 periprocedural interruptions were included in our study. The 30-day risk of ATE was 0.7% (95% CI, 0.1%-2.4%), and the 30-day risk of major bleeding was 1.7% (95% CI, 0.6%-3.9%). The 30-day risks of venous thromboembolism and clinically relevant nonmajor bleeding were 0.7% (95% CI, 0.1%-2.4%) and 4.3% (95% CI, 2.5%-7.3%), respectively. The overall risk of mortality at 30 days was 1.3% (95% CI, 0.4%-3.4%). There was one fatal postoperative stroke.. Patients with AF and active cancer in this study were at relatively low risk for ATE and postoperative bleeding complications when patients were managed according to commonly applied perioperative management recommendations.

Topics: Anticoagulants; Atrial Fibrillation; Humans; Neoplasms; Postoperative Complications; Postoperative Hemorrhage; Retrospective Studies; Risk Factors; Thrombosis; Treatment Outcome; Venous Thromboembolism; Warfarin

While aspirin is acceptable for venous thromboembolism (VTE) prophylaxis following total joint arthroplasty in most patients, more potent agents are used in patients considered higher risk for VTE. We evaluated the efficacy and safety of aspirin versus potent anticoagulation agents following total knee arthroplasty (TKA) and total hip arthroplasty (THA).. A cohort study of 72,288 TKA and 35,142 THA from the Kaiser Permanente Total Joint Replacement Registry was performed (2009 to 2019). Identified medications were aspirin, factor Xa inhibitors, low-molecular-weight heparin (LMWH), and warfarin. A validated VTE risk score was assigned to each patient. Propensity score-weighted logistic regressions were used to evaluate 90-day VTEs. Noninferiority testing was performed with a margin of 1.25 using the upper bound (UB) of the 1-sided 95% CI.. For TKA, aspirin was not inferior to LMWH (odds ratio [OR] = 0.77, UB = 1.09) and warfarin (OR = 0.64, UB = 0.90); there was no evidence to support noninferiority of aspirin compared to factor Xa inhibitors. Findings were consistent for THA (LMWH: OR = 0.59, UB = 0.75; warfarin: OR = 0.69, UB = 0.89). TKA was considered higher risk for VTE, whereas aspirin use demonstrated noninferiority compared to warfarin (OR = 0.54, UB = 0.81), we lacked evidence of noninferiority when compared to LMWH and factor Xa inhibitors. We lacked evidence of noninferiority of aspirin versus any potent anticoagulation in higher-risk THA.. Aspirin was found to be effective and safe for VTE prevention in primary total joint arthroplasty, including in patients considered higher risk for VTE.. III.

Topics: Anticoagulants; Arthroplasty, Replacement, Hip; Aspirin; Cohort Studies; Factor Xa Inhibitors; Heparin, Low-Molecular-Weight; Humans; Postoperative Complications; Venous Thromboembolism; Warfarin

The association between amiodarone treatment for postoperative atrial fibrillation (POAF) after surgical aortic valve replacement (SAVR) and both the return to normal sinus rhythm (NSR) and anticoagulation use at discharge has not been extensively studied.. We retrospectively identified all patients who underwent biological SAVR with or without concomitant coronary artery bypass grafting (CABG) at a Veterans Affairs Medical Center (2005-2015). We reviewed new-onset POAF, amiodarone use, return to NSR, and anticoagulation use with warfarin. Discharge rhythm and warfarin administration were compared among patients with POAF who were treated with amiodarone and patients who did not receive amiodarone.. Of the 395 patients (186 AVR/coronary artery bypass grafting; 209 AVR) studied, POAF developed in 191 patients (48.0%); 80.1% (153/191) of these patients received amiodarone. Among patients treated with amiodarone, 70.6% (108/153) were in SR at the time of discharge versus 65.8% (25/38) of POAF patients who were not treated with amiodarone (P = 0.57). Among amiodarone-treated patients, 30.7% (47/153) were discharged with warfarin; among patients not treated with amiodarone, 31.6% (12/38) were discharged with warfarin (P = 0.92). Among amiodarone-treated patients discharged in NSR, 89.9% (97/108 patients) were not discharged with warfarin; among patients not treated with amiodarone who were discharged in NSR, 92% (23/25) were not discharged with warfarin (P = 0.74).. POAF after SAVR appears common. Although amiodarone is often used for POAF patients, its use does not appear to be associated with surgeons' decision to anticoagulate patients. Surgeons' preferences for using rhythm control and antithrombotic therapy for POAF after SAVR warrant further exploration.

Topics: Amiodarone; Anticoagulants; Aortic Valve; Atrial Fibrillation; Humans; Postoperative Complications; Retrospective Studies; Risk Factors; Treatment Outcome; Warfarin

The incidence of postoperative complications following cardiac implantable electronic device (CIED) procedures in patients treated with antithrombotic drugs has not been studied sufficiently. Here we present a comparison of complications after CIED implantations.. Using an observational study design, the study included 1807 patients with a taking antiplatelet drugs (n: 1601), nonvitamin K anticoagulants (NOAC) (n: 136), and warfarin (n: 70) undergoing CIED surgery. Primary endpoint was accepted as cumulative events including composite of clinically significant hematoma (CSH), pericardial effusion or tamponade, pneumothorax, and infection related to device system. Secondary outcomes included each compenent of cumulative events. Multivariable analysis was performed to identify predictors of cumulative events.. The overall cumulative event rate was 3.7% (67 of 1807). Cumulative events occured 3.1% (50 of 1601) in the antiplatelet, 5.1% (7 of 136) NOAC, and 14.3% (10 of 70) warfarin groups (p < 0.001). CSH occurred in 2 of 70 patients (2.9%) in the warfarin group, as compared with 5 of 1601 (0.3%) in the antiplatelet group (p: 0.032). However, no significant differences were found between NOAC and warfarin groups in terms of CSH (0.7% vs. 2.9% respectively, p: 0.267). Warfarin treatment was an independent predictor of cumulative events and increased 2.9-fold the risk of cumulative events. Major surgical complications were rare and did not differ significantly between the study groups.. The incidence and severity of complications may be lower in patients treated with periprocedurally antiplatelet or NOAC therapy when compared with warfarin therapy. Further randomized control studies are required to confirm our findings.

Topics: Anticoagulants; Defibrillators, Implantable; Electronics; Fibrinolytic Agents; Hematoma; Humans; Pacemaker, Artificial; Postoperative Complications; Warfarin

Upper eyelid reconstruction is particularly complex due to its functional and aesthetic importance. We aim to assess the outcomes/ complications of patients who undergo upper eyelid reconstruction of the posterior lamellae with an advancing tarsonconjunctival flap from the same affected eyelid, following excision of a periocular malignancy by Mohs Micrographic Surgery.. A retrospective consecutive case note review of all eight patients who underwent the procedure between May 2016 and Jan 2021 were included. Patient demographics and factors influencing outcomes (smoking status, use of blood thinners, past medical/ drug history, size/location of the defect), follow up duration and complications were recorded.. Minor post-operative complications included an eyelid notch and retraction. There was one patient with lagophthalmos, but no exposure keratopathy. Two patients had misdirected lashes, one requiring electrolysis. Both monocular patients, who required the procedure in their only seeing eye, and were unable to tolerate a compressive dressing, had wound dehiscence. One patient was on steroids and the other on warfarin and a diabetic. No vision loss ensued and no-one underwent surgical revision. Follow up ranged from 4-52 months.. An advancing tarso-conjunctival flap is an expedient single-stage reconstructive technique that can be used to reform up to two- thirds of the posterior lamellae in full thickness upper eyelid defects involving the lid margin. Complications are minor. It is of particular benefit in patients where occlusion of the visual axis is unacceptable, although the risk of wound dehiscence is high. This technique forms a valuable part of the systematic reconstructive algorithm.

Topics: Eyelid Neoplasms; Eyelids; Humans; Plastic Surgery Procedures; Postoperative Complications; Retrospective Studies; Surgical Flaps; Warfarin

Symptomatic venous thromboembolism (VTE) following total ankle arthroplasty (TAA) can cause substantial morbidity and mortality. To prevent this complication, surgeons often prescribe postoperative chemoprophylaxis. However, much controversy exists regarding the efficacy of chemoprophylaxis because of the limited studies exploring its use. Furthermore, even less is known about its cost-effectiveness. Therefore, this study sought to determine the cost-effectiveness of commonly prescribed chemoprophylactic agents using a break-even analysis economic model.. The literature was searched, and an online database was used to identify patients who developed a symptomatic VTE after undergoing TAA. Our institutional records were used to estimate the cost of treating a symptomatic VTE, and an online drug database was used to obtain the cost of commonly prescribed chemoprophylactic agents. A break-even analysis was then performed to determine the final break-even rate necessary to make a drug cost-effective.. The low and high rates of symptomatic VTE were determined to be 0.46% and 9.8%. From 2011 to 2021, a total of 3455 patients underwent total ankle arthroplasty. Of these patients, 16 developed a postoperative symptomatic VTE (1.01%). Aspirin 81 mg was cost-effective if the initial symptomatic VTE rates decreased by an absolute risk reduction (ARR) of 0.0003% (NNT = 31 357). Aspirin 325 mg was also cost-effective if the initial rates decreased by an ARR 0.02% (NNT = 5807). Likewise, warfarin (5 mg) was cost-effective at all initial rates with an ARR of 0.02% (NNT = 4480). In contrast, enoxaparin (40 mg) and rivaroxaban (20 mg) were only cost-effective at higher initial symptomatic VTE rates with ARRs of 1.48% (NNT = 68) and 5.36% (NNT = 19). Additional analyses demonstrated that enoxaparin (40 mg) and rivaroxaban (20 mg) become cost-effective when costs of treating a symptomatic VTE are higher than our estimates.. Chemoprophylaxis following TAA can be cost-effective. A tailored approach to VTE prophylaxis with cost-effectiveness in mind may be beneficial to the patient and health system.

Topics: Ankle; Anticoagulants; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Aspirin; Chemoprevention; Cost-Benefit Analysis; Enoxaparin; Humans; Postoperative Complications; Rivaroxaban; Venous Thromboembolism; Warfarin

There were limited data on the risk of post-polypectomy bleeding (PPB) in patients on direct oral anticoagulants (DOAC). We aimed to evaluate the PPB and thromboembolic risks among DOAC and warfarin users in a population-based cohort.. We performed a territory-wide retrospective cohort study involving patients in Hong Kong from 2012 to 2020. Patients who received an oral anticoagulant and had undergone colonoscopy with polypectomy were identified. Propensity-score models with inverse probability of treatment weighting were developed for the warfarin-DOAC and between-DOAC comparisons. The primary outcome was clinically significant delayed PPB, defined as repeat colonoscopy requiring haemostasis within 30 days. The secondary outcomes were 30-day blood transfusion requirement and new thromboembolic event.. Apixaban was associated with lower PPB risk than warfarin (adjusted HR (aHR) 0.39, 95% CI 0.24 to 0.63, p<0.001). Dabigatran (aHR 2.23, 95% CI 1.04 to 4.77, adjusted p (ap)=0.035) and rivaroxaban (aHR 2.72, 95% CI 1.35 to 5.48, ap=0.002) were associated with higher PPB risk than apixaban. In subgroup analysis, apixaban was associated with lower PPB risk in patients aged ≥70 years and patients with right-sided colonic polyps.For thromboembolic events, apixaban was associated with lower risk than warfarin (aHR 0.22, 95% CI 0.11 to 0.45, p<0.001). Dabigatran (aHR 2.60, 95% CI 1.06 to 6.41, ap=0.033) and rivaroxaban (aHR 2.96, 95% CI 1.19 to 7.37, ap =0.013) were associated with higher thromboembolic risk than apixaban.. Apixaban was associated with a significantly lower risk of PPB and thromboembolism than warfarin, dabigatran and rivaroxaban, particularly in older patients with right-sided polyps.

Topics: Aged; Anticoagulants; Blood Transfusion; Cohort Studies; Colonic Polyps; Colonoscopy; Dabigatran; Factor Xa Inhibitors; Gastrointestinal Hemorrhage; Hong Kong; Humans; Male; Postoperative Complications; Pyrazoles; Pyridones; Retrospective Studies; Risk Assessment; Rivaroxaban; Thromboembolism; Warfarin

The type of periprocedural antithrombotic regimen that is the safest and most effective in percutaneous coronary intervention (PCI) patients on oral anticoagulant (OAC) therapy has not been fully investigated. We aimed to retrospectively investigate the in-hospital bleeding outcomes of patients receiving OAC and antiplatelet therapies during PCI using Japanese nationwide multicenter registry data. A total of 26,938 patients who underwent PCI with OAC and antiplatelet therapies between 2016 and 2017 were included. We investigated in-hospital bleeding requiring blood transfusion, mortality, and stent thrombosis according to the antithrombotic regimens used at the time of PCI: OAC + single antiplatelet therapy (double therapy) and OAC + dual antiplatelet therapy (triple therapy). The antiplatelet agents included aspirin, clopidogrel, and prasugrel. The OAC agents included warfarin and direct OACs. Adjusting the dose of OAC or intermitting OAC before PCI was at each operator's discretion. In the study population [mean age (SD), 73.5 (9.5) years; women, 21.5%], the double therapy and triple therapy groups comprised 5546 (20.6%) and 21,392 (79.4%) patients, respectively. Bleeding requiring transfusion was not significantly different between the groups [adjusted odds ratio (aOR), 0.700; 95% confidence interval (CI), 0.420-1.160; P = 0.165] (triple therapy as a reference). Mortality was not significantly different (aOR, 1.370; 95% CI, 0.790-2.360; P = 0.258). Stent thrombosis was significantly different between the groups (aOR, 3.310; 95% CI, 1.040-10.500; P = 0.042) (triple therapy as a reference). In conclusion, for patients on OAC therapy who underwent PCI, periprocedural triple therapy may be safe with respect to in-hospital bleeding risks. However, further investigations are warranted to establish the safety and efficacy of periprocedural triple therapy.

Topics: Aged; Aspirin; Clopidogrel; Coronary Artery Disease; Coronary Restenosis; Dual Anti-Platelet Therapy; Factor Xa Inhibitors; Female; Hemorrhage; Humans; Japan; Male; Percutaneous Coronary Intervention; Platelet Aggregation Inhibitors; Postoperative Complications; Prasugrel Hydrochloride; Registries; Retrospective Studies; Warfarin

COVID-19 and Fontan physiology have each been associated with an elevated risk of venous thromboembolism (VTE), however little is known about the risks and potential consequences of having both.. A 51 year old male with tricuspid atresia status post Fontan and extracardiac Glenn shunt, atrial flutter, and sinus sick syndrome presented with phlegmasia cerulea dolens (PCD) of the left lower extremity in spite of supratherapeutic INR in the context of symptomatic COVID-10 pneumonia. He was treated with single session, catheter directed mechanical thrombectomy that was well-tolerated.. This report of acute PCD despite therapeutic anticoagulation with a Vitamin K antagonist, managed with emergent mechanical thrombectomy, calls to attention the importance of altered flow dynamics in COVID positive patients with Fontan circulation that may compound these independent risk factors for developing deep venous thrombosis with the potential for even higher morbidity.

Topics: Amputation, Surgical; Atrial Flutter; COVID-19; Fontan Procedure; Gangrene; Heart Defects, Congenital; Humans; Image Processing, Computer-Assisted; Lower Extremity; Male; Mechanical Thrombolysis; Middle Aged; Phlebography; Postoperative Complications; Sick Sinus Syndrome; Thrombophlebitis; Tomography, X-Ray Computed; Treatment Outcome; Tricuspid Atresia; Warfarin

Management of antithrombotic therapy with warfarin in patients undergoing fistulograms and possible interventions is controversial and difficult because of lack of adequate outpatient bridging options. Our goal was to assess periprocedural outcomes in patients managed using different anticoagulation strategies.. A retrospective, single-institution analysis of all patients on chronic anticoagulation with warfarin undergoing fistulograms from 2011 to 2017 was performed. Anticoagulation management strategies were classified as suspended warfarin (SW), continued warfarin (CW), and a heparin bridge with suspended warfarin (HB). Periprocedural outcomes were analyzed.. There were 87 patients on chronic anticoagulation with warfarin who underwent 175 fistulograms. Median age was 63 years, and 43.4% were women. Indications for warfarin included atrial fibrillation (53%), prior pulmonary embolism/deep vein thrombosis (29%), and hypercoagulable state (14%). Distribution was SW (60%), CW (26%), and HB (14%). Approximately half (53%) were same-day procedures, 30% occurred during access-related admissions, and 14% were performed during nonaccess-related admissions. Common indications for a fistulogram included difficulty with dialysis (63.4%), access thrombosis (20.6%), and poor maturation (10.3%). Interventions included angioplasty (82.9%), thrombectomy/embolectomy (20.6%), and stenting (8.6%). Thirty-day outcomes for SW versus CW versus HB were similar for bleeding complications (5.7%, 6.5%, 8.3%; P = 0.89), systemic thrombotic complications (3.8%, 2.2%, 0%; P = 0.569), access rethrombosis (7.6%, 13%, 12.5%; P = 0.517), and tunneled dialysis catheter placement (11.4%, 13%, 12.5%; P = 0.958). After excluding procedures performed during a nonaccess-related admission, length of stay (LOS) was highest among HB (9.6 ± 7.8 days) compared with SW (2.6 ± 5.9 days) and CW (1 ± 2.8 days), (P < 0.0001).. CW therapy in patients undergoing fistulograms was not associated with increased morbidity and was associated with shorter LOS. Bridging with heparin is not associated with improved outcomes, warranting a thorough consideration of continuing warfarin is safe and may streamline preservation of dialysis accesses without significantly increasing resource utilization.

Topics: Adult; Aged; Anticoagulants; Arteriovenous Shunt, Surgical; Drug Administration Schedule; Drug Substitution; Female; Heparin; Humans; Kidney Failure, Chronic; Length of Stay; Male; Middle Aged; Perioperative Care; Postoperative Complications; Renal Dialysis; Retrospective Studies; Thrombosis; Time Factors; Treatment Outcome; Warfarin

Delayed bleeding after gastric endoscopic submucosal dissection (ESD) in patients receiving anticoagulants remains an unpreventable adverse event. Although direct-acting oral anticoagulants (DOACs) have superior efficacy in preventing thromboembolism, their effects on the occurrence of delayed bleeding remain unclear. This study aimed to elucidate the clinical effect of DOACs on delayed bleeding after gastric ESD.. We retrospectively examined 728 patients who received anticoagulants and were treated for gastric neoplasms with ESD in 25 institutions across Japan. Overall, 261 patients received DOACs, including dabigatran (92), rivaroxaban (103), apixaban (45) and edoxaban (21), whereas 467 patients were treated with warfarin.. Delayed bleeding occurred in 14% of patients taking DOACs, which was not considerably different in patients receiving warfarin (18%). Delayed bleeding rate was significantly lower in patients receiving dabigatran than in those receiving warfarin and lower than that observed for other DOACs. Multivariate analysis showed that age ≥ 65, receiving multiple antithrombotic agents, resection of multiple lesions and lesion size ≥ 30 mm were independent risk factors, and that discontinuation of anticoagulants was associated with a decreased risk of bleeding. In multivariate analysis among patients taking DOACs, dabigatran therapy was associated with a significantly lower risk of delayed bleeding.. The effects of DOACs on delayed bleeding varied between agents, but dabigatran therapy was associated with the lowest risk of delayed bleeding. Switching oral anticoagulants to dabigatran during the perioperative period could be a reasonable option to reduce the risk of delayed bleeding after gastric ESD.

Topics: Aged; Aged, 80 and over; Anticoagulants; Dabigatran; Endoscopic Mucosal Resection; Female; Humans; Japan; Male; Middle Aged; Postoperative Complications; Postoperative Hemorrhage; Pyrazoles; Pyridines; Pyridones; Retrospective Studies; Rivaroxaban; Stomach; Stomach Neoplasms; Thiazoles; Thromboembolism; Warfarin

Although venous thromboembolism (VTE) is relatively rare after unicompartmental knee arthroplasty (UKA), symptomatic pulmonary embolism (PE) can be fatal. Whether routine thromboprophylaxis or thrombolytic treatment is necessary for patients undergoing UKA remains unclear. Here, we present a case of delayed pulmonary embolism after UKA.. A 57-year-old women underwent cemented UKA for left localized medial knee pain. There were no risk factors of VTE besides high BMI before surgery. 2 months after surgery, the patient presented with dyspnea and palpitation, and these symptoms could not be alleviated after rest.. An arterial blood gas analysis showed decreased PO2, SO2 and PCO2. Pulmonary CTA showed multiple pulmonary embolism in the trunk of the right lower pulmonary artery and the branch of the left lower pulmonary arteries. The final diagnosis was delayed pulmonary embolism after UKA.. Urokinase thrombolysis was administered intravenously. Low molecular weight heparin and warfarin were prescribed for anticoagulation.. The patient's symptoms abated, and chest CTA showed that the pulmonary embolism had dissolved. No further thrombosis has been observed for more than 6 years.. We presented an unusual case of delayed pulmonary embolism after UKA. Despite the low incidence, its life-threatening nature makes it imperative for surgeons to be well-informed about thrombosis and pay more attention to its prevention strategies.

Topics: Anticoagulants; Arthroplasty, Replacement, Knee; Computed Tomography Angiography; Diagnosis, Differential; Female; Heparin, Low-Molecular-Weight; Humans; Infusions, Intravenous; Middle Aged; Osteoarthritis, Knee; Postoperative Complications; Pulmonary Embolism; Urokinase-Type Plasminogen Activator; Warfarin

Fontan circuit thrombosis is a significant cause of early postoperative morbidity and mortality. Thrombosis incidence and relationship to thromboprophylaxis choice and timing of initiation are not well established. We sought to evaluate the incidence of Fontan circuit thrombosis in the first 30 postoperative days and its relationship to thromboprophylaxis choice and timing. Patients undergoing Fontan surgery, 2006-2016, were reviewed. Fontan circuit thrombosis was defined by sonographic detection of intracardiac or deep venous thrombi. Logistic regression was used to assess relationships between thromboprophylaxis characteristics and thrombosis. One hundred ninety-two patients underwent Fontan. Fontan thrombosis occurred in 19 (10%) patients. 54% were started on aspirin, 27% coumadin, 4% heparin, and 7% none. There was no relationship between thrombosis and baseline anatomy, Fontan type or fenestration. Median time to thromboprophylaxis initiation was 4 days (interquartile range 2-6). Patients not started on thromboprophylaxis had 44.8 times the odds of thrombosis as those on thromboprophylaxis (confidence interval 6.4-311.7, P < 0.01); no children starting thromboprophylaxis before postoperative day 2 developed thromboses. For every day that thromboprophylaxis was delayed, odds of thrombosis increased by 30% (odds ratio 1.3; CI 1.1-1.6, P < 0.01). There was no difference in the odds of thrombosis between children taking aspirin vs other thromboprophylaxis types. Odds of early postoperative Fontan circuit thrombosis are increased in patients in whom thromboprophylaxis is delayed beyond the second postoperative day, with no difference in the odds of thrombosis between patients initiated on aspirin vs other thromboprophylaxis. Early aspirin institution post Fontan is recommended to reduce morbidity. Ultra-mini-Abstract: Odds of early postoperative Fontan circuit thrombosis are increased in patients in whom thromboprophylaxis is delayed beyond the second postoperative day, with no difference in the odds of thrombosis between patients initiated on aspirin vs other thromboprophylaxis. Early aspirin institution post Fontan is recommended to reduce morbidity and resource utilization.

Topics: Anticoagulants; Child; Humans; Postoperative Complications; Postoperative Period; Thrombosis; Venous Thromboembolism; Warfarin

Because of the nature of the Fontan physiology, patients are at an increased risk of thromboembolic complications. As such, warfarin or aspirin is generally prescribed lifelong for thromboprophylaxis. This study aimed to compare long-term rates of cerebrovascular injury, thrombosis, bleeding, bone mineral density, and quality of life in people living with Fontan circulation receiving warfarin compared with aspirin.. This was a multicenter study of a selected cohort from the Australia and New Zealand Fontan population. Participants underwent cerebral magnetic resonance imaging to detect the presence of cerebrovascular injury (n = 84) and dual-energy X-ray absorptiometry to assess bone mineral density (n = 120). Bleeding (n = 100) and quality of life (n = 90) were assessed using validated questionnaires: Warfarin and Aspirin Bleeding assessment tool and Pediatric Quality of Life Inventory, respectively.. Stroke was detected in 33 participants (39%), with only 7 (6%) being clinically symptomatic. There was no association between stroke and Fontan type or thromboprophylaxis type. Microhemorrhage and white matter injury were detected in most participants (96% and 86%, respectively), regardless of thromboprophylaxis type. Bleeding rates were high in both groups; however, bleeding was more frequent in the warfarin group. Bone mineral density was reduced in our cohort compared with the general population; however, this was further attenuated in the warfarin group. Quality of life was similar between the warfarin and aspirin groups. Home international normalized ratio monitoring was associated with better quality of life scores in the warfarin group.. Cerebrovascular injury is a frequent occurrence in the Australia and New Zealand Fontan population regardless of thromboprophylaxis type. No benefit of long-term warfarin prophylaxis could be demonstrated over aspirin; however, consideration must be given to important clinical features such as cardiac function and lung function. Furthermore, the association of reduced bone health in children receiving warfarin warrants further mechanistic studies.

Topics: Anticoagulants; Aspirin; Australia; Bone Density; Chemoprevention; Child; Cohort Studies; Female; Fontan Procedure; Heart Defects, Congenital; Hemorrhage; Humans; Long Term Adverse Effects; Male; New Zealand; Outcome Assessment, Health Care; Postoperative Complications; Quality of Life; Thromboembolism; Warfarin

Considering that there is a lack of evidence and guideline-based recommendations on the best preoperative oral anticoagulation management (OAC) for transcatheter aortic valve implantation (TAVI), this cohort study aimed to evaluate bleeding, access site complications, and early safety in patients undergoing TAVI on continued OAC therapy vs no-OAC therapy. Three-hundred forty-four patients submitted to a TAVI procedure (66.3% no-OAC vs 33.7% OAC) were consecutively enrolled. Primary endpoint was defined as in-hospital VARC-2 life-threatening or disabling bleeding. Secondary endpoints were in-hospital VARC-2 major vascular complications and VARC-2 early safety at 30 days. Propensity score matching analysis was performed to reduce potential distribution bias, resulting in 2 well-balanced groups (92 patients in each arm). In the overall cohort, mean age, median EuroScore II, and STS-score were 78.7±7.6 years, 2.9% (1.7-5.9), and 2.3% (1.6-3.6), respectively. Despite being older (78 ± 8 vs 80 ± 6, p = 0.004) and having higher STS score (2.1 vs 2.6, p = 0.001), patients on OAC had similar incidence of in-hospital VARC-2 life-threatening or disabling bleeding (1.3% vs. 0.9%, p = 0.711), major vascular complications (4.8% vs 5.2%, p = 0.888), and VARC-2 early safety at 30 days (10.1% vs 12.1%, p = 0.575). No significant differences in the main outcomes were observed when propensity score matching was applied. In conclusion, the management of patients on OAC submitted to a TAVI procedure is challenging and requires balancing the risk of bleeding with the risk of thromboembolic events. The present study suggests that continued OAC was not associated with increased in-hospital VARC-2 life-threatening or disabling bleeding, major vascular complications, and VARC-2 early safety at 30 days.

Topics: Aged; Aged, 80 and over; Anticoagulants; Aortic Valve Insufficiency; Aortic Valve Stenosis; Atrial Fibrillation; Case-Control Studies; Factor Xa Inhibitors; Female; Humans; Male; Postoperative Complications; Postoperative Hemorrhage; Preoperative Care; Propensity Score; Thromboembolism; Transcatheter Aortic Valve Replacement; Warfarin

We aimed to characterize the in-hospital analgesic use among total hip or knee arthroplasty (THA or TKA) patients, and to identify possible drug-related challenges. We identified 15 263 patients operated with a THA or TKA between 1 January 2012 and 30 April 2016. The prevalence of analgesic users and patients with potential clinically relevant drug-drug interactions (DDIs), along with the prevalence of readmission among patients with vs. without a DDI, were calculated. A DDI was defined as the combination of (A) a diuretic, an angiotensin-converting enzyme inhibitor or an angiotensin II receptor blocker, and an non-steroidal anti-inflammatory Drug (NSAID); (B) warfarin and an NSAID; and (C) a benzodiazepine or a benzodiazepine-related drug and an opioid. The prevalence of analgesics administered in THA and TKA patients was 99.3% and 99.1% for paracetamol and 93.8% and 98.8% for opioids, respectively. The prevalence of patients who received interaction A, B or C was 8.4%, 2.5% and 40.7%, respectively. Patients with vs. without a DDI had a higher prevalence of 30-day readmission. In conclusion, most THA and TKA patients were administered paracetamol or opioids. The prevalence of 30-day readmission was higher in patients with than in patients without a potential clinically relevant DDI.

Topics: Acetaminophen; Adult; Aged; Aged, 80 and over; Analgesics; Analgesics, Opioid; Angiotensins; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Diuretics; Drug Interactions; Female; Hospitals; Humans; Male; Middle Aged; Patient Readmission; Postoperative Complications; Risk Factors; Warfarin

Spontaneous spinal epidural hematoma (SSEH) is considered to be a relatively rare disease that can result in serious neurological sequelae. The pathogenesis and risk factors of SSEH are still unknown, and its differential diagnosis varies widely. Misdiagnosis with more common conditions such as stroke or aortic syndromes can occur. We report the case of a 27-year-old man who developed sudden upper back pain with no specific precipitant. Five days later, he visited our emergency department complaining of weakness in both lower limbs and dysuria. He had a history of intracardiac repair and a Blalock-Park procedure for an interrupted aortic arch and ventricular septal defect in infancy. Additionally, he had undergone an aortic root dilatation and aortic valve replacement at the age of 10 because of progression of aortic and supra-aortic stenosis and had received chronic anticoagulation and antiplatelet therapy with warfarin and aspirin, respectively. An emergency spine magnetic resonance imaging scan indicated a mass at the Th3-Th5 level with severe compression of the dural sac and the spinal cord. Emergency excision showed a spinal epidural hematoma. Mild postoperative gait disturbance and dysuria persisted, requiring rehabilitation and intermittent self-urethral catheterization. As patients with adult congenital heart disease have an increased risk of bleeding, they may be at risk of developing SSEH. However, this is the first report to describe such an association.

Topics: Adult; Anticoagulants; Aortic Valve Stenosis; Aspirin; Heart Defects, Congenital; Heart Septal Defects, Ventricular; Heart Valve Prosthesis Implantation; Hematoma, Epidural, Spinal; Humans; Magnetic Resonance Imaging; Male; Platelet Aggregation Inhibitors; Postoperative Complications; Warfarin

Venous thromboembolism (VTE) and bleeding events following total knee and hip arthroplasty (TKA/THA) are associated with significant morbidity. Clinical guidelines recommend administration of pharmacologic VTE prophylaxis post-operatively, although controversy exists regarding optimal prophylactic strategies.. We performed a retrospective cohort study in patients who underwent elective TKA/TKA in an academic medical center. Patients were stratified by surgery type (TKA/THA) and VTE risk determined by a novel risk stratification protocol and compared pre- and post-protocol implementation. Patients received warfarin pre-protocol and either aspirin or warfarin post-protocol for VTE prophylaxis. Natural language processing identified VTE events and ICD codes were used to identify bleeding events, with all events validated manually.. A total of 1379 surgeries were included for analysis, 839 TKAs and 540 THAs. Post-protocol implementation, 445 (94.1%) patients following TKA and 294 (97.4%) patients following THA received aspirin for VTE prophylaxis. A significant reduction in bleeding events (hazard ratio [HR] = 0.19, p = 0.048) was observed in low-risk THA patients treated with aspirin (post-protocol) compared patients treated with warfarin (pre-protocol). Bleeding events did not differ significantly between low-risk TKA patients treated with aspirin or warfarin. No significant differences in VTE events were observed following the protocol implementation.. The use of a novel risk stratification system to guide VTE prophylaxis selection between aspirin or warfarin following TKA and THA appears safe and effective. Among low-risk patients, aspirin use was associated with fewer bleeding events following THA, without an observed increase in VTE events.

Topics: Anticoagulants; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Aspirin; Cohort Studies; Humans; Postoperative Complications; Retrospective Studies; Venous Thromboembolism; Warfarin

The management of patients with a hip fracture is affected by the use of oral anticoagulants. A cross-sectional analysis was undertaken to investigate health outcome differences in those anticoagulated compared to those not anticoagulated.. Patients aged 50 years and over presenting to a large university hospital with hip fractures were identified from the service registry. Patient characteristics and health outcomes between those not anticoagulated were compared with those anticoagulated (warfarin and direct oral anticoagulants, DOAC).. 200/2307 (9%) patients were anticoagulated. 84% were on warfarin, and the rest a DOAC. Compared to those anticoagulated, there was a higher prevalence of dementia (25% vs. 18%, p = 0.02) and a lower prevalence of cardiovascular disease (54% vs. 78%, p < 0.01), atrial fibrillation (10% vs. 82%, p < 0.01), and polypharmacy (55% vs. 76%, p < 0.01). Renal function was lower in the anticoagulated group. Time to operation for those not anticoagulated and anticoagulated was a median (IQR) of 25 (15) and 27 (18) hours. There was no difference in blood transfusion and hospital mortality. Postoperative complications were similar except a higher rate of renal failure (14% vs. 19%, p = 0.04) and heart failure (1% vs. 5%, p < 0.01), and a longer length of stay [median (IQR): 14 (10) vs. 16 (12) days] in the anticoagulated group. This was no longer significant after adjustment of confounders.. There was no statistically significant difference in health outcomes between those anticoagulated and those not after adjusting for patient characteristics. It was feasible to avoid significant delay in hip fracture surgery in those anticoagulated.

Topics: Anticoagulants; Antithrombins; Cross-Sectional Studies; Female; Fracture Fixation; Hip Fractures; Hospital Mortality; Humans; Male; Middle Aged; Outcome and Process Assessment, Health Care; Postoperative Complications; Registries; Warfarin

The optimal antithrombotic therapy for patients undergoing TAVI with concomitant indication for oral anticoagulation remains unclear. In this high-risk population group, there is a paucity of data with regards to the use of DOACs. In the present study we compared long-term clinical outcomes of TAVI patients requiring anticoagulation, treated with warfarin versus DOACs. Consecutive patients, who underwent TAVI with indication for oral anticoagulation from the multicenter ATLAS registry were studied and divided in two groups depending on the chosen anticoagulation regimen, warfarin vs. DOACs. 30-day survival, as well as estimated 1 and 2-year all-cause mortality were compared between groups. The secondary endpoint included in-hospital major or life-threatening bleeding. The study group included 217 patients (102 treated with warfarin; 115 treated with DOACs). Kaplan-Meier estimated survival was found to be statistically similar in the warfarin and DOAC groups (90.6% vs. 93.7% for 1-year and 84.5% vs. 88.5%, for 2-year survival, respectively, P

Topics: Aged, 80 and over; Anticoagulants; Aortic Valve Stenosis; Blood Coagulation; Factor Xa Inhibitors; Female; Hemorrhage; Humans; Long Term Adverse Effects; Male; Patient Selection; Postoperative Complications; Prognosis; Registries; Survival Analysis; Thrombosis; Transcatheter Aortic Valve Replacement; Warfarin

 The risk of venous thromboembolism (VTE) in generally ill patients, both under outpatient and inpatient care, following blood transfusion has not been determined..  This retrospective population-based cohort study was conducted using the National Health Insurance Research Database. We studied patients who received blood transfusion, defined as red blood cell transfusion of any type, from January 1, 2000 to December 31, 2011. The index date was defined as the date of blood transfusion. The primary outcome was VTE. Propensity score matching and Cox proportional hazard models were used..  A total of 41,866 patients who underwent blood transfusion and 41,866 matched controls were studied. Generally, the blood transfusion cohort has 2.98 times higher risk of VTE than the control cohort (95% confidence interval [CI] = 1.23-7.22). The blood transfusion cohort had respectively 1.99 and 1.64 times higher risk of deep vein thrombosis (DVT) and pulmonary embolism (PE) compared with the control cohort (DVT, 95% CI = 1.65-2.41; PE, 95% CI = 1.19-2.26). Patients in the blood transfusion cohort who did not use warfarin were 1.95 times more likely to develop VTE than those in the control cohort (adjusted hazard ratio [HR]: 1.95, 95% CI = 1.65-2.31). Patients in the blood transfusion cohort were 1.74 times more likely to die than those in the control cohort (adjusted HR: 1.74, 95% CI = 1.48-2.05)..  Blood transfusion is associated with an increased risk of VTE. The risk of VTE decreased in those who took warfarin.

Topics: Adult; Aged; Anticoagulants; Blood Transfusion; Cohort Studies; Female; Humans; Male; Middle Aged; Population Groups; Postoperative Complications; Proportional Hazards Models; Retrospective Studies; Risk; Taiwan; Venous Thromboembolism; Warfarin

Hip fracture is common in the elderly, many of whom are on anticoagulation. However, data are limited on outcomes with anticoagulation reversal in patients undergoing hip fracture surgery.. Adults ≥60 years old on oral anticoagulation who underwent hip fracture surgery at 21 hospitals in Northern California from 2006 to 2016 were identified through electronic databases. Outcomes were compared among patients treated and untreated with anticoagulation reversal preoperatively.. Of 1984 patients on oral anticoagulation who underwent hip fracture surgery, 1943 (97.9%) were on warfarin and 41 (2.1%) were on direct oral anticoagulants. Reversal agents were administered to 1635 (82.4%). Compared to a watch-and-wait strategy, patients receiving reversal agents were more likely to be white, male, comorbid, and with higher admission and preoperative international normalized ratios (P <0.001 for all comparisons). No difference for 30-day mortality was detected between reversal vs non-reversal (7.8% vs 6.0%, respectively; hazard ratio [HR], 1.30 [95% confidence interval (CI), 0.82-2.07]). For secondary outcomes, reversal was associated with higher risk of delirium (8.6% vs 4.9%, risk ratio [RR], 1.77 [95% CI, 1.08-2.89]) and increased mean length of stay (6.4 vs 5.8 days, P <0.05). After adjustment, associations were no longer significant for delirium (RR 1.60, 95% CI, 0.97-2.65) or length of stay (mean difference 0.08, 95% CI, -0.55-0.71). No associations were detected between reversal and other secondary outcomes.. No significant associations were found between reversal agents and 30-day mortality or other outcomes in patients on oral anticoagulation who underwent hip fracture surgery. Further investigation is needed.

Topics: Aged; Aged, 80 and over; Antibodies, Monoclonal, Humanized; Anticoagulants; Antifibrinolytic Agents; Arthroplasty, Replacement, Hip; Asian; Black or African American; Blood Coagulation Factors; Blood Loss, Surgical; Blood Transfusion; Cohort Studies; Delirium; Factor Xa Inhibitors; Female; Fracture Fixation, Internal; Hip Fractures; Hispanic or Latino; Humans; International Normalized Ratio; Length of Stay; Male; Mortality; Orthopedic Procedures; Plasma; Postoperative Complications; Postoperative Hemorrhage; Preoperative Care; Proportional Hazards Models; Retrospective Studies; Sex Factors; Vitamin K; Warfarin; White People

Early in the prevention and treatment of bioprosthetic valve thrombosis (BPVT), anticoagulation is effective, but the long-term outcome after BPVT is unknown.. The goal of this study was to assess the long-term outcomes of patients with BPVT treated with anticoagulation.. This analysis was a matched cohort study of patients treated with warfarin for suspected BPVT at the Mayo Clinic between 1999 and 2017.. A total of 83 patients treated with warfarin for suspected BPVT (age 57 ± 18 years; 45 men [54%]) were matched to 166 control subjects; matching was performed according to age, sex, year of implantation, and prosthesis type and position. Echocardiography normalized in 62 patients (75%) within 3 months (interquartile range [IQR]: 1.5 to 6 months) of anticoagulation; 21 patients (25%) did not respond to warfarin. Median follow-up after diagnosis was 34 months (IQR: 17 to 54 months). There was no difference in the primary composite endpoint between the patients with BPVT and the matched control subjects (log-rank test, p = 0.79), but the former did have a significantly higher rate of major bleeding (12% vs. 2%; p < 0.0001). BPVT recurred (re-BPVT) in 14 (23%) responders after a median of 23 months (IQR: 11 to 39 months); all but one re-BPVT patient responded to anticoagulant therapy. Patients with BPVT had a higher probability of valve re-replacement (68% vs. 24% at 10 years' post-BPVT; log-rank test, p < 0.001).. BPVT was associated with re-BPVT and early prosthetic degeneration in a significant number of patients. Indefinite warfarin anticoagulation should be considered after a confirmed BPVT episode, but this strategy must be balanced against an increased risk of bleeding.

Topics: Adult; Aged; Anticoagulants; Bioprosthesis; Female; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Hemorrhage; Humans; Male; Middle Aged; Postoperative Complications; Recurrence; Retrospective Studies; Thrombosis; Warfarin

Intravenous thrombolysis is not suitable for patients undergoing oral anticoagulants therapy, with INR > 1.7 or PT > 15 s. We described a case of intravenous thrombolysis in a patient with INR 1.9.. A 66-year-old female patient was diagnosed with acute appendicitis complicated with atrial fibrillation. Seven days after admission, the patient suffered mixed aphasia with right limb asthenia. The NIHSS score was 11 points. and early infarction and hemorrhagic manifestations were not found in the emergency head CT. Thirty minutes after the onset of symptoms, NIHSS of patient increased from 11 to 14, but the INR was 1.92.. Acute ischemic stroke.. The IT therapy was recommended and all the therapy related risks were explained to the patient's parents. Briefly, the patient was given rTPA 38.5 mg. In addition to intravenous thrombolysis, VitK1 40 mg was simultaneously administered.. The patient's symptoms of drowsiness were improved. After 24 hours, all symptoms were stabilized with NIHSS of 2 points, there was a slight language obstruction, and no hemorrhagic transformation in head CT. Three months later, the review showed MRS score of 0, and the patient could take care of herself in daily life.. The clinical guidelines are still the main reference for guiding clinical practice, and the main thrombolytic standards and contraindications for treatment still need to be conformed. On this basis, for individualized patients, clinicians must accurately judge the cause of acute stroke, to make optimal choice, reduce disability and mortality, and improve quality of life of patients.

Topics: Aged; Appendicitis; Female; Fibrinolytic Agents; Humans; International Normalized Ratio; Patient Safety; Postoperative Complications; Stroke; Thrombolytic Therapy; Treatment Outcome; Warfarin

The incidence of venous thromboembolism (VTE) following arthroplasty and hip fracture surgery remains an important metric for quality and financial reasons. An audit at our institution between 2006-2010 showed a higher VTE rate than international data did at the time. This study aims to determine rates of DVT and PE in patients undergoing hip and knee arthroplasty and hip fracture surgery at Waitemata District Health Board (Waitemata DHB) between 1 January 2013 and 31 December 2016.. This study is a retrospective review of all VTE within three months of elective hip or knee replacement or hip fracture surgery. Data were identified for the period between 2013 and 2016 from Waitemata DHB patient databases, including a dedicated VTE database.. The current rates of deep vein thrombosis (DVT) and pulmonary embolism (PE) at our institution following hip or knee arthroplasty or hip fracture surgery are 1.5% and 0.6% respectively, a lower rate than 2.3% and 0.9% respectively in 2006-2010. DVTs were significantly more prevalent after hip fracture surgery than after elective hip or knee arthroplasty, and 71% of DVTs were confined to the distal veins. Of the patients undergoing surgery, 93% received post-operative chemoprophylaxis, mainly aspirin or low molecular-weight heparin (LMWH).. There has been a significant reduction in VTE rates following elective hip and knee joint replacement and hip fracture surgery between the time periods. This occurred over a period when Waitemata DHB introduced a multi-modal, interdisciplinary team approach to VTE prophylaxis utilising enhanced recovery after surgery (ERAS) pathways. These measures may therefore have contributed to the reduction in VTEs.

Topics: Aged; Aged, 80 and over; Anticoagulants; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Aspirin; Female; Heparin, Low-Molecular-Weight; Hip Fractures; Humans; Incidence; Male; Medical Audit; New Zealand; Orthopedic Procedures; Platelet Aggregation Inhibitors; Postoperative Complications; Pulmonary Embolism; Venous Thromboembolism; Venous Thrombosis; Warfarin

Hypo-attenuated leaflet thickening (HALT) in bioprosthetic aortic valve has been studied, but its equivalent in bioprosthetic mitral valve (bMV) remains uncharacterized. We sought to identify the prevalence, hemodynamic characteristics, and significance of anticoagulation therapy in bMV HALT.. A single-center cross-sectional study of 53 consecutive patients who underwent mitral valve replacement (MVR) with bMV between 2007 and 2017 was conducted. Cardiac-gated contrasted CT scans were obtained. Anticoagulant and antiplatelet therapy use were ascertained at the time of hospital discharge and CT scanning. Patient characteristics, postoperative stroke, and hemodynamic profile by echocardiogram were obtained to descriptively characterize the prevalence and characteristics associated with bMV HALT.. Three patients (5.7%) were found to have a HALT on bMV. The mean time from index MVR to CT scan was 3.4 ± 0.8 years in HALT cohort and 3.4 ± 2.7 years in non-HALT cohort. Fifty patients (94.3%) were discharged on warfarin, and 37 patients (69.8%) were on warfarin at the time of CT scans. One patient with HALT was on therapeutic warfarin at the time of the CT scan that identified HALT. All three patients were asymptomatic at the time of CT scan. In patients with HALT, mean transmitral pressure gradient were 8, 5, and 2.7 mmHg, all with trivial or mild mitral regurgitation.. In this study, the prevalence of HALT was low at 5.7%, all presenting without symptoms. One patient presented with HALT while on therapeutic oral anticoagulation, which may suggest thrombotic etiology may not adequately explain HALT.

Topics: Aged; Aged, 80 and over; Anticoagulants; Bioprosthesis; Cross-Sectional Studies; Echocardiography; Female; Heart Valve Diseases; Heart Valve Prosthesis; Hemodynamics; Humans; Male; Middle Aged; Mitral Valve; Mitral Valve Insufficiency; Platelet Aggregation Inhibitors; Postoperative Complications; Thrombosis; Tomography, X-Ray Computed; Warfarin

We studied the safety and efficacy of multimodal thromboprophylaxis in patients with a history of venous thromboembolism (VTE) who undergo total hip arthroplasty (THA) within the first 120 postoperative days, and the mortality during the first year. Multimodal prophylaxis includes discontinuation of procoagulant medications, VTE risk stratification, regional anaesthesia, an intravenous bolus of unfractionated heparin prior to femoral preparation, rapid mobilization, the use of pneumatic compression devices, and chemoprophylaxis tailored to the patient's risk of VTE.. Between 2004 to 2018, 257 patients with a proven history of VTE underwent 277 primary elective THA procedures by two surgeons at a single institution. The patients had a history of deep vein thrombosis (DVT) (186, 67%), pulmonary embolism (PE) (43, 15.5%), or both (48, 17.5%). Chemoprophylaxis included aspirin (38 patients), anticoagulation (215 patients), or a combination of aspirin and anticoagulation (24 patients). A total of 50 patients (18%) had a vena cava filter in situ at the time of surgery. Patients were followed for 120 days to record complications, and for one year to record mortality.. Postoperative VTE was diagnosed in seven patients (2.5%): DVT in five, and PE with and without DVT in one patient each. After hospitalization, three patients required readmiss-ion for evacuation of a haematoma, one for wound drainage, and one for monitoring of an elevated international normalized ratio (INR). Seven patients died (2.5%). One patient died five months postoperatively of a PE during open thrombectomy. She had discontinued anticoagulation. One patient died of a haemorrhagic stroke while receiving Coumadin. PE or bleeding was not suspected in the remaining five fatalities.. Multimodal prophylaxis is safe and effective in patients with a history of VTE. Postoperative anticoagulation should be prudent as very few patients developed VTE (2.5%) or died of suspected or confirmed PE. Mortality during the first year was mostly unrelated to either VTE or bleeding. Cite this article:

Topics: Adult; Aged; Aged, 80 and over; Anesthesia, Conduction; Anticoagulants; Arthroplasty, Replacement, Hip; Aspirin; Chemoprevention; Early Ambulation; Elective Surgical Procedures; Female; Follow-Up Studies; Heparin; Heparin, Low-Molecular-Weight; Humans; Intermittent Pneumatic Compression Devices; Male; Middle Aged; Platelet Aggregation Inhibitors; Postoperative Complications; Retrospective Studies; Risk Factors; Rivaroxaban; Venous Thromboembolism; Warfarin

Postoperative atrial fibrillation (POAF) is common after cardiac surgery and contributes to short- and long-term morbidity, particularly thromboembolism. Anticoagulation for sustained or recurrent POAF is suggested to reduce thromboembolism. Novel oral anticoagulants may present a safe alternative to warfarin with further benefits including shorter hospital length of stay and better patient convenience.. A retrospective analysis was performed on all isolated cases of coronary artery surgery (CABG) at our institution between January 2015 and December 2018, totalling 960 patients. Rates of POAF were examined with particular focus on preoperative factors, postoperative outcomes, and anticoagulation practices.. The incidence of POAF was 31.8% (305 patients) and was higher in older patients (67.6±9.4 yrs vs 63.0±10.7 yrs, p<0.001), those with a history of cerebrovascular disease (14.6% vs 8.7%, p=0.02), those with higher CHADS-VASc scores (2.5±1.3 vs 2.8±1.3, p<0.001) those who had a postoperative return to theatre (2.6% vs 0.8%, p=0.002), and those with new renal failure (4.9% vs 1.8%, p=0.02). Off-pump surgery was associated with lower incidence of POAF (29.8% vs 37.1%, p=0.03). Patients who developed POAF had significantly longer admissions than those without (12.6±10.6 days vs 9.3±16.3 days, p<0.001). In total, 106 patients (11.0%) went home anticoagulated; 77 (72.6%) on warfarin and 29 (27.4% on a NOAC). Readmission for bleeding was higher in patients on anticoagulation (1.0% vs 0.0%, p=0.02), but did not drive readmission for pericardial effusion (0.3% vs 0.6%, p=0.55). No bleeding complications occurred in patients who were discharged on a NOAC. Overall mortality at median of 2 years was 1.8% (17 patients) and no mortality occurred in any patient discharged on anticoagulation.. Postoperative atrial fibrillation is a common adverse event and is linked to higher preoperative and postoperative morbidity. Anticoagulation may be safely started in these patients and use of novel anticoagulation does not appear to increase postoperative complications, although overall numbers are low.

Topics: Aged; Anticoagulants; Atrial Fibrillation; Coronary Artery Bypass; Coronary Artery Disease; Female; Humans; Incidence; Male; Middle Aged; New South Wales; Postoperative Complications; Retrospective Studies; Risk Factors; Thromboembolism; Warfarin

Cardiac tamponade and its protean presentations are well documented. Tamponade presenting after recent cardiac surgery in a patient on anticoagulation is not unknown. However, severe headache as a presenting feature of tamponade is not documented. We describe how one can be misled into investigating causes of headache while the real cause, tamponade, lies hidden.

Topics: Anticoagulants; Cardiac Tamponade; Coronary Artery Bypass, Off-Pump; Diagnosis, Differential; Echocardiography; Headache; Humans; Jugular Veins; Male; Middle Aged; Postoperative Complications; Thrombosis; Warfarin

Anticoagulation after mitral valve repair is controversial and guidelines are not well-established. This study evaluated the association between postoperative warfarin use and complications after mitral valve repair, including bleeding and thromboembolic incidents, readmission, and mortality.. This retrospective study investigated 1097 patients who underwent elective mitral valve repair between April 2003 and March 2017, and was naïve to atrial fibrillation or prior cardiac surgery. This cohort had no other indication for or against anticoagulation. About 775 patients were placed on warfarin with international normalized ratio goal 2.5 and 322 patients were not anticoagulated. The association between anticoagulation and complications was assessed with univariate comparisons between groups and multiple logistic regression.. Postoperative warfarin use was associated with a reduced composite of bleeding and thromboembolic complications (pulmonary embolism, TIA, stroke, pericardial effusion or cardiac tamponade, gastrointestinal bleeding, and reoperation for bleeding) with an odds ratio of 0.29 (95% confidence interval, 0.13-0.64, P = .003). There was no difference in 30-day or 6-month mortality or readmission rate between groups. Long-term survival estimates were superior in the warfarin group (10-year: 92% vs 85%; log-rank P < .001).. Our analysis showed that postoperative warfarin use was associated with an overall reduced composite of bleeding and thromboembolic incidents and superior long-term survival. These findings suggest that anticoagulation with warfarin following mitral valve repair may be a safe and effective means for avoiding postoperative complications and that a large prospective randomized clinical trial is warranted.

Topics: Adult; Aged; Anticoagulants; Female; Hemorrhage; Humans; Logistic Models; Male; Middle Aged; Mitral Valve Annuloplasty; Postoperative Care; Postoperative Complications; Retrospective Studies; Thromboembolism; Warfarin

Persistent wound drainage (PWD) is one of the major risk factors for periprosthetic joint infections (PJI), arguably the most dreaded complications after a total hip and knee arthroplasty (THA and TKA). The aim of this study is to identify the rates of PWD among THA and TKA patients who received aspirin (ASA) or Coumadin for postoperative venous thromboembolism (VTE) prophylaxis.. Retrospective review of 5516 primary THA and TKA was performed. Patients with PWD were identified. Chi-square test was used to compare the incidences of PWD, 30-day VTE, and PJI at 6 months between the ASA and Coumadin groups. Multivariate regression model was used to identify independent risk factors for PWD using Charlson and Elixhauser comorbidity indexes.. The prevalence of PWD was 6.4% (353/5516). Patients receiving ASA had lower incidence of PWD (3.2% vs 8.5%, P < .0001) while having comparable rates of 30-day VTE (1.3% vs 1.4%, P = .722) and PJI at 6 months (1.8% vs 1.4%, P = .233) compared to those receiving Coumadin. Risk factors for PWD were diabetes (odds ratio [OR], 19.3; 95% confidence interval [CI], 11.8-23.2), rheumatoid arthritis (OR, 15.3; 95% CI, 10.8-17.2), morbid obesity (OR, 13.2; 95% CI, 9.7-17.5), chronic alcohol use (OR, 3.5; 95% CI, 1.8-5.5), hypothyroidism (OR, 1.9; 95% CI, 1.1-3.2), and Coumadin (OR, 1.7; 95% CI, 1.2-2.2).. Use of ASA is associated with significantly lower rates of PWD after THA and TKA when compared to Coumadin while being equally efficacious at preventing VTE. Coumadin was found to be an independent risk factor for PWD.

Topics: Arthroplasty, Replacement, Hip; Aspirin; Drainage; Humans; Postoperative Complications; Retrospective Studies; Risk Factors; Venous Thromboembolism; Warfarin

The typical cause of bioprosthetic valve dysfunction over years is calcification of leaflets, pannus formation, or tears due to structural degeneration. Thrombosis is rare as the valves get endothelialized early on, and, hence, anticoagulation is not recommended beyond 6 months after valve replacement. While bioprosthetic valve thrombosis is unusual (0.03% to 0.34%/year), it can be associated with significant mortality and morbidity. Here, we present a case of a middle-aged man with history of bioprosthetic mitral valve who presented with syncopal episode and was referred to us for mitral valve replacement for tentative bioprosthetic valve degeneration and stenosis. However, preoperative work up revealed prosthetic valve thrombosis which was successfully treated with anticoagulation.

Topics: Anticoagulants; Bioprosthesis; Echocardiography, Transesophageal; Heart Valve Prosthesis; Humans; Male; Middle Aged; Mitral Valve; Mitral Valve Stenosis; Postoperative Complications; Prosthesis Failure; Severity of Illness Index; Thrombosis; Treatment Outcome; Warfarin

Bleeding is an inevitable and often severe complication after endoscopic sphincterotomy (EST). We aimed to investigate the factors associated with post-EST bleeding in patients treated with anticoagulants.. The data of patients who underwent EST at 15 hospitals between July 2015 and June 2017 were extracted. We investigated the incidence of post-EST bleeding and risk factors for bleeding in patients treated with anticoagulants.. One hundred forty-nine patients undergoing EST who met the inclusion criteria were included in this study. The total-EST bleeding (bleeding occurring during or after EST) rate did not differ between the heparin replacement (8.0%, 6/75) and continuation (16.6%, 2/12; P = 0.37) groups of warfarin users. The total-EST-bleeding rate in the heparin replacement group (12.9%, 4/31) was significantly higher than that in the continuation group (0%, 0/31; P = 0.016) in direct oral anticoagulant (DOAC) users. The rate of total-EST bleeding with continuation of DOAC (0%, 0/31) was significantly lower with continuation of warfarin (16.6%, 2/12; P = 0.021). During-EST bleeding (bleeding occurring during EST) (P = 0.0083) and precut (P = 0.033) were significant risk factors for post-EST bleeding in all 149 patients. Heparin replacement was only a significant risk factor for total-EST bleeding (P = 0.033) in DOAC users.. Heparin replacement was a significant risk factor for post-EST bleeding in DOAC users; however, there was no significant difference between the bleeding rate of heparin replacement and that of continuation groups in patients taking warfarin. During EST and precut were significant risk factors for post-EST bleeding in all patients treated with anticoagulants.

Topics: Aged; Anticoagulants; Female; Hemorrhage; Heparin; Humans; Male; Postoperative Complications; Retrospective Studies; Risk Factors; Sphincterotomy, Endoscopic; Warfarin

The Achilles heel of mechanical valves appears to be the need for anticoagulation. Several different types of mechanical valves have come and gone. The success or lack thereof of these valves depended on their various designs. We compared the two most promising mechanical valves of different eras and the need for anticoagulation through a case review. Both the Medtronic-Hall tilting disc valve and the bileaflet On-X valve were compared and contrasted in terms of durability and management of anticoagulation in high-risk patient populations. We present two cases of challenging anticoagulation management: a patient who underwent a mitral valve replacement with a Medtronic-Hall tilting disc valve who was off anticoagulation for close to six years, and a patient who underwent On-X mitral and aortic valve replacements and suffered a subsequent intracranial bleed requiring surgical intervention. We explore the ethical dilemmas associated with these patients and the risk of restarting anticoagulation for each.

Topics: Adult; Anticoagulants; Aortic Valve; Bioethical Issues; Bioprosthesis; Drug Administration Schedule; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; International Normalized Ratio; Intracranial Hemorrhages; Loeys-Dietz Syndrome; Lung Diseases; Male; Middle Aged; Mitral Valve; Postoperative Complications; Prosthesis Design; Prosthesis Failure; Retreatment; Time Factors; Warfarin

To assess the impact of anticoagulation on patients having cataract surgery.. Patients who underwent cataract surgery with phacoemulsification and intraocular lens insertion between 1 January 2015 and 31 December 2015 at Christchurch Hospital were identified and retrospectively audited. The outcome measures were the occurrence of intraoperative and postoperative haemorrhage, and thromboembolic events within two weeks after surgery. A control group was included to assess the outcome measures in a sample of patients who were not on anticoagulants or antiplatelets.. Forty-four anticoagulated patients (46 eyes) and 41 controls (46 eyes) were identified. Seventy-four percent of those anticoagulated were on warfarin and 26% were on dabigatran. The incidence of haemorrhagic complications was 18%, 25% and 11% in the warfarin, dabigatran and control groups, respectively, although these differences were not statistically significant. Apart from one vitreous haemorrhage, which may have been present preoperatively, the haemorrhages that occurred were minor and not visually significant. No thromboembolic events were noted in any of the groups.. There is no statistically significant increase in haemorrhagic complications in cataract surgery patients who were on warfarin or dabigatran. Therefore, continuing the anticoagulation in this setting may be appropriate.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Dabigatran; Female; Humans; Male; Middle Aged; Phacoemulsification; Postoperative Complications; Postoperative Hemorrhage; Retrospective Studies; Thromboembolism; Warfarin

Although several studies now support the use of aspirin for venous thromboembolism (VTE) prophylaxis in primary total hip arthroplasty (THA) and total knee arthroplasty (TKA), the optimal chemoprophylactic agent in revision THA and TKA is not clear. The purpose of this study was to determine if the type of chemoprophylaxis has an effect on the VTE rate in patients undergoing revision total joint arthroplasty (TJA). The second aim was to compare differences in rates of wound drainage in primary and revision TJA stratified by the postoperative chemoprophylaxis used. The authors retrospectively reviewed 1917 consecutive patients undergoing primary and revision TJA. Individual records were reviewed for patient demographics, medical comorbidities, type of chemoprophylaxis, VTE risk factors, intraoperative data, and postoperative complications. Outcomes, including VTE rate and wound complications, were compared between types of anticoagulant therapy used postoperatively. Of the 1917 patients, there were 742 (38.7%) primary TKAs, 326 (17%) revision TKAs, 608 (31.7%) primary THAs, and 241 (12.6%) revision THAs. The most common prophylactic agent used was rivaroxaban (40.6%), followed by warfarin (28.5%) and aspirin (27.6%). Type of chemoprophylaxis was not associated with postoperative VTE or wound drainage (P>.05). Although revision surgery was an independent risk factor for wound drainage (odds ratio, 3.201; 95% confidence interval, 1.594-6.426; P=.001), it was not a risk factor for VTE (odds ratio, 1.847; 95% confidence interval, 0.423-8.053; P=.414). Revision arthroplasty alone was not associated with an increased rate of VTE. Aspirin is as effective as other chemoprophylactic agents without the increased risk of bleeding in low-risk patients. [Orthopedics. 2019; 42(6):323-329.].

Topics: Adult; Aged; Anticoagulants; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Aspirin; Female; Humans; Male; Middle Aged; Postoperative Complications; Postoperative Period; Reoperation; Retrospective Studies; Risk Factors; Rivaroxaban; Treatment Outcome; Venous Thromboembolism; Warfarin

The randomized, controlled BRIDGE trial established a lack of efficacy for use of bridging anticoagulation in warfarin-treated patients who underwent surgical procedures. A large nation-wide insurance claims database was used to perform a retrospective interrupted time series cohort study of adult patients with atrial fibrillation treated with warfarin who underwent surgical procedures. Patients were assessed for the use of low-molecular-weight heparin (LMWH) use as a periprocedural bridging anticoagulant between July 2015 and November 2017. The interrupted time series regression model was used to estimate the reduction in use of bridging LMWH following the publication of the BRIDGE trial in July 2015. The cohort consisted of 9,278 warfarin-treated patients with atrial fibrillation. Use of bridging LMWH declined by an estimated 6.7% (95% confidence interval [CI] 2.1% to 11.3%) to 13.0% following publication of the BRIDGE trial. The decline in bridging LMWH use was numerically larger for patients with a moderate- or high risk of stroke (8.9% decline, 95% CI 0.4% to 17.4%) than for patients at low risk for stroke (6.2% decline, 95% CI 0.7% to 11.5%). Significant predictors of bridging LMWH use include younger age and no co-morbid diabetes. In conclusion, this nation-wide, claims-based study identified a significant reduction in the use of bridging LMWH following the publication of the BRIDGE trial for warfarin-treated patients with AF.

Topics: Aged; Anticoagulants; Atrial Fibrillation; Female; Follow-Up Studies; Humans; Incidence; Male; Postoperative Complications; Preoperative Care; Prognosis; Retrospective Studies; Risk Factors; Surgical Procedures, Operative; Survival Rate; Thromboembolism; United States; Warfarin

Topics: Anticoagulants; Heart Valve Diseases; Heart Valve Prosthesis; Humans; Medication Adherence; Patient Education as Topic; Postoperative Complications; Prosthesis Implantation; Self-Management; Social Class; Thrombosis; Warfarin

Topics: Anticoagulants; Brain Neoplasms; Craniotomy; Enoxaparin; Humans; Postoperative Complications; Precision Medicine; Risk; Venous Thromboembolism; Warfarin

Left ventricular assist devices (LVADs) have become an important advancement for patients with end-stage heart failure. Left ventricular assist devices come with the risk of stroke and pump thrombosis, and to mitigate these risks, anticoagulation is given to these patients. With anticoagulation comes increased bleeding risk, and urgent reversal may be necessary. Reports have shown that the risk of thrombosis with prothrombin complex concentrate (PCC) does exist, especially in patients with baseline risk factors for thrombosis. We describe two cases of warfarin reversal with low-dose 4-factor PCC (4F-PCC) in two different LVAD patient scenarios. Low-dose 4F-PCC was administered to one patient with a Heart Mate II (HM II) LVAD, international normalized ratio (INR) of 4.7 on admission and in need of an urgent procedure. He received approximately 16 units/kg of 4F-PCC with reversal of his INR to 2.3 within 45 minutes. The second patient also had a HM II LVAD and presented with a right occipital intraparenchymal hemorrhage and subdural hematoma with an INR of 3.7. He received approximately 11 units/kg of 4F-PCC with INR reversal to 1.6 within 1 hour. Both of these patients had no thrombotic complications and successful reversal of their INR with low-dose 4F-PCC. Further investigation into low-dose 4F-PCC dosing strategies is warranted.

Topics: Aged; Anticoagulants; Blood Coagulation Factors; Heart-Assist Devices; Hemorrhage; Humans; International Normalized Ratio; Male; Postoperative Complications; Retrospective Studies; Thrombosis; Warfarin

Warfarin administration after lower limb joint replacements is associated with a high bleeding risk, creating the circumstances for periprosthetic joint infections, increased treatment costs and prolonged Length of Stay (L.o.S). We believe that previously warfarinized patients can be treated safely and discharged without delays, if appropriate policies are established and adhered to.. This is a retrospective cohort study. We have collected and analyzed data from an audit cycle between 2012 and 2015 on: 1) the post-operative Warfarin reloading protocol, identifying 4 distinct patterns: usual dose, 1.5 times or double the usual dose for 2 days and overloading, 2) timing of reloading: Evening of Surgery vs post-op Day 1, 3) frequency of INR testing: daily vs intermittent, 4) time required to reach a therapeutic INR value ≥2.0, 5) rate of INR variations ≥4.0 and 6) bleeding complications, 7) and the overall L.o.S.. We found a significant difference in the time required to reach an INR ≥2.0 between reloading with the usual dose and all other protocols (p < 0.001) without abolishing adverse sequelae. Daily INR testing reduced bleeding complications and INR variations at a significant (p < 0.001) and non-significant level respectively, while timing of restarting showed no significant effect. We found a correlation between INR variations and bleeding complications (odds ratio: 4.65, C.I: 0.59-30.87). 41% of the cohort was discharged on the day their INR turned therapeutic with an average L.o.S of 6.5 days.. We recommend to: 1) restart Warfarin at double (or in exceptional cases 1.5 times) the patient's maintenance dose for the first two doses, 2) starting on the Evening of Surgery, 3) with daily INR monitoring after the second loading dose, 4) using point of care testing devices, 5) and dosing thereafter to be guided by an anticoagulation service or computer assistance.

Topics: Adult; Aged; Anticoagulants; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Female; Humans; International Normalized Ratio; Male; Middle Aged; Postoperative Complications; Retrospective Studies; Thromboembolism; Warfarin

This study aimed to assess the risk of procedure-related complications of percutaneous epicardial access (EpiAcc) for radiofrequency catheter ablation (RFA) of ventricular arrhythmias (VAs) in patients chronically treated oral anticoagulants (OACs) with warfarin compared to those not on OACs.. We analyzed 205 patients (53 ± 16 years, 155 males) undergoing percutaneous EpiAcc as part of an RFA for VAs, and compared the outcome between patients chronically on OACs with warfarin (OAC group) and those without (non-OAC group).. Forty-seven patients (23%) were chronically treated on OACs before their procedure. EpiAcc in patients on OAC (OAC group) was not associated with an increased risk of cardiac tamponade (11% vs. 6%, p = 0.238) compared to non-OAC group, but a higher risk of need for blood transfusion (17% vs. 6%; p = 0.013). With respect to the OAC group, the international normalized ratio (INR) on the day of the RFA was ≥ 2.0 in 9 patients (19%) and < 2.0 in the remaining 38 patients (81%). The rate of all complication and blood transfusion were similar between them (11% vs. 21%; p = 0.496, 11% vs. 18%; p = 0.600).. Percutaneous EpiAcc in patients on chronic OAC with warfarin did not significantly increase the risk of cardiac tamponade, but was associated with a higher risk of need for blood transfusion. EpiACC in patients with an INR > 2.0 is reasonable in experienced hands when clinical indications are strong.

Topics: Administration, Oral; Adult; Aged; Analysis of Variance; Anticoagulants; Cardiac Tamponade; Catheter Ablation; Cohort Studies; Epicardial Mapping; Feasibility Studies; Female; Heart Failure; Humans; Male; Middle Aged; Multivariate Analysis; Postoperative Complications; Prognosis; Proportional Hazards Models; Retrospective Studies; Risk Assessment; Survival Rate; Tachycardia, Ventricular; Treatment Outcome; Warfarin

We encounter patients with mediastinal tumors invading the left innominate vein (LIV), and there is no evidence confirming whether the LIV should simply be ligated or reconstructed. The need for postoperative anticoagulant therapy after ligation of LIV is also controversial.. 3209 patients with thoracic malignant tumors underwent surgical resection between 1994 and 2014 in our institute. Nineteen (0.6%) patients had mediastinal malignant tumors invading the LIV and underwent LIV resection. Of these patients, only 3 underwent reconstruction of LIV. We did not start anticoagulant therapy routinely after resection of LIV. The patients were divided into 2 groups: group A showed at least 50% patency of LIV by preoperative contrast-enhanced computed tomography (CECT) and group B showed less than 50%. We investigated the safety of resecting LIV and the need for postoperative anticoagulant therapy.. The 30-day and 90-day mortalities were zero in both groups. Thrombosis of the LIV stump and increased edema in the left neck and upper limb were observed in 2 (10.5%) patients only in group A. After initiating the anticoagulant therapy, the embolisms disappeared and weaning the patients off warfarin could be done in less than 1 year.. In this study, there was no case of mortality or severe morbidity among the patients with LIV resection. Moreover, there was no need to initiate routine anticoagulant therapy after the LIV division as the frequency of embolism in the LIV stump was low and was expected to disappear prior to starting anticoagulant therapy.

Topics: Adult; Aged; Aged, 80 and over; Anesthesia; Anticoagulants; Brachiocephalic Veins; Female; Humans; Ligation; Male; Mediastinal Neoplasms; Middle Aged; Postoperative Complications; Postoperative Period; Prosthesis Implantation; Retrospective Studies; Risk Factors; Thoracic Surgery; Thoracic Surgical Procedures; Tomography, X-Ray Computed; Vascular Neoplasms; Warfarin

Anticoagulation therapy with warfarin is common before heart transplantation and complicates perioperative management.. This single-center, noninterventional, retrospective cohort study evaluated heart transplant patients before and after institution of a prothrombin complex concentrates-based preoperative warfarin reversal protocol for heart transplantation. Patients with international normalized ratio (INR) greater than 1.5 who received prothrombin complex concentrate (PCC) before heart transplant surgery were compared with a control group before implementation of a PCC protocol. Coprimary endpoints were utilization of individual blood products. Secondary endpoints included in-hospital mortality, reoperation for bleeding, delayed sternal closure, thromboembolic events, duration of chest tube use, time to extubation, intensive care unit length of stay, and hospital length of stay.. The study included 106 consecutive heart transplant patients (PCC cohort = 57, historical control cohort = 49). There was a significant reduction in fresh frozen plasma utilization in the PCC cohort (6 units versus 8 units, p = 0.002). Rates of packed red blood cells and platelet transfusion were similar between groups. There was a significant increase in the incidence of cryoprecipitate utilization in the PCC cohort, which can likely be attributed to decreased antifibrinolytic utilization. There were no differences in secondary endpoints between groups, including thromboembolic events.. This study found that a PCC-based warfarin reversal protocol significantly reduced fresh frozen plasma utilization compared with historical controls without affecting other clinically important surgical outcomes. These data suggest that PCC is a valuable tool for INR normalization that could safely reduce fresh frozen plasma administration and offer a practical alternative to traditional approaches for INR reversal before heart transplantation.

Topics: Adult; Aged; Anticoagulants; Blood Coagulation Factors; Blood Transfusion; Clinical Protocols; Female; Heart Failure; Heart Transplantation; Humans; International Normalized Ratio; Length of Stay; Male; Middle Aged; Plasma; Postoperative Complications; Retrospective Studies; Warfarin; Young Adult

Use of direct-acting oral anticoagulants (DOACs) is increasing, but little is known about the associated risks in patients undergoing colonoscopy with polypectomy. We aimed to determine the risk of post-polypectomy complications in patients prescribed DOACs.. We performed a retrospective analysis using Optum's de-identified Clinformatics Data Mart Database (2003-2016) (a de-identified administrative database from a large national insurance provider) to identify adults who underwent colonoscopy with polypectomy or endoscopic mucosal resection (EMR) from January 1, 2011, through December 31, 2015. We collected data from 11,504 patients prescribed antithrombotic agents (1590 DOAC, 3471 warfarin, and 6443 clopidogrel) and 599,983 patients not prescribed antithrombotics of interest (controls). We compared 30-day post-polypectomy complications, including gastrointestinal bleeding (GIB), cerebrovascular accident (CVA), myocardial infarction (MI), and hospital admissions, of patients prescribed DOACs, warfarin, or clopidogrel vs controls.. Post-polypectomy complications were uncommon but occurred in a significantly higher proportion of patients receiving any antithrombotic vs controls (P < .001). The percentage of patients in the DOAC group with GIB was 0.63% (95% CI, 0.3%-1.2%) vs 0.2% (95% CI, 0.2%-0.3%) in controls. The percentage of patients with CVA in the DOAC group was 0.06% (95% CI, 0.01%-0.35%) vs 0.04% (95% CI, 0.04%-0.05%) in controls. After we adjusted for bridge anticoagulation, EMR, Charlson comorbidity index (CCI), and CHADS. In our retrospective analysis of a large national dataset, we found that patients prescribed DOACs did not have significantly increased adjusted odds of post-polypectomy GIB, MI, CVA, or hospital admission. Bridge anticoagulation, higher CHADS

Topics: Aged; Anticoagulants; Case-Control Studies; Clopidogrel; Colonic Polyps; Colonoscopy; Endoscopic Mucosal Resection; Factor Xa Inhibitors; Female; Gastrointestinal Hemorrhage; Hospitalization; Humans; Male; Middle Aged; Myocardial Infarction; Platelet Aggregation Inhibitors; Postoperative Complications; Postoperative Hemorrhage; Retrospective Studies; Risk Factors; Stroke; Warfarin

The recommendations about antithrombotic medication use after bioprosthetic aortic valve replacement (bAVR) vary.. To describe the post-bAVR antithrombotic medication practice across the Veterans Health Administration (VHA) and to assess the association between antithrombotic strategies and post-bAVR outcomes.. Retrospective cohort study. Multivariable modeling with propensity scores was conducted to adjust for differences in patient characteristics across the 3 most common antithrombotic medication strategies (aspirin plus warfarin sodium, aspirin only, and dual antiplatelets). Text mining of notes was used to identify the patients with bAVR (fiscal years 2005-2015).. This study used VHA and non-VHA outpatient pharmacy data and text notes to classify the following antithrombotic medications prescribed within 1 week after discharge from the bAVR hospitalization: aspirin plus warfarin, aspirin only, dual antiplatelets, no antithrombotics, other only, and warfarin only. The 90-day outcomes included all-cause mortality, thromboembolism risk, and bleeding events. Outcomes were identified using primary diagnosis codes from emergency department visits or hospital admissions.. The cohort included 9060 veterans with bAVR at 47 facilities (mean [SD] age, 69.3 [8.8] years; 98.6% male). The number of bAVR procedures per year increased from 610 in fiscal year 2005 to 1072 in fiscal year 2015. The most commonly prescribed antithrombotic strategy was aspirin only (4240 [46.8%]), followed by aspirin plus warfarin (1638 [18.1%]), no antithrombotics (1451 [16.0%]), dual antiplatelets (1010 [11.1%]), warfarin only (439 [4.8%]), and other only (282 [3.1%]). Facility variation in antithrombotic prescription patterns was observed. During the 90-day post-bAVR period, adverse events were uncommon, including all-cause mortality in 127 (1.4%), thromboembolism risk in 142 (1.6%), and bleeding events in 149 (1.6%). No differences in 90-day mortality or thromboembolism were identified across the 3 antithrombotic medication groups in either the unadjusted or adjusted models. Patients receiving the combination of aspirin plus warfarin had higher odds of bleeding than patients receiving aspirin only in the unadjusted analysis (odds ratio, 2.58; 95% CI, 1.71-3.89) and after full risk adjustment (adjusted odds ratio, 1.92; 95% CI, 1.17-3.14).. These data demonstrate that bAVR procedures are increasingly being performed in VHA facilities and that aspirin only was the most commonly used antithrombotic medication strategy after bAVR. The risk-adjusted results suggest that the combination of aspirin plus warfarin does not improve either all-cause mortality or thromboembolism risk but increases the risk of bleeding events compared with aspirin only.

Topics: Aged; Aortic Valve; Aspirin; Bioprosthesis; Female; Fibrinolytic Agents; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Male; Platelet Aggregation Inhibitors; Postoperative Complications; Retrospective Studies; Treatment Outcome; Veterans Health; Warfarin

Thromboembolic events after total joint arthroplasty are potentially devastating complications. This study evaluated the efficacy of 4 different anticoagulants in preventing deep venous thrombosis and pulmonary embolism after total joint arthroplasty. The demographics and anticoagulant use (warfarin, enoxaparin, and aspirin with and without outpatient mechanical pumps) for patients who underwent primary unilateral total joint arthroplasties performed by a single surgeon from January 2013 to October 2014 were retrospectively reviewed. All patients underwent lower extremity ultrasound at the 3-week postoperative visit. A total of 613 primary unilateral total joint arthroplasties met the study inclusion criteria. There were 288 primary total knee arthroplasties and 325 primary total hip arthroplasties. The patients were 62.2% female, having a mean age of 67.6±10.6 years and a mean body mass index of 30.2±5.9 kg/m

Topics: Aged; Anticoagulants; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Aspirin; Chemoprevention; Drug Therapy, Combination; Enoxaparin; Female; Humans; Male; Middle Aged; Platelet Aggregation Inhibitors; Postoperative Complications; Retrospective Studies; Venous Thrombosis; Warfarin

Anticoagulants are used following total knee arthroplasty (TKA) to prevent venous thromboembolism (VTE). These drugs reduce VTE risk but may lead to bleeding-related complications. Recently, surgeons have advocated using antiplatelet agents including aspirin (ASA). However, there is no consensus regarding which medication has the optimal risk/benefit profile. The purpose of this study was to compare rates of VTE using different anticoagulants in anticoagulation-naïve patients being discharged home after TKA.. A national private insurance database was used to identify patients undergoing unilateral TKA. Patients with a prior history of VTE were excluded. Anticoagulants included ASA, low molecular weight heparin (LMWH), warfarin, factor Xa inhibitors (XaI), and fondaparinux. Postoperative complications, including VTE, blood transfusion, myocardial infarction, and hematoma, were identified using ICD-9 diagnosis codes. Risk of each complication was compared between groups using multivariate logistic regression controlling for demographics, length of stay, and comorbidities.. Of 30,813 patients, 1.82% were diagnosed with VTE. Using ASA as a baseline, there was significantly decreased risk of VTE with LMWH (OR 0.47), XaI (OR 0.50), and fondaparinux (OR 0.32). There was significantly higher risk of transfusion with LMWH (OR 1.56) and fondaparinux (OR 1.84), but no difference in hematoma between medications.. This study shows that there is a decreased risk of VTE with LMWH, XaI, and fondaparinux compared to ASA. However, these medications also had higher rates of bleeding-associated complications. The choice of pharmacologic prophylaxis should be made based on a balance of the risk/benefit profile of each medication.. III.

Topics: Aged; Aged, 80 and over; Anticoagulants; Arthroplasty, Replacement, Knee; Aspirin; Chemoprevention; Databases, Factual; Factor Xa Inhibitors; Female; Fondaparinux; Heparin, Low-Molecular-Weight; Humans; Logistic Models; Male; Middle Aged; Platelet Aggregation Inhibitors; Postoperative Complications; Risk Assessment; Venous Thromboembolism; Warfarin

Based on current guidelines from the American Academy of Orthopaedic Surgeons (AAOS), a number of prophylactic modalities for the prevention of venous thromboembolism in total joint arthroplasty may be used. It is common practice that more potent prophylactic agents are used for patients at higher risk of venous thromboembolism. However, we are aware of no studies that have investigated the efficacy of potent anticoagulation in higher-risk individuals. Therefore, the purpose of our study was to test the hypothesis that low-molecular-weight heparin and warfarin result in a reduction in venous thromboembolism events in high-risk patients.. A retrospective, multi-institutional study of 60,467 primary and revision total joint arthroplasties from 2000 to 2015 was performed. Identified medications were classified as aspirin, low-molecular-weight heparin, or warfarin. Patients with unavailable venous thromboembolism prophylaxis information or those not receiving the aforementioned prophylaxis were excluded. Information pertinent to the objective of this study was collected and a venous thromboembolism risk score was calculated based on 26 variables. Treatment outcomes assessed included 90-day rate of symptomatic venous thromboembolism and periprosthetic joint infection. Propensity score matching was performed (1:1), as well as logistic regression analysis on the total sample.. Aspirin prophylaxis demonstrated a lower rate of deep vein thrombosis, pulmonary embolism, and venous thromboembolism than warfarin and low-molecular-weight heparin alone throughout all risk scores. In the matched propensity score analysis, low-molecular-weight heparin and warfarin demonstrated increased odds of venous thromboembolism for both standard-risk and high-risk patients undergoing total knee arthroplasties compared with aspirin. For primary total hip arthroplasty, warfarin demonstrated an increased risk for high-risk patients and low-molecular-weight heparin demonstrated an increased risk for standard-risk patients. The prevalence of periprosthetic joint infection was higher in patients receiving warfarin (p < 0.001 for both comparisons of warfarin with aspirin and low-molecular-weight heparin).. The results of this multi-institutional study demonstrate that the use of warfarin and low-molecular-weight heparin in higher-risk patients does not necessarily result in a reduction in symptomatic venous thromboembolism. Aspirin administered to higher-risk patients seems to be as effective as potent anticoagulation and more effective than warfarin.. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Topics: Aged; Anticoagulants; Arthroplasty, Replacement; Aspirin; Female; Heparin, Low-Molecular-Weight; Humans; Logistic Models; Male; Middle Aged; Postoperative Complications; Prevalence; Propensity Score; Prosthesis-Related Infections; Reoperation; Retrospective Studies; Venous Thromboembolism; Warfarin

Topics: Anticoagulants; Cardiac Surgical Procedures; Cardiomyopathy, Hypertrophic; Echocardiography; Female; Heart Aneurysm; Humans; Magnetic Resonance Imaging; Middle Aged; Postoperative Complications; Treatment Outcome; Ventricular Outflow Obstruction; Warfarin

To compare the rates of deep venous thrombosis (DVT), rates of pulmonary embolus (PE), and complication profiles of warfarin and low-molecular-weight heparin (LMWH) in patients undergoing operative fixation of hip fractures.. Retrospective cohort study.. Insurance-based database of more than 22 million patient records.. Adult hip fracture patients who were treated operatively and received chemoprophylaxis from 2007 to 2016. A total of 7594 patients met inclusion criteria and were available for final analysis.. Pharmacological anticoagulation with warfarin or LMWH to prevent postoperative venous thromboembolism after hip fracture surgery.. Development of DVT or PE within 30 and 90 days of surgery.. Patients prescribed warfarin had higher rates of DVT and PE compared with those prescribed LMWH. Patients on warfarin were more likely to develop a postoperative hematoma and to be readmitted within 30 and 90 days compared with those on LMWH. Patients in both groups had similar rates of total complications.. Patients prescribed warfarin after hip fractures had higher rates of DVT and PE compared with those prescribed LMWH, although both agents had similar complication profiles.. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Topics: Aged; Aged, 80 and over; Anticoagulants; Chemoprevention; Female; Follow-Up Studies; Fracture Fixation, Internal; Heparin, Low-Molecular-Weight; Hip Fractures; Humans; Incidence; Male; Middle Aged; Postoperative Complications; Retrospective Studies; United States; Venous Thrombosis; Warfarin

Novel oral anticoagulants (NOAC) have been shown to have comparable risk profiles compared with warfarin. However, data on the use of NOACs in cardiac surgery patients is limited. The aim of this study is to compare postoperative effusion rates in patients who were anticoagulated with NOACs vs warfarin after coronary artery bypass grafting (CABG).. A retrospective review of 2017 patients undergoing isolated CABG from 2014 to 2017 was performed. Of those patients, 246 patients (12.2%) were placed on either a NOAC or warfarin postoperatively. The combined rates of postoperative pericardial and pleural effusions requiring invasive intervention during the index hospitalization and up to 3 months postoperatively were compared between patients who were placed on NOACs vs warfarin.. Of the 246 patients placed on oral anticoagulation after isolated CABG, 64 (26.0%) were placed on NOACs, and 182 (74.0%) received warfarin. There were no significant differences in preoperative coagulation profile and use of anticoagulation and antiplatelets preoperatively between the groups. Of the patients anticoagulated with NOACs postoperatively, 17 patients (26.6%) required invasive interventions for effusions compared with 24 patients (13.2%) in the cohort anticoagulated with warfarin (P < 0.014). Of the patients who required interventions for effusions, those on NOACs were more likely to require delayed interventions compared with those on warfarin.. Patients receiving NOACs after CABG are at increased risk of developing effusions requiring invasive interventions compared to patients receiving warfarin. This increased risk should be taken into consideration when choosing the appropriate anticoagulation strategy for postoperative patients with CABG.

Topics: Administration, Oral; Aged; Anticoagulants; Antithrombins; Coronary Artery Bypass; Factor Xa Inhibitors; Female; Humans; Male; Middle Aged; Pericardial Effusion; Pleural Effusion; Postoperative Care; Postoperative Complications; Retrospective Studies; Risk; Warfarin

Background Recent publications reached conflicting conclusions about the cost-effectiveness of left atrial appendage closure (LAAC) with the Watchman device (Boston Scientific, Marlborough, MA) for stroke risk reduction in nonvalvular atrial fibrillation (AF). This analysis sought to assess the cost-effectiveness of LAAC relative to both warfarin and nonwarfarin oral anticoagulants (NOACs) using pooled, long-term data from the randomized PROTECT AF (Watchman Left Atrial Appendage System for Embolic Protection in Patients With Atrial Fibrillation) and PREVAIL (Prospective Randomized Evaluation of the Watchman LAA Closure Device in Patients With Atrial Fibrillation Versus Long-Term Warfarin) trials. Methods and Results A Markov model was constructed from a US payer perspective with a lifetime (20-year) horizon. LAAC clinical event rates and stroke outcomes were from pooled PROTECT AF and PREVAIL trial 5-year data. Warfarin and NOAC inputs were derived from published meta-analyses. The model was populated with a cohort of 10 000 patients, aged 70 years, at moderate stroke and bleeding risk. Sensitivity analyses were performed. LAAC was cost-effective relative to warfarin by year 7 ($48 674/quality-adjusted life-year) and dominant (more effective and less costly) by year 10. LAAC became cost-effective and dominant compared with NOACs by year 5. Over a lifetime, LAAC provided 0.60 more quality-adjusted life-years than warfarin and 0.29 more than NOACs. In sensitivity analyses, LAAC was cost-effective relative to warfarin and NOACs in 98% and 95% of simulations, respectively. Conclusions Using pooled, 5-year PROTECT AF and PREVAIL trial data, LAAC proved to be not only cost-effective, but cost saving relative to warfarin and NOACs. LAAC with the Watchman device is an economically viable stroke risk reduction strategy for patients with AF seeking an alternative to lifelong anticoagulation.

Topics: Aged; Anticoagulants; Atrial Appendage; Atrial Fibrillation; Cardiac Surgical Procedures; Cost-Benefit Analysis; Factor Xa Inhibitors; Female; Humans; Male; Markov Chains; Postoperative Complications; Quality of Life; Quality-Adjusted Life Years; Severity of Illness Index; Stroke; Warfarin

The perioperative management of anticoagulation with the use of subcutaneous implantable cardioverter-defibrillator (S-ICD) implantation is still evolving.. The purpose of this study was to assess whether it is safe to perform S-ICD implantation with uninterrupted warfarin.. This is a multi-center retrospective review of patients undergoing S-ICD implantation between October 1, 2012 and June 30, 2017. Forty-eight patients underwent successful S-ICD implantation during the study period. The most common indication for implantation was primary prevention of sudden cardiac death. In 23 (47.9%) patients, warfarin was continued without any interruption. In 25 (52.1%) patients, warfarin was interrupted prior to implantation. The incidence of clinically significant lateral pocket hematoma was compared in the two groups.. The mean international normalized ratio was 2.0 ± 0.4 in the uninterrupted group and 1.4 ± 0.4 for the interrupted group. A total of seven patients developed a hematoma at the lateral pocket. No patient developed a hematoma at the parasternal pockets. Six patients in the uninterrupted group (26.1%) and one patient in the interrupted group (0.04%) developed a significant lateral pocket hematoma (P = .04). The concomitant use of dual antiplatelet therapy did not increase the risk of hematoma. There was no significant difference between HASBLED and CHA. The uninterrupted use of warfarin in the perioperative period of S-ICD implantation is associated with an increased risk of lateral pocket hematoma.

Topics: Adult; Aged; Anticoagulants; Defibrillators, Implantable; Female; Hematoma; Humans; Male; Middle Aged; Postoperative Complications; Retrospective Studies; Risk Assessment; Warfarin

Topics: Anticoagulants; Catheter Ablation; Diagnosis, Differential; Female; Heart Ventricles; Humans; Middle Aged; Postoperative Complications; Tachycardia, Ventricular; Thrombosis; Warfarin

The aims of this study were to compare the efficacy of two agents, aspirin and warfarin, for the prevention of venous thromboembolism (VTE) after simultaneous bilateral total knee arthroplasty (SBTKA), and to elucidate the risk of VTE conferred by this procedure compared with unilateral TKA (UTKA).. A retrospective, multi-institutional study was conducted on 18 951 patients, 3685 who underwent SBTKA and 15 266 who underwent UTKA, using aspirin or warfarin as VTE prophylaxis. Each patient was assigned an individualised baseline VTE risk score based on a system using the Nationwide Inpatient Sample. Symptomatic VTE, including pulmonary embolism (PE) and deep vein thrombosis (DVT), were identified in the first 90 days post-operatively. Statistical analyses were performed with logistic regression accounting for baseline VTE risk.. The adjusted incidence of PE following SBTKA was 1.0% (95% confidence interval (CI) 0.86 to 1.2) with aspirin and 2.2% (95% CI 2.0 to 2.4) with warfarin. Similarly, the adjusted incidence of VTE following SBTKA was 1.6% (95% CI 1.1 to 2.3) with aspirin and 2.5% (95% CI 1.9 to 3.3) with warfarin. The risk of PE and VTE were reduced by 66% (odds ratio (OR) 0.44, 95% CI 0.25 to 0.78) and 38% (OR 0.62, 95% CI 0.38 to 1.0), respectively, using aspirin. In addition, the risk of PE was 204% higher for patients undergoing SBTKA relative to those undergoing UTKA. For each ten-point increase in baseline VTE risk, the risk of PE increased by 25.5% for patients undergoing SBTKA compared with 10.5% for those undergoing UTKA. Patients with a history of myocardial infarction or peripheral vascular disease had the greatest increase in risk from undergoing SBTKA instead of UTKA.. Aspirin is more effective than warfarin for the prevention of VTE following SBTKA, and serves as the more appropriate agent for VTE prophylaxis for patients in all risk categories. Furthermore, patients undergoing SBTKA are at a substantially increased risk of VTE, even more so for those with significant underlying risk factors. Patients should be informed about the risks associated with undergoing SBTKA. Cite this article:

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Arthroplasty, Replacement, Knee; Aspirin; Dose-Response Relationship, Drug; Drug Administration Schedule; Female; Humans; Incidence; Logistic Models; Male; Middle Aged; Platelet Aggregation Inhibitors; Postoperative Complications; Pulmonary Embolism; Retrospective Studies; Risk Factors; Venous Thromboembolism; Venous Thrombosis; Warfarin

Antiphospholipid syndrome (APS) is a cause of chronic thromboembolic pulmonary hypertension (CTEPH) and it is associated with an increased risk of postoperative neurological complications. We experienced a case of reversible parkinsonism after pulmonary endarterectomy (PEA) and subsequent multiple cerebral infarctions under standard anticoagulation therapy in a patient with CTEPH associated with APS. Strict management using a combination of antiplatelet and anticoagulation therapy should be considered in patients with a high titer of triple antiphospholipid antibodies in the perioperative period. We should be aware of the high risk of postoperative neurologic manifestations in patients with APS.

Topics: Adult; Anticoagulants; Antiphospholipid Syndrome; Cerebral Infarction; Chronic Disease; Endarterectomy; Heparin; Humans; Hypertension, Pulmonary; Male; Parkinsonian Disorders; Postoperative Complications; Pyridines; Thiazoles; Treatment Outcome; Warfarin

Venous thromboembolism chemoprophylaxis with warfarin is common after total joint arthroplasty. Early response to warfarin initiation has been theorized to engender a transient increase in the risk of venous thromboembolism. We hypothesized that a rapid rise in the international normalized ratio is a risk factor for venous thromboembolism after total joint arthroplasty.. This study was a retrospective analysis of Medicare patients undergoing elective total joint arthroplasty who were given nomogram-dosed warfarin for venous thromboembolism prophylaxis. Logistic regression was used to assess the relationship between the postoperative rate of change in the international normalized ratio and the occurrence of symptomatic venous thromboembolism within 30 days postoperatively.. The study included 948 patients (715 total knee arthroplasty, 233 total hip arthroplasty), of whom 4.4% experienced symptomatic venous thromboembolism within 30 days postoperatively. The change in the international normalized ratio from postoperative day 1 to postoperative day 2 was significantly greater in the symptomatic venous thromboembolism group compared with the group that did not have venous thromboembolism (increase of 0.70 versus 0.46; P = 0.008). Regression analysis showed that a higher rate of change in the international normalized ratio was associated with increased risk of symptomatic venous thromboembolism (odds ratio, 2.59 per unit of change in the international normalized ratio; 95% confidence interval, 1.51-4.38; P = 0.001).. A rapid rise in the international normalized ratio after warfarin initiation in total joint arthroplasty patients is associated with increased risk of symptomatic venous thromboembolism. This novel finding identifies a population at risk for this complication. Further study of the early effects of warfarin therapy is warranted.. Level III.

Topics: Aged; Aged, 80 and over; Anticoagulants; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Blood Coagulation; Female; Humans; International Normalized Ratio; Male; Postoperative Complications; Retrospective Studies; Risk Factors; Venous Thromboembolism; Warfarin

In patients with left ventricular assist device support and aspirin allergy, the choice of effective antiplatelet strategy remains a challenge. We compared the antithrombotic effect of clopidogrel vs ticagrelor in an LVAD patient with aspirin allergy by using a modified protocol of the thrombin generation test, accounting selectively for the platelet contribution on thrombin generation. Our results demonstrate enhanced antithrombotic efficacy offered by ticagrelor. Consistent with experimental results, the patient has passed more than 300 days without thromboembolic complications. This study provides additional mechanistic rationale supporting clinical evidence and opens the perspective to identify individual poor responsiveness to drugs by specifically evaluating drug-mediated platelet function.

Topics: Aspirin; Clopidogrel; Drug Hypersensitivity; Drug Therapy, Combination; Heart Failure; Heart-Assist Devices; Humans; Male; Middle Aged; Platelet Aggregation Inhibitors; Postoperative Complications; Thrombosis; Ticlopidine; Warfarin

The purpose of this study was to evaluate whether anticoagulation (warfarin or direct oral inhibitors) affected the success of endovenous treatment.. Patients taking anticoagulation (warfarin or direct oral inhibitors) undergoing endovenous treatment in the form of endovenous laser ablation (EVLA) were matched against controls for sex, age, leg, and vein. Data were collected prospectively between January 2012 and March 2017. The primary endpoint was failure of treatment at 6-week postoperative duplex scan. The rates of major bleeding, hematoma, endothermal heat-induced thrombosis, venous thromboembolism, or pulmonary embolism were also compared between groups.. Two hundred eighty-four limbs underwent EVLA during the study period. Of this, 23/284 (8.1%) procedures were done in patients on anticoagulation. 21/23 (91.3%) limbs had venous occlusion at follow-up compared with 23/23 (100%) of controls ( P = .49). The patient who failed treatment in the anticoagulation group had undergone small saphenous vein (SSV) ablation. There was no difference in the complication rates between groups.. This study demonstrates that anticoagulation does not affect success rates of EVLA though there was higher recanalization rate in patients undergoing SSV ablation. Anticoagulation can be continued safely in patients undergoing this procedure.

Topics: Administration, Oral; Adult; Aged; Aged, 80 and over; Anticoagulants; Blood Coagulation; Endovascular Procedures; Factor Xa Inhibitors; Female; Humans; Laser Therapy; Male; Middle Aged; Postoperative Complications; Pyrazoles; Pyridones; Retrospective Studies; Risk Factors; Rivaroxaban; Saphenous Vein; Time Factors; Treatment Outcome; Venous Insufficiency; Warfarin

The safety of perioperative anticoagulation (AC) and antiplatelet (AP) therapy with subcutaneous implantable cardioverter-defibrillator (S-ICD) implantation is unknown. The purpose of this study was to identify the risk factors associated with hematoma complicating S-ICD implantation.. Records were retrospectively reviewed from 200 consecutive patients undergoing S-ICD implantation at two academic medical centers. A hematoma was defined as a device site blood accumulation requiring surgical evacuation, extended hospital stay, or transfusion.. Among 200 patients undergoing S-ICD implantation (age 49 ± 17 years, 67% men), 10 patients (5%) had a hematoma, which required evacuation in six patients (3%). Warfarin was bridged or uninterrupted in 12 and 13 patients, respectively (6% and 6.5%). Four of 12 patients with warfarin and bridging AC (33%) and two of 13 patients with uninterrupted warfarin (15%) developed a hematoma. Neither of the two patients with uninterrupted DOAC had a hematoma. No patients on interrupted AC without bridging (n = 26, 13 with warfarin, 13 with DOAC) developed a hematoma. A hematoma was also more likely with the use of clopidogrel (n = 4/10 vs 10/190, 40% vs 5.3%, P < 0.0001) in combination with aspirin in 12/14 patients. Any bridging AC (odds ratio [OR] 10.3, 1.8-60.8, P = 0.01), clopidogrel (OR 10.0, 1.7-57.7, P = 0.01), and uninterrupted warfarin without bridging (OR 11.1, 1.7-74.3, P = 0.013) were independently associated with hematoma formation.. AC and/or AP therapy with clopidogrel appears to increase the risk for hematoma following S-ICD implantation. Interruption of AC without bridging should be considered when it is an acceptable risk to hold AC.

Topics: Anticoagulants; Aspirin; Clopidogrel; Defibrillators, Implantable; Female; Hematoma; Humans; Male; Middle Aged; Platelet Aggregation Inhibitors; Postoperative Complications; Prosthesis Implantation; Retrospective Studies; Risk Factors; Warfarin

To assess association between 30 day readmission rate and treatment received after total hip and knee arthroplasty (THA/TKA) discharge (rivaroxaban vs. warfarin or non-anticoagulant). To subsequently model impact of increasing rivaroxaban use on the Hospital Readmission Reduction Program (HRRP) penalty, which was imposed on hospitals with excess 30 day readmissions after hospitalizations for selected conditions, including THA/TKA.. The US Truven Health MarketScan Medicare Supplemental database from 1 July 2010 to 30 April 2015 was used. A retrospective claims analysis was conducted to assess the risk of all-cause 30 day readmission among patients receiving either rivaroxaban or warfarin, or no anticoagulation following THA/TKA discharge. Simulations were performed to estimate the impact of post-discharge treatment on the HRRP penalty.. The risk-adjusted all-cause 30 day readmission rates were 1.21% (95% confidence interval [95% CI]: 0.94%-1.49%), 1.41% (95% CI: 1.19%-1.58%) and 1.95% (95% CI: 1.81%-2.11%) for rivaroxaban, warfarin and non-anticoagulant cohorts, respectively. Using these rates, simulations illustrated that when switching patients from warfarin or non-anticoagulant to rivaroxaban, annual penalty per hospital would be reduced up to 67% or 88%, respectively.. Rivaroxaban treatment post-THA/TKA discharge reduced the risk of 30 day readmission compared to non-anticoagulants. Simulations illustrated that increasing rivaroxaban use could decrease the HRRP penalty.

Topics: Aged; Anticoagulants; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Female; Humans; Insurance Claim Review; Male; Medicare; Patient Discharge; Patient Readmission; Postoperative Complications; Retrospective Studies; Rivaroxaban; United States; Warfarin

Warfarin has been used as prophylaxis against venous thromboembolism (VTE) after total joint arthroplasty (TJA) for over 60 years. With trends of shorter hospital stays for TJA patients, it is important to examine how many patients achieve therapeutic international normalized ratio (INR) at time of discharge. We aimed at elucidating the proportion of patients discharged at therapeutic INR and whether this is affected by inpatient specialty anticoagulation management service (AMS) involvement.. We conducted a retrospective review of 2927 primary TJA patients who received warfarin as postoperative VTE chemoprophylaxis from 2011 to 2016. An electronic chart query determined AMS input, length of stay (LOS), INR at discharge, and in-hospital complications. INR results were categorized as subtherapeutic (INR < 2.0), therapeutic (2.0 ≤ INR < 3.0), and supratherapeutic (INR ≥ 3.0). Descriptive statistics, chi-square, and t-tests were performed for analysis.. At discharge, 93.9% of patients had subtherapeutic INR. Average INR was 1.41 with average LOS of 2.53 days. Factors associated with being subtherapeutic included male gender, shorter LOS, fewer comorbidities, reduced in-hospital complications, and higher body mass index. AMS supervised postoperative warfarin dosing in 64.9% of patients. Patients managed by AMS were less likely to be subtherapeutic at discharge compared to those without AMS input; however, the absolute difference in INR may not be clinically significant. There were 19 VTEs, of which 13 had prolonged hospitalization to achieve therapeutic INR.. The majority of patients are discharged at subtherapeutic INR levels despite management by AMS. Patients may not be adequately anticoagulated with warfarin at time of discharge, raising significant patient safety concerns as well as medicolegal implications.

Topics: Aged; Anticoagulants; Arthroplasty; Arthroplasty, Replacement; Comorbidity; Female; Hospitalization; Humans; Inpatients; International Normalized Ratio; Length of Stay; Male; Middle Aged; Patient Discharge; Postoperative Complications; Retrospective Studies; Thrombolytic Therapy; Treatment Outcome; Venous Thromboembolism; Warfarin

Patients with a mechanical prosthetic heart valve implantation need to be treated with a vitamin K antagonist (VKA) due to a substantially high risk of thromboembolism. In this study we report data on patients with mechanical heart valves (MV), with the aim of evaluating the thromboembolic risk in relation to the type and site of implantation, quality of anticoagulation and risk factors associated with thromboembolism.. Observational retrospective multicenter study among Centers affiliated to the Italian Federation of Anticoagulation Clinics (FCSA) on patients with MV implanted after 1990 and followed for the management of anticoagulation.. We analyzed 2357 patients with mechanical heart valves (55.2% males), followed for 24,081 years. During the follow-up, 164 thromboembolic events (0.67/100 pt-yrs) and 243 major bleedings (1.0/100 pt-yrs) occurred. The median Time in Therapeutic Range (TTR), calculated in all intended INR classes, was 60% (IQR 47-74%). The rates of thrombotic events were significantly higher in patients intended to stay at therapeutic ranges >INR 2.0-3.0. The presence of atrial fibrillation, history of thromboembolism and of mitral prosthesis were independently associated with thromboembolism. However, a bad quality of anticoagulation (TTR <47%, 25°percentile of our population) was not correlated with thromboembolism.. A low rate of bleeding and thromboembolic events in patients with mechanical heart valves were found, despite the sub-optimal anticoagulation control. The thromboembolic risk was not associated with the low TTR.

Topics: Aged; Anticoagulants; Blood Coagulation; Drug Monitoring; Female; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Hemorrhage; Humans; International Normalized Ratio; Italy; Male; Middle Aged; Outcome Assessment, Health Care; Platelet Aggregation Inhibitors; Postoperative Complications; Retrospective Studies; Risk Factors; Thromboembolism; Warfarin

The aim of this study was to perform a population-level analysis on the effect of different types of anticoagulation on postoperative stiffness after total knee replacement, requiring manipulation under anesthesia. We hypothesized that patients receiving warfarin would have a higher rate of manipulation under anesthesia compared with patients receiving low-molecular-weight heparin. We also hypothesized that aspirin, direct factor Xa inhibitors, and fondaparinux would have no effect on the rate of manipulation under anesthesia.. Using the PearlDiver patient database, we analyzed 32,320 patients who underwent a primary unilateral total knee replacement from 2007 to 2015. Patients were included if they filled a prescription for anticoagulation medication within 2 days of their discharge and were excluded if they were taking a prescription anticoagulation medication (except for aspirin) in the 3 months before total knee replacement. The primary outcome was manipulation under anesthesia performed within 6 months after a primary total knee replacement.. The most commonly prescribed postoperative anticoagulation was warfarin (38.0%), followed by low-molecular-weight heparin (33.8%). There were 1,178 patients (3.64%) who underwent manipulation under anesthesia within 6 months of total knee replacement. In multivariable analysis using low-molecular-weight heparin as a comparison group and accounting for age, sex, comorbidities, and length of stay, there was a significant increase in the risk of manipulation under anesthesia for patients who received warfarin (hazard ratio [HR], 1.17 [95% confidence interval (CI), 1.01 to 1.36]; p = 0.032), direct factor Xa inhibitors (HR, 1.42 [95% CI, 1.20 to 1.66]; p < 0.001), or fondaparinux (HR, 1.33 [95% CI, 1.01 to 1.72]; p = 0.038). Although patients who received aspirin had the same risk estimate as patients who received warfarin, there was not a significantly increased risk of manipulation under anesthesia in patients who received aspirin compared with low-molecular-weight heparin (HR, 1.17 [95% CI, 0.72 to 1.80]; p = 0.493).. We found an increased rate of manipulation under anesthesia after total knee replacement in patients who received oral anticoagulants including warfarin, direct factor Xa inhibitors, and fondaparinux, in comparison with patients who received aspirin or low-molecular-weight heparin. We recommend that patients receiving oral anticoagulants after total knee replacement should be counseled about associated stiffness. Furthermore, surgeons should take these data into account when selecting thromboprophylaxis for patients after total knee replacement.. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Topics: Aged; Anticoagulants; Arthroplasty, Replacement, Knee; Aspirin; Female; Heparin, Low-Molecular-Weight; Humans; Male; Middle Aged; Multivariate Analysis; Postoperative Complications; Range of Motion, Articular; Retrospective Studies; Venous Thromboembolism; Warfarin

Topics: Age Factors; Anticoagulants; Aortic Valve; Bioprosthesis; Heart Valve Diseases; Heart Valve Prosthesis; Hemorrhage; Humans; Life Style; Patient Compliance; Postoperative Complications; Reoperation; Risk; Transcatheter Aortic Valve Replacement; Warfarin

Patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA) are at high risk of deep vein thrombosis (DVT) postoperatively, necessitating the use of prophylaxis medications. This investigation used a large claims database to evaluate trends in postoperative DVT prophylaxis and rates of DVT within 6 months after THA or TKA.. Truven Health MarketScan Commercial Claims and Encounters and Medicare Supplemental and Coordination of Benefits databases were reviewed from 2004 to 2013 for patients who underwent THA or TKA. Data were collected on patient age, sex, Charlson Comorbidity Index, and hypercoagulability diagnoses. Postoperative medication claims were reviewed for prescribed aspirin, warfarin, enoxaparin, fondaparinux, rivaroxaban, and dabigatran.. A total of 369,483 patients were included in the analysis, of which 239,949 patients had prescription medication claims. Warfarin was the most commonly prescribed anticoagulant. Patients with a hypercoagulable diagnosis had markedly more DVTs within 6 months after THA or TKA. More patients with a hypercoagulable diagnosis were treated with warfarin or lovenox than other types of anticoagulants. A multivariate regression analysis was performed, showing that patients prescribed aspirin, fondaparinux, and rivaroxaban were markedly less likely than those prescribed warfarin or enoxaparin to have a DVT within 6 months after THA or TKA.. After THA and TKA, warfarin is the most commonly prescribed prophylaxis. Patients with hypercoagulability diagnoses are at a higher risk of postoperative DVT. The likelihood of DVT within 6 months of THA and TKA was markedly higher in patients treated with warfarin and lovenox and markedly lower in those treated with aspirin, fondaparinux, and rivaroxaban.. Level III.

Topics: Aged; Anticoagulants; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Aspirin; Clinical Decision-Making; Dabigatran; Databases, Factual; Enoxaparin; Female; Fondaparinux; Humans; Male; Middle Aged; Postoperative Complications; Retrospective Studies; Rivaroxaban; Venous Thrombosis; Warfarin

Head and neck skin cancer surgery using a full thickness skin graft is a common procedure. Evidence concerning the effects of perioperative antithrombotic treatment on complications is limited. The aim of this study was to evaluate whether perioperative antithrombotic treatment is associated with risk of necrosis, bleeding or infection after full thickness skin graft surgery. Retrospective single-center cohort study with medical records review. Patients operated with a head and neck full thickness skin graft in 2010 and 2013-2015 had available data and were included. Any antithrombotic treatment was continued and all patients were routinely followed-up on days 7-10 after surgery. Data on demographics, concurrent disease, clinical characteristics, antithrombotic medications and postoperative necrosis, bleeding and infection were collected from electronic medical records. Associations with complications were examined using multivariate logistic regression adjusted for age, sex, reoperation, size of excision, site of surgery and concurrent disease. In total, 302 patients (53% women) were included. Antithrombotic treatment (

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Aspirin; Cohort Studies; Female; Fibrinolytic Agents; Head and Neck Neoplasms; Humans; Male; Middle Aged; Multivariate Analysis; Perioperative Care; Postoperative Complications; Retrospective Studies; Skin Neoplasms; Skin Transplantation; Warfarin; Young Adult

Warfarin is an anticoagulant indicated for patients who had undergone mechanical heart valve(s) replacement (MHVR). In these patients, time in therapeutic range (TTR) is important in predicting the bleeding and thrombotic risks.. This study aimed to describe the anticoagulation control of warfarin using TTR in patients with MHVR in a tertiary health care referral Center.. Data were collected retrospectively by reviewing clinical notes of outpatients who attended international normalized ratio (INR) clinics in November 2015. Patients who had MHVR and who took warfarin were included. The data collected were demographics, relevant laboratory investigations, and patients' prior medical history. TTR was calculated using Rosendaal and traditional methods.. A total of 103 patients with MHVR were recruited. The mean age was 51.72 ± 13.97 years and 46.6% were male. A total of 54.4% had mitral valve replacement (MVR), whereas 26.2% had aortic valve replacement (AVR). The mean TTR calculated using the Rosendaal method was 57.1%. There was no significant difference among patients with AVR, MVR, and both valves (AMVR) in terms of TTR (AVR vs. MVR vs. AMVR, 62.94 ± 23.08, 54.12 ± 21.62, 57.63 ± 17.47; p = 0.213). The average dose of warfarin for all groups was approximately 3 mg/day. Moreover, MVR, AVR, and AMVR patients who had TTR (Rosendaal method) ≤60% were 58.9%, 37.0%, and 45.0%, respectively. Only 4.8% had minor bleeding, whereas none had stroke in the period of TTR determination.. Despite a majority of patients having <60% TTR, there were low incidences of bleeding and stroke events in this center. There were no factors found to be associated with INR control in this study.

Topics: Anticoagulants; Drug Administration Schedule; Female; Follow-Up Studies; Heart Valve Prosthesis; Humans; Incidence; Malaysia; Male; Middle Aged; Outpatients; Postoperative Complications; Prognosis; Retrospective Studies; Thrombosis; Time Factors; Warfarin

Topics: Acute Disease; Anticoagulants; Aortic Aneurysm; Aortic Dissection; Aspirin; Blood Vessel Prosthesis Implantation; Coronary Angiography; Coronary Thrombosis; Heparin; Humans; Male; Middle Aged; Plastic Surgery Procedures; Platelet Aggregation Inhibitors; Postoperative Complications; Treatment Outcome; Warfarin

Thromboembolic complications occur frequently in Fontan patients with atrial arrhythmias and are a cause of significant morbidity and all-cause mortality. We report the case of an adult woman with direct atriopulmonary connection and atrial arrhythmia who developed a right atrial thrombus. She was switched to apixaban therapy because of echocardiographic evidence of thrombus progression despite combined therapy with warfarin and aspirin. After 1 year of treatment, there was evidence of complete thrombus resolution, in the absence of bleeding events. Our case shows that direct oral anticoagulants can be effective and safe for the treatment of thrombosis in adult patients with complex CHD.

Topics: Administration, Oral; Adult; Anticoagulants; Dose-Response Relationship, Drug; Echocardiography; Female; Fontan Procedure; Heart Defects, Congenital; Heart Diseases; Humans; Postoperative Complications; Thrombosis; Warfarin

Oral anticoagulant therapy is frequently and increasingly prescribed for patients at risk of arterial or venous thromboembolism (VTE). Although elective surgical or invasive procedures have necessitated temporary interruption of anticoagulants, managing these patients has been performed empirically and been poorly investigated. This study was designed to evaluate the adequacy of perioperative anticoagulation using enoxaparin. This was a retrospective, single-center study that evaluated the efficacy and safety of therapeutic-dose enoxaparin for bridging therapy in patients on long-term warfarin at Soonchunhyang University Hospital in Korea between August 2009 and July 2011. Warfarin was discontinued 5 days before surgery, and enoxaparin was administered twice daily by subcutaneous injection at a dose of 1 mg per kg from 3 days before the procedure to the last dose 24 hours before the procedure. Anticoagulation was restarted if proper hemostasis had been confirmed. There were 49 patients, of whom 25 (51%) were men, and the mean age was 63 years. Thirty-four (69%) received warfarin therapy for VTE, and 9 (18%) for atrial fibrillation. Twenty-nine patients (59%) underwent major surgery and 20 (41%) minor surgery. The mean postoperative duration of enoxaparin was 4 days. No patients had thromboembolic complications through 30 days after the procedure. The overall 30-day mortality rate was 0%. In conclusion, our findings demonstrate that bridging therapy with therapeutic-dose enoxaparin is feasible and associated with a low incidence of major bleeding and no thromboembolic complications. However, the optimal approach to managing patients perioperatively is uncertain and requires further evaluation.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Enoxaparin; Female; Heparin, Low-Molecular-Weight; Humans; Injections, Subcutaneous; International Normalized Ratio; Male; Middle Aged; Perioperative Care; Postoperative Complications; Retrospective Studies; Treatment Outcome; Venous Thromboembolism; Warfarin; Young Adult

There is considerable debate regarding the ideal agent for venous thromboembolism (VTE) prophylaxis after TKA. Numerous studies and meta-analyses have yet to provide a clear answer and often omit one or more of the commonly used agents such as aspirin, warfarin, enoxaparin, and factor Xa inhibitors.. Using a large database analysis, we asked: (1) What are the differences in VTE incidence in primary TKA after administration of aspirin, warfarin, enoxaparin, or factor Xa inhibitors? (2) What are the differences in bleeding risk among these four agents? (3) How has use of these agents changed with time?. We queried a combined Humana and Medicare database between 2007 and Quarter 1 of 2016, and identified all primary TKAs performed using ICD-9 and Current Procedural Terminology codes. All patients who had any form of antiplatelet or anticoagulation prescribed within 1 year before TKA were excluded from our study cohort. We then identified patients who had either aspirin, warfarin, enoxaparin, or factor Xa inhibitors prescribed within 2 weeks of primary TKA. Each cohort was matched by age and sex. Elixhauser comorbidities and Charlson Comorbidity Index for each group were calculated. We identified 1016 patients with aspirin, and age- and sex-matched 6096 patients with enoxaparin, 6096 patients with warfarin, and 5080 patients with factor Xa inhibitors. Using ICD-9 codes, with the understanding that patients at greater risk may have had more-attentive surveillance, the incidence of postoperative deep venous thrombosis (DVT), pulmonary embolism (PE), bleeding-related complications (bleeding requiring surgical intervention, hemorrhage, hematoma, hemarthrosis), postoperative anemia, and transfusion were identified at 2 weeks, 30 days, 6 weeks, and 90 days postoperatively. A four-way chi-squared test was used to determine statistical significance. Utilization was calculated using compound annual growth rate.. There was a difference in the incidence of DVT at 90 days (p < 0.01). Factor Xa inhibitors (2.9%) had the lowest incidence of DVT followed by aspirin (3.0%) and enoxaparin (3.5%), and warfarin (4.8%). There was a difference in the incidence of PE at 90 days (p < 0.01). Factor Xa inhibitors (0.9%) had the lowest incidence of PE followed by enoxaparin (1.1%), aspirin (1.2%), and warfarin (1.6%). There was a difference in the incidence of postoperative anemia at 90 days (p < 0.01). Aspirin (19%) had the lowest incidence of postoperative anemia followed by warfarin (22%), enoxaparin (23%), and factor Xa inhibitors (23%). There was a difference in the incidence of a blood transfusion at 90 days (p < 0.01). Aspirin (7%) had the lowest incidence of a blood transfusion followed by factor Xa inhibitors (9%), warfarin (12%), and enoxaparin (13%). There were no differences in bleeding-related complications (p = 0.81) between the groups. Aspirin use increased at a compound annual growth rate of 30%, enoxaparin at 3%, and factor Xa inhibitors at 43%, while warfarin use decreased at a compound annual growth rate of -3%.. Factor Xa inhibitors had the highest growth in utilization during our study period, followed by aspirin, when compared with enoxaparin and warfarin. When selected for the right patient, factor Xa inhibitors provided improved VTE prophylaxis compared with enoxaparin and warfarin, with a lower rate of blood transfusion. Aspirin provided comparable VTE prophylaxis compared with factor Xa inhibitors with improved VTE prophylaxis compared with enoxaparin and warfarin with the lowest risk of bleeding.. Level III, therapeutic study.

Topics: Aged; Aged, 80 and over; Anticoagulants; Arthroplasty, Replacement, Knee; Aspirin; Cohort Studies; Databases, Factual; Enoxaparin; Factor Xa Inhibitors; Female; Humans; Incidence; Male; Middle Aged; Postoperative Complications; Postoperative Hemorrhage; Pulmonary Embolism; Treatment Outcome; Venous Thromboembolism; Venous Thrombosis; Warfarin

The aim of this study was to evaluate the impact of perioperative anticoagulation on artificial urinary sphincter (AUS) device outcomes.. Following institutional review board approval, patients undergoing AUS surgery from 1983 to 2014 were evaluated to assess device survival in patients with warfarin use compared to individuals without warfarin use. Hazard regression analysis was used to determine the association between warfarin use and device outcomes.. From 1983 to 2014, there were 2125 AUS procedures at Mayo Clinic. Of these, information regarding anticoagulation use was available in 651, including 43 patients who were on warfarin and 608 who were not. On univariate analysis, the use of warfarin was associated with an increased rate of infection/erosion [hazard ratio (HR) 2.58, p = 0.02]. However, there was no increased risk of overall AUS failure (HR 1.66, p = 0.06), malfunction of AUS (HR 1.19, p = 0.74) or urethral atrophy (HR 1.09, p = 0.88). Kaplan-Meier assessment of device survival for individuals not on warfarin versus individuals on warfarin at 1 and 5 years was 91% versus 83% and 72% versus 57%, respectively (p = 0.058). On multivariate analysis, warfarin was not associated with an increased risk of infection/erosion (HR 1.37, p = 0.51).. Perioperative management of AUS patients on warfarin requires expert care; however, long-term AUS device survival is not significantly affected by warfarin use. Recognition of these outcomes is important for improving preoperative patient counseling and surgical patient selection.

Topics: Aged; Anticoagulants; Atrophy; Follow-Up Studies; Humans; Infections; Kaplan-Meier Estimate; Male; Perioperative Care; Postoperative Complications; Prosthesis Failure; Prosthesis Implantation; Reoperation; Risk Factors; Urethra; Urinary Incontinence, Stress; Urinary Sphincter, Artificial; Warfarin

Topics: Anticoagulants; Antithrombin III; Arthroplasty, Replacement, Hip; Diagnosis, Differential; Female; Femoral Neck Fractures; Heparin; Humans; Middle Aged; Popliteal Vein; Postoperative Complications; Protein C; Protein S; Thrombophilia; Treatment Outcome; Ultrasonography, Doppler, Duplex; Venous Thromboembolism; Warfarin

Patients with antiphospholipid syndrome (APS) are at high-risk for thrombotic and bleeding complications during cardiopulmonary bypass. We report an APS patient who successfully underwent aortic valve replacement while heparin concentrations were monitored using a patient-specific titration curve using viscoelastic coagulation testing.

Topics: Adult; Anticoagulants; Antiphospholipid Syndrome; Aortic Valve; Aortic Valve Insufficiency; Blood Coagulation Tests; Cardiopulmonary Bypass; Female; Heart Valve Prosthesis Implantation; Heparin; Humans; International Normalized Ratio; Monitoring, Physiologic; Perioperative Care; Postoperative Complications; Postoperative Hemorrhage; Prothrombin Time; Risk; Severity of Illness Index; Thrombosis; Warfarin

Injection medialization laryngoplasty is a procedure that has many advantages in treating vocal fold paralysis; however, undesired complications can occur. We experienced a case of a pulmonary embolism, suspected in a patient who had undergone an injection laryngoplasty with calcium hydroxylapatite (CaHA). The patient suffered dyspnea after undergoing the injection laryngoplasty. Chest embolism computed tomography (CT) scan revealed a new lesion of enhancing materials at the pulmonary vasculature in the right upper lobe. The CaHA embolism was suspected, and the patient was treated with warfarin for 12 months. The patient's symptom of dyspnea nearly disappeared and a follow up chest embolism CT scan revealed no signs of the previous lesion. Thus, we would like to report this rare case along with a review of the literature.

Topics: Biocompatible Materials; Durapatite; Female; Humans; Injections, Intralesional; Laryngoplasty; Middle Aged; Postoperative Complications; Pulmonary Embolism; Tomography, X-Ray Computed; Treatment Outcome; Vocal Cord Paralysis; Warfarin

The purpose of this study was to evaluate the effectiveness of Factor Xa inhibitors (XaI) for thromboprophylaxis following hip fracture surgery in a large cohort of patients, and compare XaI against warfarin and enoxaparin.. Patients undergoing hip fracture surgery from 2007 to 2015 were identified in a large claims database. Patients prescribed warfarin, XaI, or enoxaparin within 2 weeks of surgery were identified and grouped into cohorts. Medical comorbidities and complication incidences, including deep venous thrombosis (DVT), pulmonary embolism (PE), and bleeding complications were calculated. Chi-square analysis was performed and adjusted residuals calculated to determine significant differences.. DVT rates were significantly different between groups at thirty days only (5.03% warfarin, 2.91% XaI, 3.48% enoxaparin, p=0.047). PE rates were significantly different at all time points; enoxaparin had the lowest rates. There were no differences in the rates of other complications.. XaI are an option for thromboprophylaxis in hip fracture patients, although their possible decreased effectiveness against PE compared to enoxaparin should be considered.. This study compares the effectiveness of Factor Xa inhibitors to warfarin and enoxaparin for hip fracture patients, using a large national database. In this study, Factor Xa inhibitors had similar effectiveness for DVT prophylaxis compared to these agents.

Topics: Aged; Aged, 80 and over; Anticoagulants; Arthroplasty, Replacement, Hip; Databases, Factual; Enoxaparin; Factor Xa Inhibitors; Female; Hip Fractures; Humans; Incidence; Male; Middle Aged; Postoperative Complications; Pulmonary Embolism; Secondary Prevention; Treatment Outcome; Venous Thrombosis; Warfarin

Few data exist to evaluate the safety and efficacy of direct oral anticoagulants (DOACs) in patients with atrial fibrillation (AF) undergoing cryoballoon ablation (CB-A). This study is aimed to clarify the usefulness of DOACs in patients undergoing CB-A.. The patients (average age; 65.8±11.9 years old, male 69%) were stratified into one of five subsets based on the type of anticoagulation (warfarin, apixaban, dabigatran, rivaroxaban, or edoxaban), and underwent CB-A. A brain MRI was performed in all patients the day after the CB-A for AF. A total of 257 (19 on warfarin, 30 on apixaban, 66 on dabigatran, 81 on rivaroxaban, and 61 on edoxaban) patients met the inclusion criteria.. The incidence of silent cerebral ischemic lesion was 1 (11.1%) patients on warfarin, 5 (33.3%) on apixaban, 8 (27.6%) on dabigatran, 10 (21.3%) on rivaroxaban, and 10 (29.4%) on edoxaban (p=0.17). Major ischemic events occurred in one patient (1.6%) on edoxaban and one (5.3%) on warfarin. Minor bleeding complications occurred in 1 patient (5.3%) on warfarin, 2 (6.7%) on apixaban, 1 (1.2%) on rivaroxaban, 5 (7.6%) on dabigatran, and 2 (3.3%) on edoxaban (p=0.24). Of note, major bleeding complications occurred in 2 patients (3.3%) on apixaban, 1 (1.2%) on rivaroxaban, 1 (1.5%) on dabigatran, 1 (1.6%) on edoxaban, and 2 (10.5%) on warfarin (p<0.05).. Warfarin use significantly increased the risk of serious bleeding, in contrast, CB-A did not place the patients at an increased risk of complications under a DOAC treatment. There were no significant differences regarding preventing embolic events among the DOAC drugs.

Topics: Aged; Anticoagulants; Atrial Fibrillation; Brain; Brain Ischemia; Cryosurgery; Dabigatran; Embolism; Female; Hemorrhage; Humans; Incidence; Magnetic Resonance Imaging; Male; Middle Aged; Postoperative Complications; Pyrazoles; Pyridines; Pyridones; Rivaroxaban; Thiazoles; Warfarin

Haemostatic agents including thrombin-based haemostatic matrix are widely used in patients undergoing cardiac, vascular and spinal surgery. These agents promote local haemostasis through activation of the clotting cascade. To our knowledge, this case series is the first report of pulmonary embolization associated with FloSeal following head and neck oncology resection and free flap reconstruction.. We present five patients who were diagnosed with symptomatic pulmonary embolism after oncologic head and neck free flap reconstructions in 2014 and 2015.. There were five patients consisting of three males and two females. The mean age was 67 years, ranging from 60 to 74 years. Pulmonary embolism occurred between 3 and 30 days with a mean of 12 days. Four out of the five reported cases showed involvement of more than one lobe, and two cases had bilateral pulmonary involvement. All but one patient underwent infratemporal fossa dissections as part of the cancer resection. Ten millilitres of FloSeal was applied to the pterygoid plexi in the four patients to achieve haemostasis. All patients received heparin infusion followed by warfarin therapy for at least 6 months with no mortality or complications relating to pulmonary embolism to date.. Although inconclusive due to study design and small numbers, this series raises the possibility that there may be an association between the use of haemostatic matrix in head and neck oncologic reconstructions and pulmonary embolism. Haemostatic matrix must be used in caution when there is a direct contact with venous endolumens such as the pterygoid plexus and soleus.

Topics: Aged; Anticoagulants; Female; Free Tissue Flaps; Head and Neck Neoplasms; Hemostatics; Heparin; Humans; Infusions, Intravenous; Male; Middle Aged; Plastic Surgery Procedures; Postoperative Complications; Pulmonary Embolism; Retrospective Studies; Risk Factors; Thrombin; Warfarin

The purpose of this study was to evaluate the risks of bleeding, deep venous thrombosis (DVT), endovenous heat induced thrombosis (EHIT) and failure of ablation on patients who undergo ablation while on oral anticoagulation.. We compared 378 (3.4%) out of 11252 patients (group A) who had undergone 724 endovenous ablation of the saphenous veins from January 1, 2011 to September 30, 2014 while on oral anticoagulation to a randomly selected 375 patients (group B) who underwent 641endovenous ablation in the same time period but were not on anticoagulation. The demographic data, history of DVT, the Clinical, Etiologic, Anatomic, Pathologic (CEAP) classification and the VCSS (Venous Clinical Severity Score) scores were analyzed. The indications for anticoagulation, the anticoagulants used were recorded. The primary endpoints were bleeding, development of DVT or EHIT, and failure of ablation.. Patients in group A were older, had more men, more history of DVT and PE, had higher CEAP and VCSS scores compared to group B. The type of anticoagulation used was warfarin in 77.2% direct oral inhibitors (DOIs) in 22.8%. The rate of failure of ablation at 3 days was 39 (5.6%) for Group A and 3 (0.5%) for Group B (P<0.0001) and at one month it was 46 (10.1%) vs. 27 (6.7%) (P=0.086). The number of EHIT cases in group A at 3 days was 2 (0.3%), compared to 6 (0.9%) in group B (P=0.016) and at 1 month it was 0 compared to 4 (1.0%) (P=0.0483). The DVT, SVT, hematoma and wound infection rates were similar in the two groups.. Ablation of the saphenous veins in patients who are on oral anticoagulation is safe and does not increase the risk of bleeding or hematoma, but it may slightly lower the incidence of EHIT and increase the incidence of failure of ablation.

Topics: Ablation Techniques; Adult; Aged; Aged, 80 and over; Anticoagulants; Female; Hemorrhage; Humans; Male; Middle Aged; Postoperative Complications; Retrospective Studies; Risk Factors; Saphenous Vein; Treatment Outcome; Ultrasonography, Doppler, Duplex; United States; Varicose Veins; Venous Insufficiency; Venous Thrombosis; Warfarin; Young Adult

To evaluate the occurrence of bleeding and venous thromboembolic (VTE) events in patients receiving rivaroxaban, warfarin, or warfarin with the addition of enoxaparin during the immediate postoperative period following major orthopedic surgery.. Patients older than 18 years who received at least one dose of rivaroxaban the morning following surgery, adjusted dose warfarin, or adjusted dose warfarin with the addition of enoxaparin for VTE prophylaxis after major orthopedic surgery between October 1, 2011, and February 28, 2015, were included. Data collected from the electronic health record included patient demographics, renal function, inpatient aspirin, P2Y12 inhibitor and/or nonsteroidal antiinflammatory drug (NSAID) use, type of surgery, postoperative analgesia, and presence of VTE risk factors. Adjusted incidence rate ratio for bleeding or VTE events was estimated using modified Poisson regression with robust standard errors. Covariates included in a multivariable model were age, sex, aspirin use, P2Y12 inhibitor use, NSAID use, obesity, VTE risk factors, and creatinine clearance.. There were 3246 patients who met study inclusion criteria. Overall, incidences of bleeding and VTE events were rare. Bleeding event incidence ranged from 0.4% in the warfarin and warfarin with the addition of enoxaparin groups to 1.2% in the rivaroxaban group (p=0.088). There were two major bleeding events and 18 minor bleeding events (including hemorrhagic wound complications). VTE event incidence ranged from 0.2% in the warfarin with the addition of enoxaparin group to 0.6% in the rivaroxaban group (p=0.230). Two deep vein thromboses and 10 pulmonary emboli occurred. With use of the multivariable model, the warfarin and warfarin with the addition of enoxaparin groups had significantly lower incidence rates of bleeding compared with rivaroxaban (incidence rate ratio [IRR] = 0.218, p=0.0120, and IRR = 0.242, p=0.021, respectively).. We observed a small, yet significant, increase in rivaroxaban-related bleeding in the immediate postoperative period relative to warfarin or warfarin with the addition of enoxaparin for the prevention of VTE after major orthopedic surgery.

Topics: Aged; Anticoagulants; Dose-Response Relationship, Drug; Drug Therapy, Combination; Enoxaparin; Factor Xa Inhibitors; Female; Hemorrhage; Hospitals, Community; Humans; Male; Middle Aged; Orthopedic Procedures; Postoperative Complications; Retrospective Studies; Rivaroxaban; Venous Thromboembolism; Warfarin

This study aims to determine whether warfarin therapy influences the occurrence of endoleaks or aneurysm sac enlargement after endovascular aortic repair (EVAR).. A total of 367 patients who underwent EVAR for abdominal aortic aneurysm between 2007 and 2013 were recruited for this study. Satisfactory follow-up data including completed computed tomography scan follow-up for more than 2 years were available for 209 patients, and the mean follow-up time was 37 ± 12 months. Twenty-nine (16%) patients were on warfarin therapy (warfarin group), whereas 180 (84%) patients were not on warfarin therapy (control group).. Two- and four-year freedom rates for persistent type II endoleaks were significantly lower in patients of the warfarin group compared with the control group (85 and 49% vs 93 and 91%, respectively; P = 0.0001). Similarly, 2- and 4-year freedom rates for sac enlargement (>5 mm) were significantly lower in patients of the warfarin group compared with the control group (83 and 61% vs 92 and 82%, respectively; P = 0.0036). Using Cox regression analysis, the warfarin therapy was identified to be an independent positive predictor of sac enlargement after EVAR [hazard ratio (HR): 2.4; 95% confidence interval (CI): 1.08-5.40; P = 0.032], together with persistent type II endoleak. Warfarin therapy was also an independent predictor for persistent type II endoleak (HR: 3.7; 95% CI: 1.81-7.41; P < 0.0001) together with the number of patent lumbar arteries.. Results suggested that warfarin therapy was significantly associated with an increased risk for persistent II endoleak and sac enlargement after EVAR.

Topics: Aged; Aged, 80 and over; Anticoagulants; Aortic Aneurysm, Abdominal; Blood Vessel Prosthesis Implantation; Endoleak; Endovascular Procedures; Female; Humans; Male; Middle Aged; Postoperative Complications; Proportional Hazards Models; Retrospective Studies; Time Factors; Tomography, X-Ray Computed; Treatment Outcome; Warfarin

We describe a case of reversible thrombotic mitral valve stenosis following a valve-in-ring transcatheter mitral valve replacement. Life-long oral anticoagulation in patients who underwent transcatheter mitral valve replacement might be beneficial.

Topics: Aged; Anticoagulants; Aspirin; Bioprosthesis; Cardiac Catheterization; Clopidogrel; Female; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Mitral Valve; Mitral Valve Stenosis; Postoperative Complications; Thrombosis; Ticlopidine; Treatment Outcome; Warfarin

To describe surgical outcomes and perioperative complications in patients taking antiplatelet and anticoagulation medications while undergoing cochlear implantation.. Case series with chart review.. Two tertiary otologic referral center.. Forty-six adult patients (2005-2014) who underwent cochlear implantation while on perioperative antiplatelet and/or anticoagulation therapy without interruption. Outcomes included estimated intraoperative blood loss, perception of increased difficulty secondary to bleeding, and postoperative complications attributable to continuing anticoagulation or antiplatelet therapy.. The cases of 46 patients (mean age, 69.5 years; 30.2% female) were analyzed. Of these, 39 patients were taking aspirin, 10 warfarin, and 7 clopidogrel. Aside from 3 (6.5%) patients with postoperative bruising without hematoma and 1 patient (2.2%) who reported self-resolving oral cavity blood, no intraoperative or postoperative complications occurred in any patient that could be ascribed to antiplatelet or anticoagulant use.. These data demonstrate that the risk of perioperative complications from continued antiplatelet or anticoagulation therapy is low. For subjects who are at risk of major complications (eg, deep venous thrombosis, pulmonary embolism, myocardial infarction, cerebrovascular accident) from temporary medication cessation, continuing antiplatelet or anticoagulation therapy through the perioperative period is an appropriate strategy.

Topics: Aged; Anticoagulants; Aspirin; Blood Loss, Surgical; Clopidogrel; Cochlear Implantation; Female; Hemorrhage; Humans; Male; Platelet Aggregation Inhibitors; Postoperative Complications; Ticlopidine; Treatment Outcome; Warfarin

Compared with warfarin, novel oral anticoagulants (NOACs) are convenient to use, although they require a blanking period immediately before radiofrequency catheter ablation for atrial fibrillation (AF). We compared NOACs and uninterrupted warfarin in the peri-procedural period of AF ablation.. We compared 141 patients treated with peri-procedural NOACs (72% men; 58 ± 11 years old; 71% with paroxysmal AF) and 281 age-, sex-, AF type-, and history of stroke-matched patients treated with uninterrupted warfarin. NOACs were stopped 24 hours before the procedure and restarted on the same procedure day after hemostasis was achieved.. We found no difference in the CHA₂DS₂-VASc (p=0.376) and HAS-BLED scores (p=0.175) between the groups. The preprocedural anticoagulation duration was significantly shorter in the NOAC group (76.3 ± 110.7 days) than in the warfarin group (274.7 ± 582.7 days, p<0.001). The intra-procedural total heparin requirement was higher (p<0.001), although mean activated clotting time was shorter (350.0 ± 25.0 s vs. 367.4 ± 42.9 s, p<0.001), in the NOAC group than in the warfarin group. There was no significant difference in thromboembolic events (1.4% vs. 0%, p=0.111) or major bleeding (1.4% vs. 3.9%, p=0.235) between the NOAC and warfarin groups. Minor stroke occurred in two cases within 10 hours of the procedure (underlying CHA₂DS₂-VASc scores 0 and 1) in the NOAC group.. Pre-procedural anticoagulation duration was shorter and intra-procedural heparin requirement was higher with NOAC than with uninterrupted warfarin during AF ablation. Although the peri-procedural thromboembolism and bleeding incidences did not differ, minor stroke occurred in two cases in the NOAC group.

Topics: Aged; Anticoagulants; Atrial Fibrillation; Catheter Ablation; Female; Follow-Up Studies; Hemorrhage; Heparin; Humans; Incidence; Male; Middle Aged; Postoperative Complications; Stroke; Thromboembolism; Treatment Outcome; Warfarin

The optimal prophylaxis for prevention of venous thromboembolic events (VTEs) after revision total joint arthroplasty (TJA) remains unknown. The objective of this study was to evaluate whether aspirin, known to be effective for prevention of VTEs after primary arthroplasty, is also effective after revision TJA.. We studied 2997 consecutive patients who underwent revision TJA between 2005 and 2013 and were treated with intermittent pneumatic compression devices and either aspirin (534 patients) or warfarin (2463 patients) for VTE prophylaxis. Pertinent data including the incidence of symptomatic VTEs, bleeding events, infection, and mortality were retrieved from our prospectively collected database.. The incidence of symptomatic VTEs was significantly higher in the warfarin group at 1.75% (43 of 2463) compared with 0.56% (3 of 534) in the aspirin group (odds ratio: 3.2; 95% CI: 1.03-16.3; P = .03). There was a higher rate of bleeding events with administration of warfarin (1.5%) compared with aspirin (0.4%; P = .02; odds ratio: 4.1; 95% CI: 1.2-34.0). The rate of surgical site infection was similar between the aspirin group and the warfarin group (1.61% and 1.70%, respectively).. Administration of aspirin as prophylaxis against VTEs after revision arthroplasty may be a viable option as it appears to be more effective than warfarin in prevention of symptomatic VTEs and is associated with a lower rate of complications.

Topics: Aged; Anticoagulants; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Aspirin; Female; Hemorrhage; Humans; Incidence; Intermittent Pneumatic Compression Devices; Male; Middle Aged; Odds Ratio; Philadelphia; Platelet Aggregation Inhibitors; Postoperative Complications; Pulmonary Embolism; Reoperation; Retrospective Studies; Surgical Wound Infection; Venous Thromboembolism; Venous Thrombosis; Warfarin

Anticoagulation with warfarin following bioprosthetic mitral valve replacement (BMVR) is recommended by multiple practice guidelines. We assessed practice variability and patient characteristics associated with warfarin prescription following BMVR.. We analyzed 7,637 patients in the Society of Thoracic Surgeons Database (January 1, 2008 to June 30, 2011) who were discharged following isolated primary nonemergent BMVR. Patients requiring preoperative warfarin, those with preoperative atrial fibrillation, or those with a contraindication to warfarin were excluded. The association between patient, hospital, and surgeon characteristics and warfarin prescription were evaluated.. Fifty-eight percent of this cohort (median age, 66 years; female sex, 58.7%) was prescribed warfarin. Patients receiving warfarin were older (67 vs 65 years; P < .0001), were less likely to have had preoperative stroke (9.3% vs 12.1%; P < .001), CHF (51.4% vs 54.1%; P < .02), or dialysis (4.9% vs 9.0%; P < 0.001), and had a longer postoperative length of stay (8.0 vs 7.0 days; P < 0.01). Warfarin was prescribed less often for patients with postoperative GI events (44.4% vs 55.6%; P < .001) but more often for patients with postoperative myocardial infarction (75.8% vs 24.2%; P < .001) or new atrial fibrillation (68% vs 32%; P < .001) and those requiring blood transfusions intraoperatively (55.7% vs 44.3%; P < .001) or postoperatively (57% vs 43%; P < .03). Similar rates of warfarin prescription were observed in patients requiring reoperation for bleeding (54.9% vs 45.1%; P = .20) and those with postoperative stroke (53.6 % vs 46.4 %; P = .30). After adjusting for patient characteristics, significant surgeon and hospital variation in warfarin prescription at hospitals was observed.. Although patient characteristics and postoperative events may be associated with the prescription of warfarin following BMVR, substantial surgeon and hospital variability remains. This variability largely ignores the established practice guidelines and warrants further study to define the optimal anticoagulation strategy in patients undergoing BMVR.

Topics: Age Factors; Aged; Anticoagulants; Atrial Fibrillation; Bioprosthesis; Blood Loss, Surgical; Blood Transfusion; Databases, Factual; Female; Guideline Adherence; Heart Failure; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Length of Stay; Male; Middle Aged; Mitral Valve; Mitral Valve Insufficiency; Multivariate Analysis; Myocardial Infarction; Patient Discharge; Postoperative Complications; Postoperative Hemorrhage; Practice Guidelines as Topic; Practice Patterns, Physicians'; Renal Dialysis; Stroke; Warfarin

The place of thromboprophylaxis in arthroplasty surgery remains controversial, with a challenging requirement to balance prevention of potentially fatal venous thrombo-embolism with minimising wound-related complications leading to deep infection. We compared the incidence of fatal pulmonary embolism in patients undergoing elective primary total hip arthroplasty (THA) between those receiving aspirin, warfarin and low molecular weight heparin (LMWH) for the chemical component of a multi-modal thromboprophylaxis regime.. A prospective audit database was used to identify patients who had died within 42 and 90 days of surgery respectively between April 2000 and December 2012. A case note review was performed to ascertain the causes of death.. During this period 7983 THAs were performed. The rate of mortality was 0.43% and 0.58% at 42 and 90 days respectively. The groups comprised 1571 patients (19.7%) on warfarin, 1838 (23.0%) on LMWH and 4574 (57.3%) on aspirin. The 90-day mortality for these three groups was 0.38%, 1.09% and 0.43% respectively. The higher mortality rate for LMWH was significant (p < 0.05). There were six fatal pulmonary emboli (PEs) (0.08%). A total of three occurred within 42 days, all in the LMWH group. A total of three occurred between 42 and 90 days; one on warfarin, two on LMWH. The leading causes of death in all three groups were lower respiratory tract infections and myocardial infarction.. We confirmed that fatal PE following elective THA with a multi-modal prophylaxis regime is rare. We further found that LMWH conferred no benefit over aspirin in this context, and is associated with a higher all-cause rate of mortality.. This study proposes that aspirin may be an appropriate thromboprophylaxis agent when used as part of a multi-modal regimen, suggesting current guidelines should be reviewed. Cite this article: Bone Joint J 2016;98-B:585-8.

Topics: Aged; Anticoagulants; Arthroplasty, Replacement, Hip; Aspirin; Chemoprevention; Clinical Audit; Elective Surgical Procedures; Heparin, Low-Molecular-Weight; Humans; Myocardial Infarction; Platelet Aggregation Inhibitors; Postoperative Complications; Prospective Studies; Pulmonary Embolism; Respiratory Tract Infections; United Kingdom; Warfarin

We aimed to assess the influence of ethnicity on the incidence of heterotopic ossification (HO) after total hip arthroplasty (THA).. We studied the six-month post-operative anteroposterior radiographs of 1449 consecutive primary THAs (1324 patients) and retrospectively graded them for the presence of HO, using the Brooker Classification.. Based on multivariate analysis, African-American ethnicity was an independent risk factor for HO formation following THA with an adjusted odds ratio (OR) of 2.6 (95% confidence interval (CI) 1.3 to 5.2, p = 0.007) for severe HO and 1.9 (95% CI 1.3 to 2.7, p < 0.001) for any grade of HO.. Given the increased risk of HO formation, particularly high grade HO, and the potentially poorer outcomes associated with HO, it is important to consider using prophylaxis against HO in patients of African-American ethnicity undergoing THA.. African Americans are at an increased risk for developing heterotopic ossification and thus may benefit from HO prophylaxis. Cite this article: Bone Joint J 2016;98-B:761-6.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anticoagulants; Arthroplasty, Replacement, Hip; Black or African American; Body Mass Index; Female; Humans; Male; Middle Aged; Multivariate Analysis; Operative Time; Ossification, Heterotopic; Philadelphia; Postoperative Complications; Retrospective Studies; Risk Factors; Sex Factors; Warfarin; White People; Young Adult

To investigate the optimal anticoagulation methods and monitoring strategy for Chinese patients undergoing heart valve replacement, which is potentially quite different from western populations.. In this multicenter prospective cohort study, the anticoagulation and monitoring strategy data was acquired from 25 773 in-hospital patients in 35 medical centers and 20 519 patients in outpatient clinic in 11 medical centers from January 1st, 2011 to December 31th, 2015.. As for in-hospital patients, mean age of study population was (48.6±11.2) years old; main etiology of valve pathology was rheumatic (87.5%) origin among study cohort; 94.8% of study population received mechanical valve implantation; international normalized ratio (INR) monitoring (in all the study centers) and low-intensity anticoagulation strategy (31 hospitals chose target INR range of 1.5-2.5, and actual values of INR among 89.2% of 100 069 in-hospital monitoring samples were 1.5-2.5), with mean actual INR values of 1.84±0.53, and warfarin dosage of (2.82±0.93) mg/d were widely adopted among the study centers; strategies of in-hospital warfarin administration were similar in all the study centers; complication rates of low-intensity anticoagulation strategy were low in severe hemorrhage (0.02%), thrombosis (0.05%), and thromboembolism (0.05%) events, without anticoagulation-related death.As for 18 974 outpatient clinic patients, the follow-up rate was 92.47%, with a total of 30 012 patient-years (Pty). Anticoagulation-related morbidity and mortality rates were 0.67% and 0.15% Pty; major hemorrhage morbidity and mortality rates were 0.25% and 0.13% Pty; thromboembolism morbidity and mortality rates were 0.45% and 0.03% Pty.The mean dosage of warfarin daily dosage was (2.85±1.23) mg/d and INR value was 1.82±0.57.No significant regional difference in the intensity of anticoagulation therapy was noted during the study.. INR can be used as a normalized indicator for intensity of anticoagulation therapy in China.The optimal anticoagulation intensity with INR range from 1.5 to 2.5 is safe and effective for Chinese patients with heart valve replacement, and there is no significant regional difference in the intensity of anticoagulation therapy.

Topics: Adult; Aged; Anticoagulants; Asian People; Blood Coagulation; China; Dose-Response Relationship, Drug; Follow-Up Studies; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Hemorrhage; Humans; International Normalized Ratio; Middle Aged; Morbidity; Postoperative Complications; Prospective Studies; Thromboembolism; Warfarin

A 41-year-old female with hereditary deficiency of antithrombin III (ATIII) was diagnosed with atrial septal defect( ASD) and scheduled for the closure of ASD. She had been taking warfarin since she suffered from deep vein thrombosis 10 years ago. Preoperative management of anticoagulation included discontinuation of warfarin, and supplementation of antithrombin with heparin infusion. On the day of operation, antithrombin activity was maintained above 80% by administering antithrombin, and closure of ASD was carried out under standard cardiopulmonary bypass support using heparin. Heparin infusion was continued with antithrombin supplementation until prothrombin time-international normalized ratio(PT-INR) recovered to around 2.5 with warfarin. Her intra-and postoperative courses did not show any thromboembolic events, and she was discharged 20 days after the surgery.

Topics: Adult; Anticoagulants; Antithrombin III; Antithrombin III Deficiency; Cardiac Surgical Procedures; Female; Heart Septal Defects, Atrial; Heparin; Humans; International Normalized Ratio; Postoperative Complications; Preoperative Care; Thrombin Time; Treatment Outcome; Venous Thrombosis; Warfarin

Current guidelines for epicardial catheter ablation for ventricular tachycardia (VT) advocate that epicardial access is avoided in anticoagulated patients and should be performed prior to heparinisation. Recent studies have shown that epicardial access may be safe in heparinised patients. However, no data exist for patients on oral anticoagulants. We investigated the safety of obtaining epicardial access on uninterrupted warfarin.. A prospective registry of patients undergoing epicardial VT ablation over two years was analysed. Consecutive patients in whom epicardial access was attempted were included. All patients were heparinised prior to epicardial access with a target activated clotting time (ACT) of 300-350s. Patients who had procedures performed on uninterrupted warfarin (in addition to heparin) were compared to those not taking an oral anticoagulant.. 46 patients were included of which 13 were taking warfarin. There was no significant difference in clinical and procedural characteristics (except INR and AF) between the two groups. Epicardial access was achieved in all patients. There were no deaths and no patients required surgery. A higher proportion of patients in the warfarin group had a drop in haemoglobin of >2g/dL compared to the no-warfarin group (38.5% versus 27.3%, p=0.74) and delayed pericardial drain removal (7.8% versus 3.03%, p=0.47). There was no difference in overall procedural complication rate. No patients required warfarin reversal or blood transfusion.. Epicardial access can be achieved safely and effectively in patients' anticoagulated with warfarin and heparinised with therapeutic ACT. This may be an attractive option for patients with a high stroke risk.

Topics: Aged; Anticoagulants; Catheter Ablation; Female; Heparin; Humans; Intraoperative Complications; Male; Middle Aged; Pericardium; Perioperative Care; Postoperative Complications; Registries; Stroke; Tachycardia, Ventricular; United Kingdom; Warfarin

Implantable cardioverter defibrillator (ICD) implantation is being performed differently at many hospitals, with some keeping patients overnight after procedure while others discharge patients home same day. In addition, many centers are now performing ICD surgery while on warfarin anticoagulation. There are, however, limited data on outpatient ICD surgery on anticoagulated (AC) patients.. We wished to evaluate the safety of performing outpatient ICD surgery with and without warfarin anticoagulation.. We evaluated 866 patients who underwent outpatient ICD surgery between April 2010 and September 2014. Patients who were on novel oral anticoagulants, or did not have an international normalized ratio drawn within 24 hours of the procedure were excluded and the remainder were divided into two groups based on whether they were on (n = 230) or off (n = 518) warfarin anticoagulation. We evaluated both procedural and 30-day complications in both groups.. The complication rate at 30 days in the warfarin AC group was 4.3%, while in the nonanticoagulated (NAC) group was 2.9% and not significantly different (P = 0.31). However, the pocket hematoma rate in the warfarin anticoagulated group was 3.5%, as compared to the NAC group that was 0.4% (P = 0.001).. Complications from ICD surgery are low in the ambulatory setting on or off warfarin anticoagulation and appear to be comparable. However, warfarin use during ICD surgery is associated with an increased risk of pocket hematoma.

Topics: Aged; Ambulatory Care; Anticoagulants; Defibrillators, Implantable; Female; Hematoma; Humans; Male; Postoperative Complications; Prosthesis Implantation; Safety; Warfarin

Evidence from clinical trials shows rivaroxaban to be effective for the treatment of deep vein thrombosis. Switching to rivaroxaban following failure of indirect anticoagulants in deep vein thrombosis has not been demonstrated in a real-life setting.. A 43-year-old white woman was switched from warfarin to rivaroxaban for the treatment of thrombosis of her right common femoral vein after saphenectomy. The reason for the switch was due to the instability of anti-coagulation therapy with vitamin K antagonists over a period of 3 months during which she did not reach the "therapeutic range" of prothrombin time-international normalized ratio. The ineffectiveness of the conventional oral anticoagulant was confirmed by persistence of moderate-high values of fibrin D dimers (780 ng/ml) and by residual vein thrombosis at an ultrasound examination. Objectively, her right leg appeared to be still edematous and warm and pain was elicited by deep palpation. Rivaroxaban was administered after warfarin discontinuation (prothrombin time-international normalized ratio = 1.43) at a dosage of 15 mg every 12 hours for 3 weeks, followed by 20 mg once daily for 3 months. After this period, her objective symptoms significantly improved, with reduction of edema of her lower limb and pain relief. Her fibrin D dimer values returned to normal (210 ng/ml). An ultrasound showed recanalization of the obstructed venous segment.. In this case report, a switch to rivaroxaban from warfarin was shown to be effective and safe for the treatment of postoperative deep vein thrombosis, whereas standard oral anticoagulation therapy, which required dose adjustments over a period of 3 months, was not able to stabilize the therapeutic range of prothrombin time-international normalized ratio nor improve our patient's outcome.

Topics: Adult; Anticoagulants; Drug Administration Schedule; Female; Humans; Lower Extremity; Postoperative Complications; Rivaroxaban; Treatment Outcome; Venous Thrombosis; Warfarin

Allograft renal vein thrombosis is a rare complication of kidney transplantation. Most cases occur in the first 2 weeks after transplantation, but there are cases described many years after the transplant surgery. Allograft loss is the usual outcome.. We present a case of a renal transplant recipient with allograft renal vein thrombosis associated with deep venous thrombosis of a lower limb, 9 years after transplantation. He was successfully treated with anticoagulation alone, with recovery of allograft function.. The patient was given unfractioned heparin and elastic compression stockings. Five days later, the patient recovered diuresis and hemodialysis treatment was discontinued. Doppler ultrasound was done and revealed partial re-permeabilization of allograft renal vein, with maximal velocity of 15 cm/s. After 30 months of follow-up, the patient was maintained on oral anticoagulation with warfarin, and no thromboembolic or hemorrhagic events were documented. The patient's serum creatinine was stable, between 1.6 and 1.8 mg/dL.. Our patient demonstrated that anticoagulation alone and dialytic support might be able to promote total recovery of allograft function after renal vein thrombosis.

Topics: Allografts; Anticoagulants; Heparin; Humans; Kidney Transplantation; Male; Middle Aged; Postoperative Complications; Renal Dialysis; Renal Veins; Stockings, Compression; Transplantation, Homologous; Venous Thrombosis; Warfarin

The aim of this study is to investigate postoperative complications, mortality rates, and to determine the factors affecting mortality on the patients receiving warfarin therapy preoperatively, as well as comparing the results obtained from emergency and elective surgeries. Surgical outcomes of 61 patients on long-term oral anticoagulation with warfarin who underwent surgery in our center were retrospectively reviewed over an 8-year period. Thirty-three (54.1%) patients were female, with a mean age of 53 years. Mitral valve replacement (62.3%) was the most frequent indication for chronic anticoagulation therapy. Twelve out of 61 (19.2%) patients underwent emergency surgery; 59 (96.7%) operations were classified as major surgery. We did not observe any thromboembolic events on patients receiving our bridging therapy protocol. Cardiopulmonary dysfunction (CPD; 19.7%) and hemorrhage (16.4%) were the most encountered postoperative complications. Presence of CPD, bleeding, endocarditis, and mortality were statistically significant for emergency surgeries when compared with the results obtained from elective surgeries. There were 5 (8.2%) deaths observed during follow-up. It was found that advanced age, prolonged duration of operations, and presence of CPD had a statistically significant effect on mortality (P < 0.05). The patients receiving oral anticoagulant had high postoperative complication and mortality rates. This case was more evident in emergency surgeries. It is recommendable that as mortality is more apparent in the patients who undergo emergency surgeries-being older, having long duration of operations as well as CPD. Therefore during the postoperative follow-up process, the patients should be closely monitored.

Topics: Anticoagulants; Emergencies; Female; Humans; Middle Aged; Mitral Valve; Postoperative Complications; Preoperative Period; Retrospective Studies; Warfarin

Novel oral anticoagulant (NOAC) agents dabigatran, rivaroxaban, and apixaban are increasingly utilized as thromboembolic prevention for patients with atrial fibrillation undergoing direct current cardioversion (DCCV) with post hoc analyses of clinical trials suggesting satisfactory safety and efficacy. This study characterizes utilization, effectiveness, and complications of NOAC agents for stroke prophylaxis in the setting of DCCV.. Comparison of warfarin and NOAC agents as periprocedural anticoagulation for DCCV procedures performed at Cleveland Clinic from January 2009 through December 2013. Variables of interest include utilization rates for each NOAC agent stratified by clinical parameters including CHADS2 score, and associated clinical outcomes including cerebrovascular accident (CVA), transient ischemic attack (TIA), peripheral arterial embolism (PAE), and bleeding events during 8 weeks of postprocedure follow-up.. Among 5,320 DCCV procedures, 673 (12.6%) cases were excluded due to inadequate follow-up. Warfarin was utilized in 3,721 (80.1%), dabigatran in 719 (15.5%), rivaroxaban in 159 (3.4%), and apixaban in 48 (1.0%) with a steady increase in NOAC utilization from 2011 to 2013. There were low rates of CVA/TIA (warfarin: 0.97% vs NOAC 1.62%, P = 0.162) and bleeding (warfarin: 1.02% vs NOAC: 0.5%, P = 0.247) and no significant differences detected between agents. Higher CHADS2 /CHA2 DS2 -VASC scores were associated with thromboembolic and bleeding risk. Increasing age, chronic kidney disease, diabetes, coronary disease, and deep vein thrombosis/pulmonary embolism were associated with increased bleeding risk.. In a high-volume, single-center experience, NOAC utilization has grown to account for over a third of cardioversion procedures, and these agents appear safe and effective compared to warfarin with low rates of thromboembolic and bleeding complications.

Topics: Administration, Oral; Aged; Anticoagulants; Dabigatran; Defibrillators, Implantable; Female; Hemorrhage; Humans; Ischemic Attack, Transient; Male; Middle Aged; Postoperative Complications; Pyrazoles; Pyridones; Rivaroxaban; Stroke; Thromboembolism; Treatment Outcome; Warfarin

The benefit of early anticoagulation for stroke prophylaxis in atrial fibrillation after coronary artery bypass graft (CABG) surgery is uncertain. We therefore studied what proportion of ischemic strokes in patients with atrial fibrillation early after CABG surgery were potentially preventable by anticoagulation with warfarin.. We reviewed medical records from 2264 patients with isolated CABG performed during a period when our institution had no policy on anticoagulation for postoperative atrial fibrillation. The outcome was ischemic stroke within 30days postoperatively and verified with computed tomography (CT) in patients with new postoperative atrial fibrillation for more than 48h.. New, postoperative atrial fibrillation occurred in 403 (17.8%) of the patients and 191 of those (47.4%) were not started on warfarin at 48hours. Eight patients developed CT-verified ischemic stroke, which occurred on postoperative day 1-3 in 4 patients and in 3 patients was of the lacunar type. In two patients (stroke day 25 and day 30) warfarin could have been preventive. In another patient with onset of neurological symptoms on postoperative day 8 (4days from onset of the arrhythmia), systemic anticoagulation might have limited the severity of the stroke but warfarin therapy would not likely have reached therapeutic levels within 2days.. The preventive effect of warfarin on early stroke associated with new atrial fibrillation after CABG seems limited. Treatment with warfarin during the hospitalization has to take the risk of bleeding, particularly into the pericardium, as reported in the literature, into account.

Topics: Aged; Anticoagulants; Atrial Fibrillation; Brain Ischemia; Coronary Artery Bypass; Female; Hemorrhage; Heparin; Humans; Intracranial Embolism; Male; Middle Aged; Neuroimaging; Postoperative Complications; Retrospective Studies; Thrombophilia; Tomography, X-Ray Computed; Warfarin

Topics: Anticoagulants; Aspirin; Cardiac Tamponade; Diastole; Heart Failure; Heart-Assist Devices; Humans; Hypertension, Pulmonary; Male; Middle Aged; Postoperative Complications; Pulsatile Flow; Sternotomy; Systole; Thoracotomy; Warfarin

To review records of 330 patients who underwent surgery for femoral neck fractures with or without preoperative anticoagulation therapy.. Medical records of 235 women and 95 men aged 48 to 103 years (mean, 81.6; standard deviation [SD], 13.1) who underwent surgery for femoral neck fractures with or without preoperative anticoagulation therapy were reviewed. 30 patients were on warfarin, 105 on aspirin, 28 on clopidogrel, and 167 were controls. The latter 3 groups were combined as the non-warfarin group and compared with the warfarin group. Hospital mortality, time from admission to surgery, length of hospital stay, return to theatre, and postoperative complications (wound infection, deep vein thrombosis, and pulmonary embolism) were assessed.. The warfarin and control groups were significantly younger than the clopidogrel and aspirin groups (80.8 vs. 80.0 vs. 84.2 vs. 83.7 years, respectively, p<0.05). 81% of the patients underwent surgery within 48 hours of admission. The overall mean time from admission to surgery was 1.8 days; it was longer in the warfarin than the aspirin, clopidogrel, and control groups (3.3 vs. 1.8 vs. 1.6 vs. 1.6 days, respectively, p<0.001). The mean length of hospital stay was 17.5 (SD, 9.6; range, 3-54) days. The overall hospital mortality was 3.9%; it was 6.7% in the warfarin group, 3.8% in the aspirin group, 3.6% in the clopidogrel group, and 3.6% in the control group (p=0.80). Four patients returned to theatre for surgery: one in the warfarin group for washout of a haematoma, 2 in the aspirin group for repositioning of a mal-fixation and for debridement of wound infection, and one in the control group for debridement of wound infection. The warfarin group did not differ significantly from non-warfarin group in terms of postoperative complication rate (6.7% vs. 2.7%, p=0.228) and the rate of return to theatre (3.3% vs. 1%, p=0.318).. It is safe to continue aspirin and clopidogrel prior to surgical treatment for femoral neck fracture. The risk of delaying surgery outweighs the peri-operative bleeding risk.

Topics: Aged; Aged, 80 and over; Anticoagulants; Aspirin; Clopidogrel; Female; Femoral Neck Fractures; Humans; Male; Middle Aged; Postoperative Complications; Retrospective Studies; Ticlopidine; Warfarin

The objective of this study was to evaluate the safety and efficacy of low-intensity warfarin treatment in Chinese patients after mitral valve replacement as well as the rationality of the INR standards of the hospital (The First People's Hospital of Jining City).. We retrospectively analyzed 270 cases in our hospital from January 2009 to December 2013; 239 patients completed the 5-year follow-up. There were 192 male and 78 female subjects, age 32-65 years old with a mean age 51.51 ± 12.12 years old. All eligible candidates received a Carbomedics artificial mechanical valve replacement and were anticoagulated under this hospital's current guidelines for postoperative anticoagulant therapy mitral valve replacement (INR 1.8-2.5). We analyzed the patient's regularly recorded prothrombin times (PTs) and the occurrence of anticoagulation-related complications, such as bleeding, thrombosis, and embolism.. A follow-up for 239 of 300 patients was performed for 3-60 months. Within this group, one patient died from cerebral hemorrhage, there was 1 case of subcutaneous bleeding, 1 case of epistaxis, 12 cases of gingival bleeding, in 15 menstrual quantity increased, and in 1 case we found cerebral infarction.. In conclusion, low-intensity anticoagulation after mitral Carbomedics valve replacement is therapeutically effective and safe. There is room to improve the anticoagulation standard currently used, perhaps at a slightly lower level than this standard suggests. From our research we can formulate individualized treatment plans and effectively reduce the occurrence of complications.

Topics: Adult; Aged; Anticoagulants; China; Comorbidity; Equipment Failure Analysis; Female; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Male; Middle Aged; Mitral Valve Insufficiency; Postoperative Care; Postoperative Complications; Prevalence; Prosthesis Design; Risk Factors; Thromboembolism; Treatment Outcome; Warfarin; Young Adult

We describe a case of a patient on warfarin who developed an extensive haematoma after a hip hemiarthroplasty and was successfully treated with embolisation. This case highlights the importance of regular haematology input, careful consideration of a suitable surgical approach, close monitoring of postoperative wounds in patients on warfarin and the emerging role of embolisation.

Topics: Aged, 80 and over; Arthroplasty, Replacement, Hip; Buttocks; Embolization, Therapeutic; Female; Femoral Neck Fractures; Fracture Fixation, Internal; Hematoma; Hemiarthroplasty; Hip; Hip Fractures; Hip Joint; Hip Prosthesis; Humans; Iliac Artery; Postoperative Complications; Warfarin

Topics: Anticoagulants; Hematoma; Humans; Kidney Failure, Chronic; Kidney Transplantation; Postoperative Complications; Prognosis; Retrospective Studies; Risk Factors; Warfarin

To evaluate current practice in the perioperative management of antiplatelets (AP) and anticoagulants (AC) among men undergoing elective transurethral resection of the prostate (TURP), as well as the associated perioperative bleeding and thromboembolic complications.. Retrospective review of consecutive elective TURP patients in a single tertiary institution from January 2011 to December 2013 (n = 293). Data on the regular use of AP/AC and the perioperative management approach were collected from patients' electronic medical records. Bleeding and thromboembolic complications were assessed up to 30 days postoperative. Association between AP/AC use and perioperative complications was assessed using the Kruskall-Wallis test (continuous variables) and the Fisher exact test (categoric variables).. There were 107/293 (37%) patients receiving long-term AP while there were 25/293 (9%) patients receiving long-term AC. A total of 72/107 (67%) patients ceased AP on an average of 7.6 days preoperatively, while 35/107 (33%) continued receiving AP. Patients with coronary stents (62%) and coronary bypass graft (67%) were significantly more likely to continued receiving AP (P < 0.001). AC was ceased in all patients preoperatively, with 16/25 (64%) receiving enoxaparin bridging. Overall, there were 31 (10%) incidents of bleeding complications and 5 (2%) thromboembolic events. AC users who had enoxaparin bridging had significantly higher risk of bleeding complications (44%), compared with non-AP/AC users (8%), AP users who ceased AP (4%), AP users who continued receiving AP (17%), and AC users who did not receive enoxaparin bridging (0%) (P < 0.001). AC users who received enoxaparin bridging also reported significantly higher thromboembolic complications (17%; P < 0.001) and prolonged hospital stay (mean 5.4 days) (P = 0.002), compared with other patients.. Perioperative management of AP/AC should be based on the indications and the American College of Chest Physicians thromboembolic risk stratification. Regular AC users who had enoxaparin bridging are at increased risk of both perioperative bleeding and thromboembolic complications.

Topics: Aged; Aged, 80 and over; Anticoagulants; Aspirin; Aspirin, Dipyridamole Drug Combination; Clopidogrel; Elective Surgical Procedures; Enoxaparin; Hemorrhage; Humans; Male; Middle Aged; Perioperative Care; Platelet Aggregation Inhibitors; Postoperative Complications; Prostate; Prostatic Hyperplasia; Retrospective Studies; Thromboembolism; Ticlopidine; Transurethral Resection of Prostate; Victoria; Warfarin; Withholding Treatment

Extra-pericardial tamponade is a rare life threatening condition that has not previously been reported in association with Wolf Mini-Maze procedures. In this case, atypical presentation of cardiac tamponade caused by postoperative anticoagulation resulted in a second hospitalization, a second surgery, and delayed recovery time. The goal of this case report is to increase awareness about a life threatening complication that can occur following minimally invasive cardiac surgery.. A 60 year old male with long standing essential hypertension, who was recently treated for atrial fibrillation utilizing the Wolf Mini-Maze procedure, experienced a postoperative international normalized ratio increase from 3.6 to 5.3 over the course of six days. Fifteen days postoperatively, the patient experienced mild exercise intolerance, his condition rapidly progressed to a constellation of symptoms including severe exercise intolerance, dyspnea, hypotension, and near syncope. A diagnosis of cardiac tamponade was made, and the patient was re-admitted to the hospital. Attempts to reverse his warfarin anticoagulation with fresh frozen plasma and vitamin K were unsuccessful after 24 h. Video-assisted thoracotomy was performed to relieve the tamponade, and during surgery he was diagnosed with extra-pericardial tamponade caused by an extensive hematoma. Complications due to anticoagulation therapy required this re-admission, additional surgery, and delayed recovery. The patient has since recovered completely with no long term morbidities and is asymptomatic three years following initial presentation.. This case marks the first time extra-pericardial tamponade has been reported post cardiothoracic intervention in English literature. Many surgical procedures require postoperative anticoagulation; in the past, warfarin has been the standard of care due to its purported reversibility. This case provides an example of the challenge presented when anticoagulating with warfarin, and the reversal of this anticoagulation.

Topics: Cardiac Surgical Procedures; Cardiac Tamponade; Diagnosis, Differential; Humans; International Normalized Ratio; Male; Middle Aged; Postoperative Complications; Thoracic Surgical Procedures; Warfarin

Patients with atrial fibrillation (AF) are at risk of cardioembolism.(1,2)) Atrial thrombus formation associated with AF typically occurs in the left atrial appendage (LAA);(3)) therefore, transesophageal echocardiography (TEE) is important for detection of such a thrombus and measurement of LAA flow velocity.(4,5)) LAA closure is routinely performed during mitral valve surgery in patients with AF to prevent cardiogenic stroke.(6)) We report the case of a 65-year-old woman with severe mitral regurgitation (MR) and AF in whom a giant thrombus formed almost immediately after mitral and tricuspid valvuloplasty and concurrent LAA resection. No atrial thrombus or spontaneous echo contrast (SEC) was detected by TEE before the surgery. However, a giant intramural thrombus was detected in the left atrium 7 days after surgery. It was thought that the atrial dysfunction as well as the change in morphology of the left atrium resulting from the severe MR complicated by AF and congestive heart failure produced a thrombotic substrate. This case suggests that careful surveillance for thrombus formation and careful maintenance of anticoagulation therapy are needed throughout the perioperative period even if no SEC or thrombus is detected before surgery.

Topics: Aged; Anticoagulants; Atrial Appendage; Atrial Fibrillation; Drug Monitoring; Echocardiography, Transesophageal; Humans; Male; Mitral Valve Annuloplasty; Mitral Valve Insufficiency; Postoperative Complications; Thrombosis; Treatment Outcome; Warfarin

One of the rare causes of venous thromboembolism in pregnancy is antithrombin III deficiency. Antithrombin III deficiency is estimated to carry a 30% risk of venous thrombotic complication during each pregnancy and postpartum.. We present thea case of a A 21-year-old pregnant woman (Para 1+) with a history of large atrial septal defect repair at our hospital (Imam Ali Hospital, 2 May 2014). The patient, with unknown history of antithrombin III deficiency, was admitted at our emergency center with dyspnea and chest pain for the rule out of tamponade. She presented with a right atrial thrombosis in the second trimester of pregnancy despite the use of therapeutic doses of heparin and warfarin in the postoperative period as thromboembolic prophylaxis. The risk of warfarin emberyopaty led to termination of pregnancy, and successful redo-cardiac surgery outcome was achieved with the combined use of therapeutic anticoagulation and regular plasma-derived antithrombin concentrate infusions to normalize her antithrombin levels.. She recovered from the operation uneventfully, and wad discharged in the 12(th) postoperative day. In the 6(th) month of follow-up, antithrombin III increased to 70% in more stable level and transethoracic echocardiography showed no recurrence of right atrial thrombus formation. This case leads to further debate regarding whether full anticoagulation should be a worthy preventive measure for venous thromboembolic prophylaxis after an open heart surgery complicated by pregnancy in a women with inherited antithrombin III deficiency. This point may become more relevant as further experience is gained with the use of recombinant human antithrombin in known cases during open cardiac surgery.

Topics: Adult; Anticoagulants; Antithrombin III; Antithrombin III Deficiency; Antithrombins; Cardiac Surgical Procedures; Female; Heart Atria; Heart Septal Defects, Atrial; Humans; Postoperative Complications; Pregnancy; Pregnancy Complications; Pregnancy Trimester, Second; Venous Thrombosis; Warfarin; Young Adult

We report a rare case of a pulmonary vein stump thrombus detected by a contrast-enhanced computed tomography for transient syncope 2 days after upper division segmentectomy of the left lung for metastatic pulmonary tumor. The thrombus disappeared without embolic events after anticoagulation with intravenous heparin followed by oral warfarin. Considering this case and previous reports, thoracic surgeons should be aware of pulmonary vein stump thrombus, a latent source of systemic embolization, after pulmonary resection, especially lobectomy or segmentectomy of the left upper lobe. This possible serious complication can occur at any time from the early postoperative period.

Topics: Aged; Anticoagulants; Female; Heparin; Humans; Lung Neoplasms; Pneumonectomy; Postoperative Complications; Pulmonary Veins; Tomography, X-Ray Computed; Venous Thrombosis; Warfarin

Topics: Coronary Angiography; Equipment Failure Analysis; Female; Humans; Medication Adherence; Middle Aged; Mitral Valve; Mitral Valve Insufficiency; Mitral Valve Stenosis; Postoperative Care; Postoperative Complications; Prosthesis Design; Reoperation; Rheumatic Heart Disease; Thrombosis; Video Recording; Warfarin

To define the durability of aortic valve repair (AVRep) and the effect of surgical timing on late survival.. From June 1986 to June 2011, 331 patients underwent elective AVRep for aortic regurgitation (mean age, 53 ± 17 years; 76% men). The repair methods included commissuroplasty (n = 270; 81%), triangular resection and plication (n = 106; 32%), resuspension or cusp shortening (n = 102; 31%), and perforation closure (n = 23; 7%).. In-hospital mortality was 0.6% (2 of 332). Four patients (1%) experienced early repair failure; two underwent repeat repair. Overall survival was 91% and 81% at 5 and 10 years, respectively. After adjusting for age, greater left ventricular end-systolic dimension (per 5 mm; hazard ratio [HR], 1.49; 95% confidence interval [CI], 1.23-1.79; P < .001) and lower ejection fraction (per 5%; HR, 1.42; 95% CI, 1.25-1.63; P ≤ .001) were significant predictors of long-term mortality. Patients with ejection fraction < 50% and left ventricular end-systolic dimension > 50 mm had significantly greater odds of late death (HR, 3.46; 95% CI, 2.05-5.82; P < .001 and HR, 2.08; 95% CI, 1.05-4.12; P = .036, respectively). The risk of aortic valve reoperation was 10% and 21% at 5 and 10 years, respectively. The presence of severe aortic regurgitation (HR, 2.2; 95% CI, 1.1-5.06; P = .02) and more than mild regurgitation at discharge (HR, 5.87; 95% CI, 2.67-12.68; P ≤ .0001) were predictors of late reoperation. Freedom from other valve-related events was 94% and 91% at 5 and 10 years, respectively. Forty-seven patients (21%) with intact valve repair were using warfarin at the last follow-up visit.. AVRep can be performed with excellent late survival and freedom from valve-related events. Awaiting the onset of ventricular dysfunction increases the risk of late mortality, warranting earlier consideration of AVRep for patients with suitable anatomy.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anticoagulants; Aortic Valve; Aortic Valve Insufficiency; Cardiac Surgical Procedures; Cardiac Valve Annuloplasty; Female; Hospital Mortality; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Multivariate Analysis; Odds Ratio; Patient Selection; Postoperative Complications; Proportional Hazards Models; Reoperation; Retrospective Studies; Risk Factors; Severity of Illness Index; Stroke Volume; Time Factors; Time-to-Treatment; Treatment Outcome; Ventricular Function, Left; Warfarin; Young Adult

To determine the interventions taken to lower international normalized ratio (INR) in individuals with hip fracture using warfarin before admission for hip fracture surgery in a geriatric fracture center (GFC) and compare outcomes with those of individuals not taking warfarin.. Cohort study using retrospective chart review.. University-affiliated community teaching hospital.. Individuals aged 60 and older admitted to a GFC for surgical repair of a nonpathological, nonperiprosthetic hip fracture between April 2006 and April 2012.. Descriptive data collected from a quality improvement registry with additional information for individuals taking warfarin obtained from chart review.. Of the 1,080 individuals included in the analysis, 84 (7.8%) were taking warfarin on admission. Participants using warfarin had a higher average Charlson Comorbidity Index (3.8 vs 3.1, P < .001). Atrial fibrillation was the most common indication for anticoagulation (83.3%). Average INR before surgery was 1.7 (range 1.2-3.6). Vitamin K, fresh frozen plasma, or both were given to 100% of those taking warfarin with an admission INR of 2.0 or greater. There was a trend toward longer time to surgery in those taking warfarin than in those not taking warfarin (28.9 vs 21.7 hours, P = .05). Length of stay was longer for those taking warfarin than those not taking warfarin (4.8 vs 4.2 days, P = .04). Neither time to surgery nor length of stay were significantly different after adjustment for baseline comorbidity. Participants taking warfarin were not found to have any significant differences in thromboembolic event rates, bleeding complications rates, mortality, or 30-day readmission after surgery than those not taking warfarin on admission.. Active management in a GFC model to reverse anticoagulation before surgery may facilitate earlier surgery without increasing observed complications.

Topics: Aged; Aged, 80 and over; Anticoagulants; Comorbidity; Female; Hip Fractures; Hospital Mortality; Humans; International Normalized Ratio; Length of Stay; Male; Middle Aged; Patient Readmission; Postoperative Complications; Retrospective Studies; Treatment Outcome; Warfarin

Pulmonary thromboembolism after upper extremity operation is rare. We report a patient with thromboembolism after debridement open reduction and internal fixation for bilateral open distal radius fractures.. The Japanese patient was an 80-year-old previously healthy female who was able to walk on her own. She fell down and was taken to our hospital. She was diagnosed with bilateral open distal radius fractures and we performed debridement open reduction and internal fixation on the same day. Although she could not walk and was depressed, she was discharged on the ninth postoperative day. However, on the eleventh postoperative day, she returned to our emergency department with complaints of dyspnea and cold sweat. Her serum D-dimer level was 19.0 μg/dl, troponin T was positive, and urgent contrast computed tomography scan of her thorax revealed thrombosis in the bilateral main pulmonary artery. She was diagnosed with pulmonary thromboembolism and admitted to our hospital again. On the second admission, although she had breathing problems, she did not require a respirator. Oxygen was supplied as well as anticoagulants. On the seventh day after being diagnosed with embolism, thrombosis in the bilateral main pulmonary arteries had disappeared.. The patient did not have any "strong" risk factors as reported in the Japanese Orthopedic Association Clinical Practice Guideline on the Prevention of Venous Thromboembolism in Patients Undergoing Orthopedic Treatments. In general, upper extremity operation carries a low risk for pulmonary thromboembolism. For patients with decreased activity of daily living and depression, we should consider postponing discharge and performing rehabilitation until activity of daily living is improved.

Topics: Accidental Falls; Aged, 80 and over; Anticoagulants; Bed Rest; Bone Plates; Combined Modality Therapy; Debridement; Depression; Dyspnea; Female; Fracture Fixation, Internal; Fractures, Open; Heparin; Humans; Multiple Trauma; Oxygen Inhalation Therapy; Patient Readmission; Postoperative Complications; Pulmonary Embolism; Radius Fractures; Warfarin

Current data supporting the effect of anticoagulation drug use on aneurysm sealing and the durability of endovascular abdominal aneurysm repair (EVAR) are conflicting. This study assessed the safety of chronic anticoagulation therapy after EVAR.. Records of 1409 consecutive patients having elective EVAR during 1997-2011 who were prospectively followed were reviewed. Survival, reintervention, conversion, and endoleak rates were analyzed in patients with and without chronic anticoagulants. Cox proportional hazards models were used to estimate the effect of anticoagulation therapy on outcomes.. One-hundred and three (7.3%) patients were on chronic anticoagulation drugs (80 on vitamin K antagonists) at the time of EVAR. An additional 46 patients started on anticoagulants after repair were identified. Patients on chronic anticoagulation therapy at repair (mean age 73.6 years; 91 males) had more frequent cardiac disease (74.8% vs. 44.2%; p < 00001), but no other differences in demographic and major baseline comorbidities with respect to the others. At baseline, mean abdominal aortic aneurysm (AAA) diameter was 56.43 mm vs. 54.65 mm (p = .076) and aortic neck length 26.54 mm vs. 25.21 mm (p = .26) in patients with and without anticoagulants, respectively. At 5 years, freedom from endoleak rates were 55.5% vs. 69.9% (p < .0001), and freedom from reintervention/conversion rates were 69.4% vs. 82.4% (p < .0001) in patients with (including those with delayed drug use) and without chronic anticoagulants, respectively. Controlling for covariates with the Cox regression method, at a mean follow-up of 64.3 ± 45.2 months after EVAR, use of anticoagulation drugs was independently associated with an increased risk of endoleak (odds ratio, OR 1.6; 95% confidence interval, CI: 1.23-2.07; p < .0001) and reintervention or late conversion rates (OR 1.8; 95% CI: 1.31-2.48; p < .0001).. The safety of anticoagulation therapy after EVAR is debatable. Chronic anticoagulation drug use risks exposure to a poor long-term outcome. A critical and balanced decision-making approach should be applied to patients with AAA and cardiac disease who may require prolonged anticoagulation treatment.

Topics: Aged; Aged, 80 and over; Anticoagulants; Aortic Aneurysm, Abdominal; Endoleak; Endovascular Procedures; Female; Humans; Kaplan-Meier Estimate; Male; Postoperative Complications; Postoperative Period; Proportional Hazards Models; Retrospective Studies; Warfarin

Other than the classic skin necrosis induced by oral anticoagulants (OAC) in patients with protein C and S deficiencies, other types of OAC induced-skin ulcers are little known. Herein, we describe an original case of recurrent pyoderma gangrenosum (PG)-like ulcers induced by OAC.. A 70-year-old female heart-transplant recipient presented deep, hyperalgesic and quickly-spreading necrotic ulceration of the right leg 6 weeks after starting oral anticoagulant therapy with fluindione. Histological analysis revealed dermal infiltrate containing polynuclear neutrophils, which accords with the histopathological diagnosis of leukocytoclastic vasculitis or PG. Infectious, autoimmune and thrombophilic causes were ruled out. Fluindione was withdrawn and the ulcer healed completely within a month. Six months later, right leg ulceration recurred two weeks after the patient resumed fluindione but healed within 1 month of discontinuation of the drug. An OAC from another chemical family (warfarin) was then introduced, with further recurrence of ulceration after 2 weeks of treatment.. The chronology of events and the negativity of aetiological explorations allowed a diagnosis to be made of OAC-induced skin ulcer, a rare complication of which the pathophysiology is unclear. This is the first case of PG-like ulcers induced by OAC.

Topics: Aged; Anticoagulants; Bed Rest; Carcinoma, Basal Cell; Diagnosis, Differential; Drug Eruptions; Drug Substitution; Facial Neoplasms; Female; Heart Transplantation; Humans; Hyperalgesia; Molecular Structure; Monoclonal Gammopathy of Undetermined Significance; Phenindione; Postoperative Complications; Pyoderma Gangrenosum; Recurrence; Skin Neoplasms; Skin Ulcer; Thrombophlebitis; Vasculitis, Leukocytoclastic, Cutaneous; Warfarin

We asked whether patients under long-term warfarin and managed with current guidelines regarding bridging therapy have a higher complications rate within ninety days following total knee arthroplasty. We retrospectively identified 38 patients under long-term warfarin. They were match-paired with 76 control patients. Our results showed a significant increased rate of complications (42.1% vs. 6.9%, P < 0.001) and re-operation (21.1% vs. 5.2%, P < 0.001) in the warfarin group. The difference was related to the number of hematomas requiring surgical evacuation. The warfarin group had a significantly higher rate of blood loss, blood transfusion, and length of hospital stay. Our data suggest that current guidelines for preoperative warfarin management are associated with a high rate of bleeding complications and reoperations following TKA.

Topics: Aged; Aged, 80 and over; Anticoagulants; Arthroplasty, Replacement, Knee; Blood Transfusion; Comorbidity; Female; Hematoma; Hemorrhage; Heparin, Low-Molecular-Weight; Humans; Length of Stay; Male; Morbidity; Postoperative Complications; Reoperation; Retrospective Studies; Warfarin

Despite substantial evidence supporting a pharmacogenetic approach to warfarin therapy in adults, evidence on the importance of genetics in warfarin therapy in children is limited, particularly for clinical outcomes. We assessed the contribution of CYP2C9/VKORC1/CYP4F2 genotypes and variation in other genes involved in vitamin K and coagulation pathways to warfarin dose and related clinical outcomes in children.. Clinical and genetic data for 93 children (age ≤ 18 years) who received warfarin therapy were obtained. DNA was genotyped for 93 selected single nucleotide polymorphisms using a custom assay.. With a median age of 4.8 years, our cohort included more young children than most previous studies. Overall, 76.3% of dose variability was explained by weight, indication, VKORC1-1639G/A and CYP2C9 *2/*3, with genotypes accounting for 21.1% of variability. There was a strong correlation (R(2) = 0.68; P < 0.001) between actual and predicted warfarin dose using a pediatric genotype-based dosing model. VKORC1 genotype had a significant impact on time to therapeutic international normalized ratio (INR) (P = 0.047) and time to over-anticoagulation (INR > 4; P = 0.024) during the initiation of therapy. CYP2C9*3 carriers were also at increased risk of major bleeding while receiving warfarin (adjusted OR = 11.28). An additional variant in CYP2C9 (rs7089580) was significantly associated with warfarin dose (P = 0.020) in a multivariate clinical and genetic model.. This study confirms the importance of VKORC1/CYP2C9 genotypes for warfarin dosing in a young pediatric cohort and demonstrates an impact of genetic factors on clinical outcomes in children. Furthermore, we identified an additional variant in CYP2C9 of potential relevance for warfarin dosing in children.

Topics: Adolescent; Anticoagulants; Aryl Hydrocarbon Hydroxylases; Biotransformation; Cardiac Surgical Procedures; Child; Child, Preschool; Cytochrome P-450 CYP2C9; Cytochrome P-450 Enzyme System; Cytochrome P450 Family 4; Dose-Response Relationship, Drug; Female; Genetic Association Studies; Genotype; Hemorrhage; Humans; Infant; International Normalized Ratio; Male; Polymorphism, Single Nucleotide; Postoperative Complications; Precision Medicine; Risk; Time Factors; Treatment Outcome; Vitamin K Epoxide Reductases; Warfarin

Thromboembolic complications such as systemic embolization and valve thrombosis are a major concern early after mechanical valve replacement; however, the benefit of anticoagulation must be weighed against the risk of early postoperative bleeding complications. Thromboembolic risk is also higher in the early postoperative period (less than 6 mo) compared with the risk in the late postoperative period. Current evidence supports the use of unfractionated heparin or low-molecular-weight heparin early after valve replacement to prevent valve thrombosis or systemic embolization but provides no recommendations for the management of patients with a history of heparin-induced thrombocytopenia (HIT), in which heparin products are contraindicated. We describe the use of fondaparinux early after aortic mechanical valve replacement in a 63-year-old, 95-kg woman with a history of HIT. Fondaparinux was initiated on postoperative day 2 at a prophylactic dose of 2.5 mg subcutaneously daily; the dose was increased to a therapeutic weight-based dose of 7.5 mg subcutaneously daily on postoperative day 3. Warfarin was initiated on postoperative day 1, and fondaparinux was continued until a therapeutic international normalized ratio was achieved. The patient was discharged from the hospital receiving warfarin alone on postoperative day 6. No signs or symptoms of thrombosis or bleeding were noted during or after fondaparinux therapy or at hospital follow-up visits. To our knowledge, this is the first case report to describe the use of fondaparinux within the first 48 hours after mechanical valve replacement in a patient with a history of HIT. This case suggests that fondaparinux may be a safe and effective option to prevent thromboembolic complications early after mechanical valve replacement when heparin products are contraindicated.

Topics: Anticoagulants; Aortic Valve; Female; Follow-Up Studies; Fondaparinux; Heart Valve Prosthesis Implantation; Heparin; Humans; International Normalized Ratio; Middle Aged; Polysaccharides; Postoperative Complications; Thrombocytopenia; Thromboembolism; Treatment Outcome; Warfarin

Topics: Aged; Anticoagulants; Benzimidazoles; Bioprosthesis; Clinical Trials, Phase II as Topic; Dabigatran; Heart Valve Prosthesis; Hemorrhage; Humans; Myocardial Infarction; Postoperative Complications; Pyridines; Randomized Controlled Trials as Topic; Risk; Stroke; Thromboembolism; Warfarin

Although current guidelines recommend continuing the same antithrombotic strategy regardless of rhythm control after radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF), anticoagulation has a risk of major bleeding. We evaluated the safety of switching warfarin to aspirin in patients with successful AF ablation.. Among 721 patients who underwent RFCA of AF, 608 patients (age, 57.3±10.9 years; 77.0% male, 75.5% paroxysmal AF) who had no evidence of AF recurrence at 3 months post-RFCA were included. We compared the thromboembolic and hemorrhagic events in patients for whom warfarin was switched to aspirin (ASA group; n=296) and patients who were kept on warfarin therapy (W group; n=312).. There were no significant differences in CHA₂DS₂-VASc or HAS-BLED scores between the groups. In 30 patients in the ASA group and 37 patients in W group, AF recurred and warfarin was restarted or maintained during the 18.0±12.2 months of follow-up. There were no significant differences in thromboembolic (0.3% vs. 1.0%, p=0.342) and major bleeding incidences (0.7% vs. 0.6%, p=0.958) between ASA and W groups during the follow-up period. In the 259 patients with a CHA₂DS₂-VASc score≥2, there were no significant differences in thromboembolism (0.8% and 2.2%, p=0.380) or major bleeding incidences (0.8% and 1.4%, p=0.640) between ASA and W groups.. Switching warfarin to aspirin 3 months after successful RFCA of AF could be as safe and efficacious as long-term anticoagulation even in patients with CHA₂DS₂-VASc score≥2. However, strict rhythm monitoring cannot be overemphasized.

Topics: Aged; Anticoagulants; Aspirin; Atrial Fibrillation; Catheter Ablation; Female; Hemorrhage; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Postoperative Complications; Retrospective Studies; Risk Assessment; Thromboembolism; Treatment Outcome; Warfarin

Atrial fibrillation ablation requires peri-procedural oral anticoagulation (OAC) to prevent thromboembolic events. There are several options for OAC. We evaluate peri-procedural AF ablation complications using a variety of peri-procedural OACs.. We examined peri-procedural OAC and groin, bleeding, and thromboembolic complications for 2334 consecutive AF ablations using open irrigated-tip radiofrequency (RF) catheters. Pre-ablation OAC was warfarin in 1113 (47.7%), dabigatran 426 (18.3%), rivaroxaban 187 (8.0%), aspirin 472 (20.2%), and none 136 (5.8%). Oral anticoagulation was always interrupted and intraprocedural anticoagulation was unfractionated heparin (activated clotting time, ACT = 237 ± 26 s). Pre- and post-OAC drugs were the same for 1591 (68.2%) and were different for 743 (31.8%). Following ablation, 693 (29.7%) were treated with dabigatran and 291 (12.5%) were treated with rivaroxaban. There were no problems changing from one OAC pre-ablation to another post-ablation. Complications included 12 (0.51%) pericardial tamponades [no differences for dabigatran (P = 0.457) or rivaroxaban (P = 0.163) compared with warfarin], 12 (0.51%) groin complications [no differences for rivaroxaban (P = 0.709) and fewer for dabigatran (P = 0.041) compared with warfarin]. Only 5 of 2334 (0.21%) required blood transfusions. There were two strokes (0.086%) and no transient ischaemic attacks (TIAs) in the first 48 h post-ablation. Three additional strokes (0.13%), and two TIAs (0.086%) occurred from 48 h to 30 days. Only one stroke had a residual deficit. Compared with warfarin, the neurologic event rate was not different for dabigatran (P = 0.684) or rivaroxaban (P = 0.612).. Using interrupted OAC, low target intraprocedural ACT, and irrigated-tip RF, the rate of peri-procedural groin, haemorrhagic, and thromboembolic complications was extremely low. There were only minimal differences between OACs. Low-risk patients may remain on aspirin/no OAC pre-ablation. There are no problems changing from one OAC pre-ablation to another post-ablation.

Topics: Administration, Oral; Aged; Algorithms; Anticoagulants; Aspirin; Atrial Fibrillation; Benzimidazoles; beta-Alanine; Catheter Ablation; Combined Modality Therapy; Dabigatran; Female; Heparin; Humans; Male; Middle Aged; Morpholines; Postoperative Complications; Radio Waves; Rivaroxaban; Thiophenes; Thromboembolism; Warfarin

Topics: Anticoagulants; China; Dose-Response Relationship, Drug; Female; Heart Valve Diseases; Heart Valve Prosthesis Implantation; Humans; Incidence; Male; Middle Aged; Neural Networks, Computer; Postoperative Complications; Prognosis; Thromboembolism; Warfarin

Topics: Administration, Oral; Anticoagulants; Atrial Fibrillation; Brain Ischemia; Catheter Ablation; Humans; Needs Assessment; Patient Safety; Postoperative Complications; Treatment Outcome; Warfarin

We examined perioperative complications of transurethral resection of bladder tumor (TURBT) in patients receiving antithrombotic therapy. We retrospectively studied 276 patients who underwent TURBT in our institute from January 2007 to March 2013. The study group consisted of 105 patients (38%) who were receiving antithrombotic agents, and the other 171 patients (62%) without antithrombotic agents were assigned to the control group. The period of discontinuation of antithrombotic agents complied with our institutional rule. The most frequently used agent was aspirin (69 patients : 66%), followed by warfarin (25 patients : 24%). Fourteen patients receiving warfarin (56%) needed heparin bridging therapy. There was no significant difference in average operative time (51 minutes versus 54 minutes), or average days to removal of urethral catheter (3.7 days versus 3.3 days) between the study and control groups. Hemorrhagic and ischemic complications were noted in 11 (10.5%) and 2 (1.9%) patients in the study group and 11 (6.4%) and none (0%) of the patients in the control group, respectively, with no significant difference between the 2 groups. However, prevalence of hemorrhagic complications in patients receiving heparin bridging therapy (21.4%) was significantly higher than that in the control group. Ischemic complications in the study group included chest pain suggestive of angina in one patient and acute myocardial infarction leading to death in another patient. We should pay attention to hemorrhagic complications in patients receiving heparin bridging therapy and keep in mind the possibility of lethal ischemic complications after discontinuation of antithrombotic agents.

Topics: Aged; Aged, 80 and over; Angina Pectoris; Aspirin; Cystectomy; Female; Fibrinolytic Agents; Hemorrhage; Heparin; Humans; Male; Middle Aged; Myocardial Infarction; Postoperative Complications; Retrospective Studies; Urethra; Urinary Bladder Neoplasms; Warfarin

Topics: Anesthesia, Conduction; Anticoagulants; Heparin; Humans; Nerve Block; Platelet Aggregation Inhibitors; Postoperative Complications; Practice Guidelines as Topic; Pulmonary Embolism; Venous Thrombosis; Warfarin

Uninterrupted anticoagulation with warfarin during radiofrequency catheter ablation (RFA) of atrial fibrillation is associated with a lower risk of periprocedural complications than when warfarin is temporarily discontinued. However, the optimal international normalized ratio (INR) levels during RFA have not been defined.. In this retrospective analysis, RFA was performed in 1133 consecutive patients (mean age, 61±10 years) with paroxysmal (550) or persistent atrial fibrillation (583). Patients were grouped based on the INR on the day of RFA. There was a quadratic relationship between the INR and bleeding and vascular complications (P<0.001). Complications were less prevalent when INR was ≥2.0 and ≤3.0 (5% [31/572]) than when INR was <2.0 (10% [49/485]; P=0.004) and >3.0 (12% [9/76]; P=0.03). The prevalence of pericardial tamponade (1%) was similar at all INRs. From the quadratic model, the optimal range of INR was calculated as 2.1 to 2.5. INRs<2.0 and >3.0 were associated with a >2-fold increase in complications, with a further steep rise beyond an INR>3.5. Concomitant clopidogrel use was associated with a significant increase in complications at all INRs (odds ratio=3.1; ±95% confidence interval, 1.4-7.4). Unfractionated heparin requirements to maintain a therapeutic activated clotting time during RFA was reduced by 50% in patients with an INR>2.0.. The optimal INR range during uninterrupted periprocedural anticoagulation using warfarin is narrow. Therefore, INR levels should be carefully monitored in preparation for RFA of atrial fibrillation.

Topics: Anticoagulants; Atrial Fibrillation; Catheter Ablation; Dose-Response Relationship, Drug; Electrocardiography; Female; Follow-Up Studies; Humans; Incidence; International Normalized Ratio; Male; Middle Aged; Postoperative Complications; Prevalence; Retrospective Studies; Risk Factors; United States; Warfarin

Pocket hematoma is a troublesome complication associated with the implantation of cardiac implantable electronic devices (CIEDs). This study aims to determinate the risk factors of pocket hematoma complications in relation to different antithrombotic strategies and severity of thrombocytopenia in Chinese patients.. We conducted a retrospective study of 1093 consecutive patients undergoing implantation of CIEDs and divided them into 3 groups: no antithrombotic group (n = 512), continuing antiplatelet group (n = 477), and temporarily discontinuing warfarin with or without heparin bridging strategy (n = 104).. A pocket hematoma developed in 40 patients (3.7%). The temporarily discontinuing warfarin group (7.7%) had a higher incidence of pocket hematoma than no oral antithrombotic group (2.1%) and continuing antiplatelet group (4.4%) (P = 0.012). The dual antiplatelet group (16.2%) and the heparin bridging strategy group (14.0%) had significantly higher incidence of pocket hematoma compared with the no antithrombotic group (2.1%; P < 0.001, both). Patients having aspirin or clopidogrel alone had low incidence of pocket hematoma (3.9% and 1.2%, respectively), similar to the no antithrombotic group (P = not significant). Multivariate analysis revealed that dual antiplatelet agents (P = 0.004), heparin bridging strategy (P < 0.001), and moderate to severe thrombocytopenia (P = 0.007) were independent predictors for pocket hematoma complications.. The use of dual antiplatelet agents, heparin bridging strategy, and the presence of moderate to severe thrombocytopenia significantly increased the risk of pocket hematoma complications in the periprocedural period of CIED implant. Aspirin or clopidogrel alone did not increase the risk of pocket hematoma complications.

Topics: Aged; Aged, 80 and over; Anticoagulants; Aspirin; China; Clopidogrel; Cross-Sectional Studies; Defibrillators, Implantable; Drug Therapy, Combination; Female; Hematoma; Heparin; Humans; Incidence; Male; Middle Aged; Platelet Aggregation Inhibitors; Postoperative Complications; Retrospective Studies; Risk Factors; Thrombocytopenia; Ticlopidine; Warfarin

This report addresses whether it is safe to perform totally extraperitoneal (TEP) inguinal hernia repair for patients taking antithrombotic agents. Between January 2011 and June 2012, 77 patients (70 men, 7 women) underwent TEP repair at Osaka Police Hospital, 22 (28.6 %) of whom had been treated with antithrombotic drugs preoperatively. Warfarin was stopped at least 3 days preoperatively and antiplatelet drugs were stopped at least 7 days preoperatively. Standard bridging intravenous heparin therapy was used according to the operative risk of each patient. The mean operative time, intraoperative bleeding, postoperative complications, and length of hospital stay did not differ significantly between these patients and a control group, although the patients on antithrombotic therapy were significantly older with higher surgical risk. No major complications or recurrence developed in either group. Our TEP repair method and bridging heparin therapy seem to be safe and feasible for minimizing postoperative complications.

Topics: Age Factors; Aged; Aged, 80 and over; Anticoagulants; Feasibility Studies; Female; Fibrinolytic Agents; Heparin; Hernia, Inguinal; Humans; Male; Middle Aged; Platelet Aggregation Inhibitors; Postoperative Complications; Preoperative Care; Retrospective Studies; Risk; Secondary Prevention; Treatment Outcome; Warfarin

Pulmonary vein isolation (PVI) for atrial fibrillation is associated with a transient increased risk of thromboembolic and hemorrhagic events. We hypothesized that dabigatran can be safely used as an alternative to continuous warfarin for the periprocedural anticoagulation in PVI.. A total of 999 consecutive patients undergoing PVI were included; 376 patients were on dabigatran (150 mg), and 623 patients were on warfarin with therapeutic international normalized ratio. [corrected] Dabigatran was held 1 to 2 doses before PVI and restarted at the conclusion of the procedure or as soon as patients were transferred to the nursing floor. Propensity score matching was applied to generate a cohort of 344 patients in each group with balanced baseline data. Total hemorrhagic and thromboembolic complications were similar in both groups, before (3.2% versus 3.9%; P=0.59) and after (3.2% versus 4.1%; P=0.53) matching. Major hemorrhage occurred in 1.1% versus 1.6% (P=0.48) before and 1.2% versus 1.5% (P=0.74) after matching in the dabigatran versus warfarin group, respectively. A single thromboembolic event occurred in each of the dabigatran and warfarin groups. Despite higher doses of intraprocedural heparin, the mean activated clotting time was significantly lower in patients who held dabigatran for 1 or 2 doses than those on warfarin.. Our study found no evidence to suggest a higher risk of thromboembolic or hemorrhagic complications with use of dabigatran for periprocedural anticoagulation in patients undergoing PVI compared with uninterrupted warfarin therapy.

Topics: Aged; Anticoagulants; Atrial Fibrillation; Benzimidazoles; beta-Alanine; Confidence Intervals; Dabigatran; Dose-Response Relationship, Drug; Drug Administration Schedule; Electrocardiography; Female; Follow-Up Studies; Humans; Intraoperative Care; Kaplan-Meier Estimate; Logistic Models; Male; Middle Aged; Perioperative Care; Postoperative Complications; Prospective Studies; Registries; Risk Assessment; Severity of Illness Index; Survival Rate; Thromboembolism; Thrombolytic Therapy; Treatment Outcome; Warfarin

Topics: Anticoagulants; Aortic Valve; Aspirin; Bioprosthesis; Fibrinolytic Agents; Heart Valve Prosthesis Implantation; Humans; Postoperative Care; Postoperative Complications; Thrombosis; Warfarin

Uninterrupted oral anticoagulant (OA) therapy with warfarin has become the standard of care at many centers performing catheter ablation of atrial fibrillation (AF). Compared with warfarin, dabigatran, a direct thrombin inhibitor, has been demonstrated to reduce the risk of stroke in nonvalvular AF with similar bleeding risk. Few data exist on the safety profile of uninterrupted dabigatran therapy during AF ablation.. We compared the safety and efficacy of uninterrupted OA therapy with either warfarin or dabigatran in all patients undergoing AF catheter ablation at the University of Alabama at Birmingham between November 1, 2010 and January 31, 2012. All patients underwent a transesophageal echocardiogram (TEE) on the day of their ablation procedure to assess for the presence of intracardiac thrombi. All complications were identified and classified as bleeding, thromboembolic events, or other.. There were 212 patients in the dabigatran group and 251 patients in the warfarin group. The groups were well matched. There were 3 complications in the dabigatran group and 6 in the warfarin group (P = 0.45). There were 2 bleeding complications in the dabigatran group and 6 in the warfarin group (P = 0.23). There was one thromboembolic complication (a possible TIA) in the dabigatran group and none in the warfarin group (P = 0.28).. The administration of dabigatran is as safe and effective as warfarin for uninterrupted OA therapy during catheter ablation of AF.

Topics: Administration, Oral; Anticoagulants; Antithrombins; Atrial Fibrillation; Benzimidazoles; beta-Alanine; Catheter Ablation; Dabigatran; Echocardiography, Transesophageal; Female; Humans; Male; Middle Aged; Postoperative Complications; Pulmonary Veins; Warfarin

Vascular complications are a known risk of catheter-based pulmonary vein antral isolation (PVAI). Procedure-related thromboembolic events necessitate full-dose anticoagulation, which worsens outcomes in the event of vascular access injury.. Real-time ultrasound allows direct visualization of vascular structures. We hypothesized that ultrasound use with venipuncture reduces vascular complications associated with PVAI.. Retrospective analysis of all adverse events occurring with PVAI was performed during two periods: 2005-2006 when ultrasound was not used and 2008-2010 when ultrasound was routinely employed. All patients received full-dose IV heparin during PVAI. In the no ultrasound cohort, only 14 % underwent PVAI without stopping warfarin, while 91 % of patients in the ultrasound cohort were on continued warfarin. Only patients deemed at high risk for thromboembolism with a periprocedural international normalized ratio (INR) less than 2 were bridged with subcutaneous low-molecular-weight heparin.. Ultrasound reduced total vascular complications (1.7 vs. 0.5 %, p < 0.01) and decreased the incidence of major vascular complications by sevenfold. Warfarin with INR ≥ 1.2 on the day of PVAI was associated with more vascular complications (4.3 vs. 1.2 %, p < 0.01). Ultrasound guidance overcame the risk associated with warfarin therapy. Vascular complications in anticoagulated patients with INR ≥ 1.2 using ultrasound guidance were two- and ninefold lower than those in patients not using ultrasound with an INR < 1.2 (0.5 vs. 1.2 %, p < 0.05) and INR ≥ 1.2 (0.5 vs. 4.3 %, p < 0.01), respectively.. Ultrasound-guided venipuncture improves the safety profile of PVAI, reducing vascular complications in patients on warfarin to levels below those with no ultrasound and off warfarin.

Topics: Aged; Aged, 80 and over; Anticoagulants; Catheter Ablation; Causality; Comorbidity; Computer Systems; Female; Humans; Male; Ohio; Phlebotomy; Postoperative Complications; Prevalence; Pulmonary Veins; Retrospective Studies; Risk Factors; Surgery, Computer-Assisted; Treatment Outcome; Ultrasonography; Venous Thromboembolism; Warfarin

Topics: Atrial Fibrillation; Female; Humans; International Normalized Ratio; Male; Postoperative Complications; Warfarin

Left atrial catheter ablation for patients with atrial fibrillation (AF) requires periprocedural anticoagulation to minimize thromboembolic complications. High rates of major bleeding complications using dabigatran etexilate for periprocedural anticoagulation have been reported, raising concerns regarding its safety during left atrial catheter ablation. We sought to evaluate the safety and efficacy of a dabigatran use strategy versus warfarin, at a single high-volume AF ablation center.. We performed a retrospective analysis on consecutive patients undergoing left atrial ablation at Vanderbilt Medical Center from January 2011 through August 2012 with a minimum follow-up of 3 months. Patient cohorts were divided into two groups, those utilizing dabigatran etexilate pre- and post-ablation and those undergoing ablation on dose-adjusted warfarin, with or without low-molecular-weight heparin bridging. Dabigatran was held 24-30 h pre-procedure and restarted 4-6 h after hemostasis was achieved. We evaluated all thromboembolic and bleeding complications at 3 months post-ablation.. A total of 254 patients underwent left atrial catheter ablation for atrial fibrillation or left atrial flutter. Periprocedural anticoagulation utilized dabigatran in 122 patients and warfarin in 135 patients. Three late thromboembolic complications occurred in the dabigatran group (2.5 %), compared with one (0.7 %) in the warfarin group (p = 0.28). The dabigatran group had similar minor bleeding (2.5 vs. 7.4 %, p = 0.07), major bleeding (1.6 vs. 0.7 %, p = 0.51), and composite of bleeding and thromboembolic complications (6.6 vs. 8.9 %, p = 0.49) when compared to warfarin. There were no acute thromboembolic complications in either group (<24 h post-ablation).. In patients undergoing left atrial catheter ablation for AF or left atrial flutter, use of periprocedural dabigatran etexilate provides a safe and effective anticoagulation strategy compared to warfarin. A prospective randomized study is warranted.

Topics: Adult; Anticoagulants; Atrial Fibrillation; Atrial Flutter; Benzimidazoles; beta-Alanine; Catheter Ablation; Comorbidity; Dabigatran; Embolism; Female; Humans; Incidence; Male; Middle Aged; Postoperative Complications; Premedication; Retrospective Studies; Risk Assessment; Stroke; Tennessee; Treatment Outcome; Warfarin

Aminoglycosides are useful antimicrobial agents for treating infective endocarditis; however, they occasionally cause troublesome side effects, such as nephrotoxicity and ototoxicity. We herein report a case of infective endocarditis caused by Enterococcus faecalis that was treated successfully with continuous infusion of ampicillin without adjunctive aminoglycosides. The serum ampicillin concentrations were higher than the minimal inhibitory concentration for the target strain. Although the use of ampicillin monotherapy is currently avoided because double β-lactam therapy is reportedly more effective, continuous penicillin administration remains an effective therapeutic choice for treating infective endocarditis.

Topics: Aged; Aminoglycosides; Ampicillin; Anti-Bacterial Agents; Anticoagulants; Arthroplasty, Replacement, Hip; Atrial Fibrillation; Contraindications; Diagnosis, Differential; Endocarditis, Bacterial; Enterococcus faecalis; Femoral Neck Fractures; Gram-Positive Bacterial Infections; Humans; Infusions, Intravenous; Male; Microbial Sensitivity Tests; Mitral Valve; Postoperative Complications; Practice Guidelines as Topic; Pyelonephritis; Streptomycin; Warfarin

There are limited data available to inform decision making regarding warfarin thromboprophylaxis early after mitral valve repair.. We studied 13,082 patients from The Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS ACSD) who underwent primary mitral valve repair between January 1, 2008, and June 30, 2010. Excluded were those having other major concomitant operations or with an indication/contraindication to warfarin. The predictors of warfarin administration at dismissal were evaluated.. In this cohort (median age 58 years; 59% male), warfarin was prescribed at hospital dismissal for 46% (5,963) of patients. Median postoperative length of stay was 5 days overall (6 days warfarin versus 5 days, p < 0.0001). Substantial surgeon and center variation existed, and multivariable analysis identified that warfarin use was more common among patients with postoperative atrial fibrillation (odds ratio [OR] 4.04, 95% confidence interval [CI]: 3.57 to 4.58), postoperative neurologic events (stroke OR 1.72, 95% CI: 1.08 to 2.71; transient ischemic attack/reversible ischemic neurologic deficit OR 6.29, 95% CI: 2.67 to 14.84), and preoperative arrhythmia (OR 2.49, 95% CI: 1.84 to 3.38). Warfarin use was less common among patients having surgery in the more recent era (OR 0.92, 95% CI: 0.89 to 0.96, per half-year increase in date of surgery), those requiring intraoperative transfusion of red blood cells (OR 0.82, 95% CI: 0.71 to 0.96), and patients with advanced heart failure (New York Heart Association functional class IV OR 0.77, 95% CI: 0.59 to 1.00).. At present, half of patients are prescribed warfarin after isolated mitral valve repair in North American cardiac surgical practice which may impact the length of hospital stay. Although patient-level predictors of warfarin prescription exist, center- and surgeon-level variations are prominent. There is a pressing need for a randomized trial both to guide therapy and to ascertain the potential for resource conservation.

Topics: Aged; Anticoagulants; Aspirin; Cohort Studies; Confidence Intervals; Databases, Factual; Female; Follow-Up Studies; Heart Valve Diseases; Heart Valve Prosthesis Implantation; Humans; Length of Stay; Male; Middle Aged; Mitral Valve; Multivariate Analysis; Needs Assessment; Odds Ratio; Patient Discharge; Postoperative Complications; Randomized Controlled Trials as Topic; Retrospective Studies; Thromboembolism; Treatment Outcome; Warfarin

Topics: Anticoagulants; Benzimidazoles; beta-Alanine; Dabigatran; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Hemorrhage; Humans; Postoperative Complications; Thrombosis; Warfarin

Topics: Anticoagulants; Aortic Valve; Bioprosthesis; Heart Valve Prosthesis; Humans; Postoperative Care; Postoperative Complications; Warfarin

There is considerable controversy regarding the best method to prevent venous thromboembolism. In 2008, the American College of Chest Physicians (ACCP) published specific guidelines recommending the use of ow-molecular-weight heparin or warfarin, and a target international normalised ratio of 2.0-3.0 for a duration of at least 7-10 days, after elective knee arthroplasties. Many orthopaedic surgeons believe that these recommendations are biased toward reducing deep venous thrombosis (DVT), but neglect the implicated possibility of a higher incidence of wound complications. In order to enable an objective evaluation of the fit of the ACCP recommendations to the needs of our local cohort of patients, we aimed to look at the incidence of DVT in our local population.. This study was a prospective observational study involving existing local patients in Singapore General Hospital, Singapore, who underwent total knee arthroplasty (TKA) and were on a short course of chemothromboprophylaxis (< 7 days) after the operation. The incidence of DVT in patients was evaluated using DVT imaging 4-6 days after the operation and at one month after the operation.. In our study cohort, the prevalence of DVT during the period between postoperative Days 4 and 6 was 12% (11% were distal DVT and 1% was proximal DVT). Only 9% of the patients had DVT one month after the operation. Using chi-square analysis, we found that there was no significant increase in the number of DVT and pulmonary embolism cases 4-6 days and 1 month after the operation (p > 0.05).. Contrary to the ACCP guidelines, a short course of chemothromboprophylaxis post TKA, lasting no more than 7 days, is safe and adequate in the low-risk Asian population.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Arthroplasty, Replacement, Knee; Drug Administration Schedule; Female; Follow-Up Studies; Heparin, Low-Molecular-Weight; Humans; Incidence; Male; Middle Aged; Osteoarthritis, Knee; Postoperative Complications; Prognosis; Prospective Studies; Singapore; Treatment Outcome; Venous Thrombosis; Warfarin

We aimed to determine the possible factors leading to re-operation in patients undergoing mechanical valve replacement and to investigate the relationship between valvular thrombus formation and mean platelet volume.. The medical records of 43 patients with mechanical valve implantation, who were admitted to the Department of Cardiovascular Surgery of Dr Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital between 2000 and 2005 were analysed retrospectively. Data recorded included demographic characteristics, valve type, size and location, implantation position, warfarin use, INR level, additional cardiac intervention, presence of left atrial thrombus, valvular thrombus, pannus formation, perivalvular leak, left atrial aneurysm, platelet count and mean platelet volume (MPV), bleeding after the primary surgery and/or revision of surgery due to other reasons, valve protection, aortic root expansion, presence of valve calcification and infective endocarditis, pre- and postoperative rhythm pattern, brand name of prosthesis, distance of the patient's house from a cardiac surgery centre, and concomitant noncardiac systemic diseases.. Mean age was 49.3 years (range 19-78 years). Of the patients, 51% (n = 22) were males and 49% (n = 21) were females. The re-operation mortality was 11.6%. Age, gender, valve type, brand of valve prosthesis, and implantation position were not risk factors for re-operation. The MPV was higher and statistically significant in patients with valvular thrombus during re-operation (p < 0.001). MPV was determined to be an independent risk factor with 85% sensitivity and 87% specificity.. MPV and INR levels should be closely monitored when designing individualised postoperative medical treatment for patients undergoing heart valve re-operation.

Topics: Adult; Aged; Anticoagulants; Female; Heart Valve Diseases; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; International Normalized Ratio; Male; Mean Platelet Volume; Middle Aged; Postoperative Complications; Predictive Value of Tests; Prosthesis Design; Prosthesis Failure; Reoperation; Retrospective Studies; Risk Factors; Thrombosis; Treatment Outcome; Turkey; Warfarin; Young Adult

Thromboembolic events and anticoagulation-associated bleeding events represent frequent complications following cardiac mechanical valve replacement. Management guidelines regarding the timing for resuming anticoagulation therapy following a surgically treated subdural hematoma (SDH) in patients with mechanical valves remains to be determined.. To determine optimal anticoagulation management in patients with mechanical heart valves following treatment of SDH.. Outcomes were retrospectively reviewed for 12 patients on anticoagulation therapy for thromboembolic prophylaxis for mechanical cardiac valves who underwent surgical intervention for a SDH at the Johns Hopkins Hospital between 1995 and 2010.. The mean age at admission was 71 years. All patients had St. Jude's mechanical heart valves and were receiving anticoagulation therapy. All patients had their anticoagulation reversed with vitamin K and fresh frozen plasma and underwent surgical evacuation. Anticoagulation was withheld for a mean of 14 days upon admission and a mean of 9 days postoperatively. The average length of stay was 19 days. No deaths or thromboembolic events occurred during the hospitalization. Average follow-up time was 50 months, during which two patients had a recurrent SDH. No other associated morbidities occurred during follow-up.. Interruptions in anticoagulation therapy for up to 3 weeks pose minimal thromboembolic risk in patients with mechanical heart valves. Close follow-up after discharge is highly recommended, as recurrent hemorrhages can occur several weeks after the resumption of anticoagulation.

Topics: Aged; Anticoagulants; Aspirin; Enoxaparin; Female; Follow-Up Studies; Heart Valve Prosthesis Implantation; Hematoma, Subdural; Humans; Male; Middle Aged; Morbidity; Patient Discharge; Platelet Aggregation Inhibitors; Postoperative Complications; Retrospective Studies; Risk Factors; Thromboembolism; Warfarin

The Heart Rhythm Society, European Heart Rhythm Association, and European Cardiac Arrhythmia Society jointly recommend indefinite warfarin anticoagulation in patients with CHADS2 (congestive heart failure, hypertension, age, diabetes, and stroke) score of at least 2 who have undergone ablation for atrial fibrillation. This study determined the impact of CHADS2 score on risk of late stroke or transient ischemic attack after the performance of a surgical Cox maze procedure.. A retrospective review of 433 patients who underwent a Cox maze procedure at our institution was conducted. Three months after surgery, warfarin was discontinued regardless of CHADS2 score if the patient showed no evidence of atrial fibrillation, was off antiarrhythmic medications, and had no other indication for anticoagulation. A follow-up questionnaire was used to determine whether any neurologic event had occurred since surgery.. Follow-up was obtained for 90% of the study group (389/433) at a mean of 6.6 ± 5.0 years. Among these patients, 32% (125/389) had a CHADS2 score of at least 2, of whom only 40% (51/125) remained on long-term warfarin after surgery. Six patients had late neurologic events (annualized risk of 0.2%). Neither CHADS2 score nor warfarin anticoagulation was significantly associated with the occurrence of late neurologic events. Among the individual CHADS2 criteria, both diabetes mellitus and previous stroke or transient ischemic attack were predictive of late neurologic events.. The risk of stroke or transient ischemic attack in patients after a surgical Cox maze procedure was low and not associated with CHADS2 score or warfarin use. Given the known risks of warfarin, we recommend discontinuation of anticoagulation 3 months after the procedure if the patient has no evidence of atrial fibrillation, has discontinued antiarrhythmic medications, and is without any other indication for systemic anticoagulation.

Topics: Age Factors; Aged; Anticoagulants; Atrial Fibrillation; Cardiac Surgical Procedures; Diabetes Complications; Heart Failure; Humans; Hypertension; Ischemic Attack, Transient; Patient Acuity; Postoperative Complications; Retrospective Studies; Risk Factors; Stroke; Thromboembolism; Time Factors; Warfarin

The study aimed to determine if mitral valve repair (MVRR) or bioprosthetic mitral valve replacement (BMVR) without postoperative anticoagulation is associated with a similar risk of thromboembolism and death as anticoagulation.. We retrospectively reviewed our 2004-09 experience in 249 MVRR and bioprosthetic replacement patients (53% female; 63 year mean age). Concurrent procedures principally included antiarrhythmic surgery, aortic valve replacement, tricuspid valve repair and coronary bypass grafting. Warfarin therapy was instituted at the discretion of the surgeon. Thirty-day, a period known to have the highest risk of valve-related thromboembolism, outcomes were compared relying on the incidence of stroke and death as surrogates of thromboembolic complications. Intermediate-term survival was compared between the groups using Cox proportional hazard models. The mean follow-up was 2.9 years. Given the non-randomized warfarin use, a propensity score using patient comorbidities and concurrent procedures was created and added to the Cox models.. One hundred and ninety-two (77%) patients were discharged on warfarin and 57 (23%) were discharged without warfarin. Thirty-day mortality in patients discharged from the index hospitalization was 1.2% and was similar for the two groups (P = 0.99). Four ischaemic perioperative strokes were detected; 3 in the warfarin group and 1 in the no warfarin group (P = 0.99). Overall survival was 84%, with 84% survival in the warfarin group and 86% in the no warfarin group (P = 0.79). Bleeding complications were comparable between the two groups (P = 0.72). In a multivariate analysis, warfarin was not related to mortality.. Despite current guidelines recommending postoperative anticoagulation following MVRR or bioprosthetic replacement, the avoidance of warfarin does not increase perioperative complications and has no impact on intermediate survival. Accordingly, a prospective randomized study to adjudicate the role of extended warfarin thromboprophylaxis in mitral valve surgery is warranted.

Topics: Aged; Anticoagulants; Bioprosthesis; Female; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Mitral Valve; Postoperative Complications; Postoperative Period; Proportional Hazards Models; Statistics, Nonparametric; Stroke; Warfarin

Extrahepatic portal vein obstruction (EHPVO) is an important cause of chronic portal hypertension in children. Although usually idiopathic in etiology, genetic and acquired thrombophilia have been implicated in EHPVO. Meso-Rex bypass is increasingly used to treat EHPVO in children.. The objective of this study is to assess the relationship of postoperative anticoagulation strategies and thrombophilic risk factors to the development of bypass thrombosis following the meso-Rex bypass.. Records of children who underwent meso-Rex bypass for EHPVO at a single institution from 1999 to 2009 were reviewed, and preoperative thrombophilia testing, perioperative anticoagulation strategies, and postoperative bypass patency based on imaging at last follow-up were examined.. Sixty-five children with EHPVO underwent a first time meso-Rex bypass during the study period, and 9 of 65 (14 %) developed bypass thrombosis. The use of warfarin in the postoperative period was more common among children with thrombosed shunts than among those with open shunts [63 % vs. 20 %; OR, 6.5 (95 % CI, 1.3-31.5), p = 0.022]. The contribution of genetic or acquired thrombophilia to shunt thrombosis was inconclusive given variability in testing.. Choice of anticoagulation following meso-Rex bypass may affect postoperative incidence of bypass thrombosis. Role of thrombophilic risk factors in the development of shunt thrombosis remains unclear.

Topics: Anticoagulants; Chi-Square Distribution; Child, Preschool; Female; Humans; Hypertension, Portal; Infant; Male; Postoperative Complications; Retrospective Studies; Risk Factors; Thrombophilia; Treatment Outcome; Venous Thrombosis; Warfarin

The purpose of this study was to report the observed outcomes of anticoagulated patients undergoing transconjunctival sutureless vitrectomies using subconjunctival anesthesia without preoperative cessation of anticoagulation and antiplatelet (AC/AP) agents.. A retrospective chart review was performed on patients taking AC/AP agents who were undergoing transconjunctival sutureless vitrectomies with subconjunctival anesthesia between January 2007 and June 2009. Intra- and postoperative complications (such as massive hemorrhage), anatomical results, satisfactory analgesia (informed by patients and recorded by surgeon), anatomical results, and visual acuity were documented.. Sixty-three surgeries were performed on 56 eyes of 52 patients. Thirty-two patients were taking aspirin and clopidogrel, 18 were taking warfarin, 5 were taking clopidogrel, 3 were taking aspirin and warfarin, 2 were taking acetylsalicylic acid and dipyridamole, and 1 was taking warfarin and clopidogrel. All patients had satisfactory analgesia. No intraoperative complications occurred. Seven eyes (13%) had postoperative vitreous hemorrhage. Overall, 79% of patients had improved postoperative visual acuity, 16% of patients had unchanged visual acuity, and 5% of patients had worse visual acuity at last follow-up visit.. Medical disease requiring systemic AC/AP therapy is often present in patients with vitreoretinal disease. Transconjunctival sutureless vitrectomies using subconjunctival anesthesia may be a safe and effective surgical option in select patients in whom cessation of AC/AP and/or delayed ophthalmic intervention is imprudent.

Topics: Adult; Aged; Aged, 80 and over; Anesthesia, Local; Anesthetics, Local; Anticoagulants; Aspirin; Bupivacaine; Clopidogrel; Conjunctiva; Female; Humans; Intraoperative Complications; Male; Middle Aged; Platelet Aggregation Inhibitors; Postoperative Complications; Retrospective Studies; Suture Techniques; Ticlopidine; Treatment Outcome; Visual Acuity; Vitrectomy; Warfarin

Topics: Anticoagulants; Benzimidazoles; beta-Alanine; Blood Coagulation Disorders; Clinical Trials as Topic; Dabigatran; Humans; Morpholines; Postoperative Complications; Pyrazoles; Pyridones; Rivaroxaban; Stroke; Thiophenes; Warfarin

Subtherapeutic international normalized ratio (INR) is frequently encountered in clinical practice, and patients with high-risk atrial fibrillation (AF) and with mechanical heart valve (MHV) with inadequate anticoagulation may be exposed to an increased risk of thromboembolic events (TE). However, there are no prospective data evaluating this risk. Consecutive patients with a history of stable anticoagulation, but with a subtherapeutic INR, were prospectively included. Data on use and dose of low-molecular weight heparin (LMWH) bridging therapy were collected. The incidence of objectively confirmed TE and of major bleeding events within 90 days after the index INR was assessed. Five hundred and one patients with INR value 0.5-1 INR units below the lower limit of the patient-specific target INR were included in the study (280 with MHV and 221 with AF and CHADS2 score ≥3). LMWH was prescribed for 64 patients (12.8%). During follow-up, seven patients had a TE (1.40%; 95% confidence interval 0.68, 2.86%; 5.58 events for 100 patients year). All the events occurred within 14 days after the index INR. When we consider only patients who did not receive bridging therapy, the incidence of TE was 1.14% (5 of 437 patients; 95% confidence interval 0.49, 2.64%; 4.58 events for 100 patients year). There were no major bleeding events. The risk of TE in this population was not negligible. Given the frequent observation of subtherapeutic INR levels when monitoring vitamin K antagonists, this finding warrants additional investigation to improve the management of these patients.

Topics: Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Comorbidity; Female; Follow-Up Studies; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Hemorrhage; Heparin, Low-Molecular-Weight; Humans; Incidence; International Normalized Ratio; Male; Middle Aged; Postoperative Complications; Prospective Studies; Risk; Thromboembolism; Thrombophilia; Warfarin

Topics: Aspirin; Blood Coagulation; Cardiovascular Diseases; Coronary Artery Disease; Drug Therapy, Combination; Humans; Ischemic Attack, Transient; Myocardial Infarction; Platelet Aggregation Inhibitors; Postoperative Complications; Preoperative Period; Stroke; Thrombosis; Warfarin

Uninterrupted oral anticoagulation (OAC) therapy can be the preferred strategy in patients with atrial fibrillation at moderate to high risk of thromboembolism undergoing percutaneous coronary intervention (PCI). To evaluate the need for additional heparins in addition to therapeutic peri-PCI OAC, we assessed bleeding complications and major adverse cardiac and cerebrovascular events in 414 consecutive patients undergoing PCI during therapeutic (international normalized ratio 2 to 3.5) periprocedural OAC. Patients were divided into those with no (n = 196) and with (n = 218) additional use of periprocedural heparins. No differences in major adverse cardiac and cerebrovascular events (4.1% vs 3.2%, p = 0.79) or major bleeding (1.0% vs 3.7%, p = 0.11) were detected, but access site complications (5.1% vs 11.0%, p = 0.032) were less frequent in those without additional heparins. When adjusted for propensity score, patients with additional heparins had a higher risk of access site complications (odds ratio 2.6, 95% confidence interval 1.1 to 6.1, p = 0.022) without any increased risk of any other adverse event. Analysis of 1-to-1 propensity-matched pairs showed a significantly higher risk of access site complication in patients receiving additional AC (13.1% vs 5.7%, p = 0.049). In conclusion, therapeutic warfarin treatment seems to provide sufficient AC for PCI. Additional heparins are not needed and may increase access site complications.

Topics: Administration, Oral; Aged; Angioplasty, Balloon, Coronary; Anticoagulants; Aspirin; Atrial Fibrillation; Clopidogrel; Coronary Artery Disease; Drug Therapy, Combination; Female; Fibrinolytic Agents; Follow-Up Studies; Heparin; Humans; Injections, Subcutaneous; Male; Platelet Aggregation Inhibitors; Postoperative Complications; Preoperative Care; Prospective Studies; Thrombosis; Ticlopidine; Time Factors; Treatment Outcome; Warfarin

Topics: Bioprosthesis; Female; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Hemorrhage; Humans; Male; Postoperative Complications; Thromboembolism; Warfarin

The American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend a three-month administration of warfarin following bioprosthetic valve replacement (BVR). However, strong evidence supporting this recommendation is lacking, making process variation likely.. In the ANSWER Registry, a total of 386 patients who had received either Epic or Biocor BVRs between May 2007 and August 2008 at 40 centers was enrolled. Patterns of discharge anticoagulation and outpatient International Normalized Ratio (INR) values were collected. Mortality, embolic, and bleeding events were assessed up to six months after BVR.. The median patient age was 74 years (interquartile range (IQR): 67-80 years), 39% of patients were female, and 65% were classified as a high thromboembolic risk. Warfarin was prescribed in 38% of all BVR patients, and in 49% of those at high risk of thromboembolism. The median time to therapeutic INR was nine days (IQR: 1 to 18 days), and 20% of patients failed to reach therapeutic levels. Among those patients achieving a therapeutic INR, 78% and 57% respectively had at least one subtherapeutic or supratherapeutic INR during the subsequent follow up to three months. During the follow up, patients treated with warfarin had similar rates of embolic events (2.8% versus 3.1%, p = 0.884), but a substantially higher incidence of bleeding than those not treated with warfarin (12% versus 3%, p = 0.0012). Among patients who were anticoagulated, those with supratherapeutic INR-values had a seven-fold higher risk for overt bleeding events (26% versus 3%).. Anticoagulation strategies after BVR are highly variable. In this population, challenges in achieving and maintaining therapeutic warfarin anticoagulation are common, and are associated with an increased risk of bleeding. Further studies are required to clarify the optimal post-BVR anticoagulation strategy.

Topics: Aged; Aged, 80 and over; Anticoagulants; Bioprosthesis; Blood Coagulation; Drug Monitoring; Female; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Hemorrhage; Humans; International Normalized Ratio; Male; Mortality; Postoperative Care; Postoperative Complications; Risk Adjustment; Thromboembolism; Time Factors; Treatment Outcome; Warfarin

Since January 1990, a variety of mechanical valves (St. Jude Medical, CarboMedics, ATS Medical) have been implanted routinely at the authors' institution. The study aim was to analyze, retrospectively, the 20-year clinical results of those mechanical valves, and to challenge the anticoagulation policy employed over the years.. Between January 1990 and December 2008, a total of 2,108 mechanical valves was inserted into 1,887 consecutive patients (1,346 aortic, 725 mitral, 27 tricuspid, 10 pulmonary). The mean age of the patients was 63 +/- 13.2 years, and the majority (61%) were males. Preoperatively, 71% the patients were in NYHA class > or = III (average 3.01). The most frequent comorbidities included: atrial fibrillation (n = 594), coronary disease (n = 567) and diabetes (n = 398). The follow up (99% complete) totaled 13,721 patient-years (pt-yr), and ranged from 12 to 241 months (average 84 months).. In-hospital mortality was 5.2% (n = 98, 14 valve-related). Of the 629 late deaths, the majority were cardiac (n = 276). Survival (Kaplan-Meier estimation) was significantly better for aortic valve patients compared to mitral or multiple valve replacement (Mantel-Cox, p < 0.0001). The overall linearized incidences (as %/pt-yr) were: valve thrombosis 0.31, thromboembolism 1.08, and bleeding 0.91. However, as repeated events occurred in several patients, the hazard function was not constant. Multivariate analysis (Cox regression model) showed age > 70 years (p < 0.0001), NYHA class > or = III (p < 0.0001), non-sinus rhythm (p = 0.001), concomitant coronary artery bypass grafting (p = 0.008) and higher International Normalized Ratio (INR) values (p = 0.013) as significant risk factors for death, with a trend for redo operations (p = 0.052). Multivariate analysis found variable INR, non-sinus rhythm and NYHA class > II as significant risk factors for thromboembolism, while long-acting coumadin and NYHA class > II were significant risk factors for bleeding.. This 20-year experience demonstrated excellent clinical outcomes for patients with mechanical prostheses, with no valve structural failure and an acceptable incidence of adverse events. INR values between 2-2.5 for aortic valve patients, and 3-3.5 for mitral valve patients, yielded the fewest major adverse events.

Topics: Aged; Anticoagulants; Belgium; Blood Coagulation; Cause of Death; Drug Monitoring; Female; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Hemorrhage; Humans; International Normalized Ratio; Kaplan-Meier Estimate; Male; Middle Aged; Outcome Assessment, Health Care; Policy Making; Postoperative Complications; Proportional Hazards Models; Retrospective Studies; Risk Factors; Thromboembolism; Warfarin

To describe the incidence of thrombotic complications across all 3 stages of single ventricle palliation and the association between thromboprophylaxis use and thrombotic risk.. Two separate cross-sectional studies were performed that included 195 patients born between 2003-2008 and 162 patients who underwent Fontan after 2000.. The incidence of thrombotic complications was 40% and 28% after initial palliation and superior cavopulmonary connection (SCPC), respectively; 5-year freedom from thrombotic complications after Fontan was 79%. Thromboprophylaxis was initiated for 70%, 46%, and 94% of patients after initial palliation, SCPC, and Fontan, respectively. Thromboprophylaxis with enoxaparin (vs no thromboprophylaxis) was associated with a reduction in risk of thrombotic complications after initial palliation (hazard ratio [HR] 0.5, P = .05) and SCPC (HR 0.2, P = .04). Thromboprophylaxis with warfarin was associated with a reduction in thrombotic complications after Fontan (HR 0.27, P = .05 vs acetylsalicylic acid; HR 0.18, P = .02 vs no thromboprophylaxis). Thrombotic complications were associated with increased mortality after initial palliation (HR 5.5, P < .001) and SCPC (HR 12.5, P < .001). Three patients experienced major bleeding complications without permanent sequelae (2 enoxaparin, 1 warfarin).. Given the negative impact of thrombotic complications on survival, the low risk of serious bleeding complications, and the association between thromboprophylaxis and lowered thrombotic complication risk across all 3 palliative stages, routine use of thromboprophylaxis from the initial palliation to the early post-Fontan period in this population may be indicated.

Topics: Anticoagulants; Cross-Sectional Studies; Enoxaparin; Female; Fontan Procedure; Heart Defects, Congenital; Heart Ventricles; Humans; Infant; Infant, Newborn; Male; Palliative Care; Postoperative Complications; Thrombosis; Warfarin

Cardiac disease in pregnancy is a common problem in under-resourced countries and a significant cause of maternal morbidity and mortality. A large proportion of patients with cardiac disease have prosthetic mechanical heart valve replacements, warranting prophylactic anticoagulation.. To evaluate obstetric outcomes in women with prosthetic heart valves in an under-resourced country.. A retrospective chart review was performed of 61 pregnant patients with prosthetic valve prostheses referred to our tertiary hospital over a five-year period.. Sixty-one (6%) of 1 021 pregnant women with A diagnosis of cardiac disease had prosthetic heart valves. Fifty-nine had mechanical valves and were on prophylactic anticoagulation therapy, three had stopped their medication prior to pregnancy and two had bioprosthetic valves. There were forty-one (67%) live births, two (3%) early neonatal deaths, 12 (20%) miscarriages and six (10%) stillbirths. Maternal complications included mitral valve thrombosis (n = 4), atrial fibrillation (n = 8), infective endocarditis (n = 6), caesarean section wound haematomas (n = 7), broad ligament haematoma (n = 1) and warfarin embryopathy (n = 4). Haemorrhagic complications occurred in five patients and all five required blood transfusions.. Prophylactic anticoagulation with warfarin in patients with mechanical heart valve prostheses was associated with high rates of maternal and neonatal complications, including significant foetal wastage in the first and early second trimesters of pregnancy. Health professionals providing care for pregnant women with prosthetic heart valves must consistently advise on family planning matters, adherence to anticoagulation regimes and consider the use of prophylactic anticoagulant regimens other than warfarin, particularly during the first trimester of pregnancy.

Topics: Abnormalities, Drug-Induced; Adult; Anticoagulants; Clinical Audit; Female; Follow-Up Studies; Heart Valve Diseases; Heart Valve Prosthesis; Humans; Incidence; Middle Aged; Nasal Bone; Postoperative Complications; Pregnancy; Pregnancy Complications, Cardiovascular; Prognosis; Retrospective Studies; South Africa; Tertiary Care Centers; Time Factors; Warfarin; Young Adult

Multimodal thromboprophylaxis includes preoperative thromboembolic risk stratification and autologous blood donation, surgery performed under regional anaesthesia, postoperative rapid mobilisation, use of pneumatic compression devices and chemoprophylaxis tailored to the patient's individual risk. We determined the 90-day rate of venous thromboembolism (VTE), other complications and mortality in patients who underwent primary elective hip and knee replacement surgery with multimodal thromboprophylaxis.. A total of 1,568 consecutive patients undergoing hip and knee replacement surgery received multimodal thromboprophylaxis: 1,115 received aspirin, 426 received warfarin and 27 patients received low molecular weight heparin and warfarin with or without a vena cava filter.. The rate of VTE, pulmonary embolism, proximal deep vein thrombosis (DVT) and distal DVT was 1.2, 0.36, 0.45 and 0.36 %, respectively, in patients who received aspirin. The rates in those who received warfarin were 1.4, 0.9, 0.47 and 0.47 %, respectively. The overall 90-day mortality rate was 0.2 %.. Multimodal thromboprophylaxis in which aspirin is administered to low-risk patients is safe and effective following primary total joint replacement.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Arthroplasty, Replacement; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Aspirin; Clinical Protocols; Combined Modality Therapy; Elective Surgical Procedures; Female; Heparin, Low-Molecular-Weight; Humans; Male; Middle Aged; New York City; Patient Readmission; Platelet Aggregation Inhibitors; Postoperative Complications; Pulmonary Embolism; Retrospective Studies; Survival Rate; Thromboembolism; Treatment Outcome; Venous Thrombosis; Warfarin; Young Adult

Patients with central nervous system (CNS) malignancies have a substantial risk for developing both thrombotic and bleeding disorders. The risk of venous thromboembolism (VTE) is substantially higher in these patients, both in the perioperative period and throughout their disease course. Patients with CNS malignancy harbor a latent hypercoagulability, which predisposes to VTE, as do postoperative immobility, hemiparesis, and other factors. The management of VTE in these patients is complex, given the significant morbidity and mortality associated with intratumoral hemorrhage. In the past, the perceived risk of intracranial hemorrhage limited the use of anticoagulation for the management of VTE with many favoring nonpharmacologic methods for prophylaxis and treatment. Inferior vena cava (IVC) filters have since lost favor at many centers given significant complications, which appear to be more frequent in patients with CNS malignancy. Recent studies have demonstrated safe and efficacious use of anticoagulation in these patients with a low incidence of intracranial hemorrhage. Treatment of established VTE is now recommended in this population with many centers favoring low-molecular-weight heparin (LMWH) versus oral warfarin for short- or long-term treatment. We advocate a multimodality approach utilizing compression stockings, intermittent compression devices, and heparin in the perioperative setting as the best proven method to reduce the risk of VTE. In the absence of a strict contraindication to systemic anticoagulation, such as previous intracranial hemorrhage or profound thrombocytopenia, we recommend LMWH in patients with newly diagnosed VTE and a CNS malignancy.

Topics: Antibodies, Monoclonal, Humanized; Anticoagulants; Arginine; Bevacizumab; Central Nervous System Neoplasms; Fondaparinux; Glioblastoma; Glioma; Hemorrhage; Heparin, Low-Molecular-Weight; Hirudins; Humans; Pipecolic Acids; Polysaccharides; Postoperative Complications; Pulmonary Embolism; Recombinant Proteins; Sulfonamides; Thrombocytopenia; Vena Cava Filters; Venous Thromboembolism; Venous Thrombosis; Warfarin

Although warfarin has traditionally been used for reducing risk of stroke in patients with atrial fibrillation, over the past year, the direct thrombin inhibitor dabigatran has become an accepted alternative. No study has conclusively investigated bleeding risks of patients treated with dabigatran immediately following radiofrequency catheter ablation (RFCA) procedures.. We evaluated 156 consecutive patients referred for RFCA of atrial arrhythmias: 31 patients were on dabigatran and 125 patients were on warfarin. The incidence of bleeding complications during the first 48 h and the first week following ablation were recorded and comparisons made using Fisher's exact test. Major complications were defined as hemorrhage requiring blood products or the need for vascular intervention. Minor complications were defined as prolonged bleeding from the catheter insertion site, hematoma formation, or development of ecchymosis. Our study also took into account the intraprocedure activated clotting time (ACT) levels in an effort to describe any differences between both patient groups.. There were no differences in age, gender, procedure type, or level of intraprocedural anticoagulation between the warfarin and dabigatran groups. No major bleeding complications were observed in either patient group at either 48 h or 1 week postprocedure. Six of the 31 dabigatran patients and 21 of the 125 warfarin patients had minor bleeding complications. There was no statistically significant difference between the incidence of minor bleeding complications between the two groups (p = 0.7384), although rebleeding was more commonly observed in patients on dabigatran. In regard to the intraprocedure ACT levels, there was more variability in the dabigatran patient group, and it was more difficult to achieve the goal ACT level, yet these results did not affect overall bleeding complications.. In our cohort, bleeding-related complications 48 h and 1 week post-ablation were similar for warfarin and dabigatran. Dabigatran is associated with more intraprocedural variability in ACT than warfarin.

Topics: Aged; Anticoagulants; Antithrombins; Atrial Fibrillation; Benzimidazoles; beta-Alanine; Catheter Ablation; Dabigatran; Female; Hemorrhage; Humans; Incidence; Male; Middle Aged; Postoperative Complications; Stroke; Treatment Outcome; Warfarin

Graft thrombosis immediately after surgery remains a problem for successful pancreas transplantation. The present study evaluated the efficacy of computed tomography (CT) angiography for monitoring of graft patency in the immediate postoperative period.. The study involved 119 patients who underwent pancreas transplantation between July 1992 and December 2009 in a single center. The anticoagulation strategy was heparin during and after transplantation and then oral warfarin for 1 to 6 months. Graft thrombosis was monitored using color Doppler ultrasonography until July 2005 (group A) and, thereafter, using CT angiography (group B). We retrospectively analyzed the efficacy of diagnosis of graft thrombosis in two groups. Graft survival was assessed using Kaplan-Meier analysis.. Group A comprised 51 patients, and group B comprised 68 patients. Total vascular thrombosis was diagnosed in three (5.9%) group A and one (1.4%) group B patients, and partial venous thrombosis was diagnosed in 1 (2.0%) group A and 19 (31.6%) group B patients. Eighteen of the 19 grafts with partial thrombosis in group B were successfully treated using heparin-based anticoagulant therapy. There were no CT contrast media-related complications in group B. In group B, graft survival rates were the same for grafts with partial thrombosis and grafts without thrombosis.. CT angiography was safe and effective for evaluating graft patency after pancreas transplantation. Partial vascular thrombosis in the immediate posttransplantation period showed no effect on graft survival under intensive anticoagulation and monitoring by CT angiography.

Topics: Adult; Angiography; Anticoagulants; Female; Graft Survival; Heparin; Humans; Incidence; Male; Pancreas; Pancreas Transplantation; Postoperative Complications; Postoperative Period; Retrospective Studies; Thrombosis; Time Factors; Tomography, X-Ray Computed; Ultrasonography, Doppler; Warfarin

Topics: Anticoagulants; Atrial Fibrillation; Benzimidazoles; beta-Alanine; Clinical Trials as Topic; Dabigatran; Europe; Humans; Postoperative Complications; Practice Guidelines as Topic; United States; Vascular Surgical Procedures; Venous Thromboembolism; Warfarin

A case of a baby born preterm with an antenatal diagnosis of aortic coarctation for which prostin was electively started at birth. The baby was found to be profoundly anaemic with no clear obstetric cause. Features consistent with antenatal intracerebral haemorrhage were noted on cranial ultrasonography in the context of severe coagulopathy, prompting investigations which confirmed fetal-maternal haemorrhage. It transpired that, following aortic and mitral valve replacements, the mother was anticoagulated with warfarin at conception, having misunderstood her cardiologist's advice that: 'you cannot get pregnant whilst on warfarin'. Following conversion to low molecular weight heparin, she suffered a stroke, thus warfarin was restarted, with an international normalised ratio of 3-4.7 during pregnancy. Following transfer to the paediatric intensive care unit, fetal warfarin syndrome was diagnosed. The coagulopathy and anaemia were corrected and aortic coarctation was excluded. The baby returned to the neonatal intensive care unit for ongoing care and was discharged home in good condition around his due date. At the present time, there is no clinically overt neurological deficit.

Topics: Abnormalities, Drug-Induced; Anemia; Anticoagulants; Aortic Coarctation; Blood Coagulation; Blood Coagulation Disorders; Female; Fetal Diseases; Heart Valves; Hemorrhage; Heparin, Low-Molecular-Weight; Humans; Infant, Newborn; Infant, Premature; Maternal-Fetal Exchange; Nasal Bone; Postoperative Complications; Pregnancy; Premature Birth; Stroke; Warfarin

Right heart thrombi are unusual complications of pulmonary embolism that are associated with a high early mortality. We present a case and transoesophageal echocardiography of a 65-year-old man who presented with pulmonary embolism, following routine knee replacement and was found to have a type A right heart thrombus. Despite the increased risk associated with this presentation, treatment with heparin alone was successful.

Topics: Acute Disease; Aged; Angiography; Anticoagulants; Arthroplasty, Replacement, Knee; Atrial Fibrillation; Echocardiography, Transesophageal; Electrocardiography; Heart Atria; Heparin; Humans; Male; Postoperative Complications; Pulmonary Embolism; Thrombosis; Tomography, X-Ray Computed; Treatment Outcome; Warfarin

A 35-year-old man developed priapism with the use of low-molecular-weight heparin and warfarin following repair of left brachial artery sustained after gunshot injury. Priapism progressed to penile gangrene despite decompression and distal shunt procedure leading to total penectomy and perineal urethrostomy. We describe the mechanism of anticoagulant (heparin and warfarin)-induced penile gangrene and the possible methods to avert such a devastating complication.

Topics: Adult; Anticoagulants; Brachial Artery; Dalteparin; Drug Therapy, Combination; Gangrene; Hemopneumothorax; Humans; International Normalized Ratio; Male; Penis; Perineum; Postoperative Care; Postoperative Complications; Priapism; Saphenous Vein; Thrombosis; Ultrasonography, Doppler, Color; Urethra; Warfarin; Wounds, Gunshot

We report on a 74-year-old woman who presented with embolic stroke of the brainstem and right cerebellum. She had undergone coronary bypass surgery and prophylactic ligation of the left atrial appendage in the past. On further investigations, a source of emboli was found to be an incompletely ligated left atrial appendage. Anticoagulation with warfarin if started after surgery would have reduced the risk of embolism in this patient.

Topics: Aged; Anticoagulants; Atrial Appendage; Coronary Artery Bypass; Female; Humans; Ligation; Postoperative Complications; Stroke; Warfarin

Topics: Aged; Angiography, Digital Subtraction; Angioplasty; Brachial Artery; Embolectomy; Embolism; Forearm; Hand; Heparin; Heparin, Low-Molecular-Weight; Humans; Ischemia; Male; Postoperative Care; Postoperative Complications; Radial Artery; Suction; Ulnar Artery; Ultrasonography, Doppler, Color; Urinary Bladder Neoplasms; Warfarin

To estimate the risk of hemorrhagic complications associated with 25-gauge pars plana vitrectomy (PPV) when warfarin (Coumadin; Bristol-Myers Squibb, New York, NY) or clopidogrel (Plavix; Bristol-Myers Squibb) are continued throughout the surgical period, as compared with a control group.. A single-center, retrospective, cohort study of 289 consecutive patients receiving either warfarin therapy or clopidogrel therapy or neither of those therapies who underwent 25-gauge PPV.. Included were 61 patients (64 eyes; 64 PPV procedures) in the warfarin group and 118 (125 eyes; 136 PPV procedures) in the clopidogrel group. Warfarin patients were subdivided into 4 groups by international normalized ratio (INR). A control group included 110 patients (110 eyes; 110 PPV procedures) who were not receiving warfarin or clopidogrel.. Retrospective chart review for which the criteria included: 25-gauge PPV, minimum age of 19 years, warfarin or clopidogrel use, and, if taking warfarin, an INR obtained within 5 days of surgery.. Incidence of intraoperative and postoperative hemorrhagic complications.. The most common indications for anticoagulation therapy included: atrial fibrillation (38%), valvular heart disease (17%), and thromboembolic disease (16%). The most common indications for antiplatelet therapy included: cardiac stent (49%), coronary artery bypass grafting (24%), and history of transient ischemic attack (16%). No patient experienced anesthesia-related hemorrhagic complications resulting from peribulbar or retrobulbar block. Transient vitreous hemorrhage occurred in 1 (1.6%) of 64 PPV procedures in the warfarin group (P = 0.6531), 5 (3.7%) of 136 PPV procedures in the clopidogrel group (P = 1.0), and 4 (3.6%) of 110 PPV procedures in the control group. No choroidal or retrobulbar hemorrhages occurred in any patient.. The rate of 25-gauge PPV hemorrhagic complications in patients who underwent systemic anticoagulation or who were receiving platelet inhibitor therapy is extremely low. Given the risks associated with stopping these therapies, the authors recommend that patients continue their current therapeutic regimen without cessation.

Topics: Aged; Anticoagulants; Cardiovascular Diseases; Choroid Hemorrhage; Clopidogrel; Humans; Incidence; Intraocular Pressure; Intraoperative Complications; Microsurgery; Middle Aged; Platelet Aggregation Inhibitors; Postoperative Complications; Retinal Diseases; Retrobulbar Hemorrhage; Retrospective Studies; Risk Factors; Ticlopidine; Visual Acuity; Vitrectomy; Vitreous Hemorrhage; Warfarin

Pulmonary vein antrum isolation (PVAI) has emerged as an effective treatment for drug-refractory atrial fibrillation (AF). However, thromboembolic events are important complications of this approach. Management of anticoagulation is essential to prevent thromboembolic complications and avoid bleeding complications. The purpose of this review is to outline the general principles followed at our AF centers to address the important issue of pre-, peri-, and postprocedural anticoagulation strategies during PVAI of AF. We initiate warfarin therapy prior to the ablation procedure and continue it through the procedure. Prior work has demonstrated that continuation of therapeutic warfarin during the radiofrequency catheter ablation reduces the risk of periprocedural stroke/transient ischemic attack without increasing the risk of hemorrhagic events. In fact, a strategy that interrupts warfarin anticoagulation may increase the risk of stroke, even with bridging with enoxaparin. Data from our work have shown that minor bleeding was more frequent in the patients bridged with heparin or enoxaparin. There was no significant difference in incidence of major bleeding complications among the patients with a therapeutic level of international normalized ratio (INR) compared with patients for whom bridging therapy was used. Furthermore, the strategy of ablation during a therapeutic INR could be more economical compared with bridging therapy with enoxaparin. Continuation of therapeutic warfarin during ablation of AF may be the best strategy, especially in patients with nonparoxysmal AF, patients with higher thromboembolic risk scores, and patients who require extensive ablation during PVAI of AF.

Topics: Anticoagulants; Atrial Fibrillation; Catheter Ablation; Comorbidity; Humans; Postoperative Complications; Prevalence; Pulmonary Veins; Risk Assessment; Risk Factors; Survival Analysis; Survival Rate; Thromboembolism; Warfarin

Warfarin is a commonly used anticoagulant whose effect in vitreoretinal surgery has not been well studied.. A series of 60 patients on warfarin therapy undergoing pars plana vitrectomy were retrospectively case controlled to 60 patients with similar presenting complaints. In addition, an online survey was performed of current practice in the UK.. 2% of the patients receiving vitrectomy were on warfarin. There were 33 males and 27 females with a median age of 72.5 years; follow-up was for a mean of 0.88 years. The international normalised ratio (INR) ranged between 0.94 and 4.6 (median 2.3). Two cases of suprachoroidal haemorrhages occurred in the control group (one with preoperative choroidal haemorrhage from dislocated lens nucleus), while none occurred in the warfarin group. 12 patients with rhegmatogenous retinal detachment (RRD) in the warfarin group presented with vitreous haemorrhage compared with only four in the control group (p=0.04). From the online survey, 48 respondents (81%) would ask patients to withhold warfarin prior to vitreoretinal surgery based on the INR.. There was no increase in complications in patients continuing to take warfarin compared with controls. Patients with RRD are more likely to have vitreous haemorrhage at presentation if they are on warfarin.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Case-Control Studies; Contraindications; Female; Humans; International Normalized Ratio; Intraoperative Complications; Male; Middle Aged; Postoperative Complications; Practice Guidelines as Topic; Retinal Detachment; Retrospective Studies; Risk Factors; Scleral Buckling; United Kingdom; Vitreoretinal Surgery; Vitreous Hemorrhage; Warfarin

Topics: Anticoagulants; Aspirin; Fontan Procedure; Health Care Surveys; Humans; Platelet Aggregation Inhibitors; Postoperative Complications; Practice Patterns, Physicians'; Registries; United Kingdom; Warfarin

Topics: Aged, 80 and over; Anti-Bacterial Agents; Anticoagulants; Bicuspid; Chronic Disease; Dental Caries; Epistaxis; Female; Follow-Up Studies; Humans; Incisor; International Normalized Ratio; Male; Middle Aged; Molar, Third; Oral Hemorrhage; Polypharmacy; Postoperative Complications; Tooth Extraction; Warfarin

Topics: Aged; Alcohol Withdrawal Delirium; Anticoagulants; Aortic Aneurysm; Aortic Dissection; Aortic Valve Insufficiency; Atrial Fibrillation; Delayed Diagnosis; Diagnostic Errors; Dyspnea; Edema; Epilepsy, Tonic-Clonic; Fatal Outcome; Heart Failure; Heart Valve Prosthesis; Humans; Hypertension; Male; Postoperative Complications; Psychomotor Agitation; Tomography, X-Ray Computed; Warfarin

Vascular access site complications are among the most frequently observed complications after catheter ablation of atrial fibrillation (AF). We sought to determine whether implementation of a three-point strategy would reduce major vascular complications resulting from catheter ablation of atrial fibrillation.. Three hundred twenty-four consecutive patients undergoing catheter ablation of AF were studied: 162 in each group (with and without the test strategy). The three-point test strategy included the following: (1) performing the procedure on Warfarin with an INR from 2.0 to 3.5 (mean INR of 2.44), rather than stopping Warfarin prior to the procedure and bridging the patient back to Warfarin with low molecular heparin, (2) using a small 21 G needle to obtain femoral vein access rather than a larger 18 G needle, and (3) eliminating the use of femoral arterial access. Major vascular complications were defined as complications requiring either blood transfusion or surgical/percutaneous repair.. Major vascular complications were identified in 6/162 (3.7%) of the control patients without the strategy listed above compared to 0/162 (0%) in the test patients with implementations of this strategy (p = 0.03). The frequency of other complications was comparable between the two groups (tamponade requiring drainage: 1/162 control, 1/162 test; pericardial effusion not requiring drainage: 0/162 control, 1/162 test; transient ischemic attack: 1/162 control and 1/162 test; stroke: 1/162 control, 0/162 test): (p = NS for each).. A three-point strategy including performing procedures with therapeutic Warfarin, using a small gauge needle to obtain vascular access and eliminating femoral arterial access significantly reduced major vascular access complications and did not affect other major complications, during catheter ablation of AF. Implementation of this strategy may be useful to reduce groin complications resulting from AF ablation.

Topics: Anticoagulants; Atrial Fibrillation; Blood Transfusion; Catheter Ablation; Female; Femoral Vein; Heparin, Low-Molecular-Weight; Humans; International Normalized Ratio; Male; Middle Aged; Needles; Postoperative Complications; Punctures; Treatment Outcome; Vascular Diseases; Warfarin

Topics: Anticoagulants; Female; Humans; Intraoperative Complications; Male; Postoperative Complications; Vitreoretinal Surgery; Warfarin

Topics: Adolescent; Anticoagulants; Child; Child, Preschool; Female; Fontan Procedure; Humans; Infant; Male; Point-of-Care Systems; Postoperative Complications; Retrospective Studies; Thrombosis; Tricuspid Atresia; Warfarin

To specifically evaluate perioperative morbidity associated with men who were taking coumadin and continued on this medication at therapeutic levels for the purposes of the prostate (PVP). Increasing numbers of men are taking coumadin for medical comorbidity and this creates clinical concerns for urologists treating such men with benign prostatic obstruction. Photoselective vaporization of the PVP has been shown to be an effective treatment for men receiving anticoagulation treatment, although previously published studies have evaluated a mix of men on aspirin, coumadin, or clopidogrel.. From a prospective database of men treated with the 120-W lithium triborate (LBO) laser from November 2006 to July 2010, 43 men were identified to have been on coumadin during their PVP. The mean age was 73.4 years (range, 55-90) and mean prostate size was 75.3 mL (range, 20-227). Perioperative morbidity and early functional outcomes were examined.. No men required a blood transfusion, although 2 of 43 (4.7%) men had prolonged catheterization for bleeding. No patient required discontinuation of the coumadin during the perioperative period. Urinary tract infection occurred in 4 (9.3%) and recatheterization in 6 (14%). Apart from 3 outliers, the mean postoperative length of stay was 21.6 hours. At 3 months, improvements in International Prostate Symptom Score, peak urinary flow rate, and postvoid residual were similar to previously reported series of men not taking an anticoagulant.. PVP in this high-risk group of patients has low perioperative morbidity and is associated with good early functional outcomes.

Topics: Aged; Aged, 80 and over; Anticoagulants; Humans; Laser Therapy; Male; Middle Aged; Postoperative Complications; Prospective Studies; Prostatectomy; Prostatic Hyperplasia; Warfarin

Most anticoagulants are not associated with increased risk of severe complications during cutaneous surgery, but no data exist on clopidogrel.. We sought to determine frequency and severity of perioperative complications in patients taking clopidogrel-containing anticoagulation.. This was a retrospective review of medical records of patients undergoing Mohs micrographic surgery at Mayo Clinic, Rochester, MN, while taking clopidogrel-containing anticoagulation between 2004 and 2008, compared with control subjects taking aspirin monotherapy or no anticoagulants.. In all, 220 patients taking clopidogrel-containing anticoagulation underwent 363 surgical procedures on 268 occasions. Severe complications occurred in 11 of 363 surgical sites in 10 cases. Clopidogrel-containing anticoagulation was 28 times more likely than no anticoagulation and 6 times more likely than aspirin monotherapy to result in severe complications after Mohs procedures (P < .001 and P = .022, respectively). Severe complications were 8 times more likely after Mohs procedures in patients taking both clopidogrel and aspirin than in control subjects taking aspirin monotherapy (P = .009). No statistically significant difference was found between patients taking clopidogrel monotherapy and control subjects not taking anticoagulants (P = .15). Patients experiencing severe complications were more likely to have larger postoperative surgical sites (P < .001). No thrombotic complications were encountered with discontinuation of clopidogrel-containing anticoagulation; a postoperative thrombotic complication occurred in one patient whose clopidogrel-containing anticoagulation regimen was modified.. Retrospective nature of study, possible recall bias as a result of telephone contact, and small number of severe complications were limitations, which reduced study power.. Cutaneous surgery in patients taking clopidogrel-containing anticoagulation is associated with an increased risk of nonlife-threatening severe complications.

Topics: Aged; Aged, 80 and over; Anticoagulants; Aspirin; Clopidogrel; Dermatologic Surgical Procedures; Female; Humans; Male; Middle Aged; Mohs Surgery; Platelet Aggregation Inhibitors; Postoperative Complications; Postoperative Hemorrhage; Ticlopidine; Warfarin

Because myeloproliferative disorders (MPDs) are a frequent cause of Budd-Chiari syndrome (BCS), treatment directed toward altering platelet production and function may be more rational and effective than anticoagulation after liver transplantation.. We reviewed data on 25 patients who received liver transplantation for BCS at our institution from 1987 to 2007. Posttransplant antithrombotic treatment was based on the cause of BCS: 17 patients with MPDs received hydroxyurea/aspirin; 5 received warfarin; and 3 (2 whose hypercoagulable disorder was corrected and 1 with sarcoidosis) received no therapy.. Both graft survival (88% at 5 years) and patient survival (92% at 5 years) were superior in the BCS group compared with the 2609 patients who received liver transplants for other indications. Vascular complications included three instances of hepatic artery stenosis (NS compared with non-BCS liver recipients), one of portal vein thrombosis (nonsignificant [NS]), and one of portal vein stenosis (NS). All 25 patients underwent multiple liver biopsies with no bleeding complications.. Using hydroxyurea and aspirin to treat patients with BCS caused by an MPD seems to be safe and effective and avoids the risks of anticoagulation with warfarin.

Topics: Adolescent; Adult; Anticoagulants; Aspirin; Budd-Chiari Syndrome; Child; Female; Fibrinolytic Agents; Follow-Up Studies; Graft Survival; Hepatic Artery; Humans; Hydroxyurea; Liver Transplantation; Male; Middle Aged; Platelet Aggregation Inhibitors; Portal Vein; Postoperative Complications; Thrombosis; Warfarin; Young Adult

To assess the safety of phacoemulsification cataract extraction in patients on combined anticoagulant and antiplatelet treatment.. Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel.. Prospective interventional case series.. Consecutive patients with simple cataract on combined anticoagulant (warfarin) and antiplatelet (aspirin or clopidogrel) treatment who were unable to discontinue the treatment because of a high risk for thromboembolic events were included. Patients had cataract extraction under topical anesthesia with a clear corneal incision (CCI), phacoemulsification, and implantation of a foldable posterior chamber intraocular lens. Prothrombin time-international normalized ratio and platelet functions were evaluated immediately before surgery. Patients were also examined 1 day and 7 days postoperatively. Intraoperative and postoperative ocular bleeding and other related complications were assessed.. Forty patients (51 eyes) with a mean age of 72 years (range 51 to 90 years) had phacoemulsification. Hemorrhagic complications were not observed at surgery or during the 1-week follow-up. Surgical complications included 1 rupture of the capsulorhexis and 1 implantation of a capsular tension ring due to partial zonulysis. No patient had a thromboembolic event.. In patients with uncomplicated cataract at high risk for thromboembolic events, phacoemulsification cataract surgery using a CCI under topical needle-free anesthesia was safely performed without discontinuing systemic anticoagulant and antiplatelet treatment.

Topics: Aged; Aged, 80 and over; Anticoagulants; Aspirin; Blood Loss, Surgical; Clopidogrel; Drug Therapy, Combination; Eye Hemorrhage; Female; Humans; Intraoperative Complications; Lens Implantation, Intraocular; Male; Middle Aged; Phacoemulsification; Platelet Aggregation Inhibitors; Postoperative Complications; Prospective Studies; Prothrombin Time; Risk Assessment; Thromboembolism; Ticlopidine; Warfarin

Topics: Anticoagulants; Humans; Laser Therapy; Male; Postoperative Complications; Prostatectomy; Prostatic Hyperplasia; Warfarin

Patients on chronic oral anticoagulation can be challenging to manage in the perioperative period.. Review of patients on warfarin undergoing elective abdominal colon and rectal operations at a single institution from 2000 to 2006.. One forty-six patients underwent 165 abdominal procedures. Mean (±SEM) age was 67 ± 1 years; 59% of patients were men. Median estimated blood loss was 200 ml, and 19% received intraoperative blood products while 19% of patients received a postoperative transfusion. Sixteen patients (10%) experienced bleeding complications (three requiring reoperation). No risk factors for bleeding were identified by multivariate analysis (MVA). Five patients (3%) suffered a postoperative thromboembolic event. Preoperative anticoagulation for cerebrovascular disease was a risk factor for thromboembolism (p = 0.03). Overall operative morbidity was 30% with no identifiable risk factor in MVA. Mortality was nil.. Postoperative bleeding and thromboembolism in patients on chronic anticoagulation are not insignificant (10% and 3%, respectively). Patients on warfarin for cerebrovascular disease are at increased risk for thromboembolic events postoperatively and should be placed on appropriate prophylaxis and monitored.

Topics: Administration, Oral; Aged; Anticoagulants; Blood Loss, Surgical; Blood Transfusion; Colonic Diseases; Female; Heparin, Low-Molecular-Weight; Humans; Male; Multivariate Analysis; Postoperative Complications; Postoperative Hemorrhage; Rectal Diseases; Thromboembolism; Warfarin

Few prospective studies have evaluated the safety of dermatologic surgery.. We sought to determine rates of bleeding, infection, flap and graft necrosis, and dehiscence in outpatient dermatologic surgery, and to examine their relationship to type of repair, anatomic location of repair, antibiotic use, antiplatelet use, or anticoagulant use.. Patients presenting to University of Massachusetts Medical School Dermatology Clinic for surgery during a 15-month period were prospectively entered. Medications, procedures, and complications were recorded.. Of the 1911 patients, 38% were on one anticoagulant or antiplatelet medication, and 8.0% were on two or more. Risk of hemorrhage was 0.89%. Complex repair (odds ratio [OR] = 5.80), graft repair (OR = 7.58), flap repair (OR = 11.93), and partial repair (OR = 43.13) were more likely to result in bleeding than intermediate repair. Patients on both clopidogrel and warfarin were 40 times more likely to have bleeding complications than all others (P = .03). Risk of infection was 1.3%, but was greater than 3% on the genitalia, scalp, back, and leg. Partial flap necrosis occurred in 1.7% of flaps, and partial graft necrosis occurred in 8.6% of grafts. Partial graft necrosis occurred in 20% of grafts on the scalp and 10% of grafts on the nose. All complications resolved without sequelae.. The study was limited to one academic dermatology practice.. The rate of complications in dermatologic surgery is low, even when multiple oral anticoagulant and antiplatelet medications are continued, and prophylactic antibiotics are not used. Closure type and use of warfarin or clopidogrel increase bleeding risk. However, these medications should be continued to avoid adverse thrombotic events.

Topics: Aged; Ambulatory Surgical Procedures; Antibiotic Prophylaxis; Anticoagulants; Clopidogrel; Dermatologic Surgical Procedures; Female; Humans; Male; Mohs Surgery; Necrosis; Platelet Aggregation Inhibitors; Postoperative Complications; Postoperative Hemorrhage; Surgical Flaps; Surgical Wound Infection; Ticlopidine; Warfarin

The optimal regimen of the anticoagulant and antiplatelet therapies in patients with atrial fibrillation who have had a coronary stent is unclear. It is well recognised that "triple therapy" with aspirin, clopidogrel, and warfarin is associated with an increased risk of bleeding. National guidelines have not made specific recommendations given the lack of adequate data. In choosing the best antithrombotic options for a patient, consideration needs to be given to the risks of stroke, stent thrombosis and major bleeding. This document describes these risks, provides specific recommendations concerning vascular access, stent choice, concomitant use of proton-pump inhibitors and the use and duration of triple therapy following stent placement based upon the risk assessment.

Topics: Atrial Fibrillation; Blood Vessel Prosthesis Implantation; Consensus Development Conferences as Topic; Coronary Vessels; Drug Therapy, Combination; Hemorrhage; Humans; North America; Platelet Aggregation Inhibitors; Postoperative Complications; Risk; Stents; Thrombosis; Warfarin

Topics: Anticoagulants; Female; Humans; Intraoperative Complications; Male; Postoperative Complications; Vitreoretinal Surgery; Warfarin

The purpose of this study was to provide further information about the risks of perioperative hemorrhage in diabetic vitrectomy in patients on anticoagulation. This may help us to better understand more about the fine balance between the risks of stopping anticoagulation versus continuation for intraocular surgery.. A retrospective, comparative cohort study of all patients undergoing a diabetic pars plana vitrectomy by a single surgeon over a 30-month period at a single institution was conducted.. Ninety-seven eyes were included for analysis. Twenty-seven eyes remained on anticoagulation during the surgery. There were no perioperative complications related to the anticoagulation. Surgical intervention resulted in a significant increase in visual acuity in both groups. There was no difference in the incidence of postoperative vitreous hemorrhage or surgical reoperation between the two groups. Patients on anticoagulation had significantly worse postoperative vision compared with those not on anticoagulation (best-corrected visual acuity of 20/230 vs. 20/100, P = 0.03).. Patients undergoing diabetic vitrectomy, who are on anticoagulation or antiplatelet agents, do not exhibit a higher risk of intraoperative or postoperative vitreous hemorrhage. Anticoagulants and antiplatelets may be safely continued perioperatively to avoid complications secondary to their systemic disease.

Topics: Anticoagulants; Aspirin; Clopidogrel; Diabetic Retinopathy; Female; Humans; Incidence; Intraoperative Complications; Male; Middle Aged; Platelet Aggregation Inhibitors; Postoperative Complications; Retrospective Studies; Risk Factors; Ticlopidine; Treatment Outcome; Visual Acuity; Vitrectomy; Vitreous Hemorrhage; Warfarin

Drug interaction between Warfarin and psychiatric agents may have important therapeutic effects for patients undergoing cardiac surgery. We present a case of a patient in whom concurrent treatment with Warfarin and valproic acid resulted in supratherapeutic international normalized ratio values. A discussion of the possible mechanisms for this interaction as well as a review of interactions between Warfarin and other psychiatric medications is the subject of this case report.

Topics: Adult; Anticoagulants; Antimanic Agents; Bipolar Disorder; Drug Interactions; Drug Therapy, Combination; Female; Follow-Up Studies; Heart Valve Prosthesis; Humans; Mitral Valve Insufficiency; Postoperative Complications; Thrombosis; Valproic Acid; Warfarin

Topics: Atrial Fibrillation; Blood Vessel Prosthesis Implantation; Humans; Platelet Aggregation Inhibitors; Postoperative Complications; Warfarin

Warfarin is frequently used for the prevention of venous thromboembolism (VTE) after total hip or knee arthroplasty (THA/TKA). The current study was conducted to determine the association between international normalized ratio (INR) levels and VTE outcomes.. Patients who received warfarin following THA/TKA were followed for up to 90 days using an electronic health record database. INR measurements were categorized based on American College of Chest Physicians (ACCP) guidelines. Cox proportional hazards models were used to compare the risk of VTE between patients with INR levels below and within the ACCP-recommended range in patients with ≥2 available INR level measurements.. On or after Day 5, 33.3% and 28.6% of INR levels fell within the ACCP-recommended range for THA and TKA, respectively. VTE was diagnosed in 3% of each cohort. INR levels varied over time and were frequently below the ACCP-recommended range. Below-range INR levels were associated with greater risk of VTE in both THA (hazard ratio [HR]: 5.29; 95% CI: 2.64-10.61) and TKA (HR: 4.64; 95% CI: 2.59-8.29).. In the current study, the majority of patients had INR levels below the ACCP-recommended range of 2.0-3.0 during warfarin exposure following orthopedic surgery. INR levels below 2.0 were associated with a four- to five-fold increase in the risk of VTE.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anticoagulants; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Databases, Factual; Female; Follow-Up Studies; Humans; International Normalized Ratio; Male; Middle Aged; Pennsylvania; Postoperative Complications; Proportional Hazards Models; Retrospective Studies; Risk Factors; Venous Thromboembolism; Warfarin

Topics: Anticoagulants; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Elective Surgical Procedures; Humans; Postoperative Care; Postoperative Complications; Practice Guidelines as Topic; Pulmonary Embolism; Societies, Medical; Venous Thromboembolism; Warfarin

Patients with prosthetic heart valves require lifelong anticoagulation to prevent thromboembolism. When they have intracranial haemorrhage, anticoagulation has to be withheld. This study was aimed to identify safety duration and complications of anticoagulation withholding in patients with prosthetic heart valves and intracranial haemorrhage. This was a retrospective descriptive study in 26 prosthetic heart valve patients hospitalised in Srinagarind Hospital, Khon Kaen University because of intracranial haemorrhage from 2003 to 2008. Range of anticoagulation withholding was 1 to 26 days with mean 8.5 ± 7.7 days. Most patients (84.6%) were withheld anticoagulation for less than 14 days. There were five in-hospital deaths mostly within 3 days of admission from severe intracranial haemorrhage. No data of reintroduction of anticoagulation was found in three patients because they were lost to follow up. One patient had right basal ganglia infarction after 7 days of anticoagulation withholding. Prosthetic heart valve dysfunction was suspected in one patient who withheld anticoagulant for 76 days. Discontinuation of anticoagulation in patients with prosthetic heart valves and intracranial haemorrhage for less than 7 days was associated with low thromboembolic risk and there was no clinical evidence of prosthetic heart valve dysfunction when anticoagulation was withheld for less than 14 days.

Topics: Adult; Anticoagulants; Aspirin; Atrial Fibrillation; Combined Modality Therapy; Comorbidity; Contraindications; Craniotomy; Female; Heart Valve Prosthesis; Humans; International Normalized Ratio; Intracranial Hemorrhages; Male; Middle Aged; Postoperative Complications; Retrospective Studies; Thailand; Thromboembolism; Time Factors; Vitamin K; Warfarin

Topics: Anticoagulants; Atrial Fibrillation; Drug Administration Schedule; Heparin, Low-Molecular-Weight; Humans; International Normalized Ratio; Ophthalmologic Surgical Procedures; Postoperative Complications; Preoperative Care; Retinal Diseases; Stroke; Thromboembolism; Warfarin; Withholding Treatment

The objectives of this study were to compare the risk of venous thromboembolism (VTE), bleeding, surgical site infection, and mortality in patients receiving aspirin or guideline-approved VTE prophylactic therapies (warfarin, low-molecular-weight heparins, synthetic pentasaccharides) in total knee arthroplasty (TKA). We analyzed clinical and administrative data from 93,840 patients who underwent primary TKA at 307 US hospitals over a 24-month period. Fifty-one thousand nine hundred twenty-three (55%) patients received warfarin, 37,198 (40%) received injectable agents, and 4719 (5%) received aspirin. After adjustment for patient and hospital factors, patients who received aspirin VTE prophylaxis (VTEP) had lower odds for thromboembolism compared to warfarin patients but with similar odds compared with injectable VTEP; there were no differences in risk of bleeding, infection, or mortality after adjustment. Our results suggest that aspirin, when used in conjunction with other clinical care protocols, may be effective VTEP for certain TKA patients.

Topics: Aged; Anticoagulants; Arthroplasty, Replacement, Knee; Aspirin; Cohort Studies; Female; Fondaparinux; Heparin, Low-Molecular-Weight; Humans; Male; Middle Aged; Platelet Aggregation Inhibitors; Polysaccharides; Postoperative Complications; Prevalence; Retrospective Studies; Risk Factors; Treatment Outcome; Venous Thromboembolism; Warfarin

This study aimed to assess surgical workload and risk factors for gastrointestinal bleeding in patients on warfarin admitted to a hospital.. Data was collected for all warfarinised patients admitted between April 2005 and October 2007 with gastrointestinal bleeding.. A total of 30 patients (average 80 years) were recorded. Indications for warfarin therapy were atrial fibrillation (80%), mechanical heart valve (6.67%) and embolic disease (13.33%). Fifty percent were admitted with an INR above therapeutic range and of these patients, 83% were on one or more medications known to potentiate the anti-coagulation effect of warfarin. Nine patients were also taking anti-platelet medication. Five of these nine had an admission INR within the intended therapeutic range. Thirteen patients received blood transfusions and had a significantly higher (p<0.05) INR (average 9) than the 17 patients not requiring transfusion (average 2.8). The average cost of transfusion per patient was pound470. None of the patients required acute surgical intervention. The average length of stay was 7 days, at a total cost of pound1444 per patient. Investigations found the cause of bleeding to be diverticulosis in 9 patients and neoplastic disease in 4 patients. Almost half of the patients received no investigation due to risks from co-morbidity.. Uncontrolled anti-coagulation, polypharmacy and age were overwhelming risk factors for major gastrointestinal bleeding. Our results show that adding anti-platelet therapy has to be clearly justified against the increased risk of bleeding. Cost to the surgical department was high and no patients required surgical or radiological intervention. WHAT IS ALREADY KNOWN ABOUT THIS TOPIC?: Warfarin is an important drug, but the complications of its use are difficult and expensive to deal with. Warfarin use is a risk factor for haemorrhage, and this commonly involves the gastrointestinal tract. The use of warfarin is set to increase as the population ages and atrial fibrillation and other cardiovascular risk factors become more prevalent. Consequently, one can expect a rise in warfarin-related gastrointestinal haemorrhage. WHAT DOES THIS ARTICLE ADD?: Our study aimed to assess the burden of gastrointestinal haemorrhage secondary to warfarin on our surgical department (which was high), and also to assess what the risk factors for haemorrhage for patients on warfarin. One of the risk factors we uncovered was polypharmacy, particularly involving anti-platelets e.g. aspirin. We highlight the need for further guidance with regards to managing patients on warfarin, and suggest possible solutions to the problems uncovered.

Topics: Age Factors; Aged, 80 and over; Anticoagulants; Female; Gastrointestinal Hemorrhage; Humans; International Normalized Ratio; Length of Stay; Male; Platelet Aggregation Inhibitors; Polypharmacy; Postoperative Complications; Risk Factors; Statistics, Nonparametric; Warfarin; Workload

Factor VII is the most affected clotting factor during the early phase of warfarin therapy. An international normalized ratio (INR) of more than 1.4 is considered unsafe for epidural catheter placement or removal, according to the American Society of Regional Anesthesia and Pain Medicine. The authors tested the hypothesis that factor VII activities would be consistent with safe removal of the epidural catheter on postoperative day (POD) 1 regardless of INR value.. Data from 121 patients who took warfarin after undergoing total joint surgery and had INRs and factor VII levels determined were reviewed. Patient characteristics and factor VII activities were compared between patients with INRs of more than 1.4 and those with INRs less than or equal to 1.4 on PODs 1, 2, and 3.. Eleven patients had INRs of more than 1.4 on POD 1; their mean +/- SD factor VII activities were 60 +/- 28% (normal: 50-160%). On POD 2, 78 patients with INRs more than of 1.4 had factor VII activities of 32 +/- 15%, whereas on POD 3, 84 patients with INRs of more than 1.4 had factor VII activities of 44 +/- 19%. Variables included in the final multiple logistic regression model as predictors of an INR of more than 1.4 on POD 2 were warfarin dose on POD 1 and factor VII activity on POD 2.. The range of factor VII activities in the patients with INRs of more than 1.4 within 12 h of warfarin therapy was compatible with adequate hemostasis. The authors found no evidence that epidural catheters should not be removed even with INRs up to 1.9, the highest INR on POD 1 noted in their study.

Topics: Aged; Anesthesia, Conduction; Anticoagulants; Catheterization; Epidural Space; Factor VII; Female; Forecasting; Hemostasis; Humans; International Normalized Ratio; Logistic Models; Male; Middle Aged; Models, Statistical; Monitoring, Physiologic; Postoperative Complications; Warfarin

Topics: Aged; Anticoagulants; Atrial Appendage; Echocardiography, Transesophageal; Humans; Male; Postoperative Complications; Thrombosis; Warfarin

Clopidogrel, a new antiplatelet agent that irreversibly inhibits platelet aggregation, is widely used today. This prospective work was conducted to evaluate the safety of performing skin surgery on patients taking clopidogrel. Patients undergoing surgery for excision of skin or subcutaneous lesions under local anesthesia taking clopidogrel were the study group. The control group comprised 2073 historical patients who had undergone a similar procedure. Data collected included: age, sex, past medical history, medications, and late complications. Follow-up was done at 1 to 2 weeks and 3 to 6 months. There were 32 patients on clopidogrel, having 38 lesions removed. Of these, seven patients were on aspirin and clopidogrel combined. The groups taking clopidogrel, aspirin, and warfarin had significantly more males, were older, and had significantly more comorbid medical conditions. There was no significant difference in the incidence of any of the complications in any of the groups. This study shows that patients taking clopidogrel before skin surgery, though older and with more associated medical conditions, do not experience a greater rate of complications. We conclude that patients undergoing minor excisional cutaneous surgery should continue taking clopidogrel because there is no apparent risk for increased complications when good meticulous surgical techniques are used.

Topics: Aged; Anticoagulants; Aspirin; Case-Control Studies; Clopidogrel; Dermatologic Surgical Procedures; Drug Therapy, Combination; Drug-Related Side Effects and Adverse Reactions; Erythema; Female; Follow-Up Studies; Hematoma; Humans; Male; Platelet Aggregation Inhibitors; Postoperative Complications; Surgical Wound Dehiscence; Surgical Wound Infection; Ticlopidine; Warfarin

Portal vein complications after liver transplantation (LT) are serious complications that can lead to graft liver failure. Although the treatment of interventional radiology (IVR) by means of balloon dilatation for portal vein stenosis (PVS) after LT is an effective method, the high rate of recurrent PVS is an agonizing problem. Anticoagulant therapy for PVS is an important factor for preventing short-term recurrence following IVR, but no established regimen has been reported for the prevention of recurrent PVS following IVR. In our population of 197 pediatric patients who underwent living donor liver transplantation (LDLT), 22 patients (22/197, 11.2%) suffered PVS. In the 9 earliest patients, unfractionated heparin was the only anticoagulant therapy given following IVR. In the 13 more recent patients, 3-agent anticoagulant therapy using low-molecular-weight heparin, warfarin, and aspirin was employed. In the initial group of 9 patients, 5 patients (55.6%) suffered recurrent PVS and required repeat balloon dilatation. Among the 13 more recent patients, none experienced recurrent PVS (P = 0.002). In conclusion, our 3-agent anticoagulant therapy following IVR for PVS in pediatric LDLT can be an effective therapeutic strategy for preventing recurrent PVS.

Topics: Adolescent; Adult; Anticoagulants; Aspirin; Catheterization; Child; Child, Preschool; Constriction, Pathologic; Drug Therapy, Combination; Female; Heparin, Low-Molecular-Weight; Humans; Infant; Liver Transplantation; Living Donors; Male; Portal Vein; Postoperative Complications; Radiology, Interventional; Regional Blood Flow; Retrospective Studies; Secondary Prevention; Treatment Outcome; Ultrasonography; Vascular Diseases; Warfarin; Young Adult

The aim of this case-control study was to evaluate the outcome of isolated coronary artery bypass grafting (CABG) when using a short (median, 2 days) preoperative pause in home warfarin treatment.. A consecutive series of 162 patients on long-term warfarin treatment (median international normalized ratio at the time of operation, 1.9) who underwent isolated CABG was compared with a matched control group of 162 patients with no oral anticoagulation.. The operative risk of warfarin-treated patients was higher (p=0.001) than in the control patients. The in-hospital mortality was comparable in the warfarin and control groups (3.7% versus 2.5%; p=0.52), and there were no significant differences in the postoperative blood loss (818 versus 758 mL), transfused red blood cells (2.1 versus 1.8 units), or reoperations owing to bleeding (5.6% versus 7.4%) between the groups. The warfarin group received more (p<0.0001) fresh-frozen plasma (1.9 versus 0.5 units), needed longer treatment in the intensive care unit (4.1 versus 2.9 days; p<0.0001), and tended to have an increased risk of postoperative stroke (4.9% versus 1.2%; p=0.10). A CHADS2 score greater than 2, but not the international normalized ratio level, was associated with an increased risk of stroke when adjusted for other important comorbidities. Comparable results were observed also in 107 propensity-matched pairs.. The risk of bleeding complications after isolated CABG is not increased when using a short preoperative pause in warfarin treatment. Better preventive strategies for stroke are needed, especially in patients with a high CHADS2 score.

Topics: Aged; Anticoagulants; Case-Control Studies; Coronary Artery Bypass; Female; Hemorrhage; Humans; Male; Postoperative Complications; Preoperative Care; Retrospective Studies; Time Factors; Treatment Outcome; Warfarin

We sought to investigate the association between new-onset atrial fibrillation after coronary artery bypass graft (CABG) (post-operative atrial fibrillation [POAF]) and long-term mortality in patients with no history of atrial fibrillation.. POAF predicts longer hospital stay and greater post-operative mortality.. A total of 16,169 consecutive patients with no history of AF who underwent isolated CABG at our institution between January 1, 1996, and December 31, 2007, were included in the study. All-cause mortality data were obtained from Social Security Administration death records. A multivariable Cox proportional hazards regression model was constructed to determine the independent impact of new-onset POAF on long-term survival after adjusting for several covariates. The covariates included age, sex, race, pre-operative risk factors (ejection fraction, New York Heart Association functional class, history of myocardial infarction, index myocardial infarction, stroke, chronic obstructive pulmonary disease, peripheral arterial disease, smoking, diabetes, renal failure, hypertension, dyslipidemia, creatinine level, dialysis, redo surgery, elective versus emergent CABG, any valvular disorder) and post-operative adverse events (stroke, myocardial infarction, acute respiratory distress syndrome, and renal failure), and discharge cardiac medications known to affect survival in patients with coronary disease.. New-onset AF occurred in 2,985 (18.5%) patients undergoing CABG. POAF independently predicted long-term mortality (hazard ratio: 1.21; 95% confidence interval: 1.12 to 1.32) during a mean follow-up of 6 years (range 0 to 12.5 years). This association remained true after excluding from the analysis those patients who died in-hospital after surgery (hazard ratio: 1.21; 95% confidence interval: 1.11 to 1.32). Patients with POAF discharged on warfarin experienced reduced mortality during follow-up.. In this large cohort of patients, POAF predicted long-term mortality. Warfarin anticoagulation may improve survival in POAF.

Topics: Aged; Anticoagulants; Atrial Fibrillation; Coronary Artery Bypass; Coronary Artery Disease; Female; Georgia; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Postoperative Complications; Proportional Hazards Models; Registries; Retrospective Studies; Risk Factors; Warfarin

Anti-coagulation with heparin is often used after left ventricular assist device implantation as a transition to long-term warfarin therapy. We retrospectively evaluated the effects of heparin use on thromboembolic and bleeding complications after implantation of the HeartMate II left ventricular assist device (LVAD).. LVAD patients (n = 418) implanted as a bridge to transplant were divided into three groups: Group A patients (therapeutic, n = 118) received heparin and had a partial thromboplastin time (PTT) of >50 seconds on two or more occasions; Group B patients (sub-therapeutic, n = 178) had at least one PTT value in the range of 40 to 55 seconds; and Group C patients (no heparin, n = 122) had no PTT values >40 seconds. All patients were transitioned to warfarin and aspirin therapy. The following adverse events were evaluated: ischemic stroke; hemorrhagic stroke; pump thrombosis; bleeding requiring surgery; and bleeding requiring > or = 2 units of packed red blood cells in 24 hours.. There was no difference in the percentages of patients with ischemic (5%, 4%, 3%) or hemorrhagic (3%, 3%, 5%) strokes or pump thrombosis (3%, 2%, 2%) after post-operative day (POD) 3 among Groups A, B and C, respectively. From PODs 3 to 30, the percentage of patients requiring transfusion for bleeding was significantly lower for Group C (18%) than for Groups A (32%) and B (26%) (p = 0.04); differences after 30 days were not significant. Multivariate analysis revealed that post-operative heparin use, low post-operative platelet count and low baseline hematocrit value were independent risk factors for bleeding events between PODs 3 and 30.. In patients receiving the HeartMate II LVAD who were directly transitioned to warfarin and aspirin therapy without intravenous heparin there was no short-term increase in risk of thrombotic or thromboembolic events, and bleeding requiring transfusion was significantly reduced. Additional long-term follow-up is needed to evaluate possible late effects.

Topics: Anticoagulants; Aspirin; Drug Administration Schedule; Female; Heart Failure; Heart Transplantation; Heart-Assist Devices; Hemorrhage; Heparin; Humans; Injections, Intravenous; Male; Middle Aged; Partial Thromboplastin Time; Postoperative Care; Postoperative Complications; Postoperative Period; Retrospective Studies; Stroke; Thromboembolism; Thrombosis; Time Factors; Unnecessary Procedures; Warfarin

Warfarin is a widely used drug for the prevention of thromboembolic events. Knowledge of its adverse effects is necessary for patient follow-up. Although the development of blood dyscrasias is a potential complication in these patients, retroperitoneal bleeding is rare. This article reports the case of a patient who developed iliopsoas muscle hematoma during treatment with warfarin after implantation of a metallic prosthetic aortic valve. The clinical manifestations involved important differential diagnoses.

Topics: Aged; Anticoagulants; Diagnosis, Differential; Femoral Nerve; Gastrointestinal Hemorrhage; Heart Valve Prosthesis; Hematoma; Humans; Male; Nerve Compression Syndromes; Postoperative Complications; Psoas Muscles; Warfarin

The case of a superior vena cava syndrome due to a central venous catheter thrombosis occurring in a second renal transplant patient is described. Imaging revealed thrombosis of the right internal jugular vein with extension along the confluence of the brachiocephalic veins and partial obstruction of the superior vena cava. Anticoagulant therapy with subcutaneous low-molecular-weight heparin was followed by warfarin administration. Despite adequate treatment, the symptomatology worsened because of thrombus organization. A workup revealed a complex prothrombotic underlying condition. Cardiothoracic surgeons were consulted, and an operative reconstruction of the superior vena cava using spiral vein bypass grafting was performed. In this report we describe the clinical presentation, diagnosis, and treatment of this case, with an emphasis on the role of thrombophilia.

Topics: Anticoagulants; Female; Heparin, Low-Molecular-Weight; Humans; Jugular Veins; Kidney Failure, Chronic; Kidney Transplantation; Middle Aged; Postoperative Complications; Reoperation; Superior Vena Cava Syndrome; Thromboembolism; Warfarin

Topics: Aged; Animals; Aortic Valve; Bioprosthesis; Capsule Endoscopy; Cardiac Catheterization; Cattle; Coronary Angiography; Electrocardiography; Heart Valve Diseases; Heart Valve Prosthesis Implantation; Humans; Male; Myocardial Infarction; Platelet Aggregation Inhibitors; Postoperative Complications; Thrombosis; Ultrasonography; Warfarin

The aim of this study was to determine if warfarin should be withdrawn before a single tooth extraction on a patient with a prosthetic heart valve.. A quantitative decision tree was constructed to assess the expected utility values of 2 typical strategies to manage the dental extraction on a patient currently medicated with warfarin. Probabilities and utilities for a cardiovascular accident and major bleeding from a dental extraction were taken from the literature.. The decision slightly favors withholding warfarin: generating an optimal expected utility value of 0.976 utile. This was only 0.02 utile higher than the alternative option of continuing warfarin for a dental extraction.. The decision to withhold or continue warfarin before a dental extraction depends more on the relative risk of a major bleeding between the 2 medical management strategies than on the consequences of a cardiovascular accident.

Topics: Anticoagulants; Cardiovascular Diseases; Cause of Death; Decision Trees; Heart Valve Prosthesis; Hemostasis, Surgical; Hemostatics; Humans; Middle Aged; Postoperative Complications; Postoperative Hemorrhage; Probability; Risk Assessment; Stroke; Tooth Extraction; Treatment Outcome; Warfarin

Topics: Aortic Valve Stenosis; Coronary Artery Bypass; Coronary Artery Disease; Enoxaparin; Fibrinolytic Agents; Heart Valve Prosthesis Implantation; Hematoma; Humans; International Normalized Ratio; Male; Middle Aged; Postoperative Complications; Rupture; Sigmoid Diseases; Warfarin

To assess the utility of transoesophageal echocardiography (TEE) parameters such as spontaneous echo contrast (SEC), left atrial (LA) appendage velocities, and aortic plaque in predicting periprocedural cerebrovascular accidents (CVAs) in patients undergoing catheter ablation of atrial fibrillation (AF).. Five hundred and seventy-nine consecutive patients underwent catheter ablation of AF with pre-procedural TEE, 94% of whom also received pre-procedural warfarin and enoxaparin bridging. Of the 579 patients, 10 patients (cases) who developed periprocedural CVA (1.7%) and 40 randomly selected patients who did not develop CVA (controls) were included (50 study patients, age 58 ± 11 years, 82% male, 54% persistent AF). Periprocedural CVA was defined as a new neurological deficit that occurred anytime between the start of the procedure and 30 days after AF ablation. Demographic, clinical, and TEE variables of cases and controls were compared using standard statistical analyses. Patients with CVA more often had coronary artery disease [odds ratio (OR) 6.0, P = 0.03], previous history of CVA (OR 8.2, P = 0.02), and CHADS(2) score ≥ 2 (OR 5.4, P = 0.03) than patients without CVA. There was no difference in any of the TEE parameters (SEC, LA appendage velocity and area, patent foramen ovale, atrial septal aneurysm, valve abnormality, and aortic plaque). When these TEE parameters were adjusted for coronary artery disease, prior CVA and CHADS(2) ≥ 2, none emerged as an independent predictor of CVA.. Transoesophageal echocardiographic variables (other than LA thrombus) were not associated with the occurrence of periprocedural CVA in our patients undergoing catheter ablation of AF who generally received pre-procedural anticoagulation. Despite serving as markers of a thrombogenic milieu, the presence of SEC, low LA appendage velocities, and aortic plaque may not increase the risk of periprocedural CVA after AF ablation.

Topics: Aged; Anticoagulants; Atrial Fibrillation; Case-Control Studies; Catheter Ablation; Echocardiography, Transesophageal; Enoxaparin; Female; Humans; Male; Middle Aged; Postoperative Complications; Prospective Studies; Risk Factors; Stroke; Treatment Outcome; Warfarin

Topics: Anticoagulants; Contraindications; Drug Interactions; Hemorrhage; Humans; Perioperative Care; Postoperative Complications; Surgery, Plastic; Thromboembolism; Warfarin

An 84-year-old woman under warfarin therapy, who had undergone mechanical valve replacement 29 months previously, developed coagulation abnormalities after antibiotic treatment for pyelonephritis. Laboratory findings included PT at 47.6 sec, activated thromboplastin time (APTT) at 147 sec, factor V (FV) activity of 4% and FV inhibitor of 8 BU. Although overt bleeding was not observed, administration of prednisolone was started. Her coagulation abnormalities were rapidly normalized. It was later determined that the patient had received bovine thrombin at surgery. The presence of a FV inhibitor should be considered in the differential diagnosis in patients demonstrating an unexpected prolongation of PT under warfarin therapy following surgery.

Topics: Aged, 80 and over; Animals; Anti-Bacterial Agents; Anticoagulants; Aortic Valve; Aortic Valve Stenosis; Cattle; Ceftriaxone; Factor V; Female; Heart Valve Prosthesis; Hemorrhagic Disorders; Humans; Immunosuppressive Agents; Partial Thromboplastin Time; Postoperative Complications; Prednisolone; Prothrombin Time; Pyelonephritis; Species Specificity; Thrombin; Warfarin

The Global Orthopaedic Registry (GLORY) offers insights into multinational practice patterns of venous thromboembolism (VTE) prophylaxis in orthopedic surgery, based on data from 15,020 patients undergoing primary total knee arthroplasty or primary total hip arthroplasty from 2001 to 2004. Registry data show that the first choice for in-hospital VTE prophylaxis was low-molecular-weight heparin. Multimodal prophylaxis was common. Warfarin was more widely used in the USA than elsewhere in the world. GLORY data suggest that real-world practice often fails to meet the standards for prophylaxis recommended in the American College of Chest Physicians evidence-based guidelines, particularly in the USA. However, many US orthopedic surgeons may follow other practice guidelines, causing an underestimation of prophylaxis us in this study. Warfarin in the USA often failed to achieve recommended target International Normalized Ratio (INR) values. This paper reviews the GLORY practice findings in light of the contemporary literature on best practices for VTE prophylaxis in orthopedic patients.

Topics: Anticoagulants; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Databases, Factual; Health Planning Guidelines; Heparin, Low-Molecular-Weight; Humans; Intermittent Pneumatic Compression Devices; Postoperative Complications; Practice Patterns, Physicians'; Registries; Venous Thromboembolism; Warfarin

The authors evaluated the prophylactic protocols with unfractionated heparin (UFH) and warfarin in Japanese patients who underwent total knee arthroplasty (TKA) for osteoarthritis knee in regard to bleeding complications. Fifty-six patients who underwent TKA for osteoarthritis knee with the use of methylmethacrylate were included. Subcutaneous UFH and warfarin were administered for thromboprophylaxis to the first group of 26 patients. The second group of 30 patients did not receive any pharmacological thromboprophylaxis and were used as controls. No significant differences were found between the 2 groups for operative and postoperative blood loss. There were no cases with major bleeding as a complication, but for 2 cases, the international normalized ratio high value exceeded the remedy limits, and temporary dosage discontinuance was required. There were no clinically important bleeding events in the 2 groups. No heparin-induced thrombocytopenia or warfarin-induced skin necrosis occurred. The authors conclude that the protocol with UFH and warfarin is safe for thromboprophylaxis against deep venous thrombosis and pulmonary embolism after TKA in Japanese patients, but its efficacy can only be resolved with further studies.

Topics: Aged; Aged, 80 and over; Arthroplasty, Replacement, Knee; Blood Loss, Surgical; Female; Heparin; Humans; Male; Middle Aged; Osteoarthritis, Knee; Postoperative Complications; Prospective Studies; Pulmonary Embolism; Venous Thrombosis; Warfarin

Deep vein thrombosis (DVT) and pulmonary embolism (PE) are manifestations of venous thromboembolic events (VTEs). Patients undergoing major surgical procedures such as total hip replacement (THR), total knee replacement (TKR), and hip fracture surgery (HFS) are at an elevated risk for VTEs. The American College of Chest Physicians' (ACCP) guidelines recommend that such patients receive thromboprophylaxis for at least 10 days. In patients undergoing THR or HFS, extended prophylaxis for up to 28-35 days is the recommended approach for those at high risk of thromboembolic events. The NAFT (North American Fragmin Trial) compared the prophylactic efficacy of dalteparin with that of warfarin during the in-hospital period, and with that of placebo during the period of hospital discharge until day 35 postsurgery, in patients who underwent total hip arthroplasty. During both the in-hospital and the postdischarge time periods, dalteparin significantly reduced the occurrence of DVT. Given the clinical relevance of these results, the low specificity of the ACCP recommendations regarding optimal prophylaxis duration, and the importance of optimizing the efficiency of DVT prophylaxis in the practice setting, a cost-utility analysis was conducted comparing dalteparin 10-day and 35-day (extended) with a warfarin 10-day protocol, in patients undergoing major orthopedic surgeries such as THR, TKR, or HFS.. A three-arm decision model was developed using the prevalence of symptomatic DVT from NAFT publications, epidemiologic studies, and published meta-analyses. Healthcare resource use was abstracted from a survey of clinicians and from the economic literature. Utility estimates were obtained by interviewing a sample of 24 people from the general public using the time trade-off technique. The clinical, economic and utility data were then used to estimate the cost per quality-adjusted life-year (QALY) gained with dalteparin for 10 or 35 days relative to 10 days of warfarin.. Canadian provincial healthcare system.. The cost per QALY gained with 10 days of dalteparin was below $Can1000 for all the surgeries evaluated (all costs are reported in 2007 Canadian dollars [$Can1 = $US1, as of December 2007]). In the case of extended prophylaxis, the incremental cost per QALY gained with 35 days of dalteparin over warfarin was $Can40 100, $Can46 500, and $Can31 200 for patients undergoing THR, TKR, and HFS, respectively. Reducing the duration of prophylaxis from 35 to 28 days generated ratios that were below $Can35 000 for all three surgeries evaluated.. Ten days of dalteparin following major orthopedic surgery is a clinically and economically attractive alternative to warfarin for DVT prophylaxis. In the case of the 35-day dalteparin protocol, the results also indicated acceptable economic value to a publicly funded healthcare system, particularly in the settings of HFS and THR. In addition, reducing the duration of prophylaxis to 28 days postsurgery would be associated with a more favorable return on public healthcare expenditures.

Topics: Anticoagulants; Canada; Cost-Benefit Analysis; Dalteparin; Drug Administration Schedule; Humans; Meta-Analysis as Topic; Models, Economic; Orthopedic Procedures; Postoperative Complications; Prevalence; Quality-Adjusted Life Years; Venous Thromboembolism; Warfarin

Warfarin is a commonly used anticoagulant for patients with prosthetic heart valves, atrial fibrillation, stroke, deep vein thrombosis, or pulmonary emboli to prevent thromboembolic events. There is no clear consensus regarding the perioperative management of warfarin therapy for plastic surgery procedures. Our objective is to evaluate the safety and quantify any increased morbidity in patients on warfarin therapy, undergoing soft tissue surgery. In a retrospective chart review of prospectively collected data, patients undergoing cutaneous surgery on warfarin therapy from 2000 to 2006 were identified. Perioperative complications were evaluated, including major hemorrhage, incisional bleeding, hematoma, wound or flap complications, graft success, and cosmetic surgical outcome. A total of 26 anticoagulated patients who underwent 56 procedures were included. Intraoperative bleeding was controlled in all cases without difficulty. Minor postoperative bleeding was noted in 1 patient, and this was easily controlled with gentle pressure. All wounds healed without complication, including 2 split thickness skin grafts. The cosmesis of all scars was acceptable. Anticoagulation with warfarin can be safely continued in patients undergoing minor soft tissue procedures, thereby avoiding the risk of potentially devastating thromboembolic events.

Topics: Aged; Aged, 80 and over; Anticoagulants; Dermatologic Surgical Procedures; Female; Hemorrhage; Humans; Male; Middle Aged; Postoperative Complications; Retrospective Studies; Skin Neoplasms; Warfarin

Topics: Aged; Antibodies, Anticardiolipin; Anticoagulants; Arginine; Catheterization; Contraindications; Drug Therapy, Combination; Femoral Vein; Heparin; Humans; Iliac Vein; Infusions, Intravenous; Ischemia; Kidney; Kidney Transplantation; Male; Pipecolic Acids; Popliteal Vein; Postoperative Complications; Protein S Deficiency; Purpura, Thrombocytopenic, Idiopathic; Renal Veins; Sulfonamides; Thrombolytic Therapy; Thrombophilia; Tissue Plasminogen Activator; Vena Cava Filters; Venous Thrombosis; Warfarin

Topics: Aged; Anticoagulants; Atrial Fibrillation; Catheter Ablation; Comorbidity; Female; Humans; Incidence; Male; Middle Aged; Platelet Aggregation Inhibitors; Postoperative Complications; Risk Assessment; Risk Factors; Stroke; Survival Analysis; Survival Rate; Therapeutics; Warfarin

The best periprocedural anticoagulation strategy at the time of pulmonary vein isolation (PVI) is not known. Most centers stop administering warfarin (Coumadin) and use bridging with heparin or enoxaparin.. The purpose of this study was to evaluate the efficacy and safety of PVI under therapeutic international normalized ratio (INR).. Between January 2005 and December 2008, PVI was performed in 3,052 patients with therapeutic INR (> or =1.8) at the time of ablation. All patients were evaluated for ischemic strokes and bleeding complications.. Mean INR was 2.53 +/- 0.62. Only 3 (0.098%) patients had ischemic strokes. One patient had a hemorrhagic stroke on the third day postablation but recovered completely by 1-week follow-up. Bleeding complications occurred in 34 (1.11%) patients; most were minor (0.79%). Major hemorrhagic complications occurred in 10 (0.33%) patients (tamponade in 5, hematomas requiring intervention in 2, transfusion necessary in 3).. In a large patient population, continuation of Coumadin at a therapeutic INR at the time of PVI without use of heparin or enoxaparin for bridging is a safe and efficacious periprocedural anticoagulation strategy. It is an acceptable and potentially better alternative to strategies that use bridging with heparin or enoxaparin.

Topics: Anticoagulants; Atrial Fibrillation; Catheter Ablation; Female; Follow-Up Studies; Hemorrhage; Humans; Male; Middle Aged; Postoperative Complications; Pulmonary Veins; Stroke; Warfarin

The purpose of this study was to assess the prevalence and seriousness of adverse outcomes owing to mandatory venous thromboembolism (VTE) prophylaxis. A retrospective study of administrative claims data was conducted to look at the rate of VTEs and other complications in patients undergoing hip and knee arthroplasty. Additional analysis was done to determine whether patient characteristics could explain findings. Although rates of VTE remain unchanged from 2003 to 2007, the rate of immediate postprocedure hematoma, seroma, and hemorrhage went from 1.4% in 2003 to 9.6% in 2006. Return to a more conservative prophylaxis approach resulted in a marked decrease in rates of significant bleeding events. Although preventing VTEs is an important quality concern, mandating prophylaxis for all patients could have unintended adverse outcomes. These guidelines might need to be reevaluated for hip and knee arthroplasty patients.

Topics: Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Female; Follow-Up Studies; Guidelines as Topic; Hemorrhage; Heparin, Low-Molecular-Weight; Humans; Male; Postoperative Complications; Prospective Studies; Venous Thromboembolism; Warfarin

The risk of haemorrhage from minor cutaneous surgical procedures has long been a concern in the treatment of patients receiving warfarin as anti-coagulation therapy. Interruption, alteration, hospital admission and monitoring have resource implications as well as the potential for complications. Therefore, we wanted to determine whether it was feasible to undertake typical minor plastic surgery procedures without altering patients' warfarin dosage regimens. We undertook a prospective study of 51 patients (age range 36 to 86), with 78 wounds, undergoing a range of minor cutaneous surgical procedures including excision biopsies, local flaps and skin grafts. The patients continued their normal warfarin regimen and the INR was checked on the day of surgery, ranging from 1.1 to 4.0. There were no problems encountered during surgery, but two patients presented with bleeding from a wound a few days post-operatively. We feel that it is unnecessary to modify warfarin regimens for minor cutaneous surgery. However, a well-briefed patient and experienced surgical management with good support facilities are a prerequisite for this.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Cohort Studies; Female; Humans; Male; Middle Aged; Postoperative Complications; Skin Diseases; Warfarin

In the present study, the authors investigated the management of mechanical valve thrombosis (MVT). From January 1981 through March 2006, 2,908 mechanical valve replacements were performed in 2,298 patients at our institution. Twenty (0.87%) patients presented with MVT, 14 (70.0%) were women, and the mean age of the patients was 42.0+/-14.0 (27-66) yr. Thrombosis involved mitral in 14 (70.0%), aortic in 2 (10.0%), tricuspid/aortic in 1 (5%), and tricuspid in 3 (15%). The interval from first operation to valve thrombosis was 121.8+/-75.4 (0.9-284.7) months. The most frequent clinical presentation was heart failure (13/20, 65%), and predisposing causes of MVT were: poor compliance with warfarin (7), pregnancy (5), drug interaction (2), and unknown (6). All 20 patients underwent valve replacement: mitral (14, 70.0%), tricuspid (3, 15.0%), aortic (2, 10%) and tricuspid/aortic (1, 5%). One early death occurred due to left ventricular failure, but no late mortality occurred during 63.3+/-49.9 (0.5-165.1) months of follow-up. MVT was treated successfully, and pregnancy and inadequate anticoagulation were found to influence the occurrence of this rare complication.

Topics: Adult; Aged; Anticoagulants; Coronary Thrombosis; Drug Interactions; Female; Follow-Up Studies; Heart Valve Prosthesis; Heparin; Humans; International Normalized Ratio; Male; Middle Aged; Patient Compliance; Postoperative Complications; Pregnancy; Pregnancy Complications; Recurrence; Reoperation; Retrospective Studies; Risk Factors; Thrombolytic Therapy; Warfarin

Most orthopaedic surgeons in the UK use some form of prophylaxis against venous thromboembolic events. Warfarin has been recommended as one of the preferred methods to use. The period of in-hospital postoperative rehabilitation has reduced significantly since lower limb arthroplasty was introduced. We sought to identify and quantify any delay in discharge associated in using warfarin as chemical prophylaxis.. During a 12-week period, all patients undergoing a lower limb arthroplasty procedure were identified and any delay in discharge related to their warfarin prophylaxis was recorded.. Of the 25 arthroplasties performed in this time period, 17 (68%) were subject to a delay. The total delay in discharge was 39 days. When the standard warfarin dosing protocol was followed, 33% of patients were still delayed. When the protocol was not followed, only 23% were delayed. The majority of deviations from the protocol led to a shorter hospital stay.. Patients using warfarin prophylaxis generate an additional cost of 417 pounds related to bed occupancy. There is considerable scope for significantly reducing this cost by moving the early postoperative anticoagulation monitoring into the community. Delayed discharge is an important consideration in the economic issues that surround the choice of thromboprophylaxis.

Topics: Anticoagulants; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Clinical Protocols; Costs and Cost Analysis; Humans; Length of Stay; Postoperative Complications; Thromboembolism; Warfarin

Topics: Anticoagulants; Arthroplasty, Replacement, Hip; Aspirin; Fondaparinux; Heparin, Low-Molecular-Weight; Humans; Orthopedic Procedures; Polysaccharides; Postoperative Complications; Risk Assessment; Risk Reduction Behavior; Venous Thromboembolism; Warfarin

Topics: Aged; Anticoagulants; Aortic Valve; Blood Coagulation Factors; Cardiac Tamponade; Heart; Heart Valve Prosthesis Implantation; Humans; International Normalized Ratio; Male; Marfan Syndrome; Pericardial Effusion; Pericardiectomy; Pericardium; Postoperative Complications; Postoperative Hemorrhage; Thrombosis; Warfarin

Guidelines and local hospital protocols dealing with anticoagulation at the time of surgery vary, but most suggest stopping Warfarin at least three days preoperatively with or without interim low-molecular-weight heparin or intravenous heparin infusion. This study addresses whether it is safe to perform inguinal hernia surgery on the patient who is fully anticoagulated with Warfarin.. We performed a retrospective case note analysis of consecutive patients who underwent elective inguinal hernia repair at the Plymouth Hernia Service between 1999 and 2007. All patients on therapeutic oral anticoagulation with Warfarin were selected. Data analysis was of complications and patient-related, hernia-related, and surgery-related variables. International normalising ratio (INR) was measured on the day preceding surgery.. A total of 49 patients had been operated on whilst anticoagulated with Warfarin. The mean age of the patients was 75 years (range 44-96 years). Thirty patients were on Warfarin for atrial fibrillation, seven for previous PE, three for previous DVT, and nine for mechanical heart valves. Forty patients had a desired INR range of 2-3, and nine a desired range of 3-4. Forty-five (91.8%) patients had no complications or mild bruising requiring no further management. Three (6.1%) patients developed haematomas requiring surgical management and there was one death of unrelated cause. An INR of greater than 3 increased the risk of postoperative haematoma (P = 0.03). None of the other measured patient-related, hernia-related, or surgery-related variables predicted complications (P > 0.05).. Patients can safely undergo inguinal hernia repair whilst on Warfarin as long as the INR is less than 3.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Elective Surgical Procedures; Hematoma; Hernia, Inguinal; Humans; Middle Aged; Postoperative Complications; Retrospective Studies; Warfarin

The use of outpatient anticoagulation after major orthopedic surgery with oral or injectable anticoagulants is recommended by national guidelines. A retrospective analysis of medical and pharmacy claims data using the PharMetrics Patient-Centric Database Inc, Watertown, Mass, was conducted. After adjusting for covariates, patients receiving warfarin were approximately 30% more likely to experience a venous thromboembolism than those receiving an injectable anticoagulant (6.3% vs 4.8%; adjusted odds ratio, 1.3; 95% confidence interval, 1.1-1.5) by 30 days. The data at 90 days showed similar results. No significant differences in the incidence of major bleeding events between the cohorts were observed (incidence of major bleed <0.4%). These findings support the randomized controlled studies and expand the data to the real-world perspective. Clinicians should evaluate these data alongside the clinical trial data when selecting the safest and most effective prophylactic therapy for postdischarge anticoagulation.

Topics: Administration, Oral; Anticoagulants; Arthroplasty; Female; Hemorrhage; Humans; Injections; Male; Middle Aged; Orthopedic Procedures; Patient Discharge; Postoperative Complications; Pulmonary Embolism; Retrospective Studies; Venous Thromboembolism; Warfarin

Patients with mechanical heart valves require anticoagulation which is associated with significant maternal mortality (1-4%) and fetal complications (31%) in pregnancy. The study aim was to identify anticoagulant protocols and outcomes for pregnant women undergoing heart valve replacement (HVR) in the United Kingdom.. Women aged between 18 and 45 years and registered with the United Kingdom Heart Valve Registry (UKHVR) each completed a questionnaire, and their obstetric notes were reviewed. The data analyzed included valve type (mechanical, bioprosthetic, homograft), valve site (mitral, aortic, tricuspid, pulmonary), anticoagulation at confirmation of pregnancy, between 6-12 weeks and from 12 weeks to term, delivery, maternal and fetal outcomes, and cause of death. The summary statistics and a descriptive review of the findings are reported.. Of 2,532 women eligible for the study, 922 responded. Among these women, 72 became pregnant, with 60 pregnancies in the mechanical valve (MV) group and 45 in the tissue valve (TV) group. Three anticoagulation regimes were used during early pregnancy: unfractionated heparin (UFH), low-molecular-weight heparin (LMWH) or warfarin. All women received warfarin in the second trimester and heparin for delivery. Live births were recorded in 30% of MV pregnancies and in 60% of TV pregnancies. Miscarriage rates differed markedly (37% MV versus 2% TV). Fetal outcome was poorest in the warfarin-only group, with embryopathy occurring at a dose level of 6 mg. The maternal outcomes did not differ significantly among groups. High-dose heparin during the first trimester and for delivery was effective for the majority of mechanical valves.. The study results illustrate the diverse and uncertain manner in which UKHVR patients are managed during pregnancy. A national notification system would record much-needed prospective information on anticoagulation and pregnancy outcomes, thus aiding evidence-based management.

Topics: Abortion, Spontaneous; Adolescent; Adult; Anticoagulants; Bioprosthesis; Cause of Death; Dose-Response Relationship, Drug; Female; Fetal Diseases; Heart Failure; Heart Valve Prosthesis Implantation; Heparin; Heparin, Low-Molecular-Weight; Humans; Middle Aged; Postoperative Complications; Pregnancy; Pregnancy Complications, Cardiovascular; Pregnancy Outcome; Risk Factors; United Kingdom; Warfarin

A 6-month-old girl with a diagnosis of double-outlet right ventricle and pulmonary stenosis had a left modified Blalock-Taussig shunt. Chest computed tomography (CT) performed on postoperative day 11 showed good patency of the shunt. However, on postoperative day 16, oxygen saturation suddenly dropped below 40%, and chest CT showed thrombotic occlusion of the shunt. Urgent thrombectomy was performed successfully. Examination of coagulation factors revealed low levels of both the amount and activity of protein C (27% and 31%, respectively). Diagnosis of heterozygous hereditary protein C deficiency was made, and the patient was placed on warfarin. She is currently in good condition.

Topics: Anticoagulants; Double Outlet Right Ventricle; Emergencies; Humans; Infant; Postoperative Complications; Protein C Deficiency; Pulmonary Valve Stenosis; Radiography, Thoracic; Thrombectomy; Thrombosis; Tomography, X-Ray Computed; Vascular Surgical Procedures; Warfarin

Topics: Anti-Bacterial Agents; Anticoagulants; Humans; Immobilization; Male; Middle Aged; Pneumonia; Postoperative Complications; Pulmonary Embolism; Severity of Illness Index; Warfarin

Although relatively infrequent, groin hematoma following inguinal herniorrhaphy is a morbid complication with major ramifications of mesh infection and hernia recurrence. We have sensed an increasing frequency of this complication in our tertiary referral practice and sought to determine whether or not significant risk factors could be identified.. In this matched case-control study (1995-2003), we identified 53 patients with groin hematomas and paired them with 106 age- and gender-matched controls. Patient and procedure characteristics were analyzed using chi-square and both univariate and multivariable, conditional logistic regression analysis.. The 53 patients developing groin hematoma following inguinal hernia repair (mean age=65, range 22-87, 90% male) were well matched with 106 controls (mean age=65, range 22-87, 90% male). There was no significant difference in the location (left, right, bilateral), type (direct, indirect, pantaloon, first repair, or recurrent), or technique of hernia repair (Bassini, Lichtenstein, mesh plug, endoscopic, or McVay) between groups. While univariate analysis identified Coumadin usage (P<0.001, hazard ratio 19.1), valvular disease (P<0.001, hazard ratio 10.9), atrial fibrillation (P=0.02, hazard ratio 4.2), vascular disease (P=0.04, hazard ratio 2.2), blood abnormalities (P=0.02, hazard ratio 3.2), and previous bleeding episodes (P=0.02, hazard ratio 4.9) as significant factors, only preoperative Coumadin usage was important in multivariate analysis.. The crucial risk factor for groin hematoma developing in patients undergoing inguinal hernia repair is preoperative need for Coumadin therapy. Although the perioperative management of anticoagulation in patients undergoing inguinal herniorrhaphy is not clearly defined, meticulous management of patients requiring Coumadin therapy seems prudent.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Case-Control Studies; Chi-Square Distribution; Female; Groin; Hematoma; Hernia, Inguinal; Humans; Logistic Models; Male; Middle Aged; Minnesota; Postoperative Complications; Proportional Hazards Models; Retrospective Studies; Risk Factors; Surgical Mesh; Warfarin

Patient self-testing of the international normalized ratio (INR) has been shown to improve management of anticoagulation with warfarin and reduce risks of thromboembolism and bleeding. Self-testing instruction usually begins several weeks after hospital discharge. We evaluated the feasibility of in-hospital INR self-testing instruction in patients recovering from valve replacement.. We instituted an education program on a self-testing device before hospital discharge in 50 adult patients (median age, 54 years; 66% men) undergoing cardiac valve replacement with mechanical prostheses. Patients were monitored for 1 month to assess their ability to self-test and the accuracy of the INR measurements.. Self-testing instruction began on postoperative day 4 (range, 1 to 8 days). Each patient had an average of 3.5 teaching sessions; each session lasted approximately 20 minutes. One month after discharge, all patients (98%) but 1 were able to self-test. No patient required interval instruction. One bleeding episode occurred in a patient whose INR exceeded the therapeutic range. Once warfarin doses were stabilized, 5 patients had subtherapeutic INR values on self-testing. The mean INR test result obtained from the coagulometer correlated well with values obtained by laboratory determination (r = 0.79).. This evaluation of an in-hospital education program demonstrates that patients are able to learn INR self-testing and that most will continue to use the method without the need for interval instruction. Improved anticoagulation management by early introduction of INR self-testing should reduce thromboembolic and hemorrhagic complications after valve replacement.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anticoagulants; Diagnosis, Computer-Assisted; Equipment Design; Feasibility Studies; Female; Heart Valve Prosthesis Implantation; Humans; International Normalized Ratio; Male; Middle Aged; Patient Compliance; Patient Education as Topic; Point-of-Care Systems; Postoperative Complications; Self Care; Software; Warfarin

Prolonged wound drainage following total hip or total knee arthroplasty has been associated with an increased risk of postoperative morbidity. The purpose of this study was to determine the pharmacologic, surgical, and patient-specific factors that are associated with prolonged wound drainage and the relationship of this complication to the length of hospital stay and the rate of wound infections.. We conducted a retrospective observational study of 1211 primary total hip arthroplasties and 1226 primary total knee arthroplasties. Prospectively collected data included body mass index, intraoperative blood loss, surgical time, type of prophylaxis against deep venous thrombosis, and length of hospital stay. The association of these factors with the duration of postoperative wound drainage was analyzed. An acute infection developed after fifteen primary total hip arthroplasties and ten primary total knee arthroplasties. The patients with an acute postoperative infection were compared with their uninfected counterparts, and an odds ratio was determined to estimate the risk of prolonged wound drainage resulting in a wound infection.. Morbid obesity was strongly associated with prolonged wound drainage in the total hip arthroplasty group (p = 0.001) but not in the total knee arthroplasty group (p = 0.590). An increased volume of drain output was an independent risk factor for prolonged wound drainage in both groups. Patients who received low-molecular-weight heparin for prophylaxis against deep venous thrombosis had a longer time until the postoperative wound was dry than did those treated with aspirin and mechanical foot compression or those who received Coumadin (warfarin); this difference was significant on the fifth postoperative day (p = 0.003) but not by the eighth postoperative day. Prolonged wound drainage resulted in a significantly longer hospital stay in both groups (p < 0.001). Each day of prolonged wound drainage increased the risk of wound infection by 42% following a total hip arthroplasty and by 29% following a total knee arthroplasty.. Morbid obesity, the use of low-molecular-weight heparin, and a higher drain output were associated with a prolonged time until the postoperative wound was dry following a primary total hip arthroplasty, whereas a higher drain output was the only risk factor associated with prolonged drainage following a primary total knee arthroplasty. Prolonged drainage was associated with a higher rate of infection following a primary total hip arthroplasty, whereas obesity was the only identified independent risk factor for postoperative infection following a primary total knee arthroplasty.

Topics: Aged; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Aspirin; Body Mass Index; Drainage; Female; Heparin, Low-Molecular-Weight; Humans; Kaplan-Meier Estimate; Length of Stay; Linear Models; Logistic Models; Male; Middle Aged; Obesity, Morbid; Postoperative Complications; Retrospective Studies; Risk Factors; Surgical Wound Infection; Venous Thrombosis; Warfarin; Wound Healing

We aimed to evaluate left atrial appendage (LAA) exclusion in patients undergoing mitral valve surgery with respect to thromboembolic events.. LAA is the predominant source of emboli in patients with atrial fibrillation. Prophylactic LAA exclusion at the time of heart surgery has been recommended to reduce the risk of future thromboembolism.. An observational cohort of 136 patients undergoing LAA exclusion during mitral valve surgery was identified between May 1993 and November 1998 at our institution.. During a mean follow-up of 3.6 +/- 1.3 years, there were 14 (12.3%) thromboembolic events. Compared with patients who received warfarin upon hospital discharge, there were more thromboembolic events in patients not prescribed warfarin upon hospital discharge (n = 7/67, 10% vs n = 6/40, 15%, respectively). The warfarin status was not known for one patient. The majority of thromboembolic events (n = 10/14, 71%) occurred in those who underwent mitral valve repair.. In this observational study, patients who undergo LAA exclusion during mitral valve surgery to reduce the risk of thromboembolism have a significant incidence of thromboembolic events, especially when warfarin therapy is not prescribed upon hospital discharge.

Topics: Anticoagulants; Atrial Appendage; Atrial Fibrillation; Bioprosthesis; Cohort Studies; Comorbidity; Female; Florida; Follow-Up Studies; Heart Atria; Heart Valve Diseases; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Incidence; Male; Middle Aged; Mitral Valve; Ohio; Postoperative Complications; Risk Factors; Thromboembolism; Warfarin

Our aim was to review the safety of percutaneous injection laryngoplasty using bovine crosslinked collagen, focusing specifically on two often-stated concerns: injecting patients who are taking the anticoagulant medication warfarin, and injecting patients without prior skin hypersensitivity testing.. Retrospective chart review of injection laryngoplasty performed between 1997 and 2006 at the University of California, Los Angeles.. The study group consisted of 895 patients who underwent 1290 injection laryngoplasty procedures. No bleeding complications were noted in 59 patients taking warfarin. No allergic complications were reported in 845 patients who did not undergo skin hypersensitivity testing before injection laryngoplasty.. Percutaneous bovine crosslinked collagen injection laryngoplasty is safe in patients taking warfarin. Skin testing for hypersensitivity does not appear to be necessary before injection.. Patients on warfarin are candidates for injection laryngoplasty without the need to discontinue the medication. Eliminating skin hypersensitivity testing before percutaneous bovine crosslinked collagen injection laryngoplasty allows for a prompt treatment of glottic insufficiency.

Topics: Aged; Animals; Anticoagulants; Biocompatible Materials; Cattle; Collagen; Female; Glottis; Humans; Hypersensitivity; Injections, Intradermal; Laryngeal Diseases; Male; Postoperative Complications; Postoperative Hemorrhage; Prostheses and Implants; Retrospective Studies; Safety; Vocal Cord Paralysis; Voice Disorders; Warfarin

The antiphospholipid antibody syndrome (APLS) is characterised by the presence of antiphospholipid antibodies in association with thrombotic disorders of the arterial and/or venous system, spontaneous abortion and thrombocytopenia. Several studies have shown that end-stage renal disease patients with APLS are at extremely high risk for graft thrombosis and graft loss after kidney transplantation.. We report on the treatment and clinical courses of 6 APLS renal transplant patients.. Of 3 patients treated with low-dose subcutaneous heparin two had early graft loss due to venous graft thrombosis; of those patients treated by systemic heparin (PTT goal 45-55 s) and followed by coumadin (INR 2.5-3.0) only one had early graft loss whereas 2 grafts are doing well 2 years post-transplant.. Our experience as well as recently published data suggest that kidney transplantation can be performed successfully in APLS patients if anticoagulation therapy is performed consistently. A general APL antibody screening prior to kidney transplantation does not seem to be justified at present. A prospective, randomised multicenter study is warranted to evaluate the management of these patients with respect to intensity, type and duration of anticoagulation therapy.

Topics: Adult; Anticoagulants; Antiphospholipid Syndrome; Graft Survival; Heparin; Humans; Injections, Intravenous; Injections, Subcutaneous; Intraoperative Care; Kidney Transplantation; Lupus Erythematosus, Systemic; Partial Thromboplastin Time; Postoperative Complications; Risk Factors; Thrombosis; Warfarin

Topics: Anticoagulants; Atrial Fibrillation; Humans; Postoperative Complications; Retinal Diseases; Retrospective Studies; Risk Factors; Vitrectomy; Vitreous Hemorrhage; Warfarin

To evaluate the current practice of oral and maxillofacial surgeons in Michigan regarding perioperative warfarin therapy and dentoalveolar surgery in defined procedure risk groups.. Surveys were distributed to all surgeons (n = 188) registered with the Michigan Society of Oral and Maxillofacial Surgeons. Low/moderate/high surgery risk groups were defined based on retrospective data accumulated for procedures on pretransplant liver failure patients. We requested the surgeon's maximum tolerated International Normalized Ratio (INR) for each risk group. In addition, surgeons were asked if their routine practice for each group included continuation or discontinuation of therapeutic warfarin perioperatively.. A 72.6% response rate was achieved. The average maximum INR cutoff values for the various risk groups were: low, 2.68; moderate, 2.28; and high, 2.01. Routine discontinuation of warfarin occurred in these groups 23.6%, 48.8%, and 70.5%, respectively. Using a paired t test, these results showed statistically significant differences in patient management practices (P < .001) between the low, moderate, and high risk groupings.. Lack of uniformity exists regarding warfarin therapy and dentoalveolar surgery. No studies to date involve significant numbers of moderate/high risk procedures to provide evidence-based support of safety with maintenance of therapeutic INR. For moderate or high risk procedures, the majority of surgeons prefer warfarin discontinuation with minimally therapeutic or subtherapeutic levels, a practice that secondarily increases risk for thromboembolism. Based on these preliminary data, we believe a prospective trial to elucidate stronger management guidelines for both the moderate and high risk surgery population is indicated.

Topics: Anticoagulants; Dental Care for Chronically Ill; Hemostasis, Surgical; Humans; Michigan; Oral Hemorrhage; Oral Surgical Procedures; Postoperative Complications; Practice Guidelines as Topic; Practice Patterns, Dentists'; Risk Assessment; Statistics, Nonparametric; Thromboembolism; Warfarin

Consecutive patients having elective total hip arthroplasty were prescribed 1 mg of warfarin for 7 days preceding surgery, variable doses while in hospital (target international normalized ratio, 1.5-2.0), and discharged to rehabilitation center or home taking 1 mg daily until 4-week to 6-week follow-up visit. Lower leg pneumatic compression was used postoperatively and elastic compression stockings after discharge. Hospital and clinic charts plus auxiliary sources were reviewed for evidence of thromboembolic diseases (TED). Of 1003 consecutive patients studied, 3 (0.3%, 95% CI 0.0-0.6%) had symptomatic TED, including 2 with deep venous thrombosis and 1 with nonfatal pulmonary embolus. Follow-up rate was 99.1%. Complications from warfarin were minimal. Very-low-dose warfarin coupled with lower leg compression is effective prophylaxis against TED after elective hip arthroplasty when prescribed as described.

Topics: Adult; Aged; Anticoagulants; Arthroplasty, Replacement, Hip; Bandages; Female; Follow-Up Studies; Humans; Leg; Male; Middle Aged; Postoperative Complications; Pressure; Pulmonary Embolism; Retrospective Studies; Venous Thrombosis; Warfarin

Hip arthroplasty and extended travel are each recognized as risk factors for venous thromboembolism (VTE). The safety of travel after hip arthroplasty is currently unknown. Patients who had traveled more than 200 miles within 6 weeks of a hip arthroplasty or hip resurfacing were identified and contacted. All patients received VTE chemoprophylaxis with enoxaparin, dalteparin, fondaparinox, or warfarin. A total of 608 patients traveled an average of 1377 miles at an average of 6.5 days after surgery. Among these patients, 462 traveled by airplane, 143 by car, and 3 by train. There were no deaths, no symptomatic pulmonary embolisms, and only 5 (0.82%) symptomatic deep venous thromboses. Nine (1.5%) patients experienced bleeding complications. With chemical VTE prophylaxis, extended travel within 6 weeks of hip arthroplasty surgery is associated with a low rate of symptomatic deep venous thrombosis, with no known pulmonary embolisms and no deaths.

Topics: Anticoagulants; Arthroplasty, Replacement, Hip; Dalteparin; Enoxaparin; Fondaparinux; Hip Joint; Humans; Polysaccharides; Postoperative Complications; Risk Factors; Safety; Time Factors; Transportation; Travel; Venous Thromboembolism; Venous Thrombosis; Warfarin

An 18-year-old healthy woman with no previous history of coagulation disorders underwent general anesthesia for tonsillectomy. The procedure was uneventful. After the surgery, she was ordered to rest on bed overnight. The next day, the patient experienced transient syncope followed by hypotension (< 60 mmHg) and severe dyspnea. Epinephrine 2 mg administration restored the blood pressure promptly, yet dyspnea persisted. The lung-perfusion scintigraphy showed upper-lobe perfusion defect in the left lung and she was diagnosed as having pulmonary embolism. She received low-molecular-weight heparin and warfarin therapy and recovered fully. The postoperative laboratory analysis did not show thrombophilic disorders or prothrombotic state. The pulmonary embolism was speculated to have occurred due to deep vein thrombosis which developed after postoperative immobilization. The prophylactic maneuvers such as elastic stockings were not applied to the patient preoperatively, who had been considered unlikely to develop deep vein thrombosis. Although deep vein thrombosis in children and adolescence are rare, postoperative children should be monitored carefully for thrombotic complications. Postoperative bed rest should be minimized in terms of prevention of thrombosis.

Topics: Adolescent; Anesthesia, General; Anticoagulants; Female; Heparin; Humans; Postoperative Complications; Pulmonary Embolism; Tonsillectomy; Treatment Outcome; Venous Thrombosis; Warfarin

To determine the incidence of thromboembolism after one-stage bilateral total hip arthroplasty and the role of two different chemoprophylaxis agents, we retrospectively studied 644 consecutive patients who underwent one-stage bilateral total hip arthroplasties. All patients received a similar multimodal prophylaxis protocol, which differed only in the postoperative chemoprophylaxis: 292 patients received warfarin (Group 1) and 352 received aspirin (Group 2). All patients were followed for a minimum of 3 months. We observed no difference in the incidence of symptomatic venous thrombosis, pulmonary embolism, or mortality in the two groups. Twenty patients in each group had deep venous thrombosis (7% and 5.7%, respectively) develop. Seven patients (2.39%) in Group 1 and eight (2.27%) in Group 2 had proximal deep venous thrombosis. Four patients in each group had a nonfatal pulmonary embolism (1.36% and 1.13%, respectively). There were two deaths in each group, neither related to venous thromboembolism. One-stage bilateral total hip arthroplasties were associated with a low rate of venous thrombosis and embolism with our multimodal prophylaxis protocol, and we found no difference in the incidence of either in patients who received warfarin or aspirin for chemoprophylaxis.

Topics: Anticoagulants; Arthroplasty, Replacement, Hip; Aspirin; Clinical Protocols; Female; Humans; Incidence; Male; Middle Aged; Platelet Aggregation Inhibitors; Postoperative Complications; Preoperative Care; Pulmonary Embolism; Retrospective Studies; Survival Rate; Thromboembolism; Venous Thrombosis; Warfarin

Topics: Aged; Aged, 80 and over; Anticoagulants; Decision Making; Female; Humans; Intraoperative Complications; Male; Perioperative Care; Postoperative Complications; Practice Guidelines as Topic; Surgical Procedures, Operative; Thromboembolism; Warfarin

Diabetes mellitus patients after aorto-coronary bypass operation constitute a patient cohort at largely increased risk for secondary coronary events. Antiplatelet agents and antithrombotic agents are applied for secondary prevention. Up to now, secondary prevention has not been addressed specifically in the cohort of diabetic patients after bypass operation. Hence therapeutic recommendations are derived from the global cohort of CAD patients and based on risk assessment rather than on specific data. Since diabetic patients after myocardial infarction are at particularly high risk, combined therapy with clopidogrel and ASS may be considered even with restricted resources in the health system. Oral anticoagulation with coumadin constitutes an effective alternative to dual anti-platelet therapy. Under specific conditions (ventricular aneurysms, EF < 30%, or certain conditions in coronary anatomy) oral anticoagulants should be considered more liberally than currently.

Topics: Anticoagulants; Aspirin; Clopidogrel; Coronary Artery Bypass; Coronary Artery Disease; Diabetes Mellitus; Fibrinolytic Agents; Humans; Platelet Aggregation Inhibitors; Postoperative Complications; Risk Factors; Thrombosis; Ticlopidine; Warfarin

Inferior shoulder dislocation or luxatio erecta is an exceedingly rare form of shoulder dislocation and compromises less than 0.5% of all shoulder dislocations. Furthermore, bilateral luxatio erecta is reported only nine times in the English literature. This paper documents the tenth case of bilateral luxatio erecta. This tenth patient suffered an axial load injury to his outstretched arms and displaced both humeral heads inferiorly. After closed reduction, the patient was discharged home on hospital day two. However, he developed an axillary vein thrombosis 3 days later and required anticoagulation therapy. This report reviews the mechanisms of injury associated with inferior shoulder dislocations as well as the presentation and treatment of luxatio erecta. The complication of axillary vein thrombosis and its treatment in this patient are discussed also.

Topics: Accidents, Traffic; Adult; Anticoagulants; Arm Injuries; Axillary Vein; Drug Therapy, Combination; Emergencies; Follow-Up Studies; Heparin, Low-Molecular-Weight; Humans; Male; Manipulation, Orthopedic; Postoperative Complications; Radiography; Shoulder Dislocation; Ultrasonography, Doppler; Venous Thrombosis; Warfarin; Weight-Bearing; Wounds, Nonpenetrating

This study reviewed the effectiveness of a trimodality deep venous thrombosis (DVT) prophylactic regimen after primary and revision total hip arthroplasty. Seven hundred five patients were treated with pneumatic compression, adjusted dose warfarin (7 days), and early mobilization. Bilateral lower extremity venous ultrasonography was obtained on postoperative day 3 or 4. The incidence of asymptomatic DVT, symptomatic DVT/pulmonary embolus events within 90 days of surgery, and potential influence of risk factors was retrospectively assessed. Deep venous thrombosis incidence was 4.4% with one (0.1%) nonfatal pulmonary embolus. Increased age, male sex, and DVT history were significant risk factors for thromboembolic events within 90 days of hip arthroplasty. The combination of short-duration warfarin and mechanical prophylaxis with predischarge ultrasound screening was safe and effective in limiting the occurrence of venous thromboembolism.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anticoagulants; Arthroplasty, Replacement, Hip; Bandages; Combined Modality Therapy; Female; Humans; Male; Middle Aged; Motor Activity; Postoperative Complications; Regression Analysis; Retrospective Studies; Thromboembolism; Treatment Outcome; Venous Thrombosis; Walking; Warfarin

Postoperative thromboembolic complications associated with mechanical valve prosthesis implantation can be reduced with either antiplatelet agents or warfarin. Warfarin been shown to be more effective in adults, but the data are less clear in the pediatric population.. Seventy-two children and adolescents who survived mechanical valve implantation on the left side of the heart at the authors' institution were followed prospectively from August 1979 until December 2003. All patients underwent surgery before the age of 20 years, and follow up was included up to the age of 20 years. Initially, 53 patients received warfarin alone; mean follow up was 5.9 years, and total follow up 312 patient-years (pt-yr). Likewise, 19 patients received antiplatelet agents; mean follow up was 5.2 years, and total follow up 99 pt-yr. Results were examined using intent-to-treat analyses.. Age, gender, race, valve size and position, mean time of follow up and crossover rates were not different between groups. No differences were detected in survival or freedom from thromboembolic and hemorrhagic events. Complications associated with warfarin use were substantially more severe than those associated with antiplatelet agents.. The study results were inconclusive due to the small numbers of patient-years of follow up, but suggest that antiplatelet agents may be associated with less severe complications than warfarin. Moreover, warfarin and antiplatelet agents may be equally effective for clotting prophylaxis in children after valve replacement with St. Jude Medical prostheses.

Topics: Adolescent; Adult; Anticoagulants; Child; Child, Preschool; Disease-Free Survival; Embolism; Female; Heart Valve Prosthesis Implantation; Humans; Infant; Male; Platelet Aggregation Inhibitors; Postoperative Complications; Retrospective Studies; Thrombosis; Treatment Outcome; Warfarin

Topics: Adenoma, Villous; Aged; Anticoagulants; Cecal Diseases; Colonography, Computed Tomographic; Colonoscopy; Endoscopy, Gastrointestinal; Heart Valve Prosthesis; Humans; Intestinal Polyps; Male; Mitral Valve; Postoperative Complications; Practice Guidelines as Topic; Sigmoid Neoplasms; Thromboembolism; Warfarin

Leaflet opening angles of ATS valves in vivo tend to be less than those reported by the manufacturer, and there is a wide variation in opening angles even among valves of the same size.. Leaflet movement of aortic ATS valves was evaluated by cineradiography in 77 patients. The mean period from valve replacement to cineradiography was 40.2 months, and during that period, the ATS valve was replaced due to prosthetic valve obstruction in 1 of the 77 patients.. In 76 patients with a normally functioning ATS valve, the mean opening angle of 19-mm valves (66.3 degrees +/- 2.3 degrees) was significantly less (p < 0.0001) than that of ATS valves 21 mm or larger (72.2 degrees +/- 3.8 degrees in 21-mm, 72.4 degrees +/- 2.8 degrees in 23-mm, and 72.8 degrees +/- 2.9 degrees in 25-mm valves). No significant differences were found in the opening angles of ATS valves 21 mm or larger, and the opening angles exceeded 65 degrees in all 69 patients with valves in this category. In one case of obstruction in a 21-mm valve, the opening angle was 57.5 degrees. The closing angle was 24.9 degrees +/- 1.3 degrees, which corresponded well with the manufacturer's in vitro data.. The opening angle in the 19-mm ATS aortic valve is significantly less than that in valves 21 mm or larger, and an opening angle of less than 65 degrees probably indicates prosthetic valve obstruction in aortic ATS valves sized 21 mm or larger.

Topics: Adolescent; Adult; Aged; Anticoagulants; Aortic Valve; Aortic Valve Insufficiency; Aortic Valve Stenosis; Aspirin; Cardiac Surgical Procedures; Cineradiography; Comorbidity; Echocardiography, Doppler; Equipment Design; Female; Heart Valve Prosthesis; Hemorheology; Humans; Male; Middle Aged; Motion; Platelet Aggregation Inhibitors; Postoperative Complications; Postoperative Period; Prosthesis Failure; Reoperation; Thromboembolism; Warfarin

Topics: Anesthesia, Spinal; Anticoagulants; Colorectal Surgery; Drug Interactions; Humans; Intermittent Pneumatic Compression Devices; Postoperative Complications; Risk Factors; Stockings, Compression; Venous Thrombosis; Warfarin

Hemostatic physiology involves a complex interlinking of blood and endothelial factors. Its pharmacological manipulation invariably impacts at multiple molecular sites. Herein is reported an unusual case of coexistent warfarin-induced skin necrosis and heparin-induced thrombocytopenia following mitral valve replacement for thromboembolic phenomena associated with marantic endocarditis and bronchial adenocarcinoma. Thrombophilia in the face of endocarditis should be treated with a suspicion of underlying cancer.

Topics: Adenocarcinoma; Anticoagulants; Bronchial Neoplasms; Endocarditis; Fatal Outcome; Heart Valve Diseases; Heart Valve Prosthesis Implantation; Heparin; Humans; Intracranial Embolism; Male; Middle Aged; Mitral Valve; Necrosis; Postoperative Complications; Skin; Thrombocytopenia; Warfarin

Thromboembolic disease in the form of deep venous thrombosis and pulmonary embolism is a risk following hip and knee joint replacement. Prophylactic and screening protocols have been employed to prevent thromboembolic disease following lower extremity joint reconstruction. The purpose of the present study was to evaluate two noninvasive venous screening protocols, specifically, compression ultrasonography performed either at the time of hospital discharge or two weeks after the operation.. From 1994 through 2001, 2364 patients undergoing primary unilateral total hip or total knee arthroplasty were managed with an anticoagulation chemoprophylaxis protocol (adjusted-dose warfarin) until the time of noninvasive venous screening with use of one of two protocols. Nine hundred thirty-one patients (406 hips and 525 knees) underwent compression ultrasonography prior to hospital discharge, and the other 1433 patients (614 hips and 819 knees) underwent ultrasonographic screening two weeks after the operation.. Twenty-three proximal deep venous thromboses (prevalence, 2.5%) were identified in the group that underwent ultrasound screening at the time of hospital discharge, and thirty-one proximal thromboses (prevalence, 2.2%) were identified in the group that underwent ultrasound screening two weeks after the operation. There was no significant difference between the two protocols with regard to the detection of deep venous thrombosis.. There was no significant difference between the group that received two weeks of warfarin chemoprophylactic prophylaxis and the group that was screened at the time of hospital discharge with regard to the detection of deep venous thrombosis with use of compression ultrasound. On the basis of these findings, we no longer screen asymptomatic patients for deep venous thrombosis following hip and knee replacement, and all patients receive warfarin anticoagulation for two weeks.

Topics: Anticoagulants; Arthroplasty, Replacement; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Humans; Patient Discharge; Postoperative Complications; Ultrasonography, Doppler, Duplex; Venous Thrombosis; Warfarin

To evaluate the risk of hemorrhagic complications associated with vitreoretinal surgery in patients whose warfarin sodium therapy was continued throughout the surgical period.. A review of 1737 records of patients undergoing pars plana vitrectomy was conducted. Inclusion criteria included patients receiving warfarin therapy whose international normalized ratios (INRs) were elevated above normal values on the day of surgery. Intraoperative and postoperative hemorrhagic complications were documented.. Fifty-four patients underwent 57 vitreoretinal surgical procedures with warfarin therapy and were divided into groups as follows: group S with INRs of 1.20 to 1.49, values considered subtherapeutic; group B with INRs of 1.50 to 1.99, values considered borderline therapeutic; group T with INRs of 2.00 to 2.49, values considered therapeutic; and group HT with INRs of 2.50 or greater, values considered highly therapeutic. No patients experienced anesthesia-related or intraoperative hemorrhagic complications. Two (7.7%) of 26 eyes in group S and 2 (16.7%) of 12 eyes in group HT experienced postoperative hemorrhages. All of the patients with vitreous hemorrhages had spontaneous clearing without additional treatment.. Many patients may safely undergo vitreoretinal surgery while maintaining therapeutic levels of warfarin anticoagulation. We experienced no intraoperative hemorrhagic complications; the 4 postoperative complications resolved spontaneously without persistent visual sequelae or the need for supplemental surgery.

Topics: Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Female; Humans; International Normalized Ratio; Intraoperative Complications; Male; Middle Aged; Partial Thromboplastin Time; Postoperative Complications; Prothrombin Time; Retinal Diseases; Retrospective Studies; Risk Factors; Vitrectomy; Vitreous Hemorrhage; Warfarin

Pulmonary embolism is a leading cause of death for bariatric patients. Numerous regimens have been proposed, but a comprehensive, simple approach is lacking. This study provides a simple, easily implemented prophylaxis regimen.. One hundred fifty bariatric surgery patients were evaluated. Patients considered at high risk for venous thromboembolism had heart failure, a BMI of >/=50 kg/m(2), or a history of venous thromboembolism or pelvic surgery. Preoperatively and postoperatively, all patients received subcutaneous enoxaparin or unfractionated heparin. High-risk patients received either preoperatively inserted inferior vena cava filters or continuous heparin infusions intraoperatively. All high-risk patients were anticoagulated with warfarin (Coumadin; Bristol Myers-Squibb, Princeton, NJ) for at least 3 months postoperatively. Initially, some patients experienced significant hemorrhage; to prevent this, sutures were oversewn into staple lines.. No patient experienced venous thromboembolism; a binomial test showed that the regimen reduced the risk of this complication to less than 2% (p < 0.05). Hemorrhage sufficient to require transfusion occurred in 4 of the first 20 patients; of the remaining 130 patients, into whose staple lines sutures were oversewn, none required transfusion (p < 0.05).. Patients should be divided into those who are at high risk and those who are at low risk for venous thromboembolism. All patients should receive pre- and postoperative anticoagulation. High-risk patients should also receive either an inferior vena cava filter or intraoperative heparin infusions, as well as at least 3 months of Coumadin therapy. Oversewing of staple lines may reduce the risk of hemorrhage.

Topics: Anticoagulants; Bariatric Surgery; Body Mass Index; Enoxaparin; Hemorrhage; Heparin; Humans; Obesity, Morbid; Postoperative Complications; Retrospective Studies; Risk Factors; Thrombolytic Therapy; Treatment Outcome; Vena Cava Filters; Venous Thrombosis; Warfarin

The purpose of this study was to evaluate the risk of hemorrhagic complications associated with vitreoretinal surgery in patients in whom warfarin therapy was continued throughout the surgical period.. A review of 1,737 consecutive charts of patients undergoing pars plana vitrectomy was conducted. Inclusion criteria included patients on warfarin therapy whose international normalized ratio (INR) was elevated above normal on the day of vitreoretinal surgery. The occurrence of intraoperative and postoperative hemorrhagic complications was documented.. The retrospective review detected 54 patients who underwent 57 vitreoretinal surgical procedures while on warfarin therapy. Group S consisted of patients whose INR ranged from 1.2 to 1.49, values that were considered to be subtherapeutic. Group B had INR values ranging from 1.5 to 1.99, values that were considered to be borderline therapeutic. Group T had INRs ranging from 2.0 to 2.49, values that were considered therapeutic. Group HT had INRs of 2.5 or greater, values that were considered highly therapeutic. No patients experienced anesthesia-related or intraoperative hemorrhagic complications. Four procedures (7.0%) were complicated by postoperative hemorrhage. Two of 26 eyes (7.7%) in group S and two of 12 eyes (16.7%) in group HT experienced postoperative hemorrhages. All hemorrhagic complications cleared without additional therapy.. Our findings suggest that many patients may safely undergo vitreoretinal surgery while maintaining therapeutic levels of warfarin anticoagulation. We found no intraoperative hemorrhagic complications. Those hemorrhagic complications that occurred postoperatively resolved spontaneously without persistent visual sequelae or the need for supplemental surgery.

Topics: Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Female; Humans; International Normalized Ratio; Intraoperative Complications; Male; Middle Aged; Partial Thromboplastin Time; Postoperative Complications; Prothrombin Time; Retinal Diseases; Retrospective Studies; Risk Factors; Vitrectomy; Vitreous Hemorrhage; Warfarin

To evaluate the effect of oral anticoagulation on durability of endovascular aortic aneurysm repair (EVAR).. Retrospective review was conducted of 182 consecutive EVAR patients (169 men; mean age 75.3 years, range 53-89) between 1999 and 2003. Patients on warfarin anticoagulation (WA, n=21; International Normalized Ratio of 2 to 3) were compared against a control group (CG) with no postoperative anticoagulation (n=161). Death, aneurysm rupture, and reintervention were considered primary endpoints; endoleaks, endograft migration, and aneurysm remodeling were secondary endpoints.. Mean follow-up was 16.3+/-12.6 months. One-year mortality was 6.6% (9.5% WA versus 6.2% CG); overall mortality was 14.3% (p=0.414). No aneurysm rupture occurred. At 1, 2, and 3 years, respectively, cumulative reinterventions (20%/20%/20% WA versus 12%/15%/20% CG; p=0.633) and endoleak rates (25%/25%/25% WA versus 17%/22%/34% CG; p=0.649) were comparable. In both groups, most completion endoleaks resolved (42.9% WA versus 74.4% CG; p=0.474), but few de novo endoleaks did (0% WA versus 12.8% CG; p=0.538). Anticoagulation did not affect mean time to aneurysm sac shrinkage (1.3+/-0.3 WA versus 1.4+/-0.1 years CG; p=0.769).. After EVAR, anticoagulation appears safe and does not significantly alter mortality, risk for rupture, or the incidence of reintervention. Early endoleaks appear more common in anticoagulated patients, but anticoagulation does not preclude spontaneous endoleak resolution nor does it increase late endoleak rates. Irrespective of the anticoagulation status, early but not late endoleaks usually sealed spontaneously. Observing type II endoleaks appears safe in the absence of aneurysm enlargement.

Topics: Administration, Oral; Aged; Aged, 80 and over; Angiography; Aortic Aneurysm, Abdominal; Blood Vessel Prosthesis Implantation; Case-Control Studies; Chi-Square Distribution; Dose-Response Relationship, Drug; Drug Administration Schedule; Female; Follow-Up Studies; Humans; Male; Middle Aged; Postoperative Care; Postoperative Complications; Probability; Prosthesis Failure; Registries; Retrospective Studies; Risk Assessment; Severity of Illness Index; Survival Rate; Time Factors; Treatment Outcome; Warfarin

All patients scheduled for surgical procedures were divided into three groups depending on risk grade for pulmonary embolism (PE) in our hospital from August, 2001. Based on our experience of two PE cases after gynecologic surgery, we introduced the perioperative manual for prevention of PE from April, 2003. According to the manual criteria, we could decide indications for the physical prophylaxis or anticoagulant preventive treatment for the patients. In spite of introduction of the manual, two cases of PE occurred after femoral head prosthetic replacement for femoral head fracture patients classified low risk group in our criteria. The Japanese guideline for prevention of venous thromboembolism was published in January, 2004, but even low risk group patients were candidates for PE depending on the surgery and the situation. Even after installation of the guideline for PE, careful perioperative examination is mandatory to prevent and treat PE.

Topics: Adult; Anticoagulants; Female; Gynecologic Surgical Procedures; Heparin; Humans; Japan; Postoperative Complications; Practice Guidelines as Topic; Pulmonary Embolism; Risk; Warfarin

Topics: Chest Pain; Coronary Artery Bypass; Finland; Follow-Up Studies; Hemorrhage; Humans; Male; Middle Aged; Myocardial Infarction; Pharmacogenetics; Point Mutation; Postoperative Complications; Radiography; Risk Assessment; Warfarin

Arthrofibrosis following total knee replacement (TKR) is a relatively common complication which results in a reduction in knee range of movement and patient dissatisfaction. A retrospective study examined the relationship between anticoagulation with therapeutic warfarin and rates of arthrofibrosis following TKR. Arthrofibrosis was defined as less than 80 degrees of knee flexion 6-8 weeks post-TKR. Patients were warfarinised if they had a history of thrombophilic tendencies or medical conditions necessitating anti-coagulation, rather than as routine thromboprophylaxis. All other patients received thromboprophylaxis using low molecular weight heparin. A total of 728 patients underwent 874 primary TKR between 1993 and 2002 in one centre, performed by four surgeons. Mean age was 68 years (range 48-89 years) and there were 483 female and 391 male knees. Eighty cases were warfarinised post-operatively (53 female, 27 male). Overall, 83 of 874 TKRs (9%) had arthrofibrosis (57 female, 26 male) requiring manipulation under anaesthetic (MUA). In the warfarinised group, 21 knees (26%) had an MUA (15 female, 6 male). This compared to 62 cases (8%) requiring MUA in the non-warfarinised group (42 female, 20 male). There was a statistically significant difference on Fisher's exact testing (P<0.0001) between groups. Following MUA, knee flexion improved in 95% cases to a minimum 95 degrees but 8 cases had a fixed flexion deformity of 5-10 degrees . In conclusion, therapeutic warfarinisation post-TKR leads to a statistically greater chance of the patient developing arthrofibrosis compared to prophylactic low molecular weight heparin and that patients should be counseled appropriately.

Topics: Aged; Aged, 80 and over; Anticoagulants; Arthroplasty, Replacement, Knee; Cohort Studies; Female; Fibrosis; Heparin, Low-Molecular-Weight; Humans; Joint Diseases; Knee Joint; Male; Middle Aged; Musculoskeletal Manipulations; Pliability; Postoperative Complications; Retrospective Studies; Warfarin

Patients requiring chronic anticoagulation are theoretically at increased risk for hemorrhage or thromboembolism perioperatively. Experience with laparoscopic renal/adrenal surgery in patients on chronic warfarin is limited. We assessed hemorrhagic/thromboembolic complications in this group of patients.. The records of 787 patients undergoing laparoscopic renal/adrenal surgery were retrospectively reviewed. A total of 25 patients on chronic oral anticoagulation with warfarin were identified. The indications for warfarin therapy as well as perioperative management were reviewed. Clinical parameters, including operative time, estimated blood loss, hemorrhagic/thromboembolic complications and transfusions, were documented and compared with those in patients not receiving chronic anticoagulation.. Atrial fibrillation (56% of cases) and a prosthetic mitral valve (28%) were the most frequent indications for chronic anticoagulation. Bridging anticoagulation with unfractionated heparin was the most frequent management method (68% of cases). Patients with anticoagulation were older (p <0.001) and hospitalized longer (<0.001) than those without anticoagulation. Operative time, estimated blood loss and the conversion rate were not significantly different between the groups. However patients on chronic warfarin significantly more often required transfusion (24% vs 5.2%, p <0.005) and had more postoperative bleeding episodes (8% vs 0.9%, p <0.05) than patients not on chronic anticoagulation. No thromboembolic events occurred in the anticoagulated group, while 3 occurred in the nonanticoagulated group (p = 1).. Laparoscopic renal/adrenal surgery in patients requiring chronic anticoagulation therapy can be performed safely. The risk of intraoperative bleeding is not increased, although the incidence of postoperative bleeding as well as transfusions is higher.

Topics: Administration, Oral; Adrenalectomy; Adult; Aged; Anticoagulants; Blood Loss, Surgical; Blood Transfusion; Female; Humans; Laparoscopy; Long-Term Care; Male; Middle Aged; Nephrectomy; Postoperative Complications; Postoperative Hemorrhage; Retrospective Studies; Risk; Thromboembolism; Warfarin

Topics: Anticoagulants; Enoxaparin; Humans; International Normalized Ratio; Orthopedic Procedures; Postoperative Complications; Practice Guidelines as Topic; Thromboembolism; Warfarin

The management of patients admitted with a fracture requiring surgery who are taking warfarin anticoagulation is unclear. We examined the anticoagulation management for 33 hip fracture patients on warfarin at the time of admission. Hospital course and complications were recorded on all patients. The mean INR on admission was 3.2 and prior to surgery 2.2. Eight patients (24%) had percutaneous cancellous screws for an intracapsular fracture regardless of the admission INR. In 21 (64%) patients, surgery was delayed whilst the INR came down, with an average delay of 72 h from admission to surgery. No specific treatment to lower the INR, other than wait and watch policy adopted in 11 (33%) of these patients. Pharmacological methods used to reduce the INR were fresh frozen plasma in nine cases, and intravenous Vitamin K in four patients. One patient died from post-operative haematemesis and three died from medical complications unrelated to the warfarin therapy. There were no wound haematomas or other bleeding complications. Delaying surgery whilst waiting for the INR to fall to acceptable levels may result in significant delays to surgery and we would recommend a more aggressive policy to enable earlier surgery.

Topics: Administration, Oral; Aged; Aged, 80 and over; Anticoagulants; Antifibrinolytic Agents; Atrial Fibrillation; Female; Hip Fractures; Humans; International Normalized Ratio; Male; Middle Aged; Plasma; Postoperative Complications; Preoperative Care; Prospective Studies; Risk Factors; Time Factors; Vitamin K; Warfarin

Causes of gross hematuria in a patient with end-stage renal disease are limited compared with those in patients with normal renal function. Given the increased likelihood of patients with end-stage renal disease developing renal cell carcinoma, the workup focuses on a careful evaluation of the collecting system. The workup for gross hematuria in a renal transplant recipient is similar; however, the focus shifts toward a more thorough evaluation of the transplanted kidney and bladder because immunosuppression increases the overall risk for malignancy. An immunosuppressed patient also is at risk for infectious processes in the transplanted kidney manifesting as gross hematuria. Concerns for chronic rejection also should be investigated, although microscopic hematuria is more common in this scenario. If this is unrevealing, then close scrutiny of the native kidneys for possible sources of bleeding is warranted. We present an interesting and unusual cause of painless gross hematuria in a patient with end-stage renal disease and transplant nephrectomy 3 months before the onset of bleeding.

Topics: BK Virus; Diagnosis, Differential; Embolization, Therapeutic; Fistula; Graft Rejection; Hematuria; Hepatitis C, Chronic; Humans; Kidney Failure, Chronic; Kidney Transplantation; Male; Middle Aged; Nephrectomy; Nephritis; Polyomavirus Infections; Postoperative Complications; Renal Artery; Renal Dialysis; Suture Techniques; Thrombosis; Tumor Virus Infections; Urinary Fistula; Urologic Neoplasms; Valsalva Maneuver; Vascular Diseases; Warfarin; Weight Lifting

Topics: Anticoagulants; Arthroplasty, Replacement, Knee; Humans; Postoperative Complications; Research Design; Retrospective Studies; Venous Thrombosis; Warfarin

Anticoagulants and antiplatelet agents commonly are used to treat patients with cardiovascular and cerebrovascular diseases. Data on the safety of the use of these drugs before colonoscopic polypectomy are scanty.. An audit was conducted for a 2-year period of consecutive patients undergoing colonoscopy and polypectomy. Patient demographics, site and size of polyps, and the use of anticoagulants and antiplatelet agents were documented from a hospital on-line database. Bleeding episodes were classified as immediate or delayed and were graded as mild, moderate, or severe. Risk factors associated with postendoscopy bleeding were analyzed by multivariate logistic regression analysis.. A total of 5593 cases were reviewed. Polypectomy was performed in 1657 patients. There were 37 cases of polypectomy-associated bleeding (2.2%); bleeding was immediate in 32 and delayed in 5. Multivariate analysis showed that warfarin use, after adjustment for the effects of each of the other factors, was an independent risk factor for bleeding, with an odds ratio 13.37: 95% CI[4.10, 43.65]. Age; the location and size of polyp; and the use of aspirin, non-steroidal anti-inflammatory drugs, and other antiplatelet agents were not associated with a higher risk of polypectomy-associated bleeding.. The use of antiplatelet agents during polypectomy was not associated with an increase in post-polypectomy bleeding. In contrast, treatment with warfarin should be discontinued, because this was associated with a significant increase in post-polypectomy bleeding.

Topics: Aged; Anticoagulants; Clopidogrel; Colonic Polyps; Colonoscopy; Female; Gastrointestinal Hemorrhage; Humans; International Normalized Ratio; Male; Middle Aged; Platelet Aggregation Inhibitors; Postoperative Complications; Risk Factors; Ticlopidine; Warfarin

Myocardial infarction (MI) due to coronary artery embolization is a rare and potentially lethal complication of prosthetic heart valve thrombosis. A 58-year-old man in whom the aortic valve was replaced with a bileaflet mechanical valve presented with an acute anterior MI. Valvular dysfunction was detected by physical examination, and confirmed by two-dimensional echocardiography and cinefluoroscopy. Coronary angiography disclosed embolization of the left anterior descending artery. Thrombotic encroachment of one of the prosthetic valve leaflets was found at reoperation. Failure to achieve adequate anticoagulation was likely due to an interaction between warfarin and herbal products. These findings have significant implications regarding the diagnosis and treatment of acute MI in patients with left-sided prosthetic heart valves, and emphasizes the importance of appropriate anticoagulation in this setting.

Topics: Anticoagulants; Aortic Valve; Heart Valve Diseases; Heart Valve Prosthesis; Herb-Drug Interactions; Humans; Male; Middle Aged; Myocardial Infarction; Plants, Medicinal; Postoperative Complications; Thrombosis; Warfarin

Topics: Aged; Anticoagulants; Blood Coagulation Factors; Contraindications; Coronary Artery Bypass; Fatal Outcome; Heart Valve Prosthesis; Humans; Infarction, Middle Cerebral Artery; Male; Postoperative Complications; Risk Factors; Thromboembolism; Tomography, X-Ray Computed; Warfarin

The study evaluated all patients undergoing permanent pacemaker and ICD implantation over a 4-year period to determine if anticoagulated patients required normalization of coagulation factors in the periprocedural period. The study included 1,025 (597 men, 428 women, age 24-100 years, mean 72 years) consecutive patients who underwent device implantation using mostly a percutaneous subclavian approach. The procedures were performed without reversal of anticoagulation in 470 patients with INRs >or= 1.5 at the time of the procedure (mean INR 2.6 +/- 1.0, range 1.5-7.5). The complication rate in the anticoagulated group was similar to those in patients with a normal INR. Routine normalization of coagulation factors prior to pacemaker/ICD placement may not be necessary.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Cardiac Catheterization; Defibrillators, Implantable; Female; Follow-Up Studies; Hematoma; Heparin; Humans; International Normalized Ratio; Male; Middle Aged; Pacemaker, Artificial; Postoperative Complications; Prosthesis Implantation; Retrospective Studies; Subclavian Vein; Warfarin

A 78-year-old woman with unstable angina underwent coronary bypass surgery with complete cardiac revascularization and no immediate postoperative complications. Six days after surgery, during hospitalization for cardiac rehabilitation, the patient developed severe respiratory distress and pulmonary embolism was diagnosed. Color duplex ultrasound revealed the presence of concomitant upper extremity deep vein thrombosis (UEDVT), ipsilateral to the site of placement of a central venous line, in the absence of lower extremity deep vein thrombosis. We describe this case and provide preliminary data from a prospective observational study evaluating the prevalence of catheter-related UEDVT and symptomatic pulmonary embolism (55 and 1.4% respectively) in a series of 71 consecutive coronary bypass surgery patients admitted to a cardiac rehabilitation facility. Catheter-related UEDVT and pulmonary embolism may complicate coronary bypass surgery and should be taken into consideration when managing patients after surgery.

Topics: Aged; Angina, Unstable; Anticoagulants; Coronary Artery Bypass; Echocardiography; Female; Humans; Jugular Veins; Male; Middle Aged; Postoperative Complications; Prospective Studies; Pulmonary Embolism; Ultrasonography, Doppler, Color; Upper Extremity; Venous Thrombosis; Warfarin

Interruption of appropriate therapeutic warfarin therapy imposes a risk of morbidity and mortality on the patient. Strategies to reduce the risks of interruption impose relatively large costs in terms of prolonged hospital stay, medication and coagulation monitoring. We report a series of 47 consecutive surgical episodes on the hands of 39 patients without interruption of therapeutic warfarin anticoagulation and with an INR of between 1.3 and 2.9. There was no difficulty with intraoperative haemostasis. Two patients had minor bleeding-related complications with no long-term sequelae. The authors conclude that interruption to warfarin therapy is unnecessary if the INR is less than 3.0 and therefore inappropriate for therapeutically anticoagulated patients undergoing hand surgery.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Female; Hand; Heart Valve Prosthesis; Hematoma; Hemostasis; Humans; International Normalized Ratio; Male; Middle Aged; Postoperative Complications; Stroke; Thromboembolism; Tourniquets; Treatment Outcome; Warfarin

Stroke is a devastating complication in patients with prosthetic valves, but characterization of its late occurrence from a large cohort is lacking.. Three thousand one hundred eighty-nine adult patients who underwent a total of 3,576 operations for left-heart valve replacement were managed with contemporary anticoagulation guidelines and prospectively followed in a dedicated clinic. Total follow-up was 20,096 patient years. Bootstrapped survival analysis was used to determine the impact of patient and valve related factors on the incidence of stroke.. Most strokes were embolic. Linearized embolic stroke rates were 1.3% +/- 0.2% per year for aortic bioprostheses, 1.4% +/- 0.2% per year for aortic mechanical valves, 1.3% +/- 0.3% per year for mitral bioprostheses, and 2.3% +/- 0.4% per year for mitral mechanical valves (p = 0.002, vs other implant types). Age more than 75 years, female gender, and smoking were independent risk factors after aortic and mitral valve replacement. Atrial fibrillation, coronary disease, and tilting-disc mechanical prostheses were independent predictors of embolic stroke after aortic valve replacement. Preoperative left ventricular (LV) dysfunction was an independent risk factor in patients with mitral prostheses. Primary operative indication, diabetes, redo status, or the presence of two prosthetic valves were not associated with an increased hazard. The addition of acetyl salicylic or dipyridamole to warfarin anticoagulation did not significantly lower embolic stroke risk in patients with mechanical prostheses.. Approximately 20% of patients with valve prostheses have an embolic stroke by 15 years after valve replacement. Some risk factors such as the avoidance of smoking, mitral mechanical prostheses, aortic tilting-disc valves, and proceeding to mitral surgery before LV dysfunction occurs are potentially modifiable.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Aortic Valve; Aspirin; Atrial Fibrillation; Cerebral Hemorrhage; Comorbidity; Coronary Disease; Dipyridamole; Drug Therapy, Combination; Female; Follow-Up Studies; Heart Valve Prosthesis Implantation; Humans; Incidence; International Normalized Ratio; Intracranial Embolism; Life Tables; Male; Middle Aged; Mitral Valve; Postoperative Complications; Proportional Hazards Models; Prospective Studies; Risk Factors; Smoking; Stroke; Ventricular Dysfunction, Left; Warfarin

The treatment of patients at increased risk for arterial thromboembolism who require temporary interruption of warfarin sodium therapy is a common clinical problem. We investigated the efficacy and safety of a standardized periprocedural anticoagulation regimen with low-molecular-weight heparin.. We studied 650 consecutive patients with a mechanical heart valve, chronic atrial fibrillation, or embolic stroke who required interruption of warfarin therapy because of an invasive procedure. Warfarin was stopped 5 or 6 days before the procedure, and patients received subcutaneous dalteparin sodium, 100 IU/kg twice daily, starting 3 days before the procedure. The risk of postprocedural bleeding determined postprocedural anticoagulant management. In patients undergoing a non-high-bleeding-risk procedure who had adequate postprocedural hemostasis, warfarin was resumed on the evening of the procedure, and dalteparin sodium, 100 IU/kg twice daily, was resumed on the next day and continued until the international normalized ratio was 2.0 or more. If postprocedural hemostasis was not secured, the resumption of dalteparin was delayed. In patients undergoing a high-bleeding-risk procedure, warfarin was resumed on the evening of the procedure, but dalteparin was not given after the procedure.. Patients were followed up during the preprocedural and postprocedural period for a mean of 13.8 days (range, 10-18 days). In 542 patients who underwent a non-high-bleeding-risk procedure, there were 2 thromboembolic events (0.4%), 4 major bleeding episodes (0.7%), and 32 episodes of increased wound-related blood loss that precluded postprocedural dalteparin administration (5.9%). In 108 patients who underwent a high-bleeding-risk procedure, there were 2 deaths (1.8%) possibly due to thromboembolism and 2 major bleeding episodes (1.8%).. In patients at increased risk for arterial thromboembolism who require temporary interruption of warfarin therapy, a standardized periprocedural anticoagulant regimen with low-molecular-weight heparin is associated with a low risk of thromboembolic and major bleeding complications.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Biomarkers; Blood Loss, Surgical; Female; Fibrinolytic Agents; Follow-Up Studies; Heart Valve Diseases; Heparin, Low-Molecular-Weight; Humans; International Normalized Ratio; Intracranial Embolism; Male; Middle Aged; Perioperative Care; Postoperative Complications; Prospective Studies; Risk Factors; Surgical Procedures, Operative; Thromboembolism; Treatment Outcome; Warfarin

Warfarin-induced skin necrosis is a rare complication associated with the use of oral anticoagulants. Most patients develop this at the initiation of therapy, often while still receiving intravenous unfractionated heparin (UFH). Recently, low-molecular-weight heparins (LMWHs) have gained wider use, providing an option for outpatient treatment of deep-vein thrombosis. The treatment protocols are similar to UFH, including the early initiation of oral anticoagulation with warfarin. A Medline search failed to reveal any cases of warfarin-induced skin necrosis while using a LMWH. We present a patient with protein S deficiency who developed warfarin skin necrosis despite appropriate anticoagulation with enoxaparin, and review the chemical and clinical difference between UFH and LMWH.

Topics: Anticoagulants; Arterial Occlusive Diseases; Enoxaparin; Female; Fibrinolytic Agents; Heparin, Low-Molecular-Weight; Humans; Middle Aged; Necrosis; Popliteal Artery; Postoperative Complications; Protein S Deficiency; Skin Diseases; Subclavian Vein; Tibial Arteries; Treatment Failure; Vascular Surgical Procedures; Venous Thrombosis; Warfarin

A 34-year-old woman was admitted to our emergency room with a high fever, abdominal pain, dyspnea and confusion. High fever and abdominal pain had first occured after a cystocele operation 5 months earlier. Later, congestive heart failure with mural thrombus formation, peripheral polyneuropathy and ischemic cerebrovascular accident were identified in clinical follow-ups, and multiple arterial and venous thromboses were seen on cranial and abdominal magnetic resonance imaging angiography. The patient's symptoms improved with anticoagulant treatment. Antiphospholipid syndrome with elevated serum anticardiolipin IgG levels was diagnosed, and ischemic peripheral polyneuropathy with axonal degeneration was determined by sural nerve biopsy. In antiphospholipid syndrome, elevated anticardiolipin antibodies appear to be the most common acquired blood protein defect causing thrombosis. Disseminated vascular thrombosis in catastrophic antiphospholipid syndrome can result in multiorgan failure with increased morbidity and mortality. It rarely occurs secondary to various infections as in the case of our patient, who suffered postoperative intraabdominal infection. It is important to note that peripheral nervous system involvement is rare in antiphospholipid syndrome.

Topics: Acute Disease; Adult; Anticoagulants; Antiphospholipid Syndrome; Female; Humans; Peripheral Nervous System Diseases; Postoperative Complications; Sural Nerve; Surgical Wound Infection; Urinary Bladder Diseases; Warfarin

This report describes a patient who suffered multiple-vein thrombosis following permanent pacemaker implantation and developed a pulmonary embolism while on anticoagulation treatment, which was successfully treated by thrombolytic therapy.

Topics: Aged; Anticoagulants; Fibrinolytic Agents; Humans; Male; Pacemaker, Artificial; Postoperative Complications; Pulmonary Embolism; Streptokinase; Thrombolytic Therapy; Venous Thrombosis; Warfarin

Topics: Anticoagulants; Aspirin; Atrial Appendage; Atrial Fibrillation; Blood Loss, Surgical; Carotid Arteries; Dalteparin; Drug Administration Schedule; Elective Surgical Procedures; Filtration; Heart Valve Prosthesis Implantation; Humans; International Normalized Ratio; Intraoperative Care; Postoperative Care; Postoperative Complications; Postoperative Hemorrhage; Premedication; Stents; Thromboembolism; Thrombosis; Vitamin K; Warfarin

Paroxysmal atrial fibrillation (PAF) can be eliminated with continuous circular lesions (CCLs) around the pulmonary veins (PVs), but it is unclear whether all PVs are completely isolated.. Forty-one patients with symptomatic PAF underwent 3D mapping, and all PV ostia were marked on the 3D map based on venography. Irrigated radiofrequency energy was applied at a distance from the PV ostia guided by 2 Lasso catheters placed within the ipsilateral superior and inferior PVs. The mean radiofrequency duration was 1550+/-511 seconds for left-sided PVs and 1512+/-506 seconds for right-sided PVs. After isolation, automatic activity was observed in the right-sided PVs in 87.8% and in the left-sided PVs in 80.5%. During the procedure, a spontaneous or induced PV tachycardia (PVT) with a cycle length of 189+/-29 ms was observed in 19 patients. During a mean follow-up of 6 months, atrial tachyarrhythmias recurred in 10 patients. Nine patients underwent a repeat procedure. Conduction gaps in the left CCL in 9 patients and in the right CCL in 2 patients were closed during the second procedure. A spontaneous PVT with a cycle length of 212+/-44 ms was demonstrated in 7 of 9 patients, even though no PVT had been observed in 6 of these 7 patients during the first procedure. No AF recurred in 39 patients after PV isolation during follow-up.. Automatic activity and fast tachycardia within the PVs could reflect an arrhythmogenic substrate in patients with PAF, which could be eliminated by isolating all PVs with CCLs guided by 3D mapping and the double-Lasso technique in the majority of patients.

Topics: Adenosine; Aged; Anti-Arrhythmia Agents; Anticoagulants; Atrial Fibrillation; Cardiac Catheterization; Catheter Ablation; Combined Modality Therapy; Coronary Disease; Electrocardiography; Female; Follow-Up Studies; Heart Conduction System; Humans; Hypertension; Male; Middle Aged; Phlebography; Postoperative Complications; Prospective Studies; Pulmonary Veins; Recurrence; Tachycardia; Treatment Outcome; Warfarin

Many orthopaedic surgeons use warfarin to prevent venous thromboembolism (VTE) following hip or knee arthroplasty. Since warfarin's antithrombotic effects are delayed, we hypothesized that early VTE (occurring within 5 days post-operatively) would be more common in arthroplasty patients receiving warfarin monotherapy compared to those receiving enoxaparin. We performed a secondary analysis of a case-control study examining risk factors for post-operative thrombosis in postmenopausal women. We defined cases as patients who were diagnosed with thrombosis within 5 days of surgery. Controls without thrombosis were matched with cases by age, surgeon, year of surgery and surgical joint. 84 women with early post-operative thrombosis (cases) were matched with 206 controls. 18 cases (21.4%) had been prescribed warfarin mono-therapy, compared with 7 controls (3.4%). 58 (69.1%) cases and 195 (94.7%) controls had been prescribed subcutaneous enoxaparin 30 mg twice daily, starting 12-24 hours after surgery. The odds ratio for any early thrombosis in patients receiving warfarin as opposed to enoxaparin 30 mg twice daily was 8.6 (p<0.0001). For proximal thrombosis, the odds ratio was 11.3 (p<0.0001). Multivariate analysis did not alter these findings. Warfarin's delayed antithrombotic effects may not provide adequate VTE prophylaxis in the immediate post-operative setting. We suggest caution in employing warfarin monotherapy following joint arthroplasty.

Topics: Aged; Aged, 80 and over; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Case-Control Studies; Drug Evaluation; Enoxaparin; Female; Humans; Odds Ratio; Postoperative Complications; Premedication; Retrospective Studies; Thromboembolism; Time; Venous Thrombosis; Warfarin

Topics: Amiodarone; Anti-Arrhythmia Agents; Anticoagulants; Atrial Fibrillation; Cardiac Output, Low; Echocardiography, Doppler; Echocardiography, Transesophageal; Electrocardiography; Female; Heart Atria; Heart Diseases; Heart Valve Prosthesis Implantation; Heparin; Humans; Hypotension; Middle Aged; Mitral Valve; Postoperative Complications; Thrombosis; Time Factors; Warfarin

To provide some references for defining the Chinese optimal intensity of anticoagulation after mechanical heart valve prostheses replacement.. For the 178 patients with carbomedics mechanical prosthetic heart valves, the means of INR were compared between the patients with complications and those without complications at the standard of INR1. 4 - 2.0. Also, the variations of INR were compared among different follow-ups.. During the follow-up, 22 hemorrhagic and 1 thromboembolic complication occurred. The total linearized rate of anticoagulation-related hemorrhage was 5.83% pty. The total linearized rate thromboembolism was 0.26% pty. The late mortality was 0.79% pty (3 cases ). The final mean INR was 1.68 +/- 0.38. The final mean oral warfarin dose was 2.34 +/- 0.80 mg. The differences of variations of INR in five periods were significant (F = 5.072, P < 0.05). The mean INR in the first month of follow-up was 1.75 +/- 0.27.. For Chinese patients with mechanical prosthetic heart valve, hemorrhage is the principal complication, the ratio of which is much higher than that of thromboembolism. The low-dose anticoagulation (INR1. 4-2.0) could remarkably decrease hemorrhagic events as effectively as prevent the thrombolic events. Moreover the INR is the most unstable in the first month of follow-up, so re-examination for the patients in the first month after the operation is vitally important.

Topics: Adolescent; Adult; Anticoagulants; Aortic Valve; Cardiopulmonary Bypass; Female; Follow-Up Studies; Heart Valve Diseases; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Heparin; Humans; International Normalized Ratio; Male; Middle Aged; Mitral Valve; Postoperative Complications; Postoperative Period; Warfarin

The 30-day frequency of negative outcomes after outpatient endoscopy performed by gastroenterology fellows is unknown.. Questionnaires were mailed to 1000 consecutive patients 30 days after endoscopy to evaluate procedure-related negative outcomes (serious and minor adverse events) and patient satisfaction. Serious adverse events were defined as follows: oversedation requiring administration of a reversal agent, and those that resulted in a physician visit, emergency department visit, admission to the hospital, or death. Minor adverse events were defined as all problems other than serious adverse events that patients related to their endoscopic procedure.. The 30-day frequency of negative outcomes in the 869 patients who responded was 14.3%, of which 0.6% were serious and 13.7% were minor adverse events. The frequency of negative outcomes was 17.1% for EGD, 15.0% for colonoscopy, 24.4% for combined EGD and colonoscopy, and 7.8% for flexible sigmoidoscopy. One hundred percent of the serious adverse events were known to us, but only 16.0% of minor adverse events (p < 0.001). Multiple logistic regression identified midazolam dose (OR for each 1 mg increase in dose 4.5; 95% CI [2.7, 7.3]; p < 0.001), treatment with warfarin (OR 3.0; 95% CI [1.4, 6.2]; p = 0.003), comorbid disease (OR 2.1; 95% CI [1.3, 3.4]; p = 0.001), endoscopy performed in July or August (OR 2.0; 95% CI [1.1,3.7]; p = 0.02), and age (OR for each 1 year increase in age 1.03; 95% CI [1.01, 1.05]; p = 0.01) as independent predictors of negative outcomes. There was a significant association between negative outcomes and decreased patient satisfaction, and patients who reported negative outcomes were less likely to agree to endoscopy in the future.. Serious adverse events were rare after endoscopy performed by gastroenterology fellows. Contacting patients 30 days after outpatient endoscopy significantly improved the detection of negative outcomes. Although the majority of negative outcomes were minor, these adverse events were associated with decreased patient satisfaction.

Topics: Aged; Anticoagulants; Clinical Competence; Endoscopy, Gastrointestinal; Female; Gastroenterology; Hospitals, University; Humans; Hypnotics and Sedatives; Internship and Residency; Male; Midazolam; Patient Satisfaction; Postoperative Complications; Prospective Studies; Risk Factors; Surveys and Questionnaires; Treatment Outcome; Warfarin

Topics: Angioplasty, Balloon, Coronary; Anticoagulants; Coronary Disease; Humans; Postoperative Complications; Time; Treatment Outcome; Warfarin

Aside from anecdotal reports, there are few data on the risk of thrombotic complications in patients in whom use of warfarin and aspirin is discontinued perioperatively for cutaneous operation.. Our aim was to present a large case series of thrombotic complications resulting from this practice and to estimate the incidence of these events.. A total of 504 members of the American College of Mohs Micrographic Surgery and Cutaneous Oncology were surveyed regarding thrombotic complications when blood thinners were withheld perioperatively to ascertain the frequency of these complications and to describe associated morbidity and mortality.. A total of 168 responding physicians reported 46 patients who experienced thrombotic events. Of these patients, 54% (25 of 46) experienced the event when warfarin was withheld and 39% (18 of 46) when aspirin use was discontinued. Thrombotic events included 24 strokes, 3 cerebral emboli, 5 myocardial infarctions, 8 transient ischemic attacks, 3 deep venous thromboses, 2 pulmonary emboli, and 1 retinal artery occlusion leading to blindness. Three deaths were reported. Calculation of incidence yielded an estimated thrombotic risk of 1 event per 12,816 operations, 1 in 6219 operations when use of warfarin was discontinued and 1 in 21,448 when aspirin was withheld.. With no documented increase in severe hemorrhagic complications during continued use perioperatively of blood thinners, these data provide a compelling argument to maintain patients on medically necessary blood thinners during cutaneous operation. All relevant clinical facts must be weighed when making this decision.

Topics: Aged; Aged, 80 and over; Anticoagulants; Aspirin; Female; Humans; Ischemic Attack, Transient; Male; Middle Aged; Mohs Surgery; Perioperative Care; Platelet Aggregation Inhibitors; Postoperative Complications; Stroke; Vascular Diseases; Warfarin

An enhanced bileaflet valve, the Edwards MIRA feminine Mechanical Valve became available in 1998. Favorable hydrodynamic features and a redesigned sewing ring encouraged us to implant this device in indicated patients. Hemodynamics and clinical performance parameters were evaluated.. Between February 1998 and October 1999, 338 patients (171 males, 167 females) underwent native valve replacement with a MIRA prosthesis. Mean age 56.6+/-13.6 years, 320 patients were in NYHA class III/IV. Sixty-seven patients had echocardiographic examinations. Standard cardiopulmonary bypass was employed utilizing institutionally accepted implantation techniques. Aortic valve replacement was performed in 163 patients, mitral valve replacement in 134 patients, 35* double valve replacements and 1 triple valve replacement.. Follow-up is 98% complete. Mean follow-up is 6.9+/-3.3 months (178.2 patient years). There were no operative deaths. Four early deaths were seen (1.18%). Late deaths reported in 12 patients. Linearized rate of late mortality was 6.7% per patient year (ppy). Overall actuarial survival at 13 months is 92.2%. Mean gradients and Effective Orifice Areas (EOA's) are comparable to other bileaflet valves. Linearized rates for valve-related complications was 4.49% ppy. Only 5 transient thromboembolic events (TE = 2.81% ppy) and 3 non-structural valve dysfunction events (NSVD = 1.68%) were seen. No reports of bleeding events, prosthetic endocarditis, valve thrombosis or structural valve deterioration. One patient required mitral valve reoperation for perivalvular leak.. Short-term hemodynamic and clinical results are comparable to other bileaflet valves. The sewing ring is non-obstructive, compliant with smoother needle penetration. Early clinical results are encouraging, follow-up should be continued.

Topics: Adolescent; Adult; Aged; Anticoagulants; Aortic Valve; Biocompatible Materials; Echocardiography; Female; Follow-Up Studies; Health Status Indicators; Heart Valve Diseases; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Hemodynamics; Humans; Male; Middle Aged; Mitral Valve; Postoperative Complications; Prosthesis Design; Survival Rate; Treatment Outcome; Warfarin

No substantial recommendations exist regarding the management of anticoagulant drugs prior to ocular surgery. Stopping anticoagulation can cause fatal emboli, but sight-threatening bleeds may occur if anticoagulation is continued. We examined the effects of anticoagulation on vitreoretinal surgery.. Clinical details were prospectively entered on a database. The anticoagulant status of 541 consecutive patients undergoing vitreoretinal surgery was recorded.. Sixty patients in the study were taking aspirin and seven were taking warfarin. There were 11 cases of choroidal haemorrhage, one of which involved a warfarin user. Of 325 retinal detachment repairs, 21 (6.5%) had preoperative vitreous haemorrhages. Two of these patients were on aspirin and two were on warfarin. Sixty-six vitrectomies were performed for diabetic vitreous haemorrhages, of which nine re-bled postoperatively. One of these patients was taking warfarin. The association of warfarin with bleeding was statistically significant (relative risk 6.185).. Anticoagulation had no effect on the number of significant perioperative (choroidal) haemorrhages. Aspirin had little effect on bleeding during vitreoretinal surgery. Warfarin, however, was associated with bleeding complications. We suggest that aspirin should not be stopped prior to surgery. Warfarin may be stopped if the patient's thromboembolic risk is low.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anticoagulants; Aspirin; Child; Choroid Hemorrhage; Contraindications; Female; Fibrinolytic Agents; Humans; Intraoperative Complications; Male; Middle Aged; Postoperative Complications; Risk Factors; Scleral Buckling; United Kingdom; Vitrectomy; Vitreous Hemorrhage; Warfarin

Topics: Abnormalities, Drug-Induced; Adolescent; Adult; Anticoagulants; Bone Transplantation; Child; Child, Preschool; Female; Follow-Up Studies; Humans; Infant; Infant, Newborn; Male; Maxillofacial Development; Nose; Postoperative Complications; Pregnancy; Pregnancy Complications, Cardiovascular; Reoperation; Rhinoplasty; Thrombophlebitis; Treatment Outcome; Venous Thrombosis; Warfarin

Hereditary antithrombin (AT) deficiency is associated with a significant risk of venous thromboembolism. Patients with this disorder frequently require long-term anticoagulation. Discontinuation of anticoagulation for childbirth or surgery may carry a substantial thrombotic risk. For this reason, replacement with AT concentrate has been used when anticoagulation is interrupted. A new recombinant human AT concentrate, produced using transgenic technology, has recently been developed.. Human recombinant AT (rhAT) was provided by GTC Biotherapeutics, Inc. on a compassionate-use basis for five patients with hereditary AT deficiency who underwent six surgical procedures. Patients were treated perioperatively. Dosing was determined individually by the investigators with a goal of maintaining an AT activity of 80 to 150 percent.. There was no clinical evidence of thrombosis or bleeding. Four of the five patients had postoperative duplex ultrasound studies of the lower extremities, which showed no evidence of acute thrombosis. Four patients were tested for antirecombinant rhAT antibodies postoperatively and were negative.. These case reports indicate that rhAT can provide effective support for AT-deficient patients who undergo surgery. Further study of this product is needed to define optimal dosing and further assess clinical response.

Topics: Adult; Aged; Anticoagulants; Antithrombins; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Cesarean Section; Coronary Artery Bypass; Coronary Disease; Enoxaparin; Factor V; Female; Heparin; Humans; Hysterectomy; Leiomyoma; Male; Middle Aged; Postoperative Complications; Pregnancy; Recombinant Proteins; Splenectomy; Sterilization, Tubal; Surgical Procedures, Operative; Uterine Neoplasms; Venous Thrombosis; Warfarin

After joint arthroplasty, the risk of deep vein thrombosis and pulmonary embolism increases exponentially. Inadequate anticoagulation prophylaxis may not sufficiently reduce the risk of thrombosis, whereas excessive anticoagulation therapy may predispose the patient to a bleed. Bilateral adrenal hemorrhage is a relatively rare but potentially catastrophic life-threatening event. An 82-yr-old woman is described who was rehospitalized from a subacute rehabilitation facility complaining of epigastric pain radiating into her flank. Eight days previously, she had undergone an uncomplicated bilateral total knee arthroplasty and was subsequently administered subcutaneous heparin and warfarin. An abdominal computed tomographic scan subsequently demonstrated bilateral small adrenal hemorrhages. Acute adrenal insufficiency (Addison's disease) caused by hemorrhage within the adrenal cortices, although still uncommon, can be expected to increase as anticoagulation prophylaxis after joint arthroplasty becomes routine.

Topics: Adrenal Gland Diseases; Aged; Aged, 80 and over; Anti-Inflammatory Agents; Anticoagulants; Arthroplasty, Replacement, Knee; Female; Hemorrhage; Heparin; Humans; Hydrocortisone; Postoperative Complications; Tomography, X-Ray Computed; Treatment Outcome; Warfarin

The occurrence of deep vein thrombosis (DVT) following cases of major trauma, in particular pelvic and hip fracture, has ranged from 36% to 60%, depending on the study quoted and the method of detection. The frequency of fatal pulmonary embolism (PE) has been reported as 0.5%-12.9% of the cases. A retrospective study of 1000 consecutive hip fracture patients in a community hospital setting reveals that 95% received a combination of mechanical and pharmacologic prophylaxis for prevention of DVT. Sixty-one patients were excluded for insufficient data, leaving 939 for analysis. There were 724 female patients with an average age of 83 years and 215 male patients with an average age of 78 years. Fifty-one patients (18.4%) received no prophylaxis in the eligible population. Three hundred eighty-seven patients (41.2%) received only aspirin as the pharmacologic agent for anticoagulation. Four hundred twenty-nine patients (45.6%) were treated with the low-molecular-weight heparin (LMWH), enoxaparin. Ten patients (1.1%) received heparin for anticoagulation and 17 patients (1.8%) were treated with warfarin. A total of 43 patients received a combination of therapies. Four hundred ninety-five of the patients used concomitant intermittent pneumatic compression in addition to pharmacologic prophylaxis. There were 15 perioperative deaths from all causes, including five cases of DVT two distal and three proximal). One distal DVT occurred prior to surgery. A second distal DVT and one fatal PE occurred in the aspirin group. The rates of minor bleeding complications in the aspirin group, the < 12-hour postoperative dosing of the enoxaparin group, and the 12 to 24-hour postoperative dosing of the enoxaparin group were 3.1%, 5.7%, and 2.8%, respectively. There were no major bleeds in the aspirin group and 0.9% in the enoxaparin group. The LMWH group also had two proximal DVTs but no PEs. The combination of a relatively short half-life, predictable pharmacokinetics, and favorable safety profile makes enoxaparin an excellent drug for use in hip fracture patients. Additional trials will be necessary to establish an optimal duration of prophylaxis in this population.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anticoagulants; Cohort Studies; Enoxaparin; Female; Fracture Fixation, Internal; Hip Fractures; Humans; Incidence; Injury Severity Score; Male; Middle Aged; Postoperative Complications; Prognosis; Pulmonary Embolism; Retrospective Studies; Risk Factors; Survival Rate; Treatment Outcome; Venous Thrombosis; Warfarin

To report the results of endoscopic laser-assisted dacryocystorhinostomy in anticoagulated patients.. A retrospective study of 16 consecutive anticoagulated patients with distal nasolacrimal duct obstruction treated by endoscopic laser-assisted dacryocystorhinostomy.. A case note review was made of all patients treated with endoscopic laser-assisted dacryocystorhinostomy who were taking coumadin in two centers between 1993 and 2000. The parameters of age, gender, indications for surgery, surgical findings, complications, and outcome were analyzed. The mean follow-up time was 14 months (range, 9-26 mo).. Fifteen of the 16 patients who were treated had an eventual successful outcome, but 6 patients required revision surgery. The patient whose symptoms were not improved was shown to have functional epiphora. No patient had a problem with primary or secondary epistaxis, and no patient required admission. A major benefit was the lack of disruption of anticoagulant therapy.. Endoscopic laser-assisted dacryocystorhinostomy is a safe, efficient technique for the relief of distal nasolacrimal duct obstruction in anticoagulated patients. Not only does it avoid any disruption to their anticoagulant therapy, but it also can be performed as an outpatient procedure.

Topics: Adult; Aged; Ambulatory Surgical Procedures; Anticoagulants; Dacryocystorhinostomy; Endoscopy; Female; Follow-Up Studies; Humans; Lacrimal Apparatus Diseases; Lacrimal Duct Obstruction; Laser Therapy; Male; Middle Aged; Postoperative Complications; Reoperation; Risk Factors; United Kingdom; Warfarin

Portal vein thrombosis (PVT) is a complication of hepatic disease and a potentially lethal complication of splenectomy. The reported incidence of this complication is low (approximately 1%). However, its true incidence may have been underestimated due to difficulty in making the diagnosis. Herein we report the case of a 19 year-old woman who presented with a 2-year history of idiopathic thrombocytopenic purpura (ITP). Because she had become refractory to medical therapy, she underwent laparoscopic splenectomy. She was discharged on postoperative day 2 after an uncomplicated procedure. She did well, complaining only of mild backache, until postoperative day 21, when she presented with nausea, vomiting, and leukocytosis. CT showed PVT and superior mesenteric vein thrombosis. Despite heparin and fluid administration, her condition worsened. At laparotomy, she had diffuse small bowel edema and congestion. At a second-look procedure 24 h later, nearly all her jejunum and ileum were necrotic. After three procedures, she was left with 45 cm of proximal and 10 cm of distal small bowel. Bowel continuity was restored 8 weeks later. She continued on warfarin anticoagulation therapy for 1 year. Postsplenectomy PVT is most often seen following splenectomy for myeloproliferative disorders and almost never after trauma. The large splenic vein stump and the hypercoagulable state in patients with splenomegaly are thought to be contributory. The presentation of PVT is vague, without defining signs or symptoms. Color-flow Doppler and contrast-enhanced CT scans are the best methods for the nonoperative diagnosis of PVT. Aggressive thrombolysis offers the best hope for clot lysis and maintenance of bowel viability. Even vague symptoms must be considered seriously following splenectomy.

Topics: Adult; Anastomosis, Surgical; Anticoagulants; Back Pain; Combined Modality Therapy; Crystalloid Solutions; Diagnostic Errors; Female; Fluid Therapy; Heparin; Humans; Ileum; Immunosuppressive Agents; Ischemia; Isotonic Solutions; Jejunum; Laparoscopy; Mesenteric Veins; Muscular Diseases; Necrosis; Parenteral Nutrition; Plasma Substitutes; Plasmapheresis; Platelet Transfusion; Portal Vein; Postoperative Complications; Purpura, Thrombocytopenic, Idiopathic; Splenectomy; Splenomegaly; Venous Thrombosis; Warfarin

A cohort of 785 patients treated without any form of thromboprophylaxis was compared with an identical group of 957 patients treated with 6 weeks of low-dose warfarin. All complications seen within 90 days of surgery were recorded. The control group had a total complication rate of 2.2%, with a death rate from thromboembolic disease of 0.0% and a total death rate of 0.2%. The warfarin group had a total complication rate of 4.7%, with a death rate from thromboembolic disease of 0.0% and a total death rate of 0.1%. Both deaths in the control group were from cardiac disease, while the death in the warfarin group was due to a massive gastrointestinal bleeding. The warfarin group had twice the infection rate of the control group.

Topics: Anticoagulants; Arthroplasty, Replacement, Knee; Case-Control Studies; Chi-Square Distribution; Female; Humans; Male; Postoperative Complications; Statistics, Nonparametric; Thromboembolism; Treatment Outcome; Warfarin

We report a case of a 33-year old male admitted to our hospital with extensive lower extremity deep venous thrombosis (DVT). This patient was several days post knee arthroscopy and had a family history strongly positive for DVT. Upon testing, he was found positive for the homozygous presence of Factor V gene R506Q mutation. In inherited thrombophillia, especially in homozygous Factor V Leiden, lifelong anticoagulation treatment and screening for asymptomatic family members is controversial. Upon review and consultation, however, we recommended oral anticoagulation for life, along with genetic counseling and screening for Factor V Leiden of his three children and younger brother.

Topics: Adult; Anticoagulants; Arthroscopy; Factor V; Femoral Artery; Heparin; Humans; Knee; Male; Postoperative Complications; Treatment Outcome; Ultrasonography; Venous Thrombosis; Warfarin

Topics: Anesthesia, General; Antibodies, Antiphospholipid; Anticoagulants; Hematoma; Humans; Lipoma; Lupus Coagulation Inhibitor; Male; Middle Aged; Postoperative Complications; Thigh; Thromboembolism; Warfarin

To investigate the proper anticoagulation intensity in patients after mechanical heart valve replacement in china.. The anticoagulation therapy intensity and the complications in 480 patients after mechanical heart valve replacement were studied.. The follow-up rate was 89.17%, the total patient-years (Pty) was 2,110.04 years, the mean oral import warfarin dosage was (2.81 +/- 0.95) mg/day, and native warfarin dosage (2.38 +/- 0.46) mg/day. The mean PTR value of 2 116 samples was 1.43 +/- 0.26, and the INR value of 1 195 samples was 1.63 +/- 0.49. The total hemorrhage rate was 4.60% Pty, and the hemorrhage death rate was 0.38% Pty. The PTR and INR values were higher in the hemorrhage group than in the no-hemorrhage group. (t = 1.816, P < 0.05; t = 2.407, P < 0.01). The thromboembolism rate was 0.66% Pty, and the thromboembolism death rate was 0.05% Pty. There were 15 pregnancies in 14 women patients and no malformed newborns were found.. The most important complication of anticoagulation therapy after mechanical heart valve replacement is hemorrhage in china; The proper anticoagulation intensities of this group are INR 1.5-2.0 and PTR 1.3-1.5. It is beneficial to adopt the low intensity anticoagulation therapy for decreasing the death rate from hemorrhage, protecting pregnant women and newborns from hemorrhage and malformation, and improving the life qualities of the patients.

Topics: Adolescent; Adult; Aged; Anticoagulants; Female; Follow-Up Studies; Heart Valve Prosthesis Implantation; Hemorrhage; Humans; Male; Middle Aged; Postoperative Care; Postoperative Complications; Pregnancy; Thromboembolism; Warfarin; Young Adult

Topics: Aspirin; Cohort Studies; Female; Graft Rejection; Graft Survival; Hospitals, Veterans; Humans; Male; Netherlands; Peripheral Vascular Diseases; Postoperative Complications; Postoperative Period; Risk Assessment; Thrombolytic Therapy; Treatment Outcome; United States; Vascular Patency; Vascular Surgical Procedures; Warfarin

The management of patients anticoagulated with warfarin and referred for coronary angiography presents a substantial challenge to the physician who must minimize risks of periprocedural hemorrhage and thromboembolism. The aim of this study was to evaluate the feasibility and safety of performing diagnostic coronary angiography and percutaneous coronary intervention during uninterrupted warfarin therapy. Patients treated with warfarin were prospectively identified and enrolled in the study. Nineteen diagnostic cardiac catheterizations and six percutaneous coronary interventions were performed in 23 patients. The mean international normalized ratio was 2.4 +/- 0.5 (range, 1.8-3.5). Hemostasis was achieved with AngioSeal following 21 procedures and with Perclose following 4 procedures. No patient experienced a predefined endpoint. Specifically, no patient experienced procedure-related myocardial infarction, major or minor bleeding. We conclude that cardiac catheterization and percutaneous coronary intervention may be considered in the setting of uninterrupted warfarin therapy.

Topics: Aged; Aged, 80 and over; Angioplasty, Balloon, Coronary; Anticoagulants; Atrial Fibrillation; Cardiac Catheterization; Cerebrovascular Disorders; Clopidogrel; Coronary Angiography; Coronary Disease; Equipment Design; Feasibility Studies; Female; Follow-Up Studies; Heart Failure; Heart Septal Defects, Atrial; Heart Valve Diseases; Humans; International Normalized Ratio; Male; Middle Aged; Platelet Aggregation Inhibitors; Postoperative Complications; Ticlopidine; Treatment Outcome; Venous Thrombosis; Warfarin

Arthroscopic posterior cruciate ligament reconstruction may carry certain risks of complications, including injury to the neurovascular structures in the popliteal region. Acute occlusion of the popliteal artery, a limb-threatening complication, was reported after total knee arthroplasty. We report a case of acute popliteal artery occlusion after arthroscopic posterior cruciate ligament reconstruction. The possible causes included underlying artherosclerosis, the use of pneumatic tourniquet, surgical manipulation, and arterial spasm. Early diagnosis and prompt surgical treatment are the keys to success in the treatment of this limb-threatening complication. Spontaneous resolution of the thrombus such as is reported in this case is exceptional.

Topics: Anticoagulants; Arterial Occlusive Diseases; Arthroscopy; Heparin; Humans; Ischemia; Joint Instability; Leg; Male; Middle Aged; Popliteal Artery; Posterior Cruciate Ligament; Postoperative Complications; Remission, Spontaneous; Thrombosis; Tourniquets; Warfarin

An audit was undertaken to assess whether surgeons were informed of the readmission of their patients with postoperative deep venous thrombosis (DVT), or pulmonary embolus (PE).. A retrospective medical record review was conducted to detect patients who had an unplanned readmission in which DVT or PE formed part of the diagnosis and the first admission included a surgical procedure. The readmission was to John Hunter Hospital, Newcastle, Australia, a major tertiary referral teaching hospital, and the first admission was to any acute care hospital. The main outcome measures were: (i) hospital and specialty of the admitting doctor, (ii) the type of surgery performed, (iii) the length of time between admissions and (iv) the patient's previous medical history. The medical record was reviewed for documented evidence that the surgeon who performed the procedure was aware of the readmission.. Of the 215 patient reviewed, 34 were classified as unplanned readmissions following a surgical procedure. Twenty-four patients (70.6%) were readmitted under a different specialty, three (8.8%) patients were readmitted under the same specialty but under a different surgeon, and seven (20.6%) patients were readmitted under the same surgeon. Of the 27 patients admitted under a different consultant, only 12 (44.4%) had documented evidence that the previous surgeon was aware of the readmission.. The rate of DVT/PE complications following surgery is underestimated. This may lead to a reduced emphasis in DVT/PE prophylaxis in the mistaken belief that DVT/PE frequency is rarer than it is. Improved communication between teams is necessary to improve care.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anticoagulants; Communication; Female; General Surgery; Humans; Interprofessional Relations; Length of Stay; Male; Medical Audit; Middle Aged; Outcome Assessment, Health Care; Patient Readmission; Postoperative Complications; Pulmonary Embolism; Surgical Procedures, Operative; Venous Thrombosis; Warfarin

Topics: Acenocoumarol; Administration, Oral; Aged; Anticoagulants; Blood Proteins; Drug Administration Schedule; Drug Synergism; Erectile Dysfunction; Gingival Hemorrhage; Half-Life; Heart Valve Diseases; Humans; International Normalized Ratio; Male; Piperazines; Postoperative Complications; Protein Binding; Purines; Ranitidine; Sildenafil Citrate; Sulfones; Thrombosis; Warfarin

We sought to determine whether the Cox maze procedure provides additional benefit to patients with atrial fibrillation undergoing mitral valve operations.. Between May 1992 and August 2000, we performed 258 Cox maze procedures with mitral valve replacement (n = 147) or mitral valve repair (n = 111). We compared the outcomes of these patients with those of 61 control patients with preoperative atrial fibrillation who underwent mitral valve replacement alone during the same interval. The three cohorts were similar in age, sex, and proportion of patients in preoperative New York Heart Association functional class 3 or 4.. Although 5-year survivals were similar among the groups (94% for mitral valve replacement alone, 95% for mitral valve replacement plus maze, and 97% for mitral valve repair plus maze), freedoms from atrial fibrillation at 5 years were significantly higher in the mitral valve replacement plus maze group (78%) and the mitral valve repair plus maze group (81%) than in the mitral valve replacement group (6%, P <.0001). Freedoms from stroke at 5 years were 97% for the mitral valve replacement plus maze group, 97% for the mitral valve repair plus maze group, and only 79% for mitral valve replacement group (P <.0001). Multivariable analysis with Cox hazard model revealed that the most significant risk factor for late stroke was the omission of the Cox maze procedure (P =.003).. The addition of the Cox maze procedure to mitral valve repair and replacement was safe and effective for selected patients. Elimination of atrial fibrillation significantly decreased the incidence of late stroke.

Topics: Aged; Anti-Arrhythmia Agents; Anticoagulants; Atrial Fibrillation; Cardiac Surgical Procedures; Electrocardiography; Female; Follow-Up Studies; Heart Rate; Heart Valve Diseases; Heart Valve Prosthesis Implantation; Humans; Incidence; Japan; Male; Middle Aged; Mitral Valve; Multivariate Analysis; Postoperative Care; Postoperative Complications; Preoperative Care; Recurrence; Risk Factors; Stroke; Survival Analysis; Time Factors; Treatment Outcome; Warfarin

Warfarin is an effective agent for prophylaxis against deep-vein thrombosis following total hip or knee arthroplasty. However, management with warfarin in the postoperative setting is problematic because of the need for anticoagulant monitoring. We developed a nomogram for the dosing of warfarin that was specific for joint arthroplasty. The objective of this study was to compare the performance of this nomogram with that of physician-adjusted dosing of warfarin for patients undergoing total hip or knee arthroplasty.. The study involved two cohort trials. The historical control group consisted of 1024 patients who underwent total hip or knee arthroplasty during the course of a clinical trial (the Post-Arthroplasty Screening Study [PASS]) in which all warfarin dose adjustments were made by two hematologists. The first dose of warfarin was given on the evening of the surgery, and the warfarin dose was adjusted daily on the basis of the international normalized ratio and was discontinued at the time of discharge from the hospital. In the PASS study, the dosage of warfarin was designed to prolong the international normalized ratio to 1.7 by postoperative day 4 and to maintain it between 1.8 and 2.5 until discharge from the hospital. Subsequently, a warfarin nomogram was developed on the basis of the dose adjustments used in the PASS study, and it was used prospectively to manage a cohort of 729 patients undergoing total hip or knee arthroplasty. In the nomogram cohort, the initial dose of warfarin was given on the evening of the surgery. Both cohorts were followed for twelve weeks after the surgery to determine if any venous thromboembolic complications had developed.. The nomogram cohort and the control cohort had similar daily doses of warfarin (mean, 3.2 versus 3.3 mg) and levels of international normalized ratio on postoperative day 4 (mean, 1.9 versus 1.9) (p > 0.2). The average number of days to achieve an international normalized ratio of >1.7 was 4.0 for the nomogram cohort compared with 4.3 for the control cohort (p = 0.01). The percentage of days that the international normalized ratio was between 1.8 and 2.5 was 61% for the nomogram cohort and 58% for the control cohort (p < 0.01), and the percentage of days that the international normalized ratio was >3.0 was only 6.5% for the nomogram cohort and 6.0% for the control cohort (p > 0.2). Eighty-two percent of the patients managed with the nomogram achieved an international normalized ratio of >1.7 by the time of discharge from the hospital compared with 92% in the control cohort (p = 0.01). In the three-month follow-up period, a deep-vein thrombosis or a nonfatal pulmonary embolism developed in nineteen patients (2.6%; 95% confidence interval, 1.6% to 4.0%) in the nomogram cohort compared with fourteen patients (1.4%; 95% confidence interval, 0.7% to 2.3%) in the control cohort. No major bleeding event or fatal pulmonary embolism was observed in the patients managed with use of the nomogram.. This study demonstrated that the administration of warfarin during hospitalization with use of a nomogram designed for the prevention of deep-vein thrombosis following total hip or knee arthroplasty provided effective and safe prophylaxis that was comparable with that provided by physician-adjusted dosing of warfarin.

Topics: Anticoagulants; Arthroplasty, Replacement, Hip; Cohort Studies; Female; Humans; International Normalized Ratio; Length of Stay; Male; Postoperative Complications; Venous Thrombosis; Warfarin

The objective of this study was to evaluate the safety and efficacy of carotid artery stenting (CAS) in high-risk patients. Carotid endarterectomy (CEA) has been shown to be more effective than medical therapy but has limitations. CAS may be a reasonable alternative, particularly in high-risk patients. The authors evaluated prospectively the safety and efficacy of CAS in 299 consecutive patients who underwent CAS of 343 extracranial carotid arteries. Of the patients enrolled, 210 (70%) would have been excluded from the major trials of CEA, and 84 (28%) were referred by vascular surgeons. This series represents a very high-risk group that included patients with unstable angina, previous ipsilateral CEA, contralateral carotid occlusion, and other severe comorbid illnesses. Seventy-four (25%) patients were aged 80 years or more. All patients had independent neurologic examination before and after the procedure. Three hundred seventy-six stents were deployed in 343 arteries. Procedural success was 99%. Mean stenosis was 75 +/- 12% before and 7 +/- 8% after the procedure. Ninety-two patients had coronary intervention. Only 56 (19%) patients were North American Symptomatic Carotid Endarterectomy Trial (NASCET) eligible. During the initial hospitalization and 30 days post-CAS, there were two (0.6%) major and seven (2.3%) minor strokes. There were no myocardial infarctions or deaths during or within 30 days of CAS. None of the NASCET-eligible patients had a stroke. At a mean follow-up period of 26 +/- 13 months, eight (2.7%) patients had asymptomatic restenosis. No additional major strokes or neurologic deaths occurred. In conclusion, CAS is feasible, can be performed even in high-risk patients, and is associated with a low restenosis rate.

Topics: Aged; Aged, 80 and over; Angioplasty, Balloon, Coronary; Anticoagulants; Blood Vessel Prosthesis Implantation; Carotid Artery Thrombosis; Carotid Artery, Common; Carotid Stenosis; Female; Follow-Up Studies; Humans; Male; Maryland; Middle Aged; Postoperative Complications; Radiography; Severity of Illness Index; Stents; Time; Time Factors; Treatment Outcome; Warfarin

Acute pulmonary thromboembolism is fatal if the diagnosis and treatments are delayed. Here we present a case of acute thromboembolism to the right and left pulmonary arteries after right lung lobar resection. A 52-year-old woman who admitted to our hospital with lung cancer was performed right upper lobectomy with mediastinal lymph node dissection (pT1N0M0, well differentiated adenocarcinoma). Two days after surgery, she complained sudden chest discomfort and dyspnea. The blood pressure and oxygen saturation were rapidly decreased. Because there was no lung edema or atelectasis in the chest portable roentgenogram and no ischemic change in the electrocardiogram, pulmonary thromboembolism was suspected and emergency chest computed tomography (CT) was performed. The CT showed left and right pulmonary arterial thromboembolism and immediate anti-coagulator therapy was started. Her condition was improved and chest CT, which was performed three days after the onset of the thromboembolism, showed decreased but still remained thrombus. The anti-coagulator therapy was continued and one month after the onset of the thromboembolism, thrombus was disappeared on chest CT. She is doing well 17 months after surgery. Early diagnosis and treatments are critical for the pulmonary thromboembolism.

Topics: Adenocarcinoma; Anticoagulants; Female; Heparin; Humans; Lung Neoplasms; Lymph Node Excision; Lymphatic Metastasis; Middle Aged; Pneumonectomy; Postoperative Complications; Pulmonary Embolism; Warfarin

Skin necrosis associated with warfarin anticoagulation is a rare but serious complication. Few cases of warfarin-induced skin necrosis are found in the orthopaedic literature. We report a fatal case of warfarin-induced skin necrosis after total hip arthroplasty.

Topics: Aged; Anticoagulants; Arthroplasty, Replacement, Hip; Fatal Outcome; Female; Humans; Necrosis; Postoperative Complications; Skin; Warfarin

Premature death due to pulmonary embolism is a short-term complication of deep vein thrombosis (DVT). The long-term clinical course after DVT can be further complicated by excess mortality, recurrent venous thromboembolism (VTE), and the post-thrombotic syndrome (PTS), which may produce sizable long-term economic burdens.. The goal of this study was to determine the cost-effectiveness of the low-molecular-weight heparin (LMWH) enoxaparin versus warfarin for the universal prophylaxis of DVT and associated long-term complications in US patients undergoing total hip replacement surgery (THRS).. A model was constructed to assess the long-term cost-effectiveness of the 2 treatments. Patients undergoing THRS were exposed to a short-term risk of developing a DVT. Patients surviving a DVT were exposed to increased risk of long-term complications of DVT, including PTS, recurrent VTE, and increased mortality. Published literature, augmented by expert opinion, served as input for the model's resource use and costs for DVT prophylaxis, clinical diagnosis, and treatment of DVT, VTE, and PTS.. When the analysis included only the short-term consequences of DVT, therapy with enoxaparin resulted in a net cost of $133 per patient and a net increase of 0.04 quality-adjusted life-years (QALYs) per patient. Thromboprophylaxis with enoxaparin versus warfarin resulted in $3733 per QALY saved. In contrast, when the long-term consequences of DVT were included, enoxaparin resulted in net lifetime savings of $89 per patient and net QALY benefits of 0.16 per patient.. To the best of our knowledge, this is the first US economic analysis comparing DVT prophylaxis with the LMWH enoxaparin versus warfarin that included the long-term complications of DVT. Our model suggests that use of enoxaparin in patients undergoing THRS reduces the economic burden associated with these long-term complications.

Topics: Aged; Aged, 80 and over; Anticoagulants; Arthroplasty, Replacement, Hip; Cost-Benefit Analysis; Drug Costs; Enoxaparin; Female; Humans; Male; Models, Economic; Monte Carlo Method; Postoperative Complications; Quality of Life; Secondary Prevention; United States; Venous Thrombosis; Warfarin

This retrospective pilot study determined whether a change in the daily International Normalized Ratio (INR) correlates with a decrease in Coumadin (DuPont Pharma, Wilmington, Del) dosage. Four hundred seventeen patients yielded 1167 pairs of INR values and Coumadin doses. An increase in INR > 0.4 units correlated 81% with a decrease in the Coumadin dose (P < .05). In patients aged > or = 70 years, the correlation fell to 70% compared to an 89% correlation in patients aged < 70 years (P < .05). The correlation fell to 78% in women, while men exhibited an increase to 87% (P < .05). Although this is a pilot study, when managing postoperative Coumadin anticoagulation for orthopedic patients, an increase in INR > 0.4 units correlates highly with the need to decrease the Coumadin dose. A prospective study is needed to test the usefulness of this parameter.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anticoagulants; Arthroplasty, Replacement; Female; Humans; International Normalized Ratio; Male; Middle Aged; Pilot Projects; Postoperative Complications; Prothrombin Time; Pulmonary Embolism; Retrospective Studies; Venous Thrombosis; Warfarin

Anticoagulation is routinely employed in cardiac surgery following mechanical valve replacement. Warfarin is the most common agent used for anticoagulation. Bleeding, internal or external, remains the major complication with anticoagulant therapy. The risk is known to be higher with INR levels above 4.5. We report a case of a retropharyngeal hematoma following trivial blunt trauma to a patient whose INR had shot up to 6.8 and also discuss its management.

Topics: Anticoagulants; Female; Heart Valve Prosthesis Implantation; Hematoma; Humans; International Normalized Ratio; Middle Aged; Postoperative Complications; Warfarin

A 67-year-old male patient was scheduled for stripping of a lower limb varix. He had received long-term anticoagulant therapy using oral warfarin because of implantation of an aortic mechanical heart valve. Warfarin therapy was discontinued 3 days before surgery to prevent excessive bleeding during the perioperative period. Anesthesia was maintained with sevoflurane and nitrous oxide in oxygen and combined with continuous epidural block. The operation was uneventful. Six hours after surgery, an electrocardiogram demonstrated ventricular fibrillation, followed by respiratory arrest. Cardiopulmonary resuscitation was started immediately, and normal sinus rhythm was restored. Coronary angiography revealed significant stenosis of coronary arteries. Percutaneous transluminal coronary angioplasty was therefore performed. Acute myocardial infarction caused by the interruption of anticoagulant therapy was suspected.

Topics: Aged; Anticoagulants; Humans; Male; Myocardial Infarction; Postoperative Complications; Warfarin

Successful endovascular aortic aneurysm repair depends on exclusion and spontaneous thrombosis of the aneurysm sac. The need for chronic postoperative anticoagulation therapy could limit the applicability of this technology with delay or prevention of sac thrombosis resulting in endoleak formation and altered remodeling of the aneurysm sac. The purpose of this study was the determination of whether chronic therapeutic anticoagulation therapy with warfarin was associated with an increased incidence rate of early or delayed postoperative endoleaks or altered rates of reduction in aneurysm sac maximum diameter.. Two hundred thirty-two consecutive patients underwent abdominal aortic endografting during a 32-month period. The data were recorded prospectively with a current mean follow-up period of 18 months. The patients with endoleaks identified with 30-day postoperative computed tomographic scan angiograms subsequently underwent selective arteriography to characterize the source. The patients who underwent chronic warfarin therapy that resulted in a therapeutic internationalized normalized ratio comprised the study group. The control group was defined as all the patients with healthy coagulation profiles.. Thirty-six patients (15%) were undergoing warfarin therapy after surgery, and their conditions were chronically maintained with a therapeutic international normalized ratio. Forty-three patients (18%) had endoleaks on 30-day computed tomographic scan angiographic results. There were 39 patients with type II endoleaks and four patients with type I endoleaks. None of the type I endoleaks occurred in patients who were undergoing warfarin therapy, and all endoleaks were repaired with either proximal or distal covered extensions. At 30 days, seven patients (19.4%) undergoing chronic warfarin therapy had type II endoleaks as compared with 36 controls (18.4%; P =.798). Four patients had delayed type II endoleaks develop, two in the control group and two in the warfarin group (P =.3). Ten control individuals (31%) had spontaneous resolution of type II endoleaks develop, whereas spontaneous endoleak thrombosis was not observed in the warfarin group (P =.33). Aneurysm sac remodeling assessed with mean percent reduction in maximum sac diameter at 12 months revealed a statistical difference between the control group (17.5%) and the warfarin group (7.6%; P =.04).. Warfarin treatment is not associated with an increase in the incidence rate of early or delayed postoperative endoleaks. However, the rate of reduction in maximum aneurysm sac diameter after aortic endografting is slower in patients who undergo therapeutic warfarin therapy at 1-year follow-up examination, a statistically significant difference from the control group. In addition, type II endoleaks may be less likely to undergo spontaneous thrombosis in patients who undergo warfarin therapy.

Topics: Anticoagulants; Aortic Aneurysm, Abdominal; Case-Control Studies; Follow-Up Studies; Humans; Incidence; Postoperative Complications; Retrospective Studies; Time Factors; Warfarin

Late tamponade is a rare cause of morbidity and mortality after cardiac valve operation. We describe our recent experience with this entity.. This is a single institution, procedure-matched, retrospective review of patients undergoing pericardiocentesis more than 7 days after cardiac operation, during a 7-year period.. Pericardiocentesis for delayed tamponade was performed in 43 of 9,612 patients. Although isolated valve operation accounted for 17% of all patients overall, 76% of patients undergoing pericardiocentesis (33 of 43) had undergone isolated valve operation. The average age in this group was 58 years, compared to an average of 68 years in all patients. Patients presented with tamponade an average of 18 days after operation. Positive predictors included elevated prothrombin time on presentation. Of the patient cohort 75% presented with dyspnea, 61% with inability to diurese, and 61% with hypotension. Echocardiography detected effusions in all patients, but specific echocardiographic signs of tamponade were present in only 30%. Of the patients, 97% were successfully treated by pericardiocentesis. All were safely restarted on warfarin. One patient required pericardial window.. Delayed cardiac tamponade is more common after isolated valve operation, as opposed to coronary artery bypass grafting and valve/coronary artery bypass grafting. It tends to occur in the third postoperative week in younger patients who are aggressively anticoagulated. Pericardiocentesis with catheter placement is highly effective, and patients can be reanticoagulated safely. This series underestimates the incidence of late tamponade, as some patients may present to outside facilities. The diagnosis is aided by a high degree of suspicion.

Topics: Adult; Aged; Blood Coagulation Tests; Cardiac Tamponade; Cardiopulmonary Bypass; Combined Modality Therapy; Echocardiography; Female; Heart Valve Prosthesis Implantation; Humans; Male; Middle Aged; Pericardial Window Techniques; Pericardiocentesis; Postoperative Complications; Retrospective Studies; Risk Factors; Warfarin

A survey conducted in 1992 found that New Zealand orthopaedic surgeons relied on non-pharmacological methods of deep vein thrombosis prevention in most arthroplasty patients and almost all hip fracture patients. This survey was repeated in 1999 to ascertain whether this pattern of use had changed.. All orthopaedic consultants in New Zealand who performed hip or knee surgery in 1999 were asked to complete a one-page postal questionnaire, asking for information regarding: the frequency with which chemoprophylaxis was employed in patients undergoing surgery for hip fracture, hip arthroplasty, or knee arthroplasty; the drug regimes used; the factors that influenced the choice of chemoprophylaxis;and the factors that limited chemoprophylaxis use in orthopaedic practice.. Between 1992 and 1999, the proportion of patients given chemoprophylaxis increased from 3% to 25% for patients with hip fracture, and from 32% to 57% for elective arthroplasty patients. The proportion of surgeons using low molecular weight heparin increased over the 7-year period from 55% to 76%,while aspirin use remained stable at 7% and standard heparin and warfarin decreased to less than 5%. There was a shift away from starting chemoprophylaxis preoperatively towards continuing until discharge, rather than until the patient was mobile. Opinions on indications and contraindications for chemoprophylaxis had not changed substantially during the 7-year period.. Orthopaedic surgeons' use of chemoprophylaxis has increased in New Zealand. However, since hospital stays have decreased considerably and most orthopaedic patients are now discharged within a fortnight,prophylaxis may now cover a shorter duration of the at-risk period.

Topics: Anticoagulants; Arthroplasty, Replacement; Aspirin; Drug Utilization; Elective Surgical Procedures; Heparin; Heparin, Low-Molecular-Weight; Humans; New Zealand; Orthopedics; Postoperative Complications; Practice Patterns, Physicians'; Venous Thrombosis; Warfarin

To identify the risk of thromboembolism after withholding or reversing the effect of warfarin therapy following a major hemorrhage.. Retrospective medical record review.. Tertiary-care hospital.. Twenty-eight patients with prosthetic heart valves receiving warfarin were hospitalized for major hemorrhage from 1990 to 1997. The mean +/- SD age was 61 +/- 11 years (15 men and 13 women). Twenty patients had St. Jude valves, 4 patients had Carpentier-Edwards bioprosthetic valves, 2 patients had Starr Edwards valves, and 2 patients had Bjork-Shiley valves. Valves were in the mitral position in 12 patients, the aortic position in 12 patients, and both mitral and aortic positions in 4 patients. The average interval from valve surgery to index bleeding was 7 years. Twenty-five patients had GI or retroperitoneal hemorrhage, 2 patients had an intracranial hemorrhage, and 1 patient had a subdural hematoma.. Vitamin K was administered to five patients and fresh frozen plasma was given to seven patients to reverse anticoagulation. The mean duration of anticoagulation withholding was 15 +/- 4 days.. None of the patients had thromboembolic complications. There were four in-hospital deaths. Twenty-two of the 24 hospital survivors resumed warfarin therapy at hospital discharge. At 6-month follow-up, 10 of 19 patients remaining on warfarin therapy had recurrent GI bleeding.. Thromboembolic risk is low in prosthetic heart valve patients hospitalized with major hemorrhage when their warfarin therapy is reversed or withheld. Recurrent bleeding within 6 months of the resumption of anticoagulation is common, and aggressive treatment of the bleeding source and the risk-benefit ratio of continued anticoagulation need to be considered.

Topics: Aged; Anticoagulants; Female; Gastrointestinal Hemorrhage; Heart Valve Prosthesis; Humans; Male; Middle Aged; Postoperative Complications; Recurrence; Retrospective Studies; Thromboembolism; Warfarin

Topics: Anticoagulants; Dermatologic Surgical Procedures; Humans; Postoperative Complications; Risk Factors; Stroke; Warfarin

Deep venous thrombosis (DVT) and pulmonary embolism (PE) are serious and costly complications of total hip and knee replacement surgery. The risk of these complications is significantly reduced by prophylaxis. Low molecular weight heparins (LMWH) are being used for this indication with increased frequency. The objective of this study was to assess the cost implications of LMWH for the prevention of symptomatic DVT and PE complications following total hip and knee replacement surgery. The study design was cost analysis based on utilization and the costs of medical resources for prophylaxis and treatment of DVT/PE. A retrospective hospital data set was used to assess symptomatic DVT/PE complication rates and medical resource utilization in patients receiving warfarin, other, and no prophylaxis. The results of a clinical trial were used to estimate relative reductions in risk of symptomatic DVT/PE due to prophylaxis with LMWH. The 7721 total hip and knee replacement patients analyzed were admitted in 1992 in 57 acute-care non-federal hospitals. The measurements were of incremental costs or charges expected to be saved as a result of using LMWH prophylaxis instead of warfarin prophylaxis. Prophylaxis using LMWH rather than warfarin reduces the expected total costs (charges) of treatment by $50 ($193), not including the pharmaceutical costs associated with prophylaxis. The cost reduction in favor of LMWH was sensitive to several factors, including blood monitoring costs and DVT/PE complication rates. Where a reduction of one day in hospital stay could be realized from LMWH's early onset of action, the cost (charges) reduction increased to $226 ($624). In conclusion, LMWH has the potential to offer several short- and long-term cost advantages compared with warfarin, mostly due to lower test costs associated with prophylaxis and reduced complication rates.

Topics: Adult; Aged; Anticoagulants; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Chi-Square Distribution; Cost-Benefit Analysis; Female; Heparin, Low-Molecular-Weight; Humans; Male; Middle Aged; Postoperative Complications; Pulmonary Embolism; Retrospective Studies; Venous Thrombosis; Warfarin

Constrictive pericarditis (CP) is an unusual sequela of cardiac surgery, so the present study evaluated the clinical characteristics of patients with CP after coronary artery bypass grafting (CABG). Four hundred and sixty-three patients who underwent isolated CABG between January 1989 and March 1999 were examined retrospectively. The first choice of treatment for postoperative pericardial effusion was non-steroid anti-inflammatory agents, and an increased dose of diuretics. The second treatment choice was corticosteroids or pericardial drainage. When CP was suspected during the follow-up period (mean, 54+/-31 months), cardiac catheterization was carried out to establish the diagnosis. Of the 463 patients undergoing CABG, there were 11 (2.4%) who developed CP after surgery. The median time to the onset of symptoms after CABG was 4 weeks (range, 3-96 weeks). On univariate and multivariate analysis, normal left ventricular ejection fraction, warfarin administration, and early postoperative pericardial effusion were significantly associated with a greater potential of postoperative CP. The effusion was bloody in all cases of pericardial drainage despite warfarin therapy. Not draining the postoperative effusive pericardial effusion was a risk factor for the development of CP. Pericardial drainage for patients with significant effusion after CABG is important for the prevention of subsequent CP, especially in those patients being treated with warfarin or with normal left ventricular function.

Topics: Aged; Aged, 80 and over; Coronary Artery Bypass; Drainage; Female; Humans; Incidence; Japan; Male; Middle Aged; Pericardial Effusion; Pericarditis, Constrictive; Postoperative Complications; Retrospective Studies; Risk Factors; Stroke Volume; Time Factors; Ventricular Function, Left; Warfarin

A retrospective study was carried out on 42 clinically diagnosed cases of venous thrombo-embolism (VTE) seen over a 10 year period. The mean age at presentation was 41 years with a sex ratio M:F of 2.5:1. The three commonest primary surgical conditions in patients with VTE were spinal trauma (16 percent), benign prostatic hypertrophy (12 percent) and head injury (10 percent). Prostatectomy was performed in 18 percent, ventral hernia repair in 12 percent and splenectomy in 9 percent. Sudden severe dyspnoea was the clinical presentation in 60 percent of patients. Central chest pain occurred in 43 percent, loss of consciousness (38 percent), haemoptysis (7 percent), mental confusion (19 percent) and lower limb swelling (14 percent). Fifty-two percent of patients presented within 10-15 days. Oral warfarin and intravenous heparin were employed in management in 45 percent. Hospital mortality from massive pulmonary embolism was 64 percent while post thrombotic syndrome occurred in 5 percent of patients.

Topics: Adult; Aged; Anticoagulants; Cardiopulmonary Resuscitation; Female; Heparin; Humans; Intermittent Positive-Pressure Ventilation; Male; Middle Aged; Nigeria; Postoperative Complications; Pulmonary Embolism; Retrospective Studies; Warfarin

The American Association of Hip and Knee Surgeons (AAHKS) distributed a survey to its members exploring practice patterns implemented to prevent venous thromboembolic disease (VTED) in patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA). Of 720 (33%) members, 236 responded. Prophylaxis was prescribed for 100% of patients during the course of hospitalization for THA and TKA. Warfarin was the commonest pharmacologic treatment used for THA (66%) and TKA (59%) patients. Low-molecular-weight heparin was used in 16% of THA patients and 18% of TKA patients. The most commonly employed mechanical modality was pneumatic devices in THA (51%) and TKA (50%). Universal acceptance of the need for prophylaxis administration for patients undergoing THA and TKA is shown. The method and duration remain highly variable; although the survey illustrates such variation, it suggests there is no one best method of prophylaxis.

Topics: Anticoagulants; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Aspirin; Bandages; Cause of Death; Data Collection; Heparin, Low-Molecular-Weight; Humans; Postoperative Complications; Pulmonary Embolism; Societies, Medical; United States; Venous Thrombosis; Warfarin

A 53-year-old woman suffered intracranial hemorrhage from a cerebellar tumor several days after aortic valve replacement. Surgical intervention was not performed because the patient refused blood infusion for religious reasons (Jehovah's Witness). Instead, the anticoagulation therapy was interrupted for a week, and the patient was conservatively treated with administration of mannitol and steroid. The anticoagulation therapy was restarted 7 days after the hemorrhage. The intratumoral hemorrhage did not recur, and no systemic embolism occurred. The tumor was treated with gamma knife radiosurgery 6 weeks after the hemorrhage, under the radiological diagnosis of meningioma. Anticoagulation therapy is routinely used for patients following cardiac surgery to decrease the risk of thromboembolic complications, but also increases the risk of hemorrhagic events which often involve the central nervous system. Temporary discontinuation of anticoagulation therapy is an option for intratumoral hemorrhage in patients with replacement heart valves, and patients with known brain tumors should be informed about the risk of intracranial hemorrhage before cardiac surgery.

Topics: Adrenal Cortex Hormones; Anticoagulants; Aortic Valve; Aortic Valve Insufficiency; Cerebellar Neoplasms; Cerebral Hemorrhage; Cranial Fossa, Posterior; Female; Heart Valve Prosthesis Implantation; Heparin; Humans; Magnetic Resonance Imaging; Mannitol; Meningeal Neoplasms; Meningioma; Middle Aged; Postoperative Complications; Radiosurgery; Thromboembolism; Warfarin

To investigate the relationship among lipids, coagulation and thrombosis in the absence of atherosclerosis, spontaneous or dietary-induced hyperlipidemic (FHL) rats were studied. FHL showed higher levels of coagulation factors VII, IX, X, VIII and XII and a shortening of the occlusion time (OT) of an artificial arterial prosthesis as compared with normolipidemic (FNL) animals. Damage of abdominal aorta of FHL was followed by increased fibrin deposition in the vascular intima as compared to FNL. After 5 months of cholesterol-rich diet FNL showed increased cholesterol, triglycerides and factor II, VII, IX, X, XII levels. A significant shortening of the OT and increased fibrin deposition was also observed. Two-month diet withdrawal restored the initial condition. Warfarin treatment, at a dose decreasing vitamin K-dependent factor to levels found in FNL, prolonged the OT and reduced fibrin deposition, without modifying F XII or changing lipid profile. An increase in the activated form of F VII was observed. In contrast, no difference was found in F VII clearance. High lipid levels favour the process of thrombus formation by increasing the activation of vitamin K-dependent coagulation factors. Low-dose warfarin treatment reverts the prothrombotic effect of hyperlipidemia.

Topics: Administration, Oral; Animals; Anticoagulants; Aorta, Abdominal; Aortic Diseases; Blood Coagulation Factors; Blood Vessel Prosthesis; Cholesterol, Dietary; Diet, Atherogenic; Disease Models, Animal; Enzyme Activation; Factor VII; Hypercholesterolemia; Hyperlipidemias; Hypertriglyceridemia; Postoperative Complications; Rats; Rats, Inbred Strains; Rats, Sprague-Dawley; Thrombophilia; Thrombosis; Vitamin K; Warfarin

To review anticoagulant-related bleeding in heart valve patients on warfarin at the Kenyatta National Hospital and to determine the variables associated with anticoagulant-related bleeding.. A combined retrospective and prospective review of patients operated at the Kenyatta National Hospital. Retrospective period from June 1973 to 31st July 1997, while prospective period from August 1st 1997 to June 1st 2000.. Surgical Outpatient Department, Kenyatta National Hospital, Nairobi.. Linearised occurrence rate of anticoagulant-related bleeding and the one- five- and ten- year bleed free rates. Independent risk factors associated with anticoagulant-related bleeding determined using Cox's proportional hazards.. Thirty one bleeding episodes were recorded in 150 patients followed up for a total of 745 patient-years. The risk of occurrence of the first bleed was 16.0%; while the risk of a subsequent bleed increased thereafter with a 16.7%, 50% and 50% risk after the first, second and third bleeds respectively. The linearised rate for minor anticoagulant-related bleed was 4.16% per patient per year however, half the bleeds occurred within the first year of valve implantation or previous bleeding episode. The one-, five- and ten-year bleed free rates for all valves combined were 93%, 85% and 78% respectively. There was no statistically signicant difference between the curves comparing the bleed free rates for the first and second bleeding episodes (p=0.098). The number of valves implanted, the site of implant and the time to the occurrence of bleeding were independent risk factors associated with the occurrence of bleeding (p<.05).. The occurrence of anticoagulant-related bleeding is relatively common being slightly above the internationally reported range. Most episodes of bleeding will occur within one year of hospital discharge or the previous bleeding episode. The risk of another bleeding episode occurring increases with each episode with up to a 50% risk of re-bleed after the second bleeding episode. In this study, the number of valves implanted, their position and the time of occurrence of the bleed were risk factors to the occurrence of bleeding.

Topics: Adult; Anticoagulants; Female; Heart Valve Diseases; Hemorrhage; Humans; Kenya; Male; Postoperative Complications; Postoperative Period; Proportional Hazards Models; Prospective Studies; Retrospective Studies; Risk Factors; Warfarin

To determine the pattern of anticoagulation control for post heart-valve surgery for patients on follow up at Kenyatta National Hospital (KNH).. A combined prospective and restrospective hospital-based study. Retrospective period from January 1991 to 31st August 1997, while the prospective period was from 1st September 1997 to 31st November 1999.. Cardiothoracic surgery clinic, Kenyatta National Hospital, Nairobi.. Post heart valve surgery patients on warfarin and attending the cardiothoracic surgery clinic at Kenyatta National Hospital.. Clinic attendance intervals, average warfarin dosages, interval of dosage change, INR values and variations from accepted normal.. A total of 103 patients fulfilled the criteria for inclusion into the study consisting of 77 mitral valve replacements, 18 aortic valve replacements, seven double valve replacements and one mitral valve repair. The total follow up time for the study period is 316.9 patients years. On average, patients attended their anticoagulation clinic once every 59 days. The average dose of warfarin prescribed was 6.81 mg daily (+/-2.67 mg), with double valve replacement patients receiving a statistically significant lower dosage of 6.04 mg (+/-1.36 mg), (95% confidence limits). On average, a warfarin dose change was made 1.48 times a year per patient. For all the patients, the mean INR was 2.50 (+/-1.18). The respective values for mitral, aortic, double valve replacement and the mitral repairs were 2.53 (+/-1.21), 2.32 (+/-1.04), 2.5 (+/-1.05) and 2.02 (+/-0.53), respectively. Mitral valve repair patients maintained a significantly lower level of INR (95% confidence limits). Only during 18% of the follow up time was adequate anticoagulation maintained. During the study period only 6.9% of patients were able to maintain adequate anticoagulation for 50% or more of their follow up time.. Anticoagulation control at the KNH still needs some improvements in clinic attendance and better dosage adjustments to achieve more appropriate INR values.

Topics: Anticoagulants; Blood Coagulation Disorders; Heart Valve Diseases; Heart Valve Prosthesis Implantation; Hospitals, Public; Humans; Kenya; Postoperative Complications; Practice Patterns, Physicians'; Prospective Studies; Retrospective Studies; Warfarin

Venous thromboembolic complications occur in 50% to 70% of patients undergoing total hip arthroplasty if no prophylactic regimen is used. Because enoxaparin and warfarin are useful for extended outpatient prophylaxis, the objective of this study was to determine which of these agents is most cost effective in preventing venous thromboembolic complications. A decision tree analysis was developed to simulate a hypothetical cohort of patients with total hip arthroplasty. The analysis considered home health care services to perform monitoring and compliance verification. Accounting for prophylactic failures and treatment complications, results showed that enoxaparin maintained a cost effective advantage over warfarin for extended prophylaxis in the time after discharge and total hip arthroplasty ranging from 19 to 31 days after the patient was discharged from the hospital. The duration of cost effectiveness of enoxaparin was reduced to 14 to 17 days when home care services were excluded. These results indicated that approximately 3 weeks of outpatient therapy with enoxaparin is cost effective. With the cornerstone of managed care being cost efficiency in the provision of quality care, this conclusion warrants the development of integrated care strategies for the patient having orthopaedic surgery to achieve cost effective patient management.

Topics: Anticoagulants; Arthroplasty, Replacement, Hip; Clinical Trials as Topic; Costs and Cost Analysis; Decision Support Techniques; Decision Trees; Enoxaparin; Humans; Postoperative Complications; Probability; Sensitivity and Specificity; Thromboembolism; Warfarin

Of 263 patients who underwent total knee arthroplasty, 122 received adjusted low-dose warfarin and 141 received enoxaparin as deep vein thrombosis (DVT) prophylaxis. Three patients in the warfarin group and 3 in the enoxaparin group developed ultrasound-detectable DVT (P > .05). Although the amount of perioperative blood transfused was equivalent in both groups, the overall hemoglobin drop was greater (P < .005) in the enoxaparin group (2.9 g/dL) as compared with the warfarin group (2.3 g/dL). Five patients (4.6%) in the warfarin group and 16 (11.3%) in the enoxaparin group had bleeding complications (P < .05). Our data support earlier published reports suggesting that reductions, if any, in the incidence of DVT associated with enoxaparin are offset by a significant increase in bleeding complications as compared with adjusted-dose warfarin. We continue to use adjusted-dose warfarin as primary thromboembolic prophylaxis after total knee arthroplasty.

Topics: Aged; Anticoagulants; Arthroplasty, Replacement, Knee; Case-Control Studies; Enoxaparin; Female; Humans; Incidence; Male; Postoperative Complications; Postoperative Hemorrhage; Retrospective Studies; Risk Factors; Venous Thrombosis; Warfarin

Patients undergoing joint replacement who show signs of ileus in the postoperative period that require insertion of a nasogastric tube (NGT) must be monitored closely to avoid bleeding complications. The diagnosis of postoperative ileus was documented in 40 of 2,526 (1.6%) consecutive joint replacement operations between January 1, 1990, and March 1, 1998, at 1 hospital. Of the 40 patients with postoperative ileus, 34 received warfarin postoperatively. Of these 34 patients, 19 required a NGT for >48 hours, and 15 patients required a NGT for <48 hours or did not require a NGT. Of the 19 patients who required a NGT for >48 hours and who received warfarin anticoagulation, 17 had a prothrombin time of >20 seconds or an international normalized ratio (INR) of >2.0. None of the 15 patients who required a NGT for <48 hours and who received warfarin anticoagulation had a prothrombin time of >20 seconds or an INR of >2.0. This difference was highly statistically significant (P < .001).

Topics: Anticoagulants; Arthroplasty, Replacement; Colonic Pseudo-Obstruction; Humans; Intubation, Gastrointestinal; Postoperative Care; Postoperative Complications; Prevalence; Thromboembolism; Warfarin

This study examined the hypothesis that elderly trauma patients on warfarin before injury will have increased morbidity and mortality compared with elderly trauma patients not on warfarin.. From 1993 to 1995, trauma patients were grouped by age and presence or absence of warfarin use before injury. Groups were analyzed with respect to Injury Severity Score, Trauma Registry and Injury Severity Score, Glasgow Coma Scale score, Intensive Care Unit days, hospital days, units of blood transfused, and mortality rates. Statistical analysis was completed by using the Student's t test.. Records of 61 patients administered warfarin and 800 patients not administered warfarin were available for analysis. There were no statistically significant differences between patients on prehospital warfarin and those not on prehospital warfarin.. This study indicates that elderly trauma patients on warfarin before injury do not have increased morbidity and mortality compared with elderly trauma patients not on warfarin.

Topics: Aged; Aged, 80 and over; Anticoagulants; Female; Humans; Male; Postoperative Complications; Risk Factors; Survival Rate; Warfarin; Wounds and Injuries

To survey physicians' anticoagulation preferences in patients with chronic atrial fibrillation who are undergoing elective surgery.. A survey was performed that asked physicians to provide pre- and postoperative anticoagulation preferences for two clinical scenarios of patients with chronic atrial fibrillation (high stroke risk, low stroke risk) undergoing elective surgery. In addition to the interruption of warfarin therapy, perioperative anticoagulation options were as follows: a) in-hospital full dose intravenous heparin; b) outpatient full dose subcutaneous unfractionated heparin or low molecular weight heparin (LMWH); c) low dose unfractionated heparin or LMWH (postoperative only); d) nothing other than stopping warfarin preoperatively and restarting it postoperatively; or e) another anticoagulant strategy.. In the high stroke risk scenario, the proportions of respondents preferring anticoagulation options a, b, d and e in the preoperative period were 24%, 20%, 54% and 2%, respectively; the proportions preferring options a, b, c, d and e in the postoperative period were 35%, 13%, 15%, 35% and 1%, respectively. In the low stroke risk scenario, the proportions of respondents preferring options a, b, d and e in the preoperative period were 7%, 10%, 80% and 3%, respectively; the proportions preferring options a, b, c, d and e in the postoperative period were 11%, 9%, 10%, 68% and 2%, respectively.. In patients with chronic atrial fibrillation who underwent elective surgery, perioperative anticoagulant management preferences varied widely in patients at high risk for stroke, but were more uniform and less aggressive in patients at low risk for stroke.

Topics: Anticoagulants; Atrial Fibrillation; Chronic Disease; Elective Surgical Procedures; Heparin; Heparin, Low-Molecular-Weight; Humans; Postoperative Complications; Postoperative Period; Practice Patterns, Physicians'; Preoperative Care; Risk; Stroke; Warfarin

Topics: Anticoagulants; Dose-Response Relationship, Drug; Heart Valve Prosthesis Implantation; Humans; Inpatients; International Normalized Ratio; Postoperative Complications; Serum Albumin; Treatment Outcome; Warfarin

Patients undergoing hip fracture repair are at significant risk for deep vein thrombosis and pulmonary embolism in the postoperative period without appropriate prophylaxis. Agents available in the United States that have undergone clinical trials as pharmacoprophylaxis for this indication include warfarin, dalteparin, and danaparoid. Safety and efficacy data from these trials were used to determine the most cost-effective agent for routine deep vein thrombosis prophylaxis in patients with hip fractures. Incremental cost-effectiveness ratio calculations demonstrate that warfarin dosed to an international normalized ratio of 2-2.7 is currently the most cost-effective agent in these patients.

Topics: Anticoagulants; Cost-Benefit Analysis; Dalteparin; Hip Fractures; Humans; Leg; Postoperative Complications; Venous Thrombosis; Warfarin

Two patients undergoing cutaneous surgery had thromboembolic strokes within 1 week after surgery. Both patients had been taking warfarin for prevention of thromboembolism and warfarin was stopped 3-7 days prior to surgery.. To examine the rationale and problems associated with preoperative warfarin discontinuation.. Review of the medical literature.. When warfarin is stopped prior to surgery and restarted soon after surgery, the patient is at increased risk for thromboembolism. Although it is commonly believed that continuing warfarin during surgery is associated with an increased bleeding risk, for cutaneous surgery, this risk is extremely low and can be easily managed.. Warfarin should not be discontinued prior to cutaneous surgery because of the risk of thromboembolic stroke.

Topics: Aged; Anticoagulants; Blood Loss, Surgical; Brain Infarction; Carcinoma, Basal Cell; Drug Administration Schedule; Eyelid Neoplasms; Female; Humans; Male; Mohs Surgery; Postoperative Complications; Skin Neoplasms; Thromboembolism; Warfarin

Topics: Anticoagulants; Colon; Digestive System Surgical Procedures; Heparin; Humans; Postoperative Complications; Rectum; Risk Assessment; Venous Thrombosis; Warfarin

Although the addition of 300 mg dipyridamole to oral anticoagulants has been shown to decrease thromboembolic events after cardiac valve replacement, reports of combined therapy were few and some showed significant dipyridamole-related side effects and intolerance. The aim of this study was to compare the clinical effect of a standard monotherapy (targeting an international normalized ratio - INR - between 2.5 and 3.5) to a less intensive regimen (targeting an INR between 2 and 2.5) combined to a small dose of dipyridamole (225 mg/day).. Between January 1990 and December 1998, 486 young rheumatic patients with a St Jude mitral valve prosthesis were assigned to follow either standard monotherapy (294 patients) or low-level combined therapy (192 patients). Phenindione has been the anticoagulant of choice. Up to a maximum daily dose of 100mg, patients failing to achieve their target INR range were shifted to warfarin therapy. Prothrombin time was checked monthly and asymptomatic patients with a too low or a too high INR (<1.3 or >5) were briefly hospitalized for INR control. Complete blood picture, renal and hepatic profiles and full echocardiographic study were done biannually.. With the exception of a significantly larger left atrium in patients on low-level combined therapy (P=0.001), both groups were comparable as regards to age and sex distribution, number of patients with atrial fibrillation, left atrial thrombus and history of stroke. Patients were monitored for 1712.6 pt yr and follow-up was 96.7% complete. No phenindione-related complications were observed (mean dose 62.3+/-21.4 mg), 20 patients (4.1%) had failed to achieve their target INR range and were switched to warfarin and only three patients (1.6%) had tolerable dipyridamole-related side effects. Compared to standard monotherapy, patients on low-level combined therapy showed significantly lower annualized rates: thromboembolism (1.6 vs 0.43%: risk reduction 71%; P=0.05), thromboembolism and hemorrhage (2.7 vs 0.7%: risk reduction 72%; P=0.005), death due to valve thrombosis or stroke (1.17 vs 0. 14%: risk reduction 81%; P=0.04) as well as both non-fatal (3.3 vs 1. 57%: risk reduction 51%; P=0.04) and total late postoperative complications (5.35 vs 3.14%: risk reduction 40%; P=0.04); respectively. However, total late mortality (32 patients; 1.8% per pt yr) was comparable among both groups.. Low-level anticoagulation with phenindione combined to low dosage of dipyridamole was clinically more effective than the higher standard monotherapy. With respect to the prescribed doses, both drugs were well tolerated by almost all patients. Use of dipyridamole did not influence overall patients' survival.

Topics: Administration, Oral; Adolescent; Adult; Anticoagulants; Child; Dipyridamole; Drug Therapy, Combination; Female; Follow-Up Studies; Heart Valve Prosthesis Implantation; Humans; Male; Phenindione; Platelet Aggregation Inhibitors; Postoperative Care; Postoperative Complications; Prothrombin Time; Thromboembolism; Warfarin

Recent studies have shown that symptomatic venous thromboembolism after total hip arthroplasty most commonly develops after the patient is discharged from the hospital. Risk factors associated with these symptomatic thromboembolic events are not well defined.. Using administrative data from the California Medicare records for 1993 through 1996, we identified 297 patients 65 years of age or older who were rehospitalized for thromboembolism within three months after total hip arthroplasty. We compared demographic, surgical, and medical variables potentially associated with the development of thromboembolism in these patients and 592 unmatched controls.. A total of 89.6 percent of patients with thromboembolism and 93.8 percent of control patients were treated with pneumatic compression, warfarin, enoxaparin, or unfractionated heparin, alone or in combination. In addition, 22.2 percent and 29.7 percent, respectively, received warfarin after discharge. A body-mass index (the weight in kilograms divided by the square of the height in meters) of 25 or greater was associated with rehospitalization for thromboembolism, with an odds ratio of 2.5 (95 percent confidence interval, 1.8 to 3.4). In a multivariate model, the only prophylactic regimens associated with a reduced risk of thromboembolism were pneumatic compression in patients with body-mass indexes of less than 25 (odds ratio, 0.3; 95 percent confidence interval, 0.2 to 0.6) and warfarin treatment after discharge (odds ratio, 0.6; 95 percent confidence interval, 0.4 to 1.0).. In patients who underwent total hip arthroplasty, a body-mass index of 25 or greater was associated with subsequent hospitalization for thromboembolism. Pneumatic compression in patients with a body-mass index of less than 25 and prophylaxis with warfarin after discharge were independently protective against thromboembolism.

Topics: Aged; Aged, 80 and over; Anticoagulants; Arthroplasty, Replacement, Hip; Body Mass Index; Case-Control Studies; Female; Gravity Suits; Heparin; Hospitalization; Humans; Male; Multivariate Analysis; Postoperative Complications; Risk Factors; Thromboembolism; Warfarin

A 7.1% deep venous thrombosis rate followed total hip arthroplasty in 56 patients using a hybrid prophylactic regimen against deep venous thrombosis and pulmonary embolus. There were no bleeding complications, no symptomatic pulmonary emboli, and no unexplained deaths. The regimen consisted of an initial loading dose of warfarin, usually 10 mg, the night of surgery followed by 2.5 mg/day for 3 weeks, with dosage adjustments only in cases of over-anticoagulation. This regimen was combined with elevated sling suspension of the operative leg, bilateral pedal intermittent pneumatic compression devices, and early mobilization. This prophylactic regimen is simple, inexpensive, efficacious, and compatible with an early hospital discharge.

Topics: Arthroplasty, Replacement, Hip; Drosophila Proteins; Early Ambulation; Gravity Suits; Humans; Middle Aged; Phosphoprotein Phosphatases; Phosphoric Monoester Hydrolases; Postoperative Complications; Pulmonary Embolism; Retrospective Studies; Venous Thrombosis; Warfarin

To evaluate the effect of lower intensity anticoagulation therapy in patients with mechanical prosthetic valves, laboratory-based hematological assays including prothrombin time (PT), activity of factor X, antithrombin III (AT III), D-dimer, fibrinogen (Fg) and platel et al pha-granular membrane protein (GMP-140) were performed in 65 patients who had been on warfarin treatment for over one month. The patients were assigned to 3 groups on the basis of their International Normalized Ratios (INR), ranging from 2.00 to 2.50; 2.51 to 3.00; 3.01 to 4.50, respectively. The results showed that the D-dimer, Fg, GMP-140 levels were higher after mechanical valve replacement than those before operation, indicating the activation of coagulation and fibrinolysis system and the damage of platelets. Lower intensity anticoagulation therapy (INR 2.00 to 2.50) could effectively inhibit the activity of factor X and increase the level of AT III. There were no appreciable differences among D-dimer, Fg, GMP-140 and AT III in the 3 anticoagulation intensity groups. These results suggest that in patients with new generation mechanical prosthetic valves, target anticoagulation level (INR 2.00 to 2.50) may result in good protection from thrombo-embolism.

Topics: Adolescent; Adult; Anticoagulants; Factor X; Female; Heart Valve Diseases; Heart Valve Prosthesis Implantation; Humans; Male; Middle Aged; P-Selectin; Postoperative Complications; Rheumatic Heart Disease; Thromboembolism; Warfarin

Except for bleeding complications, relevant adverse effects of coumarin anticoagulants are comparatively rare considering the widespread use of these substances. Here we present the case of a 56-year-old woman who developed recurrent episodes of severe hepatitis following repeated exposure to phenprocoumon (Marcumar; Roche, Grenzach-Wyhlen, Germany) and warfarin (Coumadin; DuPont Pharma, Bad Homburg, Germany) after replacement of the mitral valve with a mechanical prosthesis. The diagnosis of "coumarin-induced hepatitis" is compatible with the time relationship between start of the drug and the onset of hepatopathy (first episode 8 months, second episode 4 weeks, and third episode 7 days), the rapid improvement following discontinuation of the drug, recurrence of liver dysfunction after re-exposure to the drug, and liver histology. After anticoagulant therapy was changed to heparin and acenocoumarol (Sintrom; Ciba-Geigy, Basel, Switzerland), the patient's general state was markedly improved and her liver values became almost normal. This case will be discussed and compared with other reports of coumarin-induced hepatic lesions. Although liver damage induced by coumarin derivates is rare, it is important to be aware of the hepatotoxic potential of these drugs, which, in most cases, mimics the clinical presentation of viral hepatitis.

Topics: Anticoagulants; Bioprosthesis; Chemical and Drug Induced Liver Injury; Female; Humans; Middle Aged; Mitral Valve; Phenprocoumon; Postoperative Complications; Thrombosis; Warfarin

Topics: Anticoagulants; Female; Heart Valve Prosthesis Implantation; Humans; Infant, Newborn; Male; Postoperative Complications; Pregnancy; Pregnancy Complications, Cardiovascular; Prosthesis Failure; Risk Assessment; Thromboembolism; Warfarin

Transsphenoidal surgery is the usual treatment of choice for adrenocorticotropic hormone-secreting pituitary adenomas associated with Cushing's disease. In this paper the authors investigate the complications of transsphenoidal surgery in the treatment of a contemporary series of patients with Cushing's disease.. Between January 1992 and December 1997, 105 patients with Cushing's disease underwent transsphenoidal surgery at the University of Virginia Health Sciences Center. A retrospective analysis of the complications was conducted, and the mortality rate was found to be 0.9% and permanent morbidity was 1.8%. The overall number of complications was 14 (13.3%), which included seven complications directly related to surgery; one instance of permanent diabetes insipidus; one syndrome of inappropriate secretion of antidiuretic hormone; and five medical complications (four patients developed deep vein thrombosis and one developed pneumonia).. Transsphenoidal surgery for Cushing's disease has a higher complication rate than that for pituitary adenomas in general. This is primarily related to a greater number of medical complications, most notably deep vein thrombosis, resulting from the generally debilitated state of most patients with Cushing's disease. In view of the high incidence of deep vein thrombosis in these patients, prophylaxis for thromboembolism during the perioperative period is recommended.

Topics: Adenoma; Adolescent; Adrenocorticotropic Hormone; Adult; Aged; Anticoagulants; Cause of Death; Child; Cushing Syndrome; Diabetes Insipidus; Female; Humans; Hyponatremia; Inappropriate ADH Syndrome; Leg; Male; Middle Aged; Pituitary Neoplasms; Pneumonia; Postoperative Complications; Retrospective Studies; Sphenoid Bone; Survival Rate; Venous Thrombosis; Warfarin

To assess the incidence of arterial embolic events in patients with high rate, drug resistant, severely symptomatic paroxysmal and chronic atrial fibrillation who have undergone atrioventricular (AV) node ablation and permanent pacing.. Multicentre retrospective cohort study. PATIENTS AND MANAGEMENT: From May 1987 to January 1997, AV node ablation was performed in 585 severely symptomatic patients (mean (SD) age 66 (11) years) with high rate, drug resistant paroxysmal atrial fibrillation (308) or chronic atrial fibrillation (277). Lone atrial fibrillation was present in 133 patients, while the remaining 452 suffered from dilated, ischaemic, or valvar heart disease. Patients underwent VVIR (454) or DDDR (131) pacemaker implantation, after AV node ablation. Antiplatelet agents were given to 202 patients, warfarin to 187 patients.. During a follow up of 33.6 (24.2) months, thromboembolic events were observed in 17 patients (3%); the actuarial occurrence rates of thromboembolism were 1.1%, 3%, 4.2%, and 7.4% after one, three, five, and seven years, respectively. Among five variables, univariate analysis showed that only the presence of chronic atrial fibrillation at the time of ablation (relative risk (RR) = 1.8, 95% confidence interval (CI) = 1.02 to 3. 20, p = 0.04) and the need for warfarin treatment (RR = 1.6, 95% CI 1.00 to 2.71, p = 0.048) were associated with a significantly higher risk of occurrence of thromboembolic events. On multivariate analysis the only predictor of embolic events during the follow up was the presence of chronic atrial fibrillation.. Data from this large cohort of patients indicate a fairly low incidence (1.04% per year) of thromboembolic events after AV node ablation and pacing for drug refractory, high rate atrial fibrillation.

Topics: Aged; Anticoagulants; Atrial Fibrillation; Atrioventricular Node; Cardiac Pacing, Artificial; Catheter Ablation; Chronic Disease; Follow-Up Studies; Humans; Incidence; Platelet Aggregation Inhibitors; Postoperative Complications; Proportional Hazards Models; Retrospective Studies; Risk; Thromboembolism; Warfarin

Warfarin is considered as a narrow therapeutic drug-an agent for which small changes in dosage can lead to significant changes in response. The precision of warfarin treatment is especially relevant in an acute-care setting. In this study, we examined the effect of various risk factors on warfarin response in the early postoperative period after total joint arthroplasty and hip fracture fixation. A total of 260 patients placed on warfarin for thrombosis prophylaxis were retrospectively studied. Risk factors for warfarin sensitivity include age 80 years or older and hip fracture fixation. Patients aged 80 years or older who had hip fracture fixation were 4.7 times more likely to experience an international normalized ratio (INR) at or greater than 4.0 than other patients (therapeutic target range of INR, 1.8-2.2). The largest subtherapeutic risk group in this study were men weighing 180 lb or more. They were 5.7 times less likely to achieve an INR of 1.6 than the other patients. Factors such as body weight, age, and gender should be considered when ordering warfarin therapy. Current hospital warfarin sliding scales should be reviewed for their efficacy to ensure that the target outcome is achieved.

Topics: Aged; Aged, 80 and over; Anticoagulants; Arthroplasty, Replacement, Hip; Hip Fractures; Humans; Male; Middle Aged; Postoperative Complications; Pulmonary Embolism; Retrospective Studies; Thrombosis; Venous Thrombosis; Warfarin

A 57-year-old woman was hospitalized because of gait disturbance and dysuria. Close examination revealed a cauda equina tumor at the level of L2 and L3. Tumor resection was performed, with posterolateral fusion and spinal instrumentation. On the eleventh day after the surgery, she experienced dyspnea and chest pain during standing and walking exercise. Pulmonary thromboembolism was diagnosed, based on: (1) blood gas analysis findings of hypoxemia and (2) defective images in both of the upper lobes on urgent pulmonary blood flow scintigram. Her clinical status improved with urgent thrombolytic therapy (with tisokinase and urokinase) and anticoagulation therapy (with heparin and warfarin), and her life was saved. When pulmonary thromboembolism occurs, early diagnosis by pulmonary blood flow scintigram and early thrombolytic and anticoagulative therapies are necessary. Special attention should be paid to symptoms of pulmonary thromboembolism in patients after spinal surgery.

Topics: Anticoagulants; Cauda Equina; Chest Pain; Dyspnea; Female; Heparin; Humans; Hypoxia; Lumbar Vertebrae; Middle Aged; Peripheral Nervous System Neoplasms; Plasminogen Activators; Postoperative Complications; Pulmonary Embolism; Spinal Fusion; Thrombolytic Therapy; Tissue Plasminogen Activator; Urokinase-Type Plasminogen Activator; Warfarin

This study assesses the long-term (mean 52+/-24 months) performance of the St. Jude Medical (SJM) valve in 200 young (mean age 31+/-13 years) rheumatic patients on low-level warfarin anticoagulation combined with dipyridamole. Follow-up was 95% complete and comprised 867 patient-years. There were 33 deaths (3.8%/patient-year). Death was valve related in 12 cases and due to left ventricular dysfunction in 10. Death due to left ventricular dysfunction occurred earlier after surgery than death due to other causes (10+/-7 vs 29+/-18 months, p <0.005); these patients had larger preoperative left ventricular dimensions than the rest of the group (end-systolic diameter 51+/-13 vs 37+/-16 mm, end-diastolic diameter 66+/-13 vs 50+/-19 mm, p = 0.006). Actuarial probability of survival was 81% at 86 months and probability of event-free survival was 71%. The median international normalized ratio was 1.88+/-0.54. Thromboembolism (13 events) occurred at a linearized rate of 1.5%/patient-year. There were 11 major bleeding episodes (1.3%/patient-year), 4 cases of prosthetic valve endocarditis (0.8%/patient-year), and 12 paraprosthetic leaks (1.4%/patient-year). No valve obstructions or reoperations occurred. Thus, the SJM valve performs well on low-level anticoagulation combined with dipyridamole. Left ventricular dysfunction was a common cause of death in the early postoperative period.

Topics: Actuarial Analysis; Adult; Anticoagulants; Cause of Death; Endocarditis; Female; Follow-Up Studies; Heart Valve Diseases; Heart Valve Prosthesis; Hemorrhage; Humans; Male; Middle Aged; Postoperative Complications; Rheumatic Heart Disease; Survival Analysis; Thromboembolism; Time Factors; Treatment Outcome; Warfarin

We recently performed a laparoscopic cholecystectomy on three patients receiving preoperative oral anticoagulant therapy. The patients requiring anticoagulants for pre-existing cardiac conditions have the following risks at surgery: thromboembolism, hemorrhage, endocarditis, and cardiopulmonary dysfunction. In patients receiving anticoagulant therapy, one must thus maintain a balanced international normalized ratio of the prothrombin time to prevent thromboembolism or hemorrhage. Warfarin sodium was discontinued preoperatively in all patients. Heparin sodium was individualized according to each patient's risk of thromboembolism. As a result, these patients all underwent a laparoscopic cholecystectomy without complications. Attention was paid to achieve hemostasis in the operative field and the trocar inserted sites during the procedure. The administration of warfarin sodium was resumed on the first postoperative day in all patients. Restarting warfarin sodium early also helps to simplify postoperative management. A broad spectrum of antibiotic therapy was also used to reduce the risk of endocarditis. Each patient's cardiopulmonary function was carefully monitored. The minimal invasion experienced during a laparoscopic cholecystectomy may thus facilitate the management of gallstones in patients receiving systemic anticoagulation treatment based on the findings of this limited series.

Topics: Adult; Anti-Bacterial Agents; Anticoagulants; Cholecystectomy, Laparoscopic; Cholelithiasis; Female; Heparin; Humans; Middle Aged; Postoperative Care; Postoperative Complications; Warfarin

We report the first case in which a fluid-blood interface was identified at autopsy in a patient with acute intracerebral hematoma on anticoagulant therapy. Anticoagulation may be one of the major factors contributing to the production of an intracerebral blood sedimentation level.

Topics: Aged; Anticoagulants; Blood Sedimentation; Blood-Brain Barrier; Brain; Cerebral Hemorrhage; Fibrin; Heart Valve Prosthesis Implantation; Hematoma; Humans; Male; Mitral Valve Stenosis; Postoperative Complications; Warfarin

These studies were designed to assess the effect of low-dose anticoagulation in elderly patients after mitral valve replacement.. Between 1986 and 1995, 250 patients aged > or = 50 years underwent isolated mitral valve replacement at the Cardiovascular Surgery Clinic of Turkiye Yuksek Ihtisas Hospital. The overall hospital mortality rate was 8%. Postoperatively, all patients received 2.5 mg/day warfarin, and 225 mg/day dypridamole and 250 mg/day aspirin following removal of mediastinal tubes. This regimen was continued indefinitely thereafter.. Postoperatively, the mean International Normalized Ratio (INR) was 1.4 +/- 0.67 (range: 0.9 to 4.19) and mean prothrombin time 13.33 +/- 1.98 min (range: 11.7 to 21.3 min). Mean follow up was 1.42 +/- 1.2 years (range: 2 months to 8.3 years); total cumulative follow up was 322.75 patient-years (pt-yr). During follow up, six patients (1.85% per pt-yr) developed thromboembolic complications (including mechanical valve thrombosis), two (0.62% per pt-yr) developed oral anticoagulant-related bleeding, and two (0.62% per pt-yr) developed paravalvular leak. Five patients died during follow up (late mortality rate 1.2% per pt-yr). The nine-year actuarial survival rate was 93.9 +/- 4.8% for the entire group.. Low-dose oral anticoagulation after mitral valve replacement with St. Jude Medical prosthesis in elderly patients provided satisfactory clinical results.

Topics: Actuarial Analysis; Anticoagulants; Female; Follow-Up Studies; Heart Valve Prosthesis Implantation; Hospital Mortality; Humans; Male; Middle Aged; Mitral Valve; Mitral Valve Insufficiency; Mitral Valve Stenosis; Platelet Aggregation Inhibitors; Postoperative Care; Postoperative Complications; Prosthesis Design; Time Factors; Warfarin

Topics: Anticoagulants; Heparin, Low-Molecular-Weight; Humans; Orthopedic Procedures; Postoperative Complications; Pulmonary Embolism; Thrombosis; Warfarin

Topics: Anticoagulants; Arthroplasty, Replacement, Hip; Dalteparin; Humans; Postoperative Complications; Pulmonary Embolism; Thrombosis; Warfarin

Topics: Anticoagulants; Arthroplasty, Replacement, Hip; Dalteparin; Humans; Postoperative Complications; Pulmonary Embolism; Thrombosis; Warfarin

To examine the procedural and long term success of coronary stenting in patients presenting with unstable angina and the effect of warfarin on the clinical outcome of these high risk patients.. A nonrandomized, retrospective analysis of patients presenting with unstable angina.. A tertiary care, Canadian university-affiliated teaching hospital.. Of 1250 patients who underwent percutaneous transluminal coronary angioplasty between January 1994 and June 1995, 365 underwent coronary stenting. The study population consisted of the 156 patients presenting with unstable angina who underwent coronary stenting. Patients with Canadian Cardiovascular Society class IV and postinfarction angina were included.. Stent delivery by standard techniques to the target lesion was successful in all patients. At discharge, 88 patients were prescribed warfarin, ticlopidine and acetylsalicylic acid (ASA); the remaining 68 patients received only ticlopidine and ASA. Late clinical outcomes were assessed by telephone interview.. The overall procedural success rate was 96%. One patient died in hospital (0.6%). Other events were abrupt closure (1.9%), myocardial infarction (1.9%) and urgent bypass surgery (1.9%). During follow-up, target vessel reintervention was needed in 19.6% of patients. Early and late clinical outcomes did not differ significantly between anticoagulated patients and those treated with antiplatelet agents alone, but anticoagulated patients had a significantly longer hospital stay.. Coronary stenting in patients with unstable angina was associated with excellent procedural success and favourable late clinical outcomes. Warfarin added no apparent additional clinical benefit to antiplatelet agents in this high risk population.

Topics: Angina, Unstable; Angioplasty, Balloon, Coronary; Aspirin; Coronary Artery Bypass; Coronary Disease; Follow-Up Studies; Humans; Myocardial Infarction; Postoperative Complications; Reoperation; Retrospective Studies; Stents; Ticlopidine; Treatment Outcome; Warfarin

To determine whether compression ultrasonography or clinical examination should be considered as screening tests for the diagnosis of deep vein thrombosis (DVT) after total hip or knee arthroplasty in patients receiving warfarin prophylaxis postoperatively.. A prospective cohort study.. A single tertiary care orthopedic centre.. One hundred and eleven patients who underwent elective total hip or knee arthroplasty were enrolled. Postoperatively the warfarin dose was adjusted daily to maintain the international normalized ratio between 1.8 and 2.5. Eighty-six patients successfully completed the study protocol.. Before they were discharged from hospital, patients were assessed for DVT by clinical examination, bilateral compression ultrasonography of the proximal venous system and bilateral contrast venography.. DVT was found in 29 patients (34%; 95% confidence interval [CI] 24% to 45%), and 6 patients (7%; 95% CI 3% to 15%) had proximal DVT. DVT developed in 18 (40%) of 45 patients who underwent total knee arthroplasty and in 11 (27%) of 41 patients who underwent total hip arthroplasty. The sensitivity of compression ultrasonography for the diagnosis of proximal DVT was 83% (95% CI 36% to 99%) and the specificity was 98% (95% CI 91% to 99%). The positive predictive value of compression ultrasonography was 71%. In contrast, clinical examination for DVT had a sensitivity of 11% (95% CI 2% to 28%) and a positive predictive value of 25%.. DVT is a common complication after total hip or knee arthroplasty. Compression ultrasonography appears to be a relatively accurate noninvasive test for diagnosing postoperative proximal DVT. In contrast, clinical examination is a very insensitive test. Whether routine use of screening compression ultrasonography will reduce the morbidity of venous thromboembolism after joint arthroplasty requires confirmation in a prospective trial involving long-term follow-up of patients.

Topics: Aged; Anticoagulants; Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Female; Humans; Male; Physical Examination; Postoperative Complications; Predictive Value of Tests; Prospective Studies; Thrombophlebitis; Ultrasonography; Warfarin

Topics: Acetaminophen; Analgesics, Non-Narcotic; Anticoagulants; Drug Interactions; Humans; Postoperative Complications; Warfarin

Topics: Anticoagulants; Cardiac Surgical Procedures; Cerebrovascular Disorders; Child; Cognition; Female; Heart Septal Defects, Atrial; Humans; Intracranial Embolism and Thrombosis; Postoperative Complications; Protein C Deficiency; Warfarin

We report the case of a 74-year-old woman who underwent an elective procedure to replace her mitral valve with a 27-mm CarboMedics bileaflet valve (CarboMedics, Inc.; Austin, Tex) to correct mitral incompetence. Massive thrombosis of the prosthesis was clinically evident on the 6th postoperative day, despite administration of warfarin therapy according to our usual protocol. After an unsuccessful attempt at thrombolysis with recombinant tissue plasminogen activator, the mechanical prosthesis was replaced with a bioprosthesis. The cause of the thrombosis is unknown, but transient suboptimal anticoagulation is assumed to be responsible. Although very early massive valve thrombosis is a rare occurrence, it is a known risk of prosthetic valve implantation. Antiplatelet therapy, in addition to the usual warfarin anticoagulation, can help to prevent it. If thrombosis is diagnosed, it can be managed by thrombolysis or, when thrombolysis is unsuccessful, by reoperation. Transesophageal echocardiography is fundamental in the diagnosis and management of this sequela.

Topics: Aged; Anticoagulants; Bioprosthesis; Coronary Thrombosis; Female; Heart Valve Prosthesis Implantation; Humans; Mitral Valve Insufficiency; Postoperative Complications; Reoperation; Warfarin

Aortic root replacement (ARR) is a technically demanding procedure that can be performed using a variety of prosthetic devices. Root replacement in the young, but grown-up, patient poses unique problems in terms of the long-term outcome and active lifestyle that must be guaranteed by this operation. To identify the "ideal" substitute for ARR in the young, clinical results in teenagers and young adults (<35 years) operated on in the past two decades were reviewed.. Thirty-eight patients younger than 35 years underwent ARR between January 1980 and December 1996. Eighteen patients, aged 30+/-5 years, had ARR with composite graft (group 1), whereas 20 patients, aged 28+/-6 years, had ARR with aortic homografts or pulmonary autografts (group 2). Primary indication for the operation was aortic insufficiency with anuloaortic ectasia (12 of 18) in group 1 and aortic insufficiency with or without anuloaortic ectasia (16 of 20) in group 2. Urgent ARR was required in 3 (17%) group 1 patients and 1 (5%) group 2 patient (p = 0.01).. Operative deaths were 2 (11%) in group 1, caused by hemorrhage and low output, and none in group 2. There were 4 (25%) late deaths in group 1, caused by embolism (2), hemorrhage, and myocardial infarction, and 1 (5%) in group 2, caused by arrhythmia. Survival was 81% +/- 9%, and 55%+/-18% at 2 and 10 years in group 1 versus 94%+/-5% at 2 years in group 2 (p = 0.04). Freedom from valve-related events was 93%+/-6% and 62%+/-18% at 2 and 10 years in group 1 versus 100% at 2 years in group 2 (p = 0.02). Freedom from reoperation in group 1 was 75% +/- 22% at 10 years, whereas no reoperations were done in group 2. Seven (58%) group 1 patients versus 1 (5%) group 2 patient were on cardiac medications (p = 0.001), and 11 (92%) group 1 patients versus no group 2 patients were on warfarin therapy at follow-up. All survivors were back to school or prior employment.. Survival early after ARR does not differ depending on the type of prosthesis. Valve-related events are common, and reoperation may be needed late after ARR with composite grafts. Despite limited follow-up with biologic devices, the prevalence of complications with composite grafts makes homograft or autograft ARR preferable in adolescents and young adults.

Topics: Adolescent; Adult; Age Factors; Anticoagulants; Aortic Valve; Aortic Valve Insufficiency; Bioprosthesis; Cardiac Output, Low; Cause of Death; Embolism; Female; Follow-Up Studies; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Life Style; Longitudinal Studies; Male; Myocardial Infarction; Postoperative Complications; Postoperative Hemorrhage; Pulmonary Valve; Reoperation; Retrospective Studies; Risk Factors; Survival Rate; Transplantation, Autologous; Transplantation, Homologous; Treatment Outcome; Warfarin

Use of the Internet for patient-specific consultation across international boundaries has been demonstrated. This report describes the efforts of Baylor College of Medicine and NASA to conduct a telemedicine consultation with Moscow, Russia. Consultation between Russian and American physicians was performed over the Internet with a combination of real-time and store-and-forward techniques. The clinical focus involved a 65-year old Russian scientist who had undergone mitral valve replacement in the United States 5 years earlier. Development of new activity-related chest pain, dyspnea, and intermittent atrial fibrillation led to a consultation with his American cardiologist and cardiac surgeon. Real-time video was supplemented with telephone voice communication to overcome bandwidth limitations. Prior to the video link, the patient's recent history and clinical data were made available via the Internet using file transfer protocol (FTP). The patient's medications, new electrocardiographic findings, and activity status were reviewed. Specific clinical recommendations were made as a result of this telemedicine consultation. This case illustrates the technical factors, clinical implications, and confidentiality issues related to using the Internet for telemedicine consultations and demonstrates that the Internet may provide an alternative means for long-term clinical follow-up of patients.

Topics: Aged; Angina Pectoris; Anticoagulants; Atrial Fibrillation; Computer Systems; Confidentiality; Database Management Systems; Dyspnea; Electrocardiography, Ambulatory; Follow-Up Studies; Heart Valve Prosthesis Implantation; Humans; Internet; Longitudinal Studies; Male; Mitral Valve; Postoperative Complications; Remote Consultation; Telephone; Warfarin

Topics: Anticoagulants; Enoxaparin; Humans; Knee Prosthesis; Postoperative Complications; Thrombophlebitis; Warfarin

Topics: Anticoagulants; Enoxaparin; Humans; Knee Prosthesis; Postoperative Complications; Research Design; Thrombophlebitis; Warfarin

Acute carpal tunnel syndrome is well recognized in patients with haemophilia and conservative management with factor replacement and temporary splinting is recommended. There have, however, been very few reported cases of acute carpal tunnel syndrome as a complication of oral anticoagulant therapy. We describe such a case in a patient on long-term warfarin anticoagulation, drawing attention to particular features of the history and clinical findings. In contrast to previous reports, we recommend prompt decompression under local anaesthesia and continuation of the anticoagulant therapy.

Topics: Anticoagulants; Aortic Valve; Carpal Tunnel Syndrome; Decompression, Surgical; Heart Valve Prosthesis; Hematoma; Humans; Male; Middle Aged; Postoperative Complications; Warfarin

The selection of a prophylaxis regimen and its implementation have been influenced considerably by the decreased duration of hospital stays and the pressures of cost containment. The purpose of the present study was to determine the rate of symptomatic pulmonary embolism both before and after discharge, the number of days required to achieve an adequate level of anticoagulation, and the complications associated with the use of low-dose warfarin after total hip arthroplasty. Between 1987 and 1993, 1099 primary and revision total hip arthroplasties were performed in 940 patients who received low-dose warfarin for prophylaxis against thromboembolic disease. The average duration of prophylaxis was fifteen days (range, one to twenty-nine days). The target level of anticoagulation (as indicated by a prothrombin time of fourteen to seventeen seconds) was achieved an average of three days (range, one to sixteen days) after the operation. The level of anticoagulation was lower than the target range at the time of discharge after 257 total hip arthroplasties (23.4 per cent), and the target level was never achieved during the period of hospitalization after fifty-four such procedures (4.9 per cent). Twelve total hip arthroplasties were associated with a symptomatic pulmonary embolism; the over-all prevalence of this complication therefore was 1.1 per cent (95 per cent confidence interval, 0.4 to 1.9 per cent). Four pulmonary emboli were diagnosed before discharge and eight, after discharge. A fatal pulmonary embolism occurred after one procedure (0.1 per cent). Patients who had a history of symptomatic venous thromboembolic disease had a significantly increased risk of symptomatic pulmonary embolism after total hip arthroplasty (p = 0.001, Fisher exact test). A major bleeding episode occurred after thirty-two total hip arthroplasties (2.9 per cent). Patients who had a prothrombin time of more than seventeen seconds had a significantly increased risk of hematoma formation (p = 0.003, chi-square analysis). Prophylaxis with low-dose warfarin is safe and effective for the prevention of pulmonary embolism after total hip arthroplasty.

Topics: Adult; Aged; Anticoagulants; Female; Hemorrhage; Hip Prosthesis; Humans; Male; Middle Aged; Postoperative Complications; Prospective Studies; Pulmonary Embolism; Retrospective Studies; Warfarin

Topics: Anticoagulants; Aortic Arch Syndromes; Cerebrovascular Disorders; Diabetes Complications; Diabetic Angiopathies; Female; Hemiplegia; Humans; Ischemia; Leg; Middle Aged; Postoperative Complications; Warfarin

Stroke is uncommon after orthotopic liver transplantation. We offer the first report, to our knowledge, of two posttransplant patients with stroke associated with elevated anticardiolipin antibodies, and we discuss their management, including the use of immunosuppression and antithrombotic therapy. We suggest that anticoagulation is the treatment of choice for such patients.

Topics: Antibodies, Anticardiolipin; Anticoagulants; Antiphospholipid Syndrome; Cerebrovascular Disorders; Female; Humans; Immunoglobulin G; Liver Transplantation; Male; Middle Aged; Postoperative Complications; Warfarin

Pulmonary embolism poses a risk to patients undergoing total knee arthroplasty. The selection of an appropriate prophylaxis agent and its implementation have been influenced by decreased duration of hospital stay and the pressures of cost containment. The purpose of this study was to determine the inpatient and outpatient pulmonary embolism rates, the number of days required to attain the target level of anticoagulation, and complications associated with the use of a low-dose warfarin prophylaxis protocol after primary and revision total knee arthroplasty. Between 1984 and 1993, there were 815 primary and revision total knee arthroplasties that received low-dose warfarin prophylaxis at our institution. The average time to attainment of the target level of anticoagulation was 3 days. The average duration of warfarin prophylaxis was 12 days. Overall, there were a total of three symptomatic pulmonary embolisms (0.3%; 95% confidence interval, 0.08%-1.1%). There were eight (1%) symptomatic deep vein thromboses (all distal). There were two deaths (0.3%), but neither one was secondary to a pulmonary embolism. Seventeen knees (2.5%) developed a hematoma after surgery, and two of these patients required drainage of the knee. Low-dose warfarin prophylaxis is safe and effective in preventing symptomatic pulmonary embolism after total knee arthroplasty.

Topics: Adult; Aged; Anticoagulants; Female; Humans; Knee Prosthesis; Postoperative Complications; Pulmonary Embolism; Warfarin

To evaluate the safety and efficacy of transition in practice after coronary stenting to antiplatelet therapy alone compared with anticoagulation with warfarin.. Retrospective analysis of coronary stent management in a tertiary Canadian centre.. A total of 136 consecutive patients (146 lesions) were analyzed who underwent Palmaz-Schatz coronary stenting over a 15-month period and were treated with anticoagulation with warfarin (56 patients) or antiplatelet therapy alone with ticlopidine and acetylsalicylic acid (80 patients) during the transition in poststenting therapy in the authors' practice. Treatment was continued for 30 days in both groups. High pressure stent deployment was used in the majority of cases (greater than 90%), and use of intravascular ultrasound was infrequent (less than 12%).. At 30 days, there were no clinical manifestations of stent thrombosis, coronary artery bypass surgery or repeat angioplasty in either group. One death occurred in the antiplatelet group. Periprocedural non-Q wave myocardial infarction occurred in two patients in the antiplatelet group and in one patient in the warfarin group. There was a significantly higher incidence of vascular complications in the warfarin group than in the antiplatelet group (14.3% versus 2.5%, respectively, P = 0.04). The length of hospital stay was significantly shorter in the antiplatelet group than in the warfarin group (3.0 +/- 1.8 versus 6.7 +/- 2.6 days, respectively, P < 0.001).. Reduced anticoagulation with antiplatelet therapy alone after coronary stenting, despite infrequent use of intravascular ultrasound, is an effective and safe strategy with a low rate of vascular complications, a relatively short hospital stay and a low incidence of clinical manifestations of stent thrombosis.

Topics: Adult; Aged; Aged, 80 and over; Angioplasty, Balloon, Coronary; Anticoagulants; Aspirin; Coronary Artery Bypass; Coronary Disease; Coronary Thrombosis; Female; Humans; Male; Middle Aged; Platelet Aggregation Inhibitors; Postoperative Complications; Radiography; Reoperation; Retrospective Studies; Stents; Ticlopidine; Treatment Outcome; Warfarin

Topics: Anticoagulants; Bandages; Humans; Postoperative Complications; Prospective Studies; Randomized Controlled Trials as Topic; Thromboembolism; Urologic Diseases; Warfarin

Since 1992, we have been performing VLAP using a right-angle laser delivery system (Urolase) for BPH patients with significant underlying nonurological diseases such as diabetes mellitus, cardiovascular, pulmonary, and malignant diseases. Sufficient clinical results have been obtained without major complications during short-term and long-term observation. In this study, we discuss the clinical advantages and safety of VLAP, compared with TURP, through analysis of the clinical procedure for VLAP for patients treated with anticoagulant agents such as warfarin. In our study of 40 patients, 8 patients were treated with anticoagulants for cardiovascular disease. During the procedure and after the operation, no significant complications were encountered except for transient postoperative bleeding. The 8 patients who received simultaneous anticoagulant therapy also underwent TURP to draw a comparison. The time taken for the procedure and the volume of the blood loss were significantly reduced by VLAP. The hemostatic nature of YAG laser energy seems to result in a technical improvement over conventional I URP for patients undergoing anticoagulant therapy.

Topics: Aged; Anticoagulants; Cardiovascular Diseases; Follow-Up Studies; Humans; Laser Therapy; Male; Postoperative Complications; Prostatic Hyperplasia; Transurethral Resection of Prostate; Treatment Outcome; Warfarin

Two patients experienced upper extremity thromboembolism after axillary-axillary bypass grafting (AxAG) for symptomatic subclavian artery stenosis. The first patient, a 67-year-old male, presented with left upper extremity thromboembolism 3 years after AxAG with 8 mm externally support PTFE. An arteriogram revealed a patent AxAG, thrombus in the proximal left subclavian arterial stump just distal to its occlusion, and multiple digital artery emboli. The patient was treated with warfarin for 8 months, with resolution of symptoms. The second patient, a 57-year-old male, occluded his AxAG (8 mm knitted Dacron) with minimal return of symptoms. Non-operative treatment was elected and 4 years later the patient presented with right upper extremity (donor side) thromboembolism. Arteriography revealed occlusion of the AxAG, radial artery, and digital arteries of the index, long and ring fingers. Thrombolytic therapy of the right arm was undertaken with minimal improvement. Subsequent detachment of the AxAG and placement of an interposition reversed saphenous vein graft was performed. Both patients continue to be asymptomatic during follow-up of 4.7 and 2.0 years, respectively.

Topics: Aged; Anticoagulants; Arm; Arterial Occlusive Diseases; Axillary Artery; Blood Vessel Prosthesis; Constriction, Pathologic; Embolism; Fingers; Follow-Up Studies; Graft Occlusion, Vascular; Humans; Male; Middle Aged; Polytetrafluoroethylene; Postoperative Complications; Radial Artery; Saphenous Vein; Subclavian Artery; Thromboembolism; Thrombolytic Therapy; Thrombosis; Warfarin

We reviewed anticoagulant related hemorrhage (ACRH) and thromboembolism (TE) in 84 patients after valvular surgery. There were 45 females and 39 males with a mean age of 51.8 years (range 30.5-71.2 years), who underwent valvuloplasty in 14, bioprosthetic valve replacements in 17, mechanical valve replacements in 13. A mean period from the operation to the event were 2.7 years (range 0.01-12.3 years). There were 25 ACRH events after one valvuloplasty, 4 bioprosthetic valve replacements, 20 mechanical valve replacements. About half of them, the prothrombin time were less than 25%, which was considered the effect of warfarin is high, and 8% of them had infective endocarditis (IE) previously. There were 59 TE events after 13 valvuloplasties, 13 bioprosthetic valve replacements, 33 mechanical valve replacements. In the patients with atrial fibrillation, TE occurred irrespective of operative procedures. And in the patients with mechanical valve, severely impaired left ventricular function and past history of IE, thrombi of left ventricule were caused of TE. It was suggested that past history of IE was a risk factor ACRH and TE, and severely depressed left ventricular function and atrial fibrillation were for TE.

Topics: Adult; Aged; Anticoagulants; Atrial Fibrillation; Bioprosthesis; Female; Heart Valve Diseases; Heart Valve Prosthesis; Hemorrhage; Humans; Male; Middle Aged; Postoperative Complications; Thromboembolism; Warfarin

Four hundred thirteen cemented total hip arthroplasties and 852 cemented total knee arthroplasties were evaluated prospectively for postoperative pulmonary embolism. Inclusion criteria were a diagnosis of osteoarthritis, age 50 to 75 years old, cemented primary arthroplasty, and prophylaxis with low-dose warfarin (Coumadin, DuPont Pharma, Wilmington, Delaware). All patients underwent a preoperative perfusion scan and postoperative ventilation perfusion scan with all moderate probability scans evaluated with arteriogram. The overall incidence of pulmonary embolism was 3.8% after cemented total hip arthroplasty and 5.6% after cemented total knee arthroplasty. Because of a weight bias, patient age, weight, and gender-matched comparison was performed. Two hundred eighty-two patients from each group were matched with identical age, weight, and gender. The incidence of postoperative pulmonary embolism was 4.3% for total hip arthroplasty and 4.6% for total knee arthroplasty. These results do not support the contention that pulmonary embolism is higher after total hip arthroplasty than after total knee arthroplasty.

Topics: Aged; Anticoagulants; Bone Cements; Dose-Response Relationship, Drug; Drug Administration Schedule; Female; Hip Prosthesis; Humans; Knee Prosthesis; Male; Middle Aged; Postoperative Complications; Prospective Studies; Pulmonary Embolism; Risk Factors; Warfarin

In this study 14 patients presented with 15 episodes of iliofemoral vein thrombosis after renal transplantation. Seven patients (group 1) had viable renal grafts and were treated with conventional anticoagulation. Eight patients (group 2) had non-viable renal grafts and were subjected to graft nephrectomy and simultaneous venous thrombectomy without anticoagulation. The patients in group 2 had rapid resolution of the signs and symptoms of the iliofemoral vein thrombosis, and noninvasive vascular investigation at follow-up revealed competent and patent deep veins in all patients. In contrast, only 50% of the patients in group 1 had normal venous studies at follow-up. We recommend that renal transplant recipients who develop iliofemoral vein thrombosis and nonviable allograft postoperatively should be subjected to venous thrombectomy at the time of graft nephrectomy.

Topics: Adolescent; Adult; Anticoagulants; Child; Female; Femoral Vein; Follow-Up Studies; Graft Rejection; Heparin; Humans; Iliac Vein; Kidney Transplantation; Male; Middle Aged; Nephrectomy; Postoperative Complications; Thrombectomy; Thrombosis; Treatment Outcome; Warfarin

Common indices for the quantal assessment of treatment efficacy are reviewed. The absolute risk reduction is a practical index for public health considerations. Its reciprocal has been termed the 'Number Needed to Treat' (NNT), representing the health effort that must on average be expended to accomplish one tangible treatment target. We extend the NNT to evaluate outcome combinations of treatment benefits versus treatment harms.. We describe the mathematical context of the NNT, and extend it to evaluate outcome combinations (treatment success/failure with/without treatment-induced adverse effects) in a treated population. These extensions are carried out assuming either independence or positive association between treatment benefit and treatment harm. A method is provided for calculating the standard errors of these extended NNT values. Applications to cost-effectiveness analysis are discussed.. We calculate NNT in three recent therapeutic studies. The results of a trial of the prevention of strokes with warfarin in patients with non-valvular atrial fibrillation are analysed to evaluate treatment success (stroke prevention) against treatment-induced bleeds. An NNT-related cost-benefit analysis is also carried out. We also analyse the results of a study of two modalities of chemotherapeutic treatment in small-cell lung cancer, and of two modalities of surgical intervention in the treatment of cholelithiasis.. The NNT are useful in direct evaluation of outcome-specific treatment benefits versus treatment-induced harms. They may also be used in cost-effectiveness analyses and are helpful in guiding public health programmes towards the identification of optimal treatment strategies.

Topics: Anticoagulants; Antineoplastic Combined Chemotherapy Protocols; Atrial Fibrillation; Carcinoma, Small Cell; Cerebral Hemorrhage; Cerebrovascular Disorders; Cholecystectomy; Clinical Protocols; Cost-Benefit Analysis; Decision Support Techniques; Evaluation Studies as Topic; Health Care Costs; Humans; Models, Theoretical; Postoperative Complications; Quality-Adjusted Life Years; Sweden; Therapeutics; Treatment Failure; Treatment Outcome; Warfarin

The efficacy of intermittent pneumatic compression in the prevention of proximal deep venous thrombosis was determined in a consecutive series of patients who had primary or revision total hip replacement. Two hundred and eighty-nine patients (242 primary and eighty revision hip replacements) who were at least forty years old were managed intraoperatively and postoperatively with intermittent pneumatic compression with use of thigh-high sequential compression sleeves and thigh-high elastic compression stockings as the only form of prophylaxis. Venous ultrasonography of the ipsilateral lower extremity was performed, at an average of five days postoperatively, to determine the presence of a thrombus in the femoral and popliteal veins. The prevalence of proximal deep venous thrombosis was 6 per cent (twenty of 322 procedures), and no patient had a clinically detected pulmonary embolism. The prevalence of a proximal thrombus was 4 per cent (ten of 233 procedures) when a regional anesthetic had been used and 11 per cent (ten of eighty-nine procedures) when a general anesthetic had been used; this difference was significant (p = 0.02). The prevalence of a proximal thrombus was 3 per cent (eight of 245 procedures) for patients who were less than seventy-five years old and 16 per cent (twelve of seventy-seven procedures) for patients who were seventy-five years old or more (p < 0.0001). No patient had a major bleeding complication. Twenty-nine other patients who had an additional risk factor for thrombosis, such as a history of deep venous thrombosis, were managed with intermittent pneumatic compression and low-dose warfarin. The prevalence of proximal deep venous thrombosis in this group of patients was 19 per cent (six of thirty-one procedures). Intraoperative and postoperative intermittent pneumatic compression, combined with the use of a regional anesthetic, was found to be highly effective in the prevention of proximal deep venous thrombosis after total hip replacement. Despite the limitations inherent in comparisons among series, it is noteworthy that the prevalence of proximal thrombosis in our series was similar to the reported prevalences in several large series of patients who had a total hip replacement and were managed with either low-dose warfarin or low-molecular-weight heparin. However, there was no risk of major postoperative bleeding in the current study.

Topics: Adult; Aged; Aged, 80 and over; Bandages; Female; Hip Prosthesis; Humans; Intraoperative Care; Leg; Male; Middle Aged; Postoperative Care; Postoperative Complications; Prospective Studies; Risk Factors; Thrombophlebitis; Ultrasonography; Warfarin

Topics: Aged; Anticoagulants; Cardiac Output, Low; Female; Gastrointestinal Hemorrhage; Hematoma; Hip Prosthesis; Humans; Malpractice; Postoperative Complications; Retroperitoneal Space; Risk Management; Warfarin

To study the influence of preoperative warfarin anticoagulation on postoperative blood loss and allogeneic blood requirement.. Retrospective study with a matched control group.. University and community hospital, single institutional.. 240 patients scheduled for cardiac surgery.. Warfarin sodium was administered to 125 patients preoperatively to prevent thromboembolic complications of their underlying heart disease, 115 served as control. Approximately half of the patients in each group received aprotinin treatment during operation.. The international normalized ratio (INR) of the prothrombin time was preoperatively 2.4 (95% confidence interval [CI 0.95]: 2.3 to 2.6) in the warfarin group and 1.1 (CI 0.95: 1.0 to 1.1) in the control group (p < 0.05), and postoperatively 1.9 (CI 0.95: 1.8 to 2.1) (warfarin) and 1.5 (CI 0.95: 1.4 to 1.5) (control) (p < 0.05). The postoperative blood loss after 6 and 12 hours was 381 (CI 0.95: 329 to 434)/505 (CI 0.95: 439 to 571) mL (warfarin) compared with 472 (CI 0.95: 403 to 541)/612 (CI 0.95: 527 to 697) mL (control) (p < 0.05). This difference was blunted when the proteinase inhibitor aprotinin was used. Neither preoperative nor postoperative prothrombin time correlated with blood loss. Despite lower heparin consumption the activated coagulation time (ACT) during CPB was significantly prolonged in the warfarin group.. Warfarin pretreatment does not lead to increased bleeding but may even have a beneficial anticoagulant effect that may lead to better preserved postoperative hemostasis and reduced blood loss.

Topics: Aprotinin; Blood Loss, Surgical; Blood Transfusion; Cardiac Surgical Procedures; Cardiopulmonary Bypass; Case-Control Studies; Confidence Intervals; Female; Hemorrhage; Hemostasis, Surgical; Heparin; Humans; Male; Middle Aged; Postoperative Complications; Premedication; Prothrombin Time; Retrospective Studies; Thromboembolism; Warfarin; Whole Blood Coagulation Time

Tricuspid valve replacement is not a common operation. The purpose of this study was to examine the early and late results in 60 patients who underwent 28 (47%) bioprosthetic and 32 (53%) mechanical tricuspid valve replacements. All operations took place between January 1978 and June 1993 during which period a total of 4741 patients underwent valve replacement operation. Mean patient age was 50 +/- 15 (18 to 75) years. Forty-one patients (68%) were female and 19 patients (32%) were male. Forty-nine patients (82%) were in New York Heart Association class III or IV before operation. Forty-five patients (75%) were undergoing repeat cardiac valve operation. Seventeen patients (28%) had complex congenital cardiac problems. Operation was urgent in 15 patients (25%). The hospital mortality rate was 27% (16 patients). All patients with hospital death were in New York Heart Association class III or IV, were having repeat operations, or had complex congenital disease. Low output syndrome was observed in 21 patients (35%). Reoperation because of bleeding was required in seven patients (12%). Thirteen patients (22%) required permanent (epicardial lead) pacemaker implantation. Mean follow-up is 75 +/- 45 months (maximum 173 months) and 100% complete for the 44 patients who left the hospital. There have been 14 deaths (32%). Nine of these patients (64%) had mechanical valves and five (36%) had bioprostheses. Of the 11 cardiac deaths, three were valve related (bioprostheses). Three patients (10%) required reoperation because of tricuspid valve prosthetic failure (1 thrombosed mechanical valve, 2 failed porcine valves). Of the remaining 30 patients, 20 (67%) are in New York Heart Association class I or II. Seventeen patients have mechanical valves and 13 have bioprostheses. Twenty-six patients (90%) are receiving warfarin. Thromboembolism (transient ischemic attack) has occurred in one patient with a mechanical valve who also had a previous cerebrovascular accident. In this group there has been no hemorrhage, endocarditis, or new pacemaker requirement. Actuarial survival for the whole series is 37% +/- 9% and for the hospital survivors is 50% +/- 12% at 15 years. Linearized rates of valve-related complications are not different between groups. Tricuspid valve replacement is a beneficial procedure for patients with structural tricuspid valve disease, many of whom have other valvular or congenital disease. Contemporary mechanical prostheses and bioprostheses are equally ef

Topics: Bioprosthesis; Female; Follow-Up Studies; Heart Valve Prosthesis; Hospital Mortality; Humans; Life Tables; Male; Middle Aged; Postoperative Complications; Prosthesis Design; Registries; Reoperation; Time Factors; Tricuspid Valve; Tricuspid Valve Insufficiency; Tricuspid Valve Stenosis; Warfarin

Thromboembolic phenomena involving the caval veins, right atrium, and pulmonary artery are recognised complications after the Fontan operation and other forms of total cavopulmonary connection. A rare case of systemic thromboembolism is reported in a 3 year old girl who had repeated coronary and cerebral thromboembolic events after a fenestrated total cavopulmonary shunt operation. A survey of the 18 paediatric cardiac units in the United Kingdom and Ireland showed a wide discrepancy in anticoagulation policies after Fontan-type operations. Prevention of thrombotic complications by lifelong postoperative anticoagulation may outweigh the risk of haemorrhage.

Topics: Aspirin; Cerebrovascular Disorders; Child, Preschool; Drug Administration Schedule; Female; Fontan Procedure; Humans; Myocardial Infarction; Postoperative Complications; Thromboembolism; Warfarin

Topics: Hip Prosthesis; Humans; Postoperative Complications; Thromboembolism; Warfarin

As many as two thirds of patients with new symptoms after documented DVT have postphlebitic syndrome, not DVT. Noninvasive imaging is central to the differentiation so that unnecessary anticoagulation therapy can be avoided. Recent changes in heparin and warfarin protocols for DVT are also outlined.

Topics: Bandages; Drug Therapy, Combination; Heparin; Humans; Male; Middle Aged; Popliteal Vein; Postoperative Complications; Postphlebitic Syndrome; Recurrence; Risk Factors; Thrombosis; Time Factors; Warfarin

We studied the rate of thromboembolism in patients undergoing bioprosthetic replacement of the aortic or mitral valve, or both, at serial intervals after operation and the effects of anticoagulant or antiplatelet treatment and risk factors.. Thromboembolism appears to occur early after operation, but the incidence, timing and risk factors for thromboembolism and the role, timing, adequacy, effectiveness, duration and risk of anticoagulation and antiplatelet agents are uncertain.. The rate of thromboembolism was studied at three time intervals after operation (1 to 10, 11 to 90 and > 90 days) in 816 patients who underwent bioprosthetic replacement of the aortic or mitral valve, or both, at the Mayo Clinic from January 1975 to December 1982. The effect of antithrombotic therapy (warfarin, aspirin or dipyridamole, alone or in combination) was evaluated.. Median follow-up of surviving patients was 8.6 years. The rate of thromboembolism (%/year) decreased significantly (p < 0.01) at each time interval after operation (1 to 10, 11 to 90 and > 90 days) for mitral valve replacement (55%, 10% and 2.4%/year, respectively) and over the first time interval for aortic valve replacement (41%, 3.6% and 1.9%/year, respectively). During the first 10 days, 52% to 70% of prothrombin time ratios were low (< 1.5 x control). Patients with mitral valve replacement who received anticoagulation had a lower rate of thromboembolism for the entire follow-up period (2.5%/year with vs. 3.9%/year without anticoagulation, p = 0.05). Of 112 patients with a first thromboembolic episode, permanent disability occurred in 38% and death in 4%. Risk factors for emboli were lack of anticoagulation, mitral valve location, history of thromboembolism and increasing age. Only 10% of aortic, 44% of mitral and 17% of double valve recipients had anticoagulation at the time of an event. Patients with bleeding episodes (2.3%/year) were older and usually underwent anticoagulation. Blood transfusions were required in 60 of 111 patients (1.2%/year), and 13 patients (0.3%/year) died.. Thromboembolic risk was especially high for aortic and mitral valve replacement for 90 days after operation, and overall was increased with lack of anticoagulation, mitral valve location, previous thromboembolism and increasing age. Anticoagulation reduced thromboemboli and appears to be indicated in all patients as early as possible for 3 months and thereafter in those with risk factors, but needs prospective testing.

Topics: Adult; Age Factors; Aged; Aortic Valve; Aspirin; Bioprosthesis; Dipyridamole; Female; Follow-Up Studies; Heart Valve Prosthesis; Hemorrhage; Humans; Incidence; Male; Middle Aged; Mitral Valve; Postoperative Complications; Proportional Hazards Models; Risk Factors; Survival Analysis; Thromboembolism; Time Factors; Warfarin

Congenital deficiency of antithrombin III (AT III) is the only inherited hypercoagulable disorder for which a concentrate of purified protein is available for replacement therapy during periods of increased thrombotic risk. This report describes how such concentrates have been used in a patient with congenital AT-III deficiency undergoing venous surgery. A 40-year-old woman with AT III deficiency was evaluated for bilateral grade 3 chronic venous insufficiency. Noninvasive venous assessment and ascending venography revealed incompetence of the lower leg perforators, a patent deep venous system, and competent greater and lesser saphenous veins. Staged subfascial ligations were performed. Pasteurized AT III was administered 1 hour before surgery and at 30 hours at a dose calculated to increase AT-III activity to at least 120%. Perioperative AT III activity levels were measured. Subcutaneous heparin and oral warfarin were initiated the evening of surgery. An infusion of AT III increased plasma AT III from the baseline activity of 51% to 180%; it was 87% 13 hours later. Two measurements of the initial half-life of AT III were 7 and 14 hours. No perioperative thrombotic complications occurred. The ulcers healed, and the patient remains symptom free. Pasteurized AT III concentrates are now commercially available, easily administered, and provide a useful adjunct to the anticoagulation regimen of patients with AT III deficiency undergoing vascular surgery.

Topics: Adult; Antithrombin III; Antithrombin III Deficiency; Female; Heparin; Humans; Intraoperative Complications; Postoperative Care; Postoperative Complications; Preoperative Care; Risk Factors; Thrombosis; Vascular Surgical Procedures; Venous Insufficiency; Warfarin

Topics: Anticoagulants; Heparin; Humans; Male; Osteitis; Postoperative Complications; Prostatectomy; Pubic Symphysis; Warfarin

All patients (285) undergoing mitral valve replacement (MVR) with a Carpentier-Edwards (C-E) bioprosthesis +/- coronary bypass grafts (CABG) were reviewed (109 men and 176 women with a median age of 70 years). Overall, the 5-year survival rate was 58.9%, 62.7% for MVR (199 patients) and 50.1% for MVR+CABG (86 patients). Late survival was adversely affected by the operative time variables of NYHA class IV, older (> or = 70 years) age, low (> or = 56%) ejection fraction (EF), and the additional performance of associated procedures+CABG with MVR (P < or = 0.001). The 5-year freedom from stroke rate was 89.2%, 89.1% for MVR and 90.2% for MVR +/- CABG. Advanced heart class was the only significant variable associated with a greater risk of late stroke (P < or = 0.01). Neither chronic preoperative atrial fibrillation nor operative obliteration of the left atrial appendage increased or decreased the late risk of stroke in patients following MVR. Hazard function for stroke occurring in the first postoperative year (first 48 h excluded to discount intraoperative events) demonstrated the highest rate within the first month (40%), rapidly diminishing thereafter. This pattern was reproduced in the 12-year hazard function in that the rate of stroke occurrence was greatest in the first year (6.7%) following implantation. The mean stroke rate over 12 years was 2.5%. Strokes following MVR +/- CABG are more likely to occur in older and more compromised patients, and the higher early rate is not reflected in the mean rate. A more aggressive approach to early anticoagulation with IV heparin, Coumadin, and possibly antiplatelet therapy is advocated to reduce this complication rate.

Topics: Adolescent; Adult; Age Factors; Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Bioprosthesis; Cerebrovascular Disorders; Child; Child, Preschool; Chronic Disease; Cohort Studies; Coronary Artery Bypass; Disease-Free Survival; Female; Follow-Up Studies; Heart Diseases; Heart Valve Prosthesis; Heparin; Humans; Intraoperative Complications; Male; Middle Aged; Mitral Valve; Platelet Aggregation Inhibitors; Postoperative Complications; Proportional Hazards Models; Retrospective Studies; Risk Factors; Stroke Volume; Survival Rate; Warfarin

In 14 patients aged 5-329 (mean 131) months a CarboMedics valve was implanted because of congenital heart disease. The preoperative NYHA function class was III-IV in ten cases. Seven aortic and seven atrioventricular valves were replaced without early mortality. All patients were followed up, with mean observation time 27 months (total 384 months). One of the 14 patients died of heart failure 10 months postoperatively. Thrombosis occurred in four valves, three in tricuspid and one in mitral position. In all patients who received only warfarin, anticoagulation was demonstrably inadequate. Consequently we now recommend antiplatelet medication in addition to warfarin for children with atrioventricular mechanical valve replacement. In our experience the complication rate with CarboMedics prosthesis is acceptable, provided that anticoagulant therapy is adequate.

Topics: Aortic Valve; Aspirin; Child; Dipyridamole; Female; Follow-Up Studies; Heart Defects, Congenital; Heart Valve Prosthesis; Humans; Male; Mitral Valve; Postoperative Complications; Prosthesis Design; Thrombosis; Time Factors; Tricuspid Valve; Warfarin

Topics: Enoxaparin; Humans; Postoperative Complications; Thromboembolism; Thrombophlebitis; Warfarin

Low molecular weight heparins are providing a new prophylactic option for preventing deep vein thrombosis (DVT) in patients undergoing joint replacement surgery. Fragmentation of heparin in laboratory studies revealed differences in coagulation and bleeding factors. This unexpected finding led to clinical trials, starting in 1985 in Europe and the United States. By late 1993, more than 10,000 patients had been admitted to clinical trials of low molecular weight heparins (LMWH) for prevention of DVT. Results of these trials indicated that LMWHs were more effective than unfractionated heparins or warfarin in preventing DVT with no significant increase in bleeding noted.

Topics: Clinical Trials as Topic; Enoxaparin; Heparin, Low-Molecular-Weight; Hip Prosthesis; Humans; Knee Prosthesis; Postoperative Complications; Thromboembolism; Warfarin

In 12 patients with sinus rhythm (including 5 children and 6 young women), mitral valve replacement was performed with a microporous-surfaced valve similar to the Björk-Shiley Monostrut. After the first 3 months, permitting endothelialization of the suture ring to continue over the groove and adjacent metal valve ring, no long-term anticoagulant treatment was given. There was no thromboembolic complication in this group during follow-up for 6-8 years, during which four women gave birth to a total of seven children. In eight other cases, one mitral case with atrial fibrillation, anti-coagulant was not discontinued, and in the remaining aortic cases it was reinstituted. One of them (with atrial fibrillation) had hematuria during inadequate anticoagulant medication, but no thromboembolism. Of five patients with only aortic valve replacement, two had thromboembolic complications, one without residual symptoms and one with slight hand weakness. Another had a transient ischemic attack while on anticoagulant and acetylsalicylic acid was added. Two patients with aortic and mitral valve replacement died, one from heart tamponade and the other from venous thrombosis with pulmonary embolism.

Topics: Adolescent; Adult; Anticoagulants; Child; Female; Follow-Up Studies; Heart Valve Diseases; Heart Valve Prosthesis; Heparin; Humans; Male; Mitral Valve; Pilot Projects; Postoperative Complications; Prosthesis Design; Thromboembolism; Treatment Outcome; Warfarin

Stents rarely thrombose in the first 24 hours after implantation; secondly, heparin has some influence on the extrinsic pathway. Additionally, if too much heparin is present it interferes with the INR, and the half life of prothrombin suggests that the patient should be anticoagulated with heparin for up to 96 hours after starting warfarin. This is the evidence on which our standard protocol is based.

Topics: Anticoagulants; Aspirin; Blood Coagulation Tests; Clinical Protocols; Coronary Disease; Drug Administration Schedule; Heparin; Humans; Postoperative Care; Postoperative Complications; Stents; Thrombosis; Warfarin

We experienced two patients with a prosthetic heart valve, who underwent hepatic resection for hepatoma while on anticoagulation therapy. Patients with a prosthetic heart valve have the following characteristics; an increased risk of thromboembolism due to diminished anticoagulation in the perioperative period, a greater risk of endocarditis due to the artificial material in the heart, and impaired cardiopulmonary function including possible arrhythmia and heart failure. Furthermore, when such patients also have liver cirrhosis with a hepatoma, there is an increased risk of perioperative bleeding while on anticoagulation due to coagulopathy and also a risk of infection due to decreased cellular immunity. Patients with a prosthetic heart valve therefore require special care and attention whenever they have to undergo hepatic resection. With respect to anticoagulation, a minimal level is required to prevent bleeding and thromboembolism. Warfarin being administered preoperatively may be switched to heparin while closely monitoring the activated clotting time (biomaterial valve: 130-150 sec, non-biomaterial valve: 150-180 sec); the heparin should then be changed back to warfarin immediately after starting oral intake following operation. For the prevention of infection, a broad spectrum antibiotic should be used prophylactically both intra-operatively and postoperatively. The cardiopulmonary function must also be carefully monitored. For the assessment of postoperative liver function, lecithin: cholesterol acyltransferase, serum bilirubin and albumin are useful because there is no relevance of coagulation parameters such as prothrombin time under anticoagulation.

Topics: Carcinoma, Hepatocellular; Clinical Protocols; Combined Modality Therapy; Heart Valve Diseases; Heart Valve Prosthesis; Heparin; Hepatectomy; Humans; Liver Neoplasms; Male; Middle Aged; Mitral Valve; Postoperative Complications; Preoperative Care; Treatment Outcome; Tricuspid Valve; Warfarin

We analyzed the long-term results of valve replacement with the St. Jude Medical bileaflet valve (St. Jude Medical, Inc., St. Paul, Minn.) in our first 1000 implantations between 1978 and 1992. A total of 399 patients had mitral valve replacement, 471 aortic valve, and 130 double (mitral and aortic) valve replacement. The average patient age was 64 +/- 15 years and the majority of patients (52%) had concomitant coronary disease. With 4328 patient-years of follow-up, 83% of the mitral group, 76% of the aortic group, and 77% of the double valve group were free of thromboembolism at 10 years after operation, and 87% of the mitral group, 82% of the aortic group, and 85% of the double valve group were free of valve-related hemorrhage. At 10 years, 91% of the mitral group, 84% of the aortic group, and 84% of the double valve group were free of valve-related death. However, overall survival at 10 years was only 42% +/- 4% for the mitral group, 43% +/- 4% for the aortic group, and 43% +/- 6% for the double valve group. For all three groups, age was a highly significant factor stratifying survival (p < 0.001), as was the presence of coronary disease (all p < 0.001). The excellent freedom from valve-related death at 10 years of 84% to 91% is in striking contrast to the overall survivals of 42% to 43% at 10 years. This difference suggests that the primary factors limiting long-term survival after valve replacement with the St. Jude Medical valve are not valve-related factors, but other patient factors such as age and concomitant coronary disease.

Topics: Aged; Aortic Valve; Female; Follow-Up Studies; Heart Valve Prosthesis; Hospital Mortality; Humans; Los Angeles; Male; Middle Aged; Mitral Valve; Postoperative Complications; Prosthesis Design; Reoperation; Treatment Outcome; Warfarin

Coumadin, a long-acting antagonist of Vitamin K-dependent clotting factors, is commonly used for prevention of thromboembolism and potentially lethal clotting of mechanical heart valves. When patients require surgery for subsequent problems, inadequate perioperative management of coagulation may result in hemorrhage or thrombosis. Reversal with Vitamin K makes subsequent anticoagulation therapy difficult, and normalization of coagulation with fresh frozen plasma exposes the patient to the risk of fatal valvular thrombosis. In addition, third party payers and governmental reimbursement policies discourage most, if not all, preoperative hospitalization. Twenty-one patients on chronic Coumadin therapy required surgery for diseases unrelated to their original need for anticoagulation. Seven patients had hemorrhagic complications, and 14 did not. In these two groups, sex, current operation, reason for anticoagulation, other drugs, admitting CBC, and platelet count were similar. Preoperative hospital days averaged 5.2 days in both groups. Statistically significant differences were noted in age, preoperative Coumadin dose, admitting prothrombin times, and postoperative stays (P = 0.05). Although the perioperative prothrombin times, partial thromboplastin times, and perioperative heparin doses were similar, more patients in the bleeding group were operated with a prothrombin time > 13.0 seconds. The current evolved protocol is to discontinue Coumadin 5 days before surgery, and begin intravenous heparin @ 1000 u/hr with adjustment to keep partial thromboplastin times at therapeutic levels. Heparin is stopped early on the morning of surgery and restarted at 200-400 units/hr at 4 to 6 hours after surgery. Coumadin is restarted as soon as the patient can tolerate it. It is considered safe to operate only when the prothrombin time is less than 13 seconds.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Adult; Aged; Female; Heart Valve Diseases; Hemorrhage; Heparin; Humans; Infusions, Intravenous; Length of Stay; Male; Middle Aged; Partial Thromboplastin Time; Patient Admission; Postoperative Complications; Preoperative Care; Prothrombin Time; Retrospective Studies; Surgical Procedures, Operative; Thromboembolism; Thrombosis; Warfarin

Topics: Aspirin; Coronary Artery Bypass; Graft Occlusion, Vascular; Humans; Postoperative Complications; Time Factors; Warfarin

In a prospective nonrandomized study, a protocol was examined for prophylaxis of deep venous thrombosis and pulmonary embolism in patients with operative treatment of acetabular and pelvic fractures. There were 197 patients in the study with 203 fractures, including 148 acetabular and 55 pelvic fractures. There were 2 cases of bilateral acetabular fractures and 4 cases with both acetabular and pelvic fractures. The protocol involved preoperative noninvasive screening of the lower extremities, intraoperative and postoperative use of mechanical antithrombotic devices, and chemical prophylaxis with warfarin for 3 weeks following removal of surgical drains. There were 11 cases (6%) of preoperative deep venous thrombosis detected. There were 6 cases of postoperative deep venous thrombosis and 2 cases of pulmonary embolism. The incidence of postoperative venous thrombosis and pulmonary embolism was 3% and 1%, respectively. The protocol was found to be effective for preoperative detection of venous thrombosis and prevention of deep venous thrombosis and pulmonary embolism in trauma patients with minimal bleeding complications and no morbidity from embolic disease.

Topics: Acetabulum; Adolescent; Adult; Aged; Aged, 80 and over; Bandages; Child; Female; Fracture Fixation, Internal; Fractures, Bone; Humans; Male; Middle Aged; Pelvic Bones; Postoperative Complications; Postoperative Period; Preoperative Care; Pressure; Prospective Studies; Pulmonary Embolism; Thrombosis; Ultrasonography; Warfarin

Protein S is an antithrombotic plasma protein that serves as a cofactor for another plasma protein, activated protein C. Patients who express a deficiency of protein S have an increased propensity to experience thromboembolic events. These events are often precipitated by factors that may cause thrombosis in nondeficient individuals, particularly in cases of trauma, pregnancy, or surgery. Anticoagulation therapy was instituted in a 45-year-old woman with known protein S deficiency and bilateral total hip arthroplasties.

Topics: Female; Heparin; Hip Prosthesis; Humans; Middle Aged; Osteoarthritis, Hip; Plasma; Postoperative Complications; Protein S; Protein S Deficiency; Thromboembolism; Thrombosis; Warfarin

This study aimed at elucidating the role of anticoagulation in the genesis of late pericardial effusion and tamponade after cardiac surgery. Using serial 2-D echocardiography, 141 patients undergoing surgery for coronary artery bypass (56), valvular (69) or congenital (16) [corrected] heart disease were studied postoperatively. Group 1 (74 patients) received full anticoagulation (warfarin 73; heparin 1) and group 2 (67 patients) received either antithrombotic agents (aspirin plus dipyridamole), or no treatment. Fifty percent (70/141) of patients developed effusion. There was no significant difference between the two groups in the incidence of either effusion in general (43/74; 58% vs 27/67; 40%, respectively) or small or medium sized effusion. However, a large effusion was significantly more common in group 1 than in group 2 (32% vs 4%, P < 0.005). Twelve patients (12/141; 8.5%) developed late tamponade, 7 to 33 (15 +/- 7.3 mean +/- SD) days after surgery. All had a large effusion demonstrated by echo, drained by pericardiocentesis, and none died. All 12 patients with tamponade belonged to group 1 (P < 0.001). Excess anticoagulation was detected at least once in 41 of the 74 group 1 patients (55%). When compared to properly anticoagulated patients, excessively anticoagulated patients had a similar overall incidence of effusion and a similar incidence of small or moderate effusion, but a higher incidence of large effusion (18% vs 44%, [corrected] P < 0.05) and tamponade (3% vs 27%, P < 0.025). We conclude that, unlike small or medium-sized effusions, large pericardial effusions and tamponade are more likely to occur among anticoagulated patients, especially if they are excessively anticoagulated.

Topics: Adult; Anticoagulants; Aspirin; Cardiac Surgical Procedures; Cardiac Tamponade; Coronary Artery Bypass; Dipyridamole; Echocardiography; Female; Heart Defects, Congenital; Heart Valves; Heparin; Humans; Male; Pericardial Effusion; Postoperative Complications; Warfarin

Splenic, portal, or mesenteric venous thrombosis after splenectomy for hematologic disease has not been reported in the pediatric literature. It is a rare complication associated with significant morbidity and mortality in adult reports. Between 1981 and 1991, 3 patients (13-year-old boy with hereditary elliptocytosis [HE], 13-year-old boy with thalassemia intermedia [TI], and 18-year-old girl with idiopathic thrombocytopenic purpura [ITP]) presented with abdominal pain, nausea, with or without fever, at 4, 11, and 13 days postsplenectomy, respectively. Abdominal Doppler ultrasound (US) and/or computed tomography (CT) showed: (1) an intraluminal filling defect with partial obstruction to flow in the right branch of the portal vein with the remaining vessels patent (HE); (2) splenic vein thrombosis with complete occlusion of the main portal vein and proximal superior mesenteric vein (TI); and (3) complete thrombosis of the splenic vein, proximal superior mesenteric vein and portal vein (including central radicles), with retrogastric collateralization (ITP). Subsequent imaging showed either complete resolution of vascular obstruction on no treatment (patient 1), or portal venous cavernomatous transformation with hepatofugal flow after 6 months of systemic anticoagulation (patients 2 and 3), and all 3 patients are currently asymptomatic. Postoperative sonographic evaluation of a consecutive series of pediatric splenectomies for hematologic disease (n = 16), was performed at a median of 51 days (range, 3 to 124). This demonstrated one case of asymptomatic left portal venous thrombosis with subsequent recanalization in the absence of treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Adolescent; Child; Female; Hematologic Diseases; Heparin; Humans; Male; Portal Vein; Postoperative Complications; Splenectomy; Thrombosis; Ultrasonics; Ultrasonography; Warfarin

The efficacy and safety of routine use of adjusted low-dose warfarin for twelve weeks--without sonography or venography--for the prophylaxis of deep-vein thrombosis after total hip replacement was assessed in 268 patients (134 men and 134 women) who were between the ages of forty and eighty-five years (average, sixty-one years). The patients were given warfarin orally both before and after the operation. The initial dose was usually ten milligrams on the night before the operation and five milligrams on the night after the operation. Thereafter, the dose was adjusted to keep the prothrombin time between fourteen and sixteen seconds. The control time was ten to twelve seconds. The partial thromboplastin time was also measured, and the dose of warfarin was reduced if the value was more than fifty seconds. All 268 patients continued to take low-dose warfarin for twelve weeks after the operation. There were 170 primary and ninety-eight revisional total hip-replacement operations. Thirty-four patients (13 per cent) had a history of thromboembolic disease or venous stasis in a lower limb. Neither phlebography nor sonography was done routinely. All of the patients were followed for six months after the operation. There were no fatal pulmonary emboli during the period of the study and no known pulmonary emboli after any patient was discharged from the hospital. Two non-fatal pulmonary emboli were identified, both during hospitalization. Ten patients (4 per cent) had an episode of major bleeding--a wound hematoma in nine and a gastrointestinal hemorrhage in one--during hospitalization.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Adult; Aged; Aged, 80 and over; Female; Hemorrhage; Hip Prosthesis; Humans; Male; Middle Aged; Partial Thromboplastin Time; Postoperative Complications; Prospective Studies; Prothrombin Time; Pulmonary Embolism; Thrombophlebitis; Warfarin

Topics: Aged; Female; Fracture Fixation, Internal; Hip Fractures; Humans; Necrosis; Postoperative Complications; Skin; Thromboembolism; Warfarin

Between February 1984 and December 1990, 622 St. Jude Medical valves were implanted in 548 patients. There were 382 males (69.7%) and 166 females (30.3%) with a mean age of 32.3 +/- 11.9 years (range 9-68 years). Sixty-eight percent of the patients were referred from rural areas. Three hundred and forty patients underwent aortic valve replacement (AVR), 134 had mitral valve replacement (MVR), and 74 had aortic and mitral valve replacement (DVR). The hospital mortality was 4.7% (16/340) for AVR, 6.7% (9/134) for MVR and 10.8% (8/74) for DVR. Follow-up period ranged from 1.1 to 7.2 years. Total follow-up was 1317.3 patient-years (py). All patients received 2.5 mg warfarin, 225 mg dipyridamole, and 250 mg aspirin daily, regardless of prothrombin time and cardiac rhythm. Thromboembolism was observed in 10 patients (0.75 py); there were 3 mortalities (0.22% py). Valve thrombosis occurred in 4 patients (0.30% py): 3 in the MVR group (0.94% py) and 1 in the AVR group (0.11% py). Hemorrhage occurred in 19 patients (1.44% py) with 11 fatal outcomes (0.83% py). It is concluded that a random daily dose of 2.5 mg warfarin with 225 mg dipyridamole and 250 mg aspirin is sufficient for safe anticoagulation without the need for serial prothrombin-time adjustments.

Topics: Adolescent; Adult; Aged; Anticoagulants; Aortic Valve; Aspirin; Child; Dipyridamole; Drug Therapy, Combination; Female; Follow-Up Studies; Heart Valve Prosthesis; Hospital Mortality; Humans; Male; Middle Aged; Mitral Valve; Postoperative Care; Postoperative Complications; Prosthesis Design; Turkey; Warfarin

Two patients who were initially treated for an infection as a cause for their swollen stump were subsequently found to have deep venous thrombosis. The diagnosis was made noninvasively by compressive ultrasound (CU) scanning. DVT should be considered in the different diagnosis of stump swelling in the otherwise stable, post-rehabilitated lower extremity amputee patient.

Topics: Amputation Stumps; Diagnosis, Differential; Female; Heparin; Humans; Male; Middle Aged; Postoperative Complications; Thrombophlebitis; Ultrasonography; Warfarin

The incidence of pulmonary embolism (PE) in osteoarthritic patients prophylaxed with low-dose coumadin after cemented total knee arthroplasty (TKA) was investigated prospectively. Each patient had a preoperative perfusion scan and a ventilation-perfusion scan on the seventh postoperative day. Pulmonary embolism was diagnosed by a high probability ventilation-perfusion scan or positive arteriogram. Patients with a moderate probability scan had an arteriogram to rule out PE. Pulmonary embolus was identified in 48 (5.6%) of 852 TKAs in 755 patients. Of these, six (0.7%) were symptomatic, and no fatal PE was identified. Age, gender, and weight did not show statistical differences comparing the PE and non-PE groups, nor did the incidences of previous PE, contralateral phlebitis, malignancy, and diabetes. A history of ipsilateral phlebitis increased the risk of PE from 5.2% to 13%, and a history of cardiac disease decreased the risk from 7.8% to 4.2%. Type of anesthesia, blood loss, tourniquet time, and prosthesis type were not significant factors. With the exception of previous contralateral phlebitis, traditional risk factors for PE were not found to increase risk of PE with low-dose coumadin prophylaxis. Spinal anesthesia that has been shown to be protective in total hip surgery was not a significant factor in this study.

Topics: Aged; Angiography; Female; Humans; Incidence; Knee Prosthesis; Male; Middle Aged; Postoperative Complications; Pulmonary Embolism; Risk Factors; Ventilation-Perfusion Ratio; Warfarin

Topics: Aged; Female; Hip Prosthesis; Humans; Necrosis; Osteoarthritis, Hip; Postoperative Complications; Skin; Warfarin

Valve replacement in children has always been associated with a high mortality, outgrowth of the prosthetic valve and difficulty in managing anticoagulation. Between January 1985 and April 1991, 20 patients (14 males and 6 females) underwent replacement of a left-sided cardiac valve. The median age at diagnosis was 21.6 months (1 to 120 months) and the median age at surgery was 85 months (11 to 213 months). Six patients were under 4 years of age. The site of valve replacement was aortic in 11 patients and left atrioventricular (AV) valve in 9 patients. The indications for aortic valve replacement were stenosis (6) and incompetence (5). The left AV valve was replaced in three patients following repair of AV septal defect, in one patient with corrected transposition of the great arteries (LTGA), in one patient with severe dysplasia and insufficiency, and in four patients for congenital mitral stenosis. A Bjork-Shiley prosthesis was used in three mitral and one aortic position, all the other patients receiving a St. Jude prosthesis: six mitral and ten aortic. All patients were anticoagulated (warfarin) for 3 months post implantation and then switched to a regimen of aspirin and persantine. There was no early or late death. Median follow-up was 12.3 months (4 to 72 months). Total follow-up was 59 patient-years or 708 months. There was one incident of thromboembolism (1.7%/patient-year) and four instances of bleeding (6.8%/patient-year). There was no valve thrombosis. Our regime of early warfarin followed by long-term antiplatelet therapy has been associated with a low incidence of thromboembolism and no valve thrombosis.

Topics: Adolescent; Aortic Valve; Aspirin; Child; Child, Preschool; Dipyridamole; Female; Follow-Up Studies; Heart Valve Prosthesis; Hemorrhage; Humans; Infant; Male; Mitral Valve; Patient Compliance; Postoperative Complications; Retrospective Studies; Thromboembolism; Time Factors; Warfarin

Two cases of late cardiac tamponade after valve replacement surgery are reported: both patients were treated with oral anticoagulants (warfarin) after operation. An erratic response in the international normalised ratio (INR) was found before the diagnosis of late tamponade. It is suggested that this response of the INR may be an early indicator of late cardiac tamponade rather than a cause.

Topics: Aortic Valve; Blood Coagulation Tests; Cardiac Tamponade; Heart Valve Prosthesis; Humans; Liver; Liver Function Tests; Male; Middle Aged; Mitral Valve; Postoperative Complications; Time Factors; Warfarin

To find out which children are treated with oral anticoagulants and how their treatment is controlled in the United Kingdom.. Two questionnaires were used. The first was sent to general haematologists and the other to paediatric cardiologists and cardiac surgeons.. There were 273 (58%) replies to the first questionnaire. Most children were treated because of artificial cardiac valve replacement. The mean target International Normalised Ratio (INR) used was 2.73 to 4.0 for children with heart valves and 2.1 to 3.25 for children with venous thrombosis. The second questionnaire elicited replies from 11 of 22 cardiac centres. The mean target INR used for children with cardiac valves ranged from 2.59-3.77. Of 68 children covered in the survey, there have been two major bleeds and two thrombotic episodes: 78.8% of children were controlled with a venous prothrombin time and 21.2% with a capillary test. There was no consistency in the dose regimens used for the induction of oral anticoagulant treatment with warfarin.. The levels of anticoagulation used for maintenance are similar to those recommended by the British Society for Haematology for adults (3.0 to 4.5). They seem to be safe for children too.

Topics: Administration, Oral; Adolescent; Child; Child, Preschool; Heart Valve Prosthesis; Humans; Infant; Postoperative Complications; Thrombophlebitis; Warfarin

Joint registry and hospital data bases for 5,024 total hip and total knee arthroplasties done between 1986 and 1988 at the Mayo Clinic were used to study prophylactic measures and frequency of symptomatic deep venous thrombosis and pulmonary embolism. In virtually all patients, graduated compression stockings were used, with or without another type of prophylaxis. Only 44 of 3,115 patients who underwent hip arthroplasty (1.4%) and 32 of 1,909 patients who underwent knee arthroplasty (1.7%) had definite or probable deep venous thrombosis or pulmonary embolism. Death definitely or possibly attributable to pulmonary embolism occurred in 11 patients who underwent hip arthroplasty (0.35%) and 1 patient who underwent knee arthroplasty (0.05%). Although patients with a history of deep venous thrombosis or pulmonary embolism were more likely to receive warfarin than were patients without such a history, the relative risk of symptomatic deep venous thrombosis or pulmonary embolism in patients who underwent hip arthroplasty and received warfarin postoperatively was approximately half that in patients who received other types of prophylaxis. The risk of death from pulmonary embolism was similarly diminished in the group that received warfarin. The lower rates of these complications in the patients who received warfarin support the prophylactic use of this agent after total hip arthroplasty.

Topics: Aspirin; Bandages; Hip Prosthesis; Humans; Knee Prosthesis; Postoperative Complications; Pulmonary Embolism; Risk Factors; Thrombophlebitis; Warfarin

During a 5 1/2-year period from January 1984 to July 1989, 736 patients between the ages of 50 and 75 with a diagnosis of osteoarthritis had either cemented or uncemented primary total hip arthroplasty. Patients were treated with low-dose sodium warfarin for prophylaxis against pulmonary embolism and had preoperative and postoperative serial lung scanning. The overall incidence of pulmonary embolism was not statistically different between the cemented and uncemented groups (3.87% and 6.19%, respectively; P > .05). Eighty-one percent of the pulmonary emboli were asymptomatic. The incidence of pulmonary embolism was higher in men than in women (7.3% and 2.93%, respectively; P < .05) but did not differ within each individual sex for the cemented and uncemented groups. Of greater significance, when the two initial groups were matched to control for sex and weight differences (564 patients), the incidence of pulmonary embolism narrowed to 4.3% and 5.3% in the cemented and uncemented groups, respectively (P > .55). These data indicate that the use of uncemented total hip arthroplasty does not offer any additional protective value against pulmonary embolism when using low-dose sodium warfarin prophylaxis.

Topics: Aged; Cementation; Female; Hip Prosthesis; Humans; Incidence; Male; Middle Aged; Postoperative Complications; Prosthesis Design; Pulmonary Embolism; Sex Factors; Warfarin

Topics: Aged; Aortic Valve Stenosis; Drug Costs; Female; Heart Valve Prosthesis; Humans; Medicaid; Postoperative Complications; United States; Warfarin

This study was designed to identify those total arthroplasty patients at high risk for embolism even while on a proven warfarin prophylactic regimen and to identify the measure of anticoagulation that would be most efficacious in the prevention of pulmonary embolism (PE). A series of 2348 total arthroplasty patients had a preoperative perfusion scan and a postoperative ventilation/perfusion scan. All patients were placed on a low-dose warfarin protocol. Eighty-one patients were identified as having a PE by pulmonary arteriography (incidence of 3.4%). Of these, 89% were asymptomatic and no case was fatal. A control group of 159 patients without PE was used for comparison. Patients older than 65 years of age with a history of genitourinary infection were identified as being at higher risk of PE while on a proven warfarin prophylactic program. These patients may need additional prophylactic measures to reduce the risk of PE. In contrast, patients with a history of phlebitis, PE, obesity, or varicosities were not at excess risk for PE while on warfarin prophylaxis; therefore, no additional prophylactic measures are required. All prothrombin time profiles were within the prophylactic range. Therefore, the actual prothrombin time may not be the critical determinant of the level of anticoagulation or prophylaxis achieved.

Topics: Analysis of Variance; Chi-Square Distribution; Hip Prosthesis; Humans; Knee Prosthesis; Lung; Postoperative Care; Postoperative Complications; Proportional Hazards Models; Prothrombin Time; Pulmonary Artery; Pulmonary Embolism; Radiography; Radionuclide Imaging; Risk Factors; Ventilation-Perfusion Ratio; Warfarin

Two cases of intracerebral hemorrhage in patients with prosthetic heart valves receiving anticoagulant therapy without preceding embolic cerebral infarction are reported. Phytonadione and fresh frozen plasma were immediately given, and the intracerebral hematoma evacuated successfully. In one case, intractable bleeding occurred perioperatively until the thrombotest value reached 40% or more. This patient later developed fatal massive multiple intracerebral hemorrhages.

Topics: Adolescent; Cerebral Hemorrhage; Heart Valve Prosthesis; Hematoma; Humans; Incidence; Male; Middle Aged; Postoperative Complications; Prothrombin Time; Risk Factors; Warfarin

In a retrospective study we collected patient data relating to clinically detected postoperative thromboembolic complications before (n = 1710) and after (n = 2212) adopting a protocol for prophylaxis of deep vein thrombosis (DVT). A relatively low incidence of clinically diagnosed DVT, four per thousand, before systematic instructions for prophylaxis in 1981 could be explained by the frequent use of dextran as a volume expander in critically ill patients. However, following systematic prophylaxis the frequency of DVT decreased further (one per thousand).

Topics: Adolescent; Adult; Aged; Anticoagulants; Bandages; Combined Modality Therapy; Dextrans; Dihydroergotamine; Drug Combinations; Early Ambulation; Female; Fractures, Bone; Heparin; Heparin, Low-Molecular-Weight; Humans; Male; Middle Aged; Multiple Trauma; Postoperative Complications; Pulmonary Embolism; Risk Factors; Thrombophlebitis; Warfarin

To identify risk factors for lower limb loss after arterial embolectomy a cohort of 1189 patients was studied. Detailed data were obtained for 165 patients who underwent a major amputation within 30 days of embolectomy and for 165 matched controls. The amputation risk was increased in patients with two or more myocardial infarctions (odds ratio (OR) 3.1, 95 per cent confidence interval (CI) 0.8-11.2), chronic ischaemia (OR 2.1, CI 0.9-4.9), long duration of symptoms (OR 4.3, CI 1.9-9.6, for greater than or equal to 25 h versus less than or equal to 6 h) or postoperative heart failure (OR 3.4, CI 1.8-6.5). Reduced risks were found in association with acute myocardial infarction (OR 0.3, CI 0.1-0.9) and postoperative anticoagulation treatment with warfarin (OR 0.3, CI 0.1-0.9). The independent prognostic value of chronic ischaemia and symptom duration, and the beneficial effect of postoperative anticoagulation gained additional support in multivariate analysis. We conclude that the risk of early amputation after arterial embolectomy or thrombectomy can be predicted by several clinical characteristics.

Topics: Acute Disease; Adult; Aged; Aged, 80 and over; Amputation, Surgical; Arterial Occlusive Diseases; Case-Control Studies; Cohort Studies; Female; Heart Arrest; Humans; Ischemia; Leg; Male; Middle Aged; Myocardial Infarction; Postoperative Complications; Risk Factors; Warfarin

Postoperative orthopaedic patients remain at risk for venous thromboembolism (VTE) after hospital discharge. Therefore, the authors designed and implemented a program for prevention of VTE that included outpatient adjusted-dose warfarin using twice-weekly prothrombin time (PT) determinations, a dedicated telephone line for PT results, and vigilant nurse-physician supervision to administer prophylaxis to 125 postoperative orthopaedic patients against VTE for an average of 31.4 days after discharge. PT was maintained between 13.2 and 18.3 seconds (1.1-1.5 x control) in the average patient. There was a failure rate of 3.2% and 0.8% for clinically suspected and radiologically confirmed deep venous thrombosis (DVT) and pulmonary embolism (PE), respectively. The rate of bleeding complications was 3.2%, but none of these patients required transfusion or hospital readmission for hemorrhage. The authors conclude that the described program for VTE prevention is a safe, effective, and practical program to administer prophylaxis to postoperative orthopaedic patients against clinically evident VTE for the first month after hospital discharge.

Topics: Adult; Aged; Aged, 80 and over; Female; Follow-Up Studies; Humans; Male; Middle Aged; Orthopedics; Patient Discharge; Postoperative Complications; Prothrombin Time; Pulmonary Embolism; Radiography; Risk Factors; Thromboembolism; Thrombophlebitis; Warfarin

To examine the diagnostic work-up and subsequent management of patients with pulmonary embolism, we retrospectively reviewed the medical records of 60 patients who had arteriographically proven pulmonary embolism. Ventilation-perfusion scans were utilized in 47 patients and were classified as showing a high (55.3%), moderate (14.9%), low (8.5%), or indeterminate (21.3%) probability of pulmonary embolism. Of the 33 patients treated with anticoagulation, complications occurred in 10 (30.3%). Of the 39 patients treated with inferior vena cava filters, complications occurred in 16 (41.0%) patients, with the most clinically significant complication being recurrent pulmonary embolism, found to occur in one (2.6%) patient. For patients treated with anticoagulation, heparin was started an average of 0.3 (+/- 0.5) days following the initial suspicion of a pulmonary embolism. The average time to reach a therapeutic partial thromboplastin time level was 2.0 (+/- 1.8) days, and warfarin was started an average of 6.2 (+/- 4.1) days after heparin was begun. Among the 60 patients, five (8.3%) died from the pulmonary embolism, and two of these had at least a five day delay before diagnosis was made by pulmonary arteriography. Since the ventilation-perfusion scan had a sensitivity of 70.2% and a false negative rate of 8.5%, it is not always sufficiently accurate in making final treatment decisions, so there should be less hesitation in attaining pulmonary arteriograms. Therapeutic partial thromboplastin time levels should be more aggressively sought. Warfarin should be started within the first few days of heparin therapy. Inferior vena cava filters should be utilized in patients who have a contraindication to anticoagulation therapy or a complication from anticoagulation therapy.

Topics: Adult; Angiography; Anticoagulants; Combined Modality Therapy; Female; Humans; Male; Middle Aged; Postoperative Complications; Practice Patterns, Physicians'; Pulmonary Embolism; Risk Factors; Survival Rate; Vena Cava Filters; Vena Cava, Inferior; Warfarin

Heparin and warfarin sodium (Coumadin, Panwarfin, Sofarin) are used most often to treat acute and recurrent venous thromboembolic disease, arterial disease, valvular heart disease, and atrial fibrillation. These agents along with dextran, pneumatic compression devices, and gradient stockings are also used to prevent deep venous thrombosis and pulmonary embolism in patients at high risk (eg, those with venous stasis, lower limb or spinal cord trauma, clotting abnormalities). Anticoagulation therapy is monitored by maintaining the activated partial thromboplastin time and the prothrombin time in the therapeutic range.

Topics: Anticoagulants; Atrial Fibrillation; Heart Valve Diseases; Heparin; Humans; Postoperative Complications; Pulmonary Embolism; Recurrence; Risk Factors; Thrombophlebitis; Warfarin

Topics: Aged; Aged, 80 and over; Hip Prosthesis; Humans; Intraoperative Period; Knee Prosthesis; Middle Aged; Postoperative Complications; Thrombophlebitis; Warfarin

A theoretical analysis was performed regarding the cost-effectiveness in terms of lives saved (reduction of fatal pulmonary embolism [PE]) and in terms of money (dollars spent for prevention and treatment) of seven strategies in the management of venous thromboembolic disease in patients over 39 years of age undergoing elective total hip replacement (THR). Strikingly, this theoretical analysis suggests that low-dose warfarin combined with clinical surveillance of deep vein thrombosis would reduce the incidence of fatal PE from 20 per 1,000 patients to 4 per 1,000 patients and simultaneously reduce the charges for venous thromboembolic disease from $550,000 to about $400,000 per 1,000 patients. Based on this analysis, we strongly recommend this measure on a routine basis. Adding venography or duplex sonography routinely to this prophylactic regimen would, in this theoretical analysis, reduce the incidence of fatal PE from 4 per 1,000 patients to 0.15 per 1,000, but adds charges of $200,000 per extra life saved in the case of routine venography and $50,000 in the case of routine sonography. Low-dose warfarin prophylaxis combined with routine sonography does not generate more charges than no prophylaxis with no screening while drastically reducing the incidence of fatal PE from 20 to 0.3 per 1,000 patients. Where duplex sonography is not easily available, a 12-week postoperative course of low-dose warfarin for every patient with no routine screening will be efficacious in reducing fatal PE and as cost-effective.

Topics: Adult; Cohort Studies; Cost-Benefit Analysis; Hemorrhage; Heparin; Hip Prosthesis; Humans; Phlebography; Postoperative Complications; Primary Prevention; Pulmonary Embolism; Thromboembolism; Thrombophlebitis; Ultrasonography; Warfarin

The rate of deep vein thrombosis (DVT) after total knee arthroplasty (TKA) without prophylaxis has been reported as high as 84%. Coumadin anticoagulation and pneumatic calf compression (PCC) boots are two current therapies that have been thought to be effective in reducing this high rate of DVT. To investigate these two methods, a nonrandomized prospective study was designed. The first group involved treating 48 consecutive knee arthroplasties with a regimen of coumadin anticoagulation. The second group involved 81 consecutive knee arthroplasties treated with sequential PCC boots. Bilateral lower extremity venography was performed between the eighth and tenth hospital postoperative days. The overall incidence of DVT in the coumadin group was 33%, with 29% having calf thrombi and 6% having thigh thrombi. The overall incidence of DVT in the boot group was 31%, with 27% having calf thrombi and 6% having thigh thrombi. In both groups, there were no treatment-related complications. Cost analysis of the administration of each type of therapy showed coumadin to be approximately 50% more expensive than PCC boots. Although coumadin and PCC boot therapy are safe and effective in reducing the incidence of DVT after TKA, there are economic factors that make the latter a more favorable option.

Topics: Female; Gravity Suits; Humans; Knee Prosthesis; Male; Postoperative Complications; Prospective Studies; Thrombophlebitis; Warfarin

In order to determine optimum anticoagulation levels for the Medtronic Hall valve, the effect of low anticoagulation (mean International Normalized Ratio [INR] 2.5, 1979-1984) and moderate anticoagulation (mean INR 3.0, 1985-1989) was determined in 345 patients (183 low, 162 moderate) undergoing isolated mitral valve replacement (MVR) and 241 patients (91 low, 150 moderate) undergoing isolated aortic valve replacement (AVR). There were no cases of valve thrombosis. Embolic events and bleeding events were graded in severity and multiple decrement event-free survival calculated according to valve site and anticoagulation level: MVR low, MVR moderate, AVR low, and AVR moderate. In the MVR low group, 80% were free of all events and 93% free of serious events at 3 years compared with 89% and 98%, respectively, in the MVR moderate group. The AVR low group experienced a very small incidence of embolic events (one only) and no bleeding events. The AVR moderate group suffered more bleeding and more embolic events and at 3 years only 87% were event-free compared with 99% in the AVR low group. In both AVR groups, all embolic events were associated with one or more known stroke risk factors. Patients under 70, in sinus rhythm who were normotensive and were nonsmokers suffered no embolic events irrespective of their anticoagulation level. We conclude that the optimum INR for the average Medtronic Hall patient is 3.0 after MVR and 2.5 after AVR but some adjustments may be required in relation to stroke risk factor analysis.

Topics: Aortic Valve; Cerebrovascular Disorders; Female; Heart Valve Prosthesis; Humans; Male; Middle Aged; Mitral Valve; Postoperative Complications; Prosthesis Design; Risk Factors; Thrombosis; Warfarin

Topics: Aged; Foot; Humans; Knee Prosthesis; Male; Necrosis; Postoperative Complications; Skin; Warfarin

to audit anticoagulant control and endocarditis prophylaxis following heart valve surgery.. retrospective review of all 190 patients living in Canterbury who had heart valve surgery between January 1981 and December 1986 to determine the incidence of endocarditis and complications of anticoagulation.. there were 35 late deaths, of which nine were attributed to thromboembolism (3), major bleeding (2), or endocarditis (4). The rate of thromboembolic events, and major bleeding was 4.6 and 3.3/100 patient years of warfarin therapy respectively, while the incidence of late endocarditis was 0.96/100 patient years. Two episodes of endocarditis occurred after minor dental procedures performed without antibiotic prophylaxis. Many dentists indicated that they would not have recommended prophylactic therapy for these procedures. Some patients had inadequate recall of important details of anticoagulant control or endocarditis prophylaxis. Only 24% knew their latest prothrombin ratio, yet a survey of general practitioners revealed that, in their view, the majority of patients may be capable of monitoring their own anticoagulant therapy.. the incidence of potentially preventable long term complications of heart valve surgery is comparable to other series. Nevertheless, these complications could be reduced by better patient education possibly enhanced by greater involvement of the patient in their anticoagulant control. The indications for antibiotic prophylaxis for dental procedures should be broadened for this group of patients.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Dental Care; Endocarditis, Bacterial; Evaluation Studies as Topic; Female; Follow-Up Studies; Heart Valve Diseases; Hemorrhage; Humans; Male; Medical Audit; Middle Aged; New Zealand; Patient Education as Topic; Postoperative Care; Postoperative Complications; Prothrombin Time; Retrospective Studies; Thromboembolism; Warfarin

From 1973 through 1987 25 patients underwent mitral valve replacement in the first year of life for mitral stenosis and mitral regurgitation. The patients with mitral stenosis included two with mitral arcade, two with supravalvular mitral stenosis with hypoplastic mitral valve, and one with parachute mitral valve. Included in the group of patients with mitral regurgitation were 12 with atrioventricular canal defect, six with chordal and leaflet defects, one with Marfan's syndrome, and one with bacterial endocarditis. Prostheses included 12 Björk-Shiley (17 mm), seven St. Jude Medical (19 mm in four, 21 mm in three), five stent-mounted dura mater valves (12 mm to 16 mm), and one porcine xenograft (19 mm). In four patients the valves were placed in the left atrium in a supraannular location. There were nine operative (atrioventricular canal defect seven, mitral regurgitation two) and five late (atrioventricular canal defect four, mitral stenosis one) deaths, giving actuarial 1- and 5-year survival rates of 52% and 43%, respectively. All 6 patients with tissue valves died; the four with supraannular mitral valve replacement survived. Since 1983 operative mortality has been reduced to 0% (70% confidence limits 0% to 24%). Nine patients required a second mitral valve replacement for prosthetic stenosis 5 to 69 (mean 30) months after the original mitral valve replacement (one operative death). Because of improvements in repair of atrioventricular canal defect in infancy, the need for mitral valve replacement at atrioventricular canal defect repair has decreased. Although valvuloplasty has been advocated for repair of congenital mitral valve disease and is applicable in some infants with mitral regurgitation, mitral valve replacement is frequently unavoidable for congenital mitral disease and can now be accomplished at a low operative risk, even when the prosthesis has to be positioned supraannularly.

Topics: Age Factors; Bioprosthesis; Follow-Up Studies; Heart Valve Prosthesis; Humans; Infant; Infant, Newborn; Mitral Valve; Postoperative Complications; Reoperation; Survival Rate; Warfarin

Between April 1988 and February 1989, 877 patients undergoing total hip (394 patients) and total knee (483 patients) replacement surgeries were given warfarin prophylaxis perioperatively and were tested with impedance plethysmography (IPG) approximately 17 days postoperatively (10 days post-discharge) in the outpatient office. There were 69 positive IPG tests (7.8%). Further assessment of patients with positive IPG results using duplex scanning or venography confirmed DVT in 25 of the 69 patients (3.6%) in the popliteal or thigh areas, and ruled out venous disease in 44 patients. All 25 patients were readmitted for anticoagulation therapy with intravenous (IV) heparin and warfarin. There were no cases of pulmonary embolus. This study indicates that IPG testing is a safe and effective method of screening patients for DVT and its potentially fatal sequela of pulmonary embolus. Furthermore, IPG testing has proven to be cost effective, as it is a relatively simple procedure which can be administered by non-professional personnel in the outpatient office setting.

Topics: Aged; Female; Heparin; Hip Prosthesis; Humans; Knee Prosthesis; Male; Plethysmography, Impedance; Postoperative Complications; Postoperative Period; Thrombosis; Warfarin

The St. Jude Medical valve is a bileaflet prosthesis with excellent hemodynamic characteristics, but the long-term surgical experience with this valve, its durability, and its biocompatibility are unknown. During a 10-year period from March 1978 to 1988, 690 prostheses (290 aortic, 252 mitral, and 74 double aortic-mitral) were inserted as the initial valve replacement substitute in 616 patients (mean age 63 years). Coronary atherosclerosis was present in 58%. Follow-up totaled 2031 patient-years (mean 3.3 years) and was 95% complete (32 lost). Early (30-day) mortality rates were 5.2%, 11.9%, and 8.1% after aortic, mitral, and double valve replacement; 5- and 9-year actuarial survival rates were 71% +/- 3% and 51% +/- 8%, 59% +/- 4% and 41% +/- 6%, and 69% +/- 6% and 47% +/- 15%, respectively. Deaths were associated with extensive coronary atherosclerosis (p less than 0.001), older age (p less than 0.001), advanced preoperative New York Heart Association functional class (p less than 0.05), and malignant ventricular arrhythmias (p less than 0.05). No structural failures have been observed. Embolism (40 events) occurred at a rate of 2.0%/pt-yr (2.3% aortic, 1.6% mitral, 2.0% double). There were six cases of valve thrombosis (0.3%/pt-yr; one fatal). Hemorrhage was the most frequent complication (2.6%/pt-yr); 13 (25%) of 52 events were fatal, accounting for 62% of all valve-related deaths. After the target prothrombin time ratio was lowered, the rate of hemorrhage decreased by 44% (2.7% to 1.5%/pt-yr), while the combined rate of embolism and valve thrombosis increased slightly (2.2% to 2.5%/pt-yr, a 14% change). In summary, the St. Jude Medical valve remains a durable valve substitute. Survival was strongly related to the presence of associated coronary atherosclerosis. The most common complication has been hemorrhage; a less intensive warfarin regimen may reduce hemorrhagic risk while maintaining thromboembolic protection.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Aortic Valve; Child; Child, Preschool; Female; Follow-Up Studies; Heart Valve Diseases; Heart Valve Prosthesis; Humans; Male; Middle Aged; Mitral Valve; Postoperative Complications; Reoperation; Risk Factors; Thromboembolism; Warfarin

The combination of multiple surgical procedures is attractive and convenient to the patient. Increased awareness of wound healing difficulties and pulmonary complications, however, suggest caution with this approach, particularly when combining abdominal lipectomy with intraabdominal procedures. This study confirms the high risk of pulmonary emboli in patients with combined abdominal lipectomy and intraabdominal gynecological procedures. The use of perioperative warfarin may reduce the incidence of pulmonary embolism in patients who have combined abdominal lipectomy and gynecological surgical procedures, and it is not associated with increased bleeding or other postoperative complications.

Topics: Adult; Female; Hemostasis, Surgical; Humans; Hysterectomy; Lipectomy; Postoperative Care; Postoperative Complications; Premedication; Pulmonary Embolism; Warfarin

During an 8-year period ending in 1988, 173 consecutive patients with a history of previous cerebrovascular accident underwent general anesthesia for surgery. Five patients (2.9%) had documented postoperative cerebrovascular accidents from 3 to 21 days (mean, 12.2 days) after surgery. The risk of postoperative cerebrovascular accident did not correlate with age, sex, history of multiple cerebrovascular accidents, poststroke transient ischemic attacks, American Society for Anesthesia physical status, aspirin use, coronary artery disease, peripheral vascular disease, intraoperative blood pressure, time since previous cerebrovascular accident, or cause of previous cerebrovascular accident. Postoperative stroke was more common in patients given preoperative heparin sodium. We conclude that the risk of perioperative stroke is low (2.9%) but not easily predicted and that the risk continues beyond the first week of convalescence. Unlike myocardial infarction, cerebral reinfarction risk does not seem to depend on time since previous infarct.

Topics: Adult; Age Factors; Aged; Aged, 80 and over; Anesthesia, General; Aspirin; Cerebrovascular Disorders; Female; Heparin; Humans; Incidence; Ischemic Attack, Transient; Male; Middle Aged; Postoperative Complications; Retrospective Studies; Risk Factors; Surgical Procedures, Operative; Warfarin

The overall incidence of pulmonary embolism (PE) among neurosurgical in-patients, whose ages ranged from 23 to 80, was 0.7%. Our report here is based on five cases of patients with PE. Four of these five patients were over 50 years of age. They had been admitted because of such reasons as brain tumor, spinal cord injury, intracerebral hematoma, and venous sinus thrombosis. Deep vein thrombosis (DVT) was seen in four but none were diagnosed before they had developed PE. Decreased level of consciousness and prolonged bed rest appeared to be common risk factors for PE. Mean duration between admission and onset of PE was 31 days. Although non-specific, tachycardia, tachypnea and hypoxemia were the most common signs and symptoms. As a definitive diagnostic procedure, pulmonary angiography was performed in most of cases. One patient required surgical embolectomy and others were treated with anticoagulation or fibrinolytic agents. In order to prevent recurrent thromboembolic phenomena, ligation of the inferior vena cava was a useful mode of treatment when anticoagulation was not indicated. And this approach seemed to be valid in most neurosurgical patients. We conclude that PE and DVT were not uncommon complications among Japanese neurosurgical patients and they can be treated successfully in collaboration with a cardiovascular surgeon if the diagnosis can be made correctly.

Topics: Adult; Aged; Brain Diseases; Female; Humans; Male; Middle Aged; Postoperative Complications; Pulmonary Embolism; Spinal Cord Diseases; Thrombolytic Therapy; Urokinase-Type Plasminogen Activator; Vena Cava, Inferior; Warfarin

Twelve resections of prostate and 1 extensive bladder tumour were performed in patients on long-term anticoagulation without withdrawal of warfarin therapy. The mean preoperative prothrombin index was 2.3. Four patients required blood transfusion. There were no major complications. The effects of surgery and infusion of fresh frozen plasma (FFP) on the level of anticoagulation were monitored. FFP reduced the prothrombin index by 0.25/unit. Transurethral resection can be carried out safely by an experienced urologist on patients anticoagulated with warfarin, reducing the risk of serious thromboembolic complications associated with withdrawal of anticoagulation.

Topics: Aged; Blood Transfusion; Hemoglobins; Humans; Male; Middle Aged; Plasma; Postoperative Complications; Prostatectomy; Prothrombin; Urinary Bladder Neoplasms; Warfarin

The continued good results after mitral valve reconstruction prompted this retrospective study to compare operative and late results from our institutional experience since 1976 with 975 porcine mitral valve replacements (MVRs) (1976 to December 1987), 169 mechanical MVRs (1976 to December 1987), and 280 Carpentier-type mitral valve reconstructions (CVRs) (1980 to mid-1988). The operative mortality was 2.0% for isolated CVR, 6.6% for isolated mechanical MVR, and 8.5% for isolated porcine MVR. The overall operative mortality was 5.0% for CVR, 16.6% for mechanical MVR, and 10.6% for porcine MVR. The overall 5-year survival including hospital deaths was 76% for CVR, 72% for mechanical MVR, and 69% for porcine MVR. By multivariate analysis, the predictors of increased operative risk and of decreased survival were age, New York Heart Association functional class IV status, previous cardiac operation, and performance of concomitant cardiac surgical procedures. The type of valvular procedure was not predictive of operative risk or overall survival. The 5-year freedom from reoperation was 94.4% for nonrheumatic patients having CVR, 77.4% for rheumatic patients having CVR, 96.4% for mechanical MVR, and 96.6% for porcine MVR (p less than 0.05, rheumatic patients with CVR versus both MVR groups). The 5-year freedom from all valve-related morbidity and mortality was significantly better for valve reconstruction compared with both types of valve replacement. Thus, the operative risk and late survival obtained after mitral valve reconstruction were at least equivalent to those obtained after MVR. In addition, patients receiving mitral valve reconstruction had less valve-related combined morbidity than patients receiving valve replacement, thus making mitral valve reconstruction preferable in some patients with mitral insufficiency.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Bioprosthesis; Child; Endocarditis; Female; Follow-Up Studies; Heart Valve Prosthesis; Humans; Male; Middle Aged; Mitral Valve; Mitral Valve Insufficiency; Mitral Valve Stenosis; Postoperative Complications; Reoperation; Retrospective Studies; Thromboembolism; Warfarin

We analyzed data of 50 patients receiving long-term warfarin sodium therapy who underwent ocular surgery between 1982 and 1986. The frequency of hemorrhagic and thrombotic complications was compared in patients in whom anticoagulants were continued, those in whom the anticoagulants were discontinued in the perioperative period, and a group of matched control patients. There were six perioperative hemorrhagic complications in the warfarin-treated group (12%) compared to none in the control group. This difference was significant (P less than .03). However, no significant difference in hemorrhagic complications was seen between patients in whom warfarin sodium was continued and those in whom it was discontinued.

Topics: Adult; Aged; Aged, 80 and over; Cataract Extraction; Eye Hemorrhage; Female; Follow-Up Studies; Humans; Intraoperative Care; Lenses, Intraocular; Male; Middle Aged; Postoperative Complications; Prothrombin Time; Thrombosis; Time Factors; Warfarin

Between 1970 and 1987, 3000 total hip replacements were performed at the University of California at Los Angeles, and all patients were given warfarin prophylactically, in conjunction with early postoperative elevation of the lower limb in balanced suspension and the application of elastic hose. Since 1973, the first dose of warfarin has been given on the night of the operation, and the prothrombin time has been maintained between sixteen and eighteen seconds. A pulmonary embolism occurred after fourteen (0.5 per cent) of the 3000 operations. It was never fatal. Bleeding occurred after forty-four operations (1.5 per cent). The effectiveness of the protocol of the University of California at Los Angeles was demonstrated in a large number of patients over a seventeen-year period. Since 1974, the protocol has included closer monitoring of the prothrombin time. After 2595 hip replacements that were done between 1974 and 1987, the rate of pulmonary embolism was 0.2 per cent and the rate of bleeding complications was 1.0 per cent. However, recently a higher incidence of bleeding complications (2.3 per cent) has been noted after non-cemented total hip (stem-type) replacement.

Topics: Drug Evaluation; Gastrointestinal Hemorrhage; Hip Prosthesis; Humans; Los Angeles; Postoperative Care; Postoperative Complications; Prospective Studies; Prothrombin Time; Pulmonary Embolism; Warfarin

The efficacy of low-dose warfarin therapy for prophylaxis of venous thromboembolic disease was studied prospectively in a group of 1,392 patients undergoing cemented total hip arthroplasty between 1978 and 1985. The incidence of both symptomatic and asymptomatic pulmonary emboli was determined after surgery in all patients using ventilation-perfusion lung scanning as the diagnostic endpoint. The total incidence of postoperative pulmonary embolus was 3.2%, with two-thirds asymptomatic and one-third symptomatic pulmonary emboli. There were no fatalities due to pulmonary embolism in the entire patient population. Bleeding complications requiring surgical intervention developed in 2.4% of patients. The authors conclude that low-dose warfarin therapy is a safe and easily administered form of inpatient treatment for prophylaxis of venous thromboembolic disease in all total hip arthroplasty patients and has demonstrated complete protection against fatal pulmonary embolism in this population.

Topics: Aged; Drug Evaluation; Female; Hip Prosthesis; Humans; Male; Postoperative Complications; Prospective Studies; Pulmonary Embolism; Warfarin

Topics: Dextrans; Gastrointestinal Hemorrhage; Graft Rejection; Humans; Kidney Tubular Necrosis, Acute; Pancreas Transplantation; Postoperative Complications; Thrombosis; Warfarin

To assess dose requirements of warfarin in children, we analyzed retrospectively the treatment of 26 patients with the drug. Subsequently we treated 15 children, prospectively, with a regimen derived from our retrospective analysis (0.2 mg/kg/day for 2 days). In the retrospective analysis we found the prothrombin time (PT) at day 2 to correlate significantly with the dose given on day 0 (p less than 0.001) and with the cumulative dose on days 0 and 1 (p less than 0.001), but the standardized loading regimen resulted in a wide range of PTs independent of age, weight, or body surface area. The warfarin dose contributes only 40% of the variability in PT; an individual child's response to warfarin cannot be predicted accurately on the basis of the usual morphometric measurements.

Topics: Child; Dose-Response Relationship, Drug; Heart Valve Prosthesis; Humans; Liver Function Tests; Postoperative Complications; Prospective Studies; Prothrombin Time; Retrospective Studies; Thrombosis; Warfarin

Topics: Heart Valve Prosthesis; Hemorrhage; Humans; Postoperative Complications; Warfarin

Topics: Blood Platelets; Dipyridamole; Drug Therapy, Combination; Heart Valve Prosthesis; Humans; Platelet Aggregation Inhibitors; Postoperative Complications; Thrombosis; Ticlopidine; Warfarin

104 patients who had prosthetic valve replacements were followed up for a period from 5 months to 63 months. The incidence of minor and major thromboembolism for aortic valve replacement was 1.2%/Pt.yr respectively, while the incidence for mitral valve replacement was 3.8%/Pt.yr. respectively. The haemorrhagic complication rate due to anticoagulation was 3.7%/Pt.yr. and the fatality rate due to it was 1.4%/Pt.yr. 75% of the patients who had haemorrhagic complications had a thrombotest of less than 4%. Anticoagulation related morbidity and mortality are significant in this series. Elimination of anticoagulation related complications could have improved the long term mortality rate from 2.95%/Pt.yr. to 1.4%/Pt.yr.

Topics: Adolescent; Adult; Aged; Female; Follow-Up Studies; Heart Valve Diseases; Heart Valve Prosthesis; Hemorrhage; Humans; Male; Middle Aged; Postoperative Complications; Prosthesis Design; Thromboembolism; Warfarin

Topics: Adolescent; Adult; Aspirin; Drug Evaluation; Female; Heart Valve Prosthesis; Humans; Male; Middle Aged; Platelet Aggregation Inhibitors; Postoperative Complications; Protein C; Thromboembolism; Ticlopidine; Warfarin

Pulmonary embolism remains a frequent and often fatal disorder. For the majority of patients, anticoagulation with heparin followed by warfarin represents the primary mode of treatment. Thrombolytic therapy is recommended for the patient with massive pulmonary embolism that has produced hypotension. Embolectomy is reserved for the patient with post embolic systemic hypotension who has an absolute contraindication to thrombolysis or who deteriorates despite thrombolytic therapy. Following successful embolectomy the surgeon must treat the complications of the surgery and prevent recurrence. Complications include cerebral infarction, pulmonary infarction and endobronchial hemorrhage, right ventricular failure, local or systemic bleeding and venous stasis. A case of successful pulmonary embolectomy with a complicated postoperative course is presented and the pathophysiology and treatment of the complications are discussed.

Topics: Adrenal Gland Diseases; Chest Pain; Dyspnea; Female; Heparin; Humans; Hypotension; Middle Aged; Pain; Postoperative Complications; Pulmonary Embolism; Syncope; Warfarin

A 65-year-old female, presenting 32 weeks after mitral valve replacement with malaise and weight loss, was found to have a massive left atrial thrombus. She was treated successfully with streptokinase 1,000,000 units followed by anticoagulation with heparin then warfarin. The Doppler ultrasound recordings of left ventricular inflow were biphasic on admission but had resumed a normal appearance 11 days afterwards when clot retraction had occurred. We suggest that thrombolysis should be considered as alternative therapy in patients thought too frail for surgery.

Topics: Aged; Bioprosthesis; Drug Therapy, Combination; Echocardiography; Female; Heart Atria; Heart Valve Diseases; Heart Valve Prosthesis; Heparin; Humans; Mitral Valve; Postoperative Complications; Streptokinase; Thrombosis; Warfarin

Current concern about adolescent pregnancy is based largely on its negative impact on the social, developmental, and economic prospects of the mother and her infant. The issues of adolescent pregnancy are more complex when the mother has a severe heart defect. Our case illustrates the problems that can arise in the pressure of associated medical problems. Although the patient's behavior contributed substantially to a tragic outcome, we believe that greater professional awareness and sensitivity regarding the needs of such adolescent patients might have produced a more favorable outcome.

Topics: Adolescent; Aortic Valve Stenosis; Combined Modality Therapy; Female; Heart Valve Prosthesis; Heparin; Humans; Postoperative Complications; Pregnancy; Pregnancy Complications, Cardiovascular; Prognosis; Risk Factors; Warfarin

Warfarin provides effective prophylaxis against postoperative venous thromboembolic complications in adults undergoing elective hip surgery, but at the risk of increased bleeding complications. Although patients on this drug are routinely monitored by prothrombin time (PT), mild elevations of the partial thromboplastin time (PTT) have been reported with warfarin therapy. In a prospective study of 194 patients undergoing elective hip surgery, the authors assessed the incidence of elevation of the PTT above 50 seconds while the patient was receiving warfarin prophylaxis and the effect of this elevation on bleeding complications. The prophylactic warfarin was begun the night prior to surgery. Thirty-eight patients (19.6%) had a PTT greater than 50 seconds (group 1) and 156 had milder or no elevation of the PTT (group 2). The mean maximum PTT in group 1 was 61.2 ( +/- 12.9), versus 39.9 ( +/- 5.0) seconds in group 2. Major postoperative bleeding complications occurred in 26.3% of group 1 patients, versus 4.5% of group 2 (P less than .01). This subset of patients with an abnormal PTT elevation despite appropriate control of the PT is at a significantly increased risk of major postoperative bleeding. This observation may also prove valuable in reducing bleeding complications from warfarin use in nonsurgical patients.

Topics: Blood Coagulation Tests; Hemorrhage; Hip Prosthesis; Humans; Middle Aged; Partial Thromboplastin Time; Postoperative Complications; Premedication; Risk Factors; Thrombophlebitis; Warfarin

One thousand four Medtronic Hall valves (601 mitral, 398 aortic, and five tricuspid) were implanted in 847 patients between December 1979 and June 1987. Total experience at the end of June 1987 was 2,640 patient-years of follow-up. Prothrombin time ratios were reviewed for all patients (16,866 observations), and these ratios were found to be therapeutically low (median international normalized ratio, 2.6) and highly variable (lower 10th percentile, 1.6; upper 10th percentile, 3.9). During the follow-up period, there were no valvular thromboses; the 95% confidence limit for the risk of thrombosis (0.14 per 100 patient-years) is below that reported for other mechanical prostheses. Sixty percent of all thromboembolic events left no residual deficit, and 75% of all bleeding events did not require treatment. Only 11% of thromboembolic events and 7% of bleeding events were fatal. The linearized rate of fatal bleeding was 0.2% per year, and the linearized rate of moderate to severe bleeding was 0.5% per year. Five-year actuarial embolic-free rates were 92%, 84%, and 83% for aortic, mitral, and double valves, respectively. The low risk of valvular thrombosis and of serious thromboembolic events in the Medtronic Hall valve, regardless of the range and variability of anticoagulation, offers greater patient safety than other mechanical prostheses, provides a credible alternative to bioprostheses, and may be particularly relevant to third-world populations.

Topics: Actuarial Analysis; Embolism; Follow-Up Studies; Heart Valve Prosthesis; Heart Valves; Humans; Middle Aged; Postoperative Complications; Thromboembolism; Thrombosis; Warfarin

There have been few relatively complete follow-up studies of long-term mitral valve function after Carpentier-type surgical reconstruction. Between January 1980 and May 1986, 148 patients underwent Carpentier reconstruction for mitral valve disease (43% degenerative and 30% rheumatic). Operative mortality was 5.4% overall (1.2% for isolated mitral reconstruction), and follow-up (mean, 26 months) was completed for all survivors. Five-year survival from late cardiac death was 90.0%, as was 5-year freedom from postreconstruction mitral valve replacement. Postreconstruction mitral replacement was needed in eight patients, in only five for failure of repair. Follow-up echocardiographic studies on 83.2% (104 of 125) of eligible patients showed 92.3% were free of significant (3+ or 4+) mitral regurgitation. Freedom from mitral valve replacement or recurrent severe (4+) insufficiency was 84.4% at 5 years overall, but was lower for the rheumatic type of mitral disease than for the degenerative type (71.6% vs. 88.3%). At 5 years, 95.2% of patients were free from thromboembolism without the necessity for long-term warfarin (Coumadin) therapy. At follow-up, 95.3% of survivors had improved to New York Heart Association Class I or II. The functional durability of mitral reconstruction and consistently high level of freedom from late endocarditis and thromboembolic and anticoagulant complications support the value of the Carpentier method of mitral reconstruction for mitral insufficiency, especially insufficiency due to degenerative disease.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Child; Child, Preschool; Echocardiography; Endocarditis, Bacterial; Follow-Up Studies; Humans; Methods; Middle Aged; Mitral Valve; Mitral Valve Insufficiency; Platelet Aggregation Inhibitors; Postoperative Care; Postoperative Complications; Thromboembolism; Warfarin

Topics: Cataract Extraction; Humans; Hyphema; Lenses, Intraocular; Postoperative Complications; Prothrombin Time; Warfarin

Topics: Administration, Oral; Barbiturates; Cardiopulmonary Bypass; Drug Therapy, Combination; Heart Valve Prosthesis; Humans; Platelet Aggregation; Postoperative Complications; Thromboembolism; Ticlopidine; Warfarin

Doses of oral anticoagulants in 50 patients on long term treatment were easily and satisfactorily monitored over six months by an automated chromogenic assay of prothrombin (CPA). It is suggested that chromogenic assay of one or more of the vitamin K dependent coagulation factors would provide a readily standardised alternative to those conventional tests which depend on human brain derived reagents, now regarded as a biohazard.

Topics: Administration, Oral; Adult; Aged; Anticoagulants; Chromogenic Compounds; Humans; Long-Term Care; Methods; Middle Aged; Oligopeptides; Postoperative Complications; Prothrombin; Prothrombin Time; Warfarin

Four patients under 45 years old presented with small bowel infarction secondary to superior mesenteric venous thrombosis. Diagnosis was not made pre-operatively in three patients and delay to operation of over 4 days occurred in two patients. In each case infarcted bowel was resected and a primary anastomosis fashioned. A further resection of infarcted small bowel was necessary in three patients. Each patient was discharged on long-term warfarin therapy. Two patients required permanent total parenteral nutrition, one of whom died of liver failure at one year. The remaining patients remain well.

Topics: Adult; Female; Humans; Infarction; Intestine, Small; Male; Mesenteric Vascular Occlusion; Mesenteric Veins; Parenteral Nutrition, Total; Postoperative Complications; Prognosis; Thrombosis; Warfarin

Topics: Adult; Aged; Aortic Valve; Heart Valve Prosthesis; Hemorrhage; Heparin; Humans; Middle Aged; Mitral Valve; Postoperative Care; Postoperative Complications; Prothrombin Time; Quality of Life; Retrospective Studies; Thromboembolism; Warfarin

Lower doses of warfarin are effective in the treatment of proven proximal deep vein thrombosis (DVT), and at a substantially lower risk of bleeding complications than with standard doses. The authors compared low-dose warfarin with external pneumatic compression (EPC) boots for prophylaxis against DVT and efficacy and safety in a population of total hip replacement patients at high risk for DVT and bleeding complications. DVT developed in 12 of 72 patients on low-dose warfarin and 11 of 66 patients on EPC. Both regimens were as efficacious as traditional higher doses of warfarin used in prior studies. No major bleeding complications occurred in either group. Low-dose warfarin appears to be an effective and relatively safe form of prophylaxis against postoperative DVT, as does sequential EPC of the calf and thigh.

Topics: Adult; Female; Hip Prosthesis; Humans; Male; Postoperative Complications; Pressure; Risk; Thrombophlebitis; Warfarin

Systemic and local complications associated with the use of warfarin for deep vein thrombosis prophylaxis in total knee arthroplasty (TKA) are significant. Forty-seven patients with primary TKAs considered at high risk for developing thromboembolic disease were treated with a regimen of preoperative and postoperative warfarin. The incidence (n = 2) of systemic complications was 4%. The incidence (n = 6) of wound complications requiring specific treatment or discontinuing physiotherapy was 12%. In this series, wound complications did not jeopardize the end results of TKA. However, such wound complications as may have delayed recovery occurred with a frequency similar to that reported in other series of TKA using different antithromboembolic modalities.

Topics: Aged; Blood Coagulation Disorders; Female; Hemorrhage; Humans; Knee Prosthesis; Male; Middle Aged; Postoperative Complications; Thromboembolism; Warfarin; Wound Healing

Between January 1980 and April 1986, 204 patients were hospital survivors after aortic, mitral, or double valve replacement with the St. Jude Medical valve. One hundred ninety patients underwent anticoagulation with modest doses of warfarin (Coumadin), with prothrombin times in the range of 1.3 to 1.5 times control. Fourteen patients received aspirin and dipyridamole only. Follow-up ranged from 0.5 to 6.6 years (mean 3.1) and was 99.5% complete. The group was analyzed for occurrence of thromboembolism, hemorrhage, valve thrombosis, endocarditis, perivalvular leak, valve failure, late cardiac death, and all morbidity and mortality combined in linear and actuarial terms over the 7 year period. With this anticoagulation regimen, the linear rate for thromboembolism and hemorrhage was 0.67% and 1.3% patient-year, respectively, and the actuarial event-free incidence at 5 years was 97.4% and 94.4%, respectively. There were no instances of structural valve failure and one instance of valve thrombosis in the mitral position. Eighty-seven percent of patients were alive at 5 years and 76.7% of patients were alive and free of all complications at 5 years. We conclude that the St. Jude Medical valve has a low incidence of thromboembolism, hemorrhagic complications, and valve thrombosis in patients receiving modest doses of warfarin.

Topics: Actuarial Analysis; Adult; Aged; Aortic Valve; Female; Follow-Up Studies; Heart Valve Diseases; Heart Valve Prosthesis; Hemorrhage; Humans; Male; Middle Aged; Mitral Valve; Postoperative Complications; Prosthesis Design; Thromboembolism; Time Factors; Warfarin

Topics: Dose-Response Relationship, Drug; Drug Administration Schedule; Humans; Postoperative Complications; Thromboembolism; Warfarin

Topics: Diabetic Retinopathy; Diet; Female; Heparin; Humans; Lactation; Platelet Aggregation Inhibitors; Postoperative Complications; Pregnancy; Risk Factors; Teratogens; Warfarin

The experience at the University of Colorado with the St. Jude Medical cardiac valve was reviewed to determine the feasibility of placing this prosthesis in children and the role of anticoagulation. A St. Jude Medical cardiac valve was placed in 33 patients ranging in age from 2.5 months to 17 years. Seven patients were less than 1 year of age. Nineteen valves were placed in the aortic position in patients aged 5 months to 17 years (mean 9.5 years). Five patients had valve replacement only, 13 had concomitant aortoventriculoplasty and 1 a Manouguian procedure. Indications for anulus enlarging procedures were recurrent subaortic stenosis or inability to place an adult-sized valve in the native aortic anulus, or both. There were no early or late deaths. Fourteen valves were placed in the mitral position. They were anular positioned in 6 patients aged 6 months to 16 years and supraanular positioned in 8 patients aged 2.5 months to 2 years. There were no deaths with the anular positioned replacements and seven deaths (two early and five late) with the supraanular positioned replacements. Four of the five late deaths were associated with marked pre- and postoperative left ventricular dysfunction. The follow-up time was 784 patient-months in 31 long-term survivors. Anticoagulation was achieved with warfarin, usually in combination with sulfinpyrazone, dipyridamole or aspirin. There were four episodes of thromboembolism, three occurring in patients with suboptimal anticoagulation, and one in a patient lost to follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Adolescent; Anticoagulants; Aortic Valve; Child; Child, Preschool; Follow-Up Studies; Heart Valve Prosthesis; Humans; Infant; Mitral Valve; Postoperative Complications; Prosthesis Design; Time Factors; Warfarin

To evaluate coagulable state, beta-thromboglobulin (beta-TG) levels have been followed sequentially in 70 postoperative patients with lung cancer. Nineteen out of them were treated with warfarin plus ticlopidine at a dosage enough to prolong the thrombo-test time to approximately 20% of normal value. There was a significant rise in beta-TG compared with control subjects and beta-TG was correlated with stages of disease. Serial beta-TG determinations revealed that beta-TG and CEA levels fairly paralleled with each other which suggested beta-TG might be useful in following tumor progression or response to therapy in postoperative period. As to the relation between beta-TG levels and five-year survivals, patients whose beta-TG were under 50 ng/ml showed more favorable prognoses than those who had higher levels. Long term anticoagulation with warfarin plus ticlopidine reduced the beta-TG levels of 19 stage 3 or 4 patients, especially in stage 4 the rate of reduction was marked. Nineteen patients with anticoagulant-treated group demonstrated a more prolonged time from beginning of treatment to first evidence of disease progression than 18 non-treated patients. Also anticoagulant-treated group had a more prolonged clinical course than non-treated group after disease progression. These results might be associated with disease stabilization which achieved with anticoagulant therapy. Survival at 30 months after initiation of treatment was 74% in the treated group and 64% in the nontreated group. Although there was no statistical difference in two groups, survival of treated group exceeded that of the non-treated group throughout the observation period. In stage 4 patients, however, the difference between two groups was statistically significant.

Topics: Adult; Aged; Anticoagulants; beta-Thromboglobulin; Blood Coagulation Disorders; Female; Humans; Lung Neoplasms; Male; Middle Aged; Postoperative Complications; Thiophenes; Ticlopidine; Warfarin

Clinically significant myositis ossificans of the distal thigh following virginal porous-ingrowth total knee arthroplasty has not been previously reported. Associated and potentially contributing factors in this particular case were (1) the patient's preoperative hypertrophic gonarthrosis, (2) our difficulty in regulating her postoperative sodium warfarin (Coumadin) dosages, (3) the postoperative knee manipulation, and (4) possibly, the additional surgical exposure of this patient's distal femur required to use the femur-based alignment instrumentation. Postoperative heterotopic ossification developing in the vicinity of a porous-ingrowth total knee prosthesis can have clinical significance. Treatment of this problem by a means that does not interfere with early bone ingrowth into the implant is a practical concern that warrants investigation.

Topics: Aged; Anti-Bacterial Agents; Female; Humans; Knee Prosthesis; Manipulation, Orthopedic; Myositis Ossificans; Postoperative Complications; Radiography; Thigh; Warfarin

Topics: Anticoagulants; Aortic Valve; Aspirin; Atrial Fibrillation; Bioprosthesis; Dipyridamole; Drug Therapy, Combination; Follow-Up Studies; Heart Valve Diseases; Heart Valve Prosthesis; Hemorrhage; Humans; Mitral Valve; Platelet Aggregation; Postoperative Complications; Thromboembolism; Warfarin

Deep venous thrombosis is a complex process involving many factors in the circulatory system, an important one apparently being the intrinsic fibrinolytic system. Specific activators of the process include venous trauma and hypercoagulability states. In spite of efforts at prophylaxis, venous thrombosis will occur, a dangerous condition in itself and also a precursor of pulmonary embolism. Several schemes for prophylaxis, including drug regimens and mechanical means, have been tried, and future research will surely identify others. A patient's best protection against thrombosis at present, however, is a vigilant physician with a high index of suspicion who will expedite diagnosis and treatment if necessary.

Topics: Antithrombin III Deficiency; Aspirin; Blood Coagulation Disorders; Catheters, Indwelling; Contraceptives, Oral; Dihydroergotamine; Female; Glycoproteins; Heparin; Humans; Parity; Postoperative Complications; Pregnancy; Pregnancy Complications; Protein C; Sulfinpyrazone; Thrombophlebitis; Warfarin

To determine the necessity of long-term warfarin anticoagulation after St. Jude Medical aortic valve replacement in adults, we evaluated the risks of thromboembolism, valve thrombosis, anticoagulant hemorrhage, and sudden cardiac death in two groups of patients. Group I consisted of 41 patients treated with conventional long-term warfarin therapy. Forty-two patients in Group II were treated primarily with antiplatelet therapy (aspirin, dipyridamole, or both); 17 of these patients received warfarin for a short time postoperatively and seven others received it intermittently during the study period. The groups were similar with respect to age, sex, associated cardiovascular disease, and length of follow-up (mean 29 months per patient). In the warfarin-treated group, three late sudden deaths occurred, one of which was preceded by a cerebrovascular accident, for a cardiac mortality of 2.7% per patient-year. There were eight major nonfatal complications (7.3% per patient-year), of which four were hemorrhagic and four embolic. In Group II, there was one sudden cardiac death (1.1% per patient-year) and four major complications occurred (3.2% per patient-year). Two of the complications were embolic and two were episodes of valve thrombosis, both necessitating reoperation. Although the incidence of serious morbidity in the warfarin-treated group was twice that of patients treated with antiplatelet therapy, there were no statistically significant differences in the rates of sudden death or major complications. These data suggest that antiplatelet therapy may be as effective as warfarin in preventing embolism from the St. Jude Medical valve in the aortic position. Valve thrombosis occurred in two patients, both receiving antiplatelet therapy (2.2% per patient-year). Whether this type of valve failure can be prevented by warfarin remains in question.

Topics: Adolescent; Adult; Aged; Anticoagulants; Aortic Valve; Aspirin; Cineradiography; Dipyridamole; Echocardiography; Embolism; Female; Heart Valve Prosthesis; Humans; Male; Middle Aged; Postoperative Complications; Reoperation; Risk; Warfarin

Clinical information on the Medtronic-Hall valve prosthesis was obtained by reviewing the records of 379 patients, 164 of whom had aortic valve replacement (AVR), 163 of whom had mitral valve replacement (MVR), and 52 of whom had double valve replacement over 90 months (1,225 patient-years) (mean follow-up, 42.01 +/- 1.3 months [+/- standard error]). Mean age was 53.8 +/- 12 years. One hundred ninety-three patients (50.9%) had some type of concomitant operation, such as tricuspid annuloplasty, coronary artery bypass grafting, or resection of ascending aortic aneurysm. Ninety-one percent were in New York Heart Association (NYHA) Functional Class III or IV preoperatively. Early mortality and late mortality were 7.7% (29 patients) and 13.5% (51 patients), respectively. The actuarial survival at 7 1/2 years was 74.1 +/- 2.7% for the total group and 69.0 +/- 4.5% for those having AVR, 81.0 +/- 3.2% for those having MVR, and 67.0 +/- 8.9% for those having double valve replacement. All patients but 2 were maintained on a regimen of chronic anticoagulation with warfarin sodium. Twenty-six thromboembolic episodes occurred (2.1/100 patient-years): 13 after MVR (2.3/100 patient-years), 11 after AVR (2.1/100 patient-years), and 2 after double valve replacement (1.4/100 patient-years). Four thromboembolic episodes were fatal; no valve thrombosis occurred. There were no structural failures. Of the 350 late survivors, 92% were in NYHA Functional Classes I and II. Total valve-related complications have been minimal.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Aortic Valve; Cardiopulmonary Bypass; Evaluation Studies as Topic; Female; Follow-Up Studies; Heart Valve Diseases; Heart Valve Prosthesis; Hemorrhage; Humans; Hypothermia, Induced; Male; Middle Aged; Mitral Valve; Postoperative Complications; Prosthesis Design; Prosthesis Failure; Thromboembolism; Tricuspid Valve; Warfarin

The incidence of thromboembolic complications after St Jude Medical aortic valve replacement was evaluated in patients who received antiplatelet drugs alone (aspirin and dipyridamole). This report includes 107 consecutive patients undergoing aortic valve replacement with the St. Jude Medical prosthesis from February, 1980, until December, 1983. There were three perioperative deaths (2.8%). Thirty-seven of these patients received life-time warfarin anticoagulation and therefore were excluded from further analysis. The remaining 67 patients receiving antiplatelet drugs were followed up for 22 +/- 8 months (range 5 to 54 months) with a total observation period of 123 patient-years. Group 1 consisted of 52 patients having single St. Jude Medical aortic valve replacement (mean age 27 +/- 10 years). Group 2 included 15 patients having St. Jude Medical aortic valve replacement with additional mitral valve replacement (mean age 27 +/- 11 years). There were no postoperative embolic events in Group 1, but two St. Jude Medical aortic prostheses became thrombotic (2.1 per 100 patient-years) 19 and 32 months after the operation. Emergency aortic valve replacement was done in one of these patients and aortic thrombectomy in the other. Both patients are alive and doing well. In Group 2, three patients (10 per 100 patients-years) had thrombosis of the St. Jude Medical aortic valve 10, 12, and 30 months after the operation, and two of them required emergency aortic value replacement. One of these patients also had a massive left coronary embolus and could not be weaned from cardiopulmonary bypass. The third patient, who was asymptomatic, was prescribed warfarin anticoagulation and has been well. None of the seven patients in this group with St. Jude Medical aortic and mitral prostheses has had a thromboembolic event. These results indicate that antiplatelet drugs alone are associated with a very low risk of embolism but are insufficient to prevent thrombosis of St. Jude Medical aortic valves, even when the patients have sinus rhythm.

Topics: Adolescent; Adult; Aortic Valve; Aspirin; Blood Platelets; Dipyridamole; Female; Follow-Up Studies; Heart Valve Prosthesis; Humans; Male; Mitral Valve; Postoperative Complications; Prosthesis Design; Rheumatic Heart Disease; Risk; Thromboembolism; Time Factors; Warfarin

Cosmetic surgery of the abdomen is requested frequently by patients and is being performed increasingly at the time of elective gynecologic surgery. However, little information is available regarding the safety of combining these procedures. In this study intraoperative and postoperative morbidity was compared in the following groups of patients: 1) abdominoplasty plus one of five common gynecologic procedures (N = 76); 2) one of the five gynecologic procedures alone, matched for age, weight, and time of operation (N = 76); and 3) abdominoplasty alone (N = 70). Patients in group 1 experienced significantly longer operative time, longer hospital stays, and greater blood loss, which required more transfusions than group 2 or 3. These problems were accentuated in patients who weighed more than 70 kg or were older than age 35. In addition, five patients (6.6%) in group 1 had a documented pulmonary embolus within 18 days of surgery, whereas no pulmonary emboli occurred in group 2 or 3. Because of the increased morbidity, careful patient selection is necessary when abdominoplasty and gynecologic procedures are performed at the same time.

Topics: Abdomen; Adult; Age Factors; Blood Transfusion; Body Weight; Female; Hemorrhage; Heparin; Humans; Hysterectomy; Hysterectomy, Vaginal; Length of Stay; Middle Aged; Postoperative Complications; Pulmonary Embolism; Risk; Surgery, Plastic; Warfarin

Fibrinaemia following total hip replacement was evaluated in eighteen patients, grouped according to a negative and a positive fibrinogen uptake test (FUT), after having excluded two patients due to a false negative test, using phlebography as reference. The ethanol gelation test (EGT) was employed for detection of circulating soluble fibrin, and the conversion of fibrinogen to fibrin was evaluated by the level of fibrinopeptide A (FPA). Eight patients were cleared with respect to thrombosis, whereas ten had a positive FUT. All patients developed a positive EGT, irrespective of thrombosis, coinciding with the postoperative increase in fibrinogen. FPA increased to approximately twice its preoperative level in both groups of patients, but reached its maximum earlier in patients with thrombosis. However, this parameter had no discriminative value in this type of postoperative thrombosis, possibly due to massive thromboplastin release in both groups.

Topics: Aged; Aprotinin; Female; Fibrin; Fibrinogen; Fibrinopeptide A; Heparin; Hip Prosthesis; Humans; Male; Middle Aged; Postoperative Complications; Reference Values; Thrombophlebitis; Time Factors; Warfarin

Topics: Cerebrovascular Disorders; Drug Interactions; Female; Hemorrhage; Heparin; Humans; Infusions, Parenteral; Monitoring, Physiologic; Myocardial Infarction; Postoperative Complications; Pregnancy; Pregnancy Complications, Hematologic; Surgical Procedures, Operative; Thromboembolism; Warfarin

Topics: Adult; Aged; Cardiac Surgical Procedures; Drainage; Female; Humans; Male; Middle Aged; Pericardial Effusion; Postoperative Complications; Time Factors; Warfarin

In a prospective study of 100 consecutive patients who underwent operations for intracranial aneurysms, the incidence of deep vein thrombosis (DVT) was 14%. The diagnosis was based on contrast venography, which was carried out in any patient who showed clinical symptoms and signs of DVT. In the presence of DVT the patient was placed on bed rest and intravenous plus peroral anticoagulation was begun. No complications thought to be related to anticoagulation were observed. A programme of postoperative prophylaxis is suggested for a selected group of aneurysm patients with a high risk for thromboembolic disease.

Topics: Adolescent; Adult; Drug Therapy, Combination; Early Ambulation; Heparin; Humans; Intracranial Aneurysm; Middle Aged; Postoperative Complications; Risk; Thrombophlebitis; Warfarin

Mitral valve prolapse (MVP), often the result of myxomatous degeneration of the mitral valve, is the most commonly known pathologic entity leading to pure mitral regurgitation (MR). Reconstruction of the mitral valve rather than replacement is particularly applicable to this pathologic defect, but is not often used in the U.S. Experience with reconstruction of the mitral valve for MR secondary to MVP during the period January 1970 to January 1984 was reviewed. A total of 479 patients with mitral valve disease underwent operation during this period, 82 (17%) of whom had MR secondary to MVP. Thirty-one patients (6%) had valve reconstruction by a technique of leaflet plication and posteromedial anuloplasty. Eleven of these patients had associated cardiac disease requiring correction: 2 requiring aortic valve replacement and 9 requiring coronary artery bypass grafting procedures. One hospital death (3%) and 6 late deaths (19%) occurred, of which only 3 were related to cardiac factors. Major complications included recurrent MR in 5 patients and cerebral embolus in 1 patient. The adjusted 5-year survival rate was 89 +/- 6 (mean +/- standard error of the mean), and the overall survival rate of patients free of cardiac-related complications was 73 +/- 9%. Thus, reconstruction of the mitral valve is a highly effective surgical approach to the management of symptomatic patients with MR secondary to MVP, and its use is favored over replacement in the management of these patients.

Topics: Actuarial Analysis; Chordae Tendineae; Female; Humans; Male; Middle Aged; Mitral Valve Insufficiency; Mitral Valve Prolapse; Postoperative Complications; Recurrence; Rupture, Spontaneous; Thromboembolism; Warfarin

Topics: Adult; Anticoagulants; Blood Coagulation; Dipyridamole; Female; Heart Valve Diseases; Heart Valve Prosthesis; Humans; Male; Middle Aged; Platelet Aggregation; Postoperative Complications; Thiophenes; Thrombosis; Ticlopidine; Warfarin

The value of the 125I-labelled fibrinogen uptake test as a screening method for deep vein thrombosis was estimated in 49 patients (97 extremities) undergoing elective hip operations. The legs were monitored preoperatively, on the 1st, 2nd and 4th postoperative days. Contrast venography, as a reference method, was performed on the 5th postoperative day. The sensitivity was 73%, specificity 85%, positive predictive value 63%, negative predictive value 86% and correlation coefficient 55%. 78% of fibrinogen uptakes appeared within the first 24 hours, and 6% on the 4th postoperative day. Only 1 of 3 patients with a positive fibrinogen uptake test in the femoral region had roentgenologic evidence of deep vein thrombosis. According to these results the isotope-labelled fibrinogen uptake test can also be utilized as a screening method in elective hip surgery.

Topics: Fibrinogen; Hip; Humans; Iodine Radioisotopes; Middle Aged; Postoperative Complications; Thrombophlebitis; Warfarin

Thromboembolism was prospectively studied in 215 patients who survived aortic valve replacement with porcine bioprostheses. All patients were anticoagulated with warfarin sodium during the first 3 postoperative months. Thereafter, 80 patients received aspirin (325 or 650 mg per day) and 135 received no antiplatelet or anticoagulant drugs. The two groups of patients were similar. Thromboembolic complications were carefully searched for during the follow-up interviews. Patients were removed from the study after a thromboembolic event unless there was no change in their management. The follow-up ranged from 6 to 80 months (mean, 36 months). The linearized thromboembolic rate in patients on a regimen of aspirin was 1.3% per patient-year and in patients not taking aspirin, 5.2% per patient-year (p less than 0.02). Replacement of the ascending aorta and patch enlargement of the aortic annulus with a Teflon graft were identified as significant risk factors for thromboembolism in patients with aortic porcine bioprostheses. These findings indicate that patients with aortic porcine bioprostheses should receive aspirin, especially if they also had replacement of the ascending aorta or patch enlargement of the aortic annulus with a Teflon graft.

Topics: Adolescent; Adult; Aged; Aorta; Aortic Valve; Aspirin; Bioprosthesis; Blood Vessel Prosthesis; Female; Follow-Up Studies; Heart Valve Prosthesis; Humans; Male; Middle Aged; Polytetrafluoroethylene; Postoperative Complications; Prospective Studies; Risk; Thromboembolism; Time Factors; Warfarin

An inherited disorder of the fibrinolytic system has been discovered as a cause of unusual clotting. An abnormal immunoreactive plasminogen was identified in eight patients who presented with unexplained thrombosis. Six patients presented with spontaneous arterial or venous thrombosis, and two patients developed postoperative occlusion of an arterial reconstruction. Five of the six patients with spontaneous thrombosis had recurrent episodes involving both the arterial and venous system at time intervals between the thrombotic episodes varying from 1 month to several years. Detection of an abnormal plasminogen was made by immunoelectrophoresis of the patient's serum with an antiplasminogen sera. In normal patients, plasminogen migrates as a single band toward the anode. In these eight patients a separate immunoreactive band located nearer the anode and distinct from the normal band was detected. Examination of family members of two patients identified a similar abnormal plasminogen with an overall incidence suggestive of an autosomal dominant inheritance pattern. This study suggests the presence of a genetically determined plasminogen variant resulting in a functional deficiency of the plasminogen system causing a reduction of fibrinolytic activity and a latent thrombotic tendency. Recommended treatment is long-term warfarin anticoagulation.

Topics: Adult; alpha 1-Antitrypsin; alpha-2-Antiplasmin; alpha-Macroglobulins; Antigens; Antithrombins; Blood Coagulation Tests; Female; Follow-Up Studies; Humans; Immunodiffusion; Immunoelectrophoresis; Male; Middle Aged; Pedigree; Plasminogen; Postoperative Complications; Recurrence; Thromboembolism; Thrombosis; Warfarin

Topics: Adult; Constriction; Diabetes Mellitus, Type 1; Heparin; Humans; Ileum; Immunosuppressive Agents; Jejunum; Methods; Middle Aged; Pancreas; Pancreas Transplantation; Pancreatic Ducts; Pancreatic Fistula; Postoperative Complications; Warfarin

Antithrombotic medication is effective in the prevention of thromboembolic complications after valve replacement. Therapy with oral anticoagulant (warfarin), platelet inhibitor drugs and long-term warfarin administration an have good clinical results. However, thrombosis may occur in the early postoperative period, when the oral administration of warfarin is impossible. We have evaluated treatment with urokinase, low-dose heparin and dipyridamole, administered intravenously, instead of warfarin, during the early postoperative period. This procedure was carried out in 30 patients, among whom there was no evidence of thrombosis or of such side-effects as bleeding or a marked tendency to bleed.

Topics: Aortic Valve; Heart Valve Diseases; Heart Valve Prosthesis; Humans; Mitral Valve; Postoperative Complications; Thromboembolism; Tricuspid Valve; Urokinase-Type Plasminogen Activator; Warfarin

The occurrence and distribution of deep vein thrombosis after elective hip surgery were studied in 22 consecutive patients wearing graded pressure stockings as thromboprophylaxis. The frequency of thrombosis, as evidenced by leg-scan and phlebography, was 59%. Thirty-six per cent of the patients developed femoro-popliteal thrombosis. Thrombosis was unilateral and located in the operated limb, except for one patient who had concurrent leg-vein thrombosis in the non-operated limb. Two patients developed symptomatic lung embolism. Antithrombin III was determined pre- and postoperatively. There was no evidence of antithrombin III consumption due to postoperative thrombosis.

Topics: Aged; Antithrombin III; Clothing; Female; Hematocrit; Heparin; Hip Joint; Hip Prosthesis; Humans; Male; Postoperative Complications; Pulmonary Embolism; Thrombosis; Warfarin

Topics: Chronic Disease; Drainage; Follow-Up Studies; Heart Valve Prosthesis; Hematoma, Subdural; Humans; Male; Middle Aged; Mitral Valve; Postoperative Complications; Warfarin

Topics: Animals; Calcium Phosphates; Cattle; Heart, Artificial; Postoperative Complications; Thrombosis; Warfarin

The influence of cefamandole and vancomycin used for prophylaxis on the warfarin anticoagulation response in 60 cardiac valve replacement patients during the postoperative period is presented. Patients were divided into two groups, hyper-responders prothrombin time (PT) greater than or equal to 32 sec, 48 hr after the initial warfarin dose (GrIHR), or normal responders PT less than 32 sec (GrIINR). Fifteen patients (25%) were in GrIHR (PT 44.3 +/- 10.5) and 45 in GrIINR (21 +/- 5). Fourteen of the 15 GrIHR patients received cefamandole and 1 of the 15 GrIHR patients received vancomycin p less than 0.05, as prophylaxis. Warfarin sensitivity was assessed using a warfarin dose index (WDI) calculated in the initial postoperative period (WDIINT) and at discharge (WDIDIS). GrIHR patients had greater WDIINT and WDIDIS compared to GrIINR p less than 0.001. Baseline prothrombin time measured 8 hours prior to start of warfarin therapy (PTBL), was linearly correlated to the WDIINT with r = 0.8, p less than 0.001 in cefamandole patients only. The data suggests that cefamandole increases warfarin sensitivity early in the postoperative course of oral anticoagulation therapy, which may lead to excessively high prothrombin times with the possibility for serious bleeding.

Topics: Blood Coagulation; Cefamandole; Female; Heart Valve Diseases; Heart Valve Prosthesis; Humans; Hypoprothrombinemias; Male; Postoperative Complications; Postoperative Period; Premedication; Retrospective Studies; Surgical Wound Infection; Thromboembolism; Vancomycin; Warfarin

To ascertain the risk of thromboembolism and anticoagulant-related hemorrhage following mitral valve replacement with bioprostheses, an 8 year retrospective study between two groups of patients was analyzed. Group I included 206 patients undergoing mitral valve replacement with porcine xenograft valves. They were placed on a regimen of long-term oral anticoagulation (greater than 8 weeks, mean 6 months). Follow-up was 524.3 patient-years, mean 30.5 months. There were 24 thromboembolic events (4.6% per patient-year), four of which were fatal. Actuarially, 80.7% +/- 4.3% are free of thromboembolism at 8 years. There were 12 instances of major bleeding episodes, for a linearized incidence of 2.5% per patient-year; two were fatal. Group II included 322 patients undergoing mitral valve replacement with a bovine pericardial valve. They were placed on a program of short-term anticoagulation (6 weeks only). Follow-up was 1,106 patient-years, mean 46.4 months. There were four thromboembolic episodes (none fatal), an incidence of 0.36% per patient-year. Seven bleeding episodes occurred, 0.63% per patient-year; none was fatal. The difference between the groups reached statistical significance (p less than 0.001). The low risk of thromboembolism with the bovine pericardial valve appears to be due to its superior hydraulic characteristics. Use of this valve allows mitral valve replacement without long-term oral anticoagulation and the associated risk of anticoagulant-related hemorrhage.

Topics: Adolescent; Adult; Aged; Bioprosthesis; Female; Hemorrhage; Humans; Male; Middle Aged; Mitral Valve; Postoperative Complications; Retrospective Studies; Risk; Thromboembolism; Warfarin

A total of 479 valve replacements were performed in 469 patients for aortic, mitral, and tricuspid disease. A total of 529 valves were implanted (311 Carpentier-Edwards, 118 Hancock, 94 Björk-Shiley, and six other mechanical valves). Of the 479 operations, 51.1% (245) were carried out in male patients and 48.9% (234) were carried out in female patients. The mean age was 57.6 years; however, 28.6% (137) of the operations were performed in patients over 65 years of age. One hundred five patients (21.9%) had had previous cardiac operations of one type or another. Follow-up was 99.6% and the average length of follow-up was 36.2 months. The overall operative mortality was 5.6%. The operative mortality in the isolated aortic valve replacement group was 2.0% and that in the mitral valve replacement group, 4.4%. There was a 5.9% valve explant rate in the Hancock series; however, no valve explants were required because of valve dysfunction in either the Carpentier-Edwards or the Björk-Shiley groups. The thromboembolic rate in the aortic valve position was 2.4, 1.1, and 2.1 emboli per 100 patient-years in the Hancock, Carpentier-Edwards, and Björk-Shiley groups, respectively. The thromboembolic rate in the mitral valve position was 2.8, 2.2, and 1.0 emboli per 100 patient-years in the Hancock, Carpentier-Edwards, and Björk-Shiley groups, respectively.

Topics: Aged; Aortic Valve; Bioprosthesis; Endocarditis, Bacterial; Female; Follow-Up Studies; Heart Valve Diseases; Heart Valve Prosthesis; Humans; Male; Middle Aged; Mitral Valve; Postoperative Complications; Reoperation; Sex Factors; Thromboembolism; Time Factors; Tricuspid Valve; Warfarin

Topics: Adult; Aortic Valve Insufficiency; Aortic Valve Stenosis; Heart Valve Prosthesis; Hematoma, Subdural; Humans; Male; Mitral Valve Stenosis; Postoperative Complications; Warfarin

Seventy consecutive patients who had undergone coronary artery bypass surgery were postoperatively treated with either dipyridamole or warfarin for 6 months. The dipyridamole series consisted of 28 patients given 150 mg dipyridamole 3 times daily and the warfarin series, of 42 patients who received the appropriate daily dose of warfarin needed to maintain the prothrombin time within the therapeutic range. The majority of patients in both series belonged to the NYHA class III. Sixty-one percent of the patients in the dipyridamole series and 66% of those of the warfarin series had triple vessel disease. In all, 70 and 105 coronary artery branches were bypassed in the dipyridamole and warfarin series, respectively. This resulted in 2.5 distal anastomoses per patient in each series. The patency of the grafts was confirmed angiographically. There was no mortality during the 23.6 +/- 2.4 months follow-up period in the dipyridamole series or the 12.8 +/- 2.7 months in the warfarin series. The patency rates were 95.7% and 88.6% in the dipyridamole and warfarin series, respectively. It is apparent that dipyridamole is not less effective than warfarin in preventing postoperative coronary graft occlusion.

Topics: Adult; Blood Vessel Prosthesis; Coronary Artery Bypass; Dipyridamole; Female; Humans; Male; Middle Aged; Postoperative Complications; Prothrombin Time; Thrombosis; Time Factors; Warfarin

This report describes successful management of recent peripheral arterial occlusions by intra-arterial low dosage thrombolytic drug infusions and percutaneous balloon angioplasty. An intra-arterial infusion of either streptokinase or urokinase at 1/20 of the usual systemic dose was delivered through an angiographic catheter into the region of the thrombus. Clot lysis was achieved for arterial occlusions of the iliac artery, an old aortofemoral graft limb and femoropopliteal arteries. Arterial clots of several weeks duration were lysed. Recurrent thrombosis can be prevented by anticoagulation, balloon angioplasty or surgical repair of causative arterial lesions. Thrombolytic therapy for arterial occlusions is not a replacement for surgical management but an important adjunct to the over-all treatment. Low dosage regional thrombolytic therapy deserves wider application in the management of selected arterial occlusions.

Topics: Aged; Angioplasty, Balloon; Aorta; Arterial Occlusive Diseases; Blood Pressure Determination; Blood Vessel Prosthesis; Female; Femoral Artery; Fibrinolytic Agents; Foot; Humans; Infusions, Intra-Arterial; Leg; Male; Middle Aged; Popliteal Artery; Postoperative Complications; Radiography; Streptokinase; Thrombosis; Urokinase-Type Plasminogen Activator; Warfarin

We reviewed the experience with infective endocarditis at some major US Army Medical Centers. One hundred patients were studied, comparing 82 patients who had native valve endocarditis (NVE) with 18 patients who had prosthetic valve endocarditis (PVE). Among patients with PVE, four had porcine valves and 14 had synthetic. None of the patients with NVE had received anticoagulants; 14 of 18 patients with PVE had received anticoagulants. The major causes of death were central nervous system hemorrhage, congestive heart failure, uncontrolled infection, and embolic phenomena. The principal cause of death in patients with PVE was CNS hemorrhage. Of the patients with PVE, 36% had symptomatic cerebral hemorrhage while receiving anticoagulants and 80% of them died.

Topics: Anti-Bacterial Agents; Anticoagulants; Aortic Valve; Cerebral Hemorrhage; Drug Evaluation; Endocarditis, Bacterial; Heart Failure; Heart Valve Prosthesis; Humans; Mitral Valve; Postoperative Complications; Premedication; Prothrombin Time; Retrospective Studies; Thromboembolism; Warfarin

Topics: Dyspnea; Hemoptysis; Humans; Leg; Male; Middle Aged; Pain, Postoperative; Postoperative Care; Postoperative Complications; Pulmonary Embolism; Thorax; Thrombophlebitis; Warfarin

Topics: Angiography; Electrocardiography; Heparin; Humans; Oxygen; Postoperative Complications; Pulmonary Embolism; Warfarin

The effect of anticoagulative treatment of pulmonary embolism was studied in 63 patients out of 348 operated on with total hip replacement. Screening diagnosis of pulmonary embolism was obtained from 99mTc perfusion scintigraphy in combination with 99mTc-microaerosol ventilation scintigraphy and chest radiogram. The administration of heparin and warfarin was associated with hemorrhagic side effects in 7 per cent. The final outcome of surgery, however, was not interfered with. Fatal pulmonary embolism occurred in one patient (0.3 per cent) in whom the diagnosis had been missed.

Topics: Aged; Female; Heparin; Hip Joint; Hip Prosthesis; Humans; Male; Postoperative Complications; Pulmonary Embolism; Radionuclide Imaging; Warfarin

Topics: Hip Prosthesis; Humans; Leg; Middle Aged; Phlebography; Postoperative Complications; Technetium; Thrombosis; Warfarin

Topics: Aged; Bed Rest; Heparin; Humans; Male; Middle Aged; Postoperative Complications; Thrombophlebitis; Warfarin

Twenty-four children (ages 1 to 18 years, mean 12.2 years) underwent 27 operations for aortic, mitral, or combined aortic and mitral valve replacement. There was 1 operative death. Of the 23 operative survivors (12 aortic, 8 mitral, 3 combined valve replacement), only 5 were given warfarin for long-term anticoagulation. The remaining 18 (10 aortic, 8 mitral valve replacement) were given aspirin (plus dipyridamole in 5). Twelve of the 18 had at least one mechanical valve (11 Björk-Shiley and Beall valves; 1 Björk-Shiley valve was replaced with a Beall disc valve as the child grew). These 18 patients were followed for 1 to 59 months (mean, 20.4 months). There was no thrombotic, embolic, or bleeding complications. There were 2 late deaths (one cardiac). Review of the available literature indicates that in children with prosthetic cardiac valves, aspirin (with or without dipyridamole) provides adequate protection against thromboemboli and avoids the hemorrhagic complications associated with warfarin.

Topics: Adolescent; Anticoagulants; Aortic Valve; Aspirin; Bioprosthesis; Child; Child, Preschool; Dicumarol; Dipyridamole; Drug Therapy, Combination; Heart Valve Diseases; Heart Valve Prosthesis; Humans; Infant; Mitral Valve; Postoperative Complications; Retrospective Studies; Thromboembolism; Warfarin

Topics: Anticoagulants; Heart Valve Prosthesis; Humans; Postoperative Complications; Prothrombin Time; Vitamin K; Warfarin

Topics: Aspirin; Coronary Artery Bypass; Dipyridamole; Drug Interactions; Heart Valve Prosthesis; Humans; Postoperative Complications; Warfarin

The purpose of this investigation was to analyze the thromboembolic and/or major bleeding complications of 124 consecutive but nonrandomized patients who had only mitral valve replacement with the Hancock porcine xenograft between September, 1974 and June, 1979. These patients were treated either with or without anticoagulants. Four basic study groups were created: Group 1, warfarin; Group 2, aspirin; Group 3, no anticoagulants; and Group 4, warfarin and aspirin. Group 5 combined Groups 1 and 4 (warfarin and warfarin plus aspirin) and Group 6 combined Groups 2 and 3 (aspirin and no anticoagulants). The cardiac rhythm, history of embolism, and intraoperative findings of a thrombus in the left atrium were examined as risk factors for later thromboembolism . Follow-up time was 3.03 years (range 2.0 to 4.2 years). The embolic rate was not significantly different in any group (n = NS). In Groups 5 and 6 the embolic rate was 2.97 and 3.25 embolisms per 100 patient-years, respectively. Warfarin therapy resulted in significant major bleeding episodes, including two deaths (p less than 0.05). The number of patients with a history of a previous embolism, the finding of an intraoperative left atrial thrombus, or abnormal cardiac rhythm was insufficient to test embolic risk in the four treatment groups. We conclude that long-term warfarin therapy increases the risk of bleeding complications but may not significantly influence the incidence of thromboembolism arising from the Hancock porcine xenograft mitral valve. Other and larger studies are needed to confirm this last point.

Topics: Adult; Aged; Aspirin; Bioprosthesis; Cerebral Hemorrhage; Female; Gastrointestinal Hemorrhage; Heart Valve Prosthesis; Humans; Male; Middle Aged; Mitral Valve; Postoperative Complications; Risk; Thromboembolism; Warfarin

Eight hundred twenty-four patients who had cardiac valve replacement with a porcine bioprosthesis were given either Coumadin (sodium warfarin) or aspirin. No patient in sinus rhythm no matter what valve or valves were replaced had thromboembolism whether treated with Coumadin (124 patients) or aspirin (260 patients). One hundred fifty-one patients who had mitral valve replacement, were in atrial fibrillation, and were treated with Coumadin had seven embolic events (4.6%), while 135 similar patients treated with aspirin had five embolic events (3.7%). Fifty-one patients who had double-valve replacement, were in atrial fibrillation, and were treated with coumadin had three embolic episodes (5.9%), while 86 similar patients treated with aspirin had three embolic events (3.5%). No statistical difference was found in the incidence of thromboembolism between similar groups of patients whether treated with Coumadin or aspirin (p greater than 0.05). Hemorrhagic complications were higher and reached statistical significance (p less than 0.001) for the group treated with Coumadin. This study shows that aspirin prevents thromboembolic complications as well as Coumadin in patients having cardiac valve replacement with a bioprosthesis, and results in a lower rate of complications.

Topics: Adolescent; Adult; Aged; Aortic Valve; Aspirin; Bioprosthesis; Child; Female; Follow-Up Studies; Heart Valve Prosthesis; Humans; Male; Middle Aged; Mitral Valve; Postoperative Complications; Thromboembolism; Tricuspid Valve; Warfarin

Because of the controversy surrounding prophylaxis for thromboembolism after total hip surgery, we undertook a prospective study comparing the results of the administration of aspirin with that of low doses of warfarin in 194 patients (200 hips) undergoing total hip replacement. The incidences of both clinically apparent and silent (asymptomatic) pulmonary emboli were determined using the objective criteria of preoperative and postoperative levels of arterial blood gases, chest roentgenograms, electrocardiograms, and perfusion lung scans. With this surveillance plan, the accuracy of diagnosis of clinically symptomatic pulmonary emboli was improved and the detection of otherwise silent pulmonary emboli became possible. The group of patients who received low doses of warfarin showed a 6 per cent total incidence of pulmonary emboli compared with a 19 per cent incidence in the group receiving aspirin (p less than 0.05). There was, however, no significant difference when the incidences of only the clinically suspected emboli were compared, the rates for the two groups being 5 and 8 per cent, respectively (p greater than 0.05). There was also no significant difference between men and women with regard to the prophylactic efficacy of aspirin in preventing pulmonary embolism.

Topics: Aspirin; Female; Hip Joint; Hip Prosthesis; Humans; Male; Middle Aged; Postoperative Complications; Prospective Studies; Pulmonary Embolism; Warfarin

Topics: Adrenal Cortex Diseases; Hemorrhage; Hernia, Inguinal; Humans; Male; Middle Aged; Postoperative Complications; Tomography, X-Ray Computed; Warfarin

Topics: Adult; Female; Humans; Postoperative Complications; Pulmonary Embolism; Warfarin

Two hundred thirty-two consecutive patients (October 3, 1977, through December, 31, 1980) underwent aortic (AVR), mitral (MVR), or double (DVR) valve replacement with the St. Jude Medical (SJM) prosthesis. Operative mortality for the entire group was 7.3%. There was 100% follow-up. Warfarin (Coumadin) anticoagulation was recommended for all patients. There were no cases of mechanical failure. The incidence of thromboembolism was 0.6/1,000 patient-months for those with AVR, 3/1,000 patient-months for those with MVR, and 0% for those with DVR. Thrombosis of a prosthesis occurred in two patients with DVR. Clinically significant hemolysis occurred in three patients with paravalvar leaks following MVR. Late postoperative prosthetic infection has not occurred. Postoperative catheterization studies in 33 patients revealed no transvalvular gradient at rest in 21 patients. The remainder of the patients catheterizd had low transvalvular gradients. There was a minimal increase in transvalvular gradient with exercise. The SJM cardiac valve is a viable alternative in the surgical therapy of valvular heart disease.

Topics: Adolescent; Adult; Aged; Aortic Valve; Child; Child, Preschool; Female; Heart Valve Prosthesis; Humans; Infant; Male; Middle Aged; Mitral Valve; Postoperative Complications; Thromboembolism; Tricuspid Valve; Warfarin

Since October, 1978, 181 St Jude medical cardiac valves have been implanted in 166 patients throughout Australia. There were 152 single implants, 13 combined mitral and aortic valve implants, and one triple valve implant. Hospital mortality rates were similar to those for all types of prosthetic cardiac valves. Thromboembolic complications occurred less frequently in the patients with St Jude valves than in reports of similar patients with other prostheses, provided that anticoagulation was maintained.

Topics: Adolescent; Adult; Aged; Anticoagulants; Aortic Valve; Australia; Child; Child, Preschool; Female; Heart Valve Prosthesis; Humans; Infant; Male; Middle Aged; Mitral Valve; Postoperative Complications; Thromboembolism; Tricuspid Valve; Warfarin

Topics: Adult; Aged; Anti-Arrhythmia Agents; Aortic Valve; Arrhythmias, Cardiac; Death, Sudden; Female; Heart Valve Prosthesis; Heart Ventricles; Humans; Male; Middle Aged; Postoperative Complications; Stroke Volume; Tachycardia; Time Factors; Warfarin

Topics: Adolescent; Adult; Barbiturates; Endocarditis, Bacterial; Female; Heart Valve Prosthesis; Hemorrhage; Humans; Male; Middle Aged; Oral Hemorrhage; Postoperative Complications; Thrombosis; Tooth Extraction; Warfarin

Mesenteric vein thrombosis is an abdominal emergency that is rarely diagnosed early. Review of the literature has shown that most cases have been treated by intestinal resection, a few by thrombectomy with or without resection. Three cases of mesenteric vein thrombosis were treated by resection, heparinization, and a second-look operation after 24 hours. When necessary, resection was carried out at the second surgical procedure followed by a third-look operation after 24 hours. After the last inspecting operation without further resection, full heparinization was continued and anticoagulation was ultimately maintained with warafin sodium (Coumadin) for at least three months. The authors believe that optimal treatment for mesenteric vein thrombosis should include anticoagulation with heparin sodium and a mandatory second-look operation.

Topics: Adult; Female; Heparin; Humans; Ileum; Jejunum; Male; Mesenteric Vascular Occlusion; Mesenteric Veins; Middle Aged; Postoperative Complications; Thrombophlebitis; Thrombosis; Warfarin

The present study was designed for long-term evaluation of the recently developed Hall-Kaster heart valve prosthesis. Mitral valve replacement was performed in 33 dogs. A detailed description of the operative procedure used is given. Extracorporeal circulation was instituted using a nonhemic priming volume resulting in an extreme hemodilution with hematocrit of about 15%. 19 of the animals died within 24 h, while 7 survived the observation period of 4--6 weeks. Thrombus on the valve was the major cause of early and late deaths. Anticoagulants were therefore given, and the therapy was made more extensive as the study progressed. The anticoagulation regime finally comprised warfarin administration preoperatively and throughout the experiment, and heparin infusion during the first 24 h postoperatively. Neomycin was used for preoperative sterilization of the gut. Later, cephalotin and penicillin were given. The use of these anticoagulants and antibiotics was found to be of major significance in providing us with a satisfactory canine model for long-term in vivo evaluation of the prosthesis.

Topics: Animals; Disease Models, Animal; Dogs; Heart Valve Prosthesis; Mitral Valve; Postoperative Complications; Thrombosis; Warfarin

Topics: Blood Platelets; Dipyridamole; Drug Evaluation; Drug Therapy, Combination; Glomerulonephritis; Graft Rejection; Humans; Kidney Glomerulus; Kidney Transplantation; Postoperative Complications; Renal Artery; Renal Artery Obstruction; Thrombosis; Transplantation, Homologous; Warfarin

Sixty Carpentier-Edwards porcine valve bioprostheses stabilized with glutaraldehyde were implanted in 55 patients with acquired and congenital heart disease. The follow-up period ranged between 1 and 12 months. There were 3 hospital deaths (5%) and 2 late deaths (4%) in 24 mitral, 24 aortic, 5 mitral-aortic, 1 tricuspid and 1 pulmonary valve replacements. All patients were anticoagulated from the second postoperative day onwards for a period of 3 months after which those with sinus rhythm had their anticoagulants withdrawn. Paravalvular leakage led to re-operation in 3 cases (4%). No valve failure due to cusp rupture was encountered and no thromboembolic complications have occurred. Thirty-three patients were studied postoperatively by non-invasive methods and the results are presented.

Topics: Adolescent; Adult; Aged; Aortic Valve; Aspirin; Bioprosthesis; Child; Female; Follow-Up Studies; Heart Valve Prosthesis; Humans; Male; Middle Aged; Mitral Valve; Postoperative Complications; Pulmonary Valve; Rehabilitation, Vocational; Tricuspid Valve; Warfarin

Topics: Cataract Extraction; Humans; Lenses, Intraocular; Postoperative Complications; Warfarin

The management of patients who require surgery while being treated with oral anticoagulants is a difficult balance between the risks of bleeding and those of recurrent thromboembolism. The urgency and the extent and site of surgery are important considerations, as are the strength of the indication for anticoagulants and the degree of anticoagulation. A practical approach is outlined for various situations that may be encountered.

Topics: Administration, Oral; Blood Transfusion; Hemorrhage; Heparin; Humans; Intraoperative Care; Postoperative Care; Postoperative Complications; Preoperative Care; Prothrombin Time; Thrombophlebitis; Vitamin K; Warfarin

Topics: Adult; Anticoagulants; Blood Coagulation; Female; Heart Valve Diseases; Heart Valve Prosthesis; Humans; Indoprofen; Male; Middle Aged; Phenylpropionates; Platelet Aggregation; Postoperative Complications; Thrombosis; Warfarin

Thromboembolic complication was correlated with the methods of anticoagulant therapy used in the patients with Starr-Edwards non cloth-covered or cloth-covered ball valve. A new anticoagulant therapy combining Bucolome with Warfarin has been used for the patients who were unable to be maintained in a suitable range of thrombotest Owren with Warfarin alone. The results obtained in this new therapy showed that the incidence of thromboembolism was reduced to 0.02 per patient year or less in the patients with Starr-Edwards ball valve as well as Björk-Shiley tilting disc valve.

Topics: Aortic Valve; Barbiturates; Drug Therapy, Combination; Heart Valve Prosthesis; Humans; Metals; Mitral Valve; Postoperative Complications; Silicone Elastomers; Thromboembolism; Warfarin

Pericardial tamponade occurring late in the hospitalization of a patient who has undergone a heart operation can be life threatening. Recognition of this insidious, but treatable, complication is difficult. Three patients experienced delayed tamponade while receiving warfarin prophylactically following coronary arter bypass. Two-dimensional echocardiography was useful in recognizing the effusion (and thus aided the diagnosis of tamponade) in each patients. The question of whether prophylactic antiocagulatin should be employed for patients undergoing coronary artery bypass procedures is also considered in light of both the present experience and collected reports from the literature.

Topics: Adult; Cardiac Tamponade; Coronary Artery Bypass; Echocardiography; Humans; Male; Middle Aged; Postoperative Complications; Thrombosis; Time Factors; Warfarin

We studied 100 consecutive patients to evaluate the potential effect of platelet active and antithrombotic agents prescribed preoperatively on bleeding complications after coronary-artery bypass graft surgery. Preoperative hemostatic values were normal in all patients. Mean mediastinal blood loss was significantly greater in 13 patients taking aspirin (892 +/- 91 ml) and six patients taking Coumadin (warfarin sodium) (858 +/- 168 ml) within 7 days of surgery than in 64 control subjects (439 +/- 28, P less than 0.001). Less marked but similar differences (P less than 0.05) were noted with other agents inhibiting platelet function. However, in nine patients given heparin, mean mediastinal blood loss (436 +/- 61 ml) was no different from that of control subjects. The degree of mediastinal blood loss did not correlate with age, sex, mean total operative time, bypass time, or number of vessels diseased or bypassed. In addition, patients taking aspirin or Coumadin required prolonged chest tube drainage compared to those in heparin or control groups (34 +/- 4 versus 20 +/- 1 h) (P less than 0.001).

Topics: Aged; Aspirin; Coronary Artery Bypass; Female; Hemorrhage; Humans; Male; Middle Aged; Postoperative Complications; Preoperative Care; Warfarin

Case histories of 140 patients who had mitral valve replacement with the Hancock xenograft were reviewed according to the incidence of thromboembolic complications. There were 16 patients with preoperative and/or postoperative low-output syndrome (Group A.) Eight of these patients died, and six had autopsies which showed major thrombi on the heterograft valve. In 126 long-term survivors (followed 1 to 33 months) nine thromboembolic events occurred (thromboembolic incidence 5.3 percent per patient-year). All patients with emboli were in atrial fibrillation. Additional predisposing factors included a history of systemic emboli and the presence of atrial clots at the time of surgery. The majority (7/9) of emboli occurred during the first 3 postoperative months. Two emboli occurred immediately following the operation (before oral anticoagulation therapy could have been begun). Five occurred in patients who were not on anticoagulation (Group B) and two occurred under warfarin treatment (Group C). There was no thromboembolic event in patients taking aspirin (Group D). It is concluded that hemodynamically stable patients have a decreased risk of thromboembolism and do not require anticoagulation. Patients with atrial fibrillation have an increased thromboembolic risk and should be on a regimen of warfarin for 3 months postoperatively and then on aspirin therapy.

Topics: Adolescent; Adult; Aged; Animals; Aortic Valve; Aspirin; Atrial Fibrillation; Blood Vessel Prosthesis; Child; Child, Preschool; Female; Humans; Male; Middle Aged; Mitral Valve; Postoperative Complications; Swine; Thromboembolism; Transplantation, Heterologous; Warfarin

Topics: Administration, Oral; Anticoagulants; Cerebrovascular Disorders; Drug Interactions; Hemorrhage; Humans; Postoperative Complications; Prothrombin Time; Pulmonary Embolism; Thromboembolism; Warfarin

One hundred eighty-three patients with cloth-covered valves were studied from 1 1/2 to 8 years after operation, with an average follow-up time of 3 1/2 years. Over the total period, patients taking Coumadin sustained a 4 percent embolic incidence (1.2 per 100 patient-years); those taking aspirin had a 7 percent incidence (2.6 per 100 patient-years); and those taking Persantine had a 43 percent incidence (10 per 100 patient-years). Patients on no regimen of anticoagulation had a 16 percent embolic rate (four per 100 patient-years), whereas another group of patients who stopped anticoagulants after a year incurred a 13 percent embolic incidence in the subsequent 2 years (6.4 per 100 patient-years). These data showed a significantly lowered embolic rate with anticoagulation and suggest that all patients with cloth-covered valves should be taking anticoagulants. That these valves become epithelialized and do not form thrombus after a year was not borne out by this study. Persantine alone is not a satisfactory anticoagulant. Coumadin appears to be the superior anticoagulant, but if careful monitoring of its use is in question or if serious bleeding complications ensue, aspirin may provide satisfactory protection.

Topics: Anticoagulants; Aortic Valve; Aspirin; Connecticut; Dipyridamole; Embolism; Female; Follow-Up Studies; Heart Valve Prosthesis; Humans; Male; Mitral Valve; Postoperative Complications; Warfarin

From September 1972 to January 1975, 390 patients underwent valve replacement using the Björk-Shiley tilting disc prosthesis. For the group as a whole hospital mortality was 13.3 per cent and was lowest in those undergoing isolated mitral or aortic valve replacement (5.3 and 9.4%, respectively). Available for follow-up were 209 patients of whom 123 were maintained on dipyridamole and 96 on warfarin. Thromboembolic complications were significantly (P less than 0.01) commoner in the dipyridamole (28 of 123, 22%) than warfarin (6 of 86, 7%) treated group. In the dipyridamole treated group the incidence of thromboembolic complications was similar whichever valve was replaced and thromboembolic complications were responsible for 14 of the 28 late deaths. In the warfarin treated group thromboembolic complications only occurred in patients with a mitral prosthesis. Anticoagulation is indicated for all patients with this prosthesis wherever inserted.

Topics: Anticoagulants; Dipyridamole; Heart Valve Prosthesis; Humans; Postoperative Complications; Thromboembolism; Warfarin

Symptoms and signs of decreased cardiac output associated with an elevated venous pressure should alert one to the possibility of delayed cardiac tamponade. Enlargement of the cardiothoracic ratio shown by serial roentgenograms and demonstration of significant pericardial effusion by echocardiogram or radionuclide angiocardiography support the diagnosis. Erratic response of the prothrombin time to administration of warfarin and abnormal results of liver function test are additional clues to its diagnosis. Right heart catheterization documents the presence of tamponade and excludes other diagnostic considerations. Operative decompression of the pericardial space can be accomplished by pericardicentesis, subxiphoid pericardiotomy, median sternotomy, or thoracotomy. Hemodynamic observations following the relief of tamponade assure that an adequate therapeutic procedure has been performed.

Topics: Adult; Blood Pressure; Cardiac Tamponade; Echocardiography; Female; Humans; Male; Middle Aged; Postoperative Complications; Prothrombin Time; Warfarin

Single mitral valve replacement was undertaken in 220 patients between March, 1971, and October, 1977. Bjork-Shiley prostheses (BS) were inserted in 42 patients, Braunwald-Cutter prostheses (BC) in 52, and Ionescu-Shiley pericardial xenografts (PX) in 126. No attempt was made at randomization. The actuarial survival rate was 81.9 +/- 12.8 percent at 7 years for patients with BS prostheses, 41.7 +/- 22.9 percent at 6 years for patients with BC prostheses, and 89.0 +/- 9.3 percent for patients with PX valves 7 years following valve replacement. Of the late deaths in patients with BC prostheses, 62.5 percent were valve related. The incidence of thromboembolism was 4.7, 1.8, and 1.5 episodes per 100 patient-years in the BS, BC, and PX groups, respectively. Long-term anticoagulation was used only in patients with BS and BC prostheses. Late postoperative hemodynamic studies were performed in six patients each with BS and BC prostheses and in 29 patients with PX valves. The mean diastolic gradients at rest were 6.2, 8.3, and 6.4 mm. Hg in the respective groups. The corresponding figures for calculated valve area were 1.8, 1.6, and 2.0 sq. cm. There was no statistically significant difference between the data recorded from the three groups of patients except for the survival rate of the BC prosthesis and the PX valve. The BS prosthesis and the PX valve have similar durability and hemodynamic performance for an almost identical duration of follow-up. Because of the improved quality of life and reduced morbidity without anticoagulants, we are using the PX valve exclusively for heart valve replacement.

Topics: Bioprosthesis; Blood Pressure; Cardiac Output; Diastole; Follow-Up Studies; Heart Valve Prosthesis; Hemodynamics; Humans; Mitral Valve; Oxygen; Postoperative Complications; Pulmonary Circulation; Thromboembolism; Vascular Resistance; Warfarin

Topics: Barbiturates; Heart Valve Prosthesis; Humans; Mitral Valve; Postoperative Complications; Thrombosis; Warfarin

From 1962-73 7,959 total hip replacements were performed by a standardized technique at Wrightington Hospital with 628 (7.89%) non-fatal emboli. Of 603 available for study the effect of different forms of anticoagulant therapy were compared with no therapy. The various antithromboembolic regimens in 295 cases had recurrent emboli in 13 per cent, while without anticoagulant therapy in 308 there were only 3.2 per cent recurrent pulmonary emboli.

Topics: Anticoagulants; Heparin; Hip Joint; Humans; Joint Prosthesis; Postoperative Complications; Pulmonary Embolism; Recurrence; Streptokinase; Warfarin; Wound Healing

The case of a 41-year-old male with a history of multiple emboli and short bowel syndrome who was successfully anticoagulated with sodium warfarin is described. The prothrombin times were stabilized in a therapeutic range with warfarin doses of 5.0 mg -7.5 mg daily. The pharmacokinetics of warfarin suggests that absorption is high in the proximal intestine. The successful use of sodium warfarin in the patient substantiates this finding and demonstrates that short bowel does not necessarily preclude the use of warfarin for anticoagulation. It is suggested that patients with short bowel syndrome may be successfully anticoagulated with oral products; however, careful monitoring of each patient's prothrombin time is necessary because of the variability and extent of bowel loss.

Topics: Adult; Embolism; Humans; Intestinal Diseases; Intestines; Male; Postoperative Complications; Time Factors; Warfarin

The morbidity and incidence of thromboembolic complications can be reduced by patient awareness, nursing staff concern, and physician responsibility using mechanical measures and drugs. Preoperative exercise instrutions, early ambulation, calf exercise, antiembolism hose, postoperative circle-bed turning and use of the Trendelenburg position, the use of intravenous dextran postoperatively and, in selected cases, low doses of sodium warfarin (Coumadin) form the foundation of our approach to the prophylaxis of thromboembolic phenomena. In the presence of thrombophlebitis, phenylbutazone (Butazolidin) is used. Dextran is used with caution in the presence of diminished biliary function. Heparin is avoided except in proven pulmonary embolism. No complications have resulted from this regimen.

Topics: Aspirin; Bandages; Dextrans; Exercise Therapy; Heparin; Hip Joint; Humans; Joint Prosthesis; Phenylbutazone; Postoperative Complications; Prospective Studies; Pulmonary Embolism; Thromboembolism; Thrombophlebitis; Warfarin

Topics: Aged; Anticoagulants; Arthritis, Rheumatoid; Arthroplasty; Aspirin; Blood Coagulation; Blood Platelets; Dextrans; Follow-Up Studies; Heparin; Hip Joint; Humans; Joint Prosthesis; Osteoarthritis; Postoperative Complications; Spondylitis, Ankylosing; Vitamin K; Warfarin

The incidence of fatal and nonfatal thromboemboli and bleeding episodes was compared in 53 patients who received sodium warfarin and in 17 successive patients who received no sodium warfarin after Beall mitral valve replacement. Actuarial curves showed that by 12 months postoperatively patients not receiving sodium warfarin had a greater incidence of emboli (P less than 0.01). This significant difference remained when the combined incidence of emboli and hemorrhage was considered (P less than 0.05). Deaths due to emboli or hemorrhage, however, were not statistically different in the two groups. The quality of control of prothrombin times (percent of prothrombin times two to two and a half times control) did not significantly influence the incidence of ebmoli although the numbers were small. However, fatal and nonfatal hemorrhagic episodes which did occur were almost invariably associated with prothrombin times greater than three to eight times control. Results of pre- and post-operative graded treadmill exercise tests in 39 patients receiving a Beall mitral valve replacement showed significant postoperative improvement in exercise tolerance. Nevertheless, the patients' postoperative working capacity was only 55% to 57% of that of age- and sex-matched sedentary controls. The present study supports the use of sodium warfarin therapy and strict anticoagulation control in Beall mitral valve replacement patients. It also documents a significant residual impairment in physical working capacity.

Topics: Adult; Aged; Exercise Test; Female; Georgia; Heart Valve Prosthesis; Hemorrhage; Humans; Male; Middle Aged; Mitral Valve; Postoperative Complications; Thromboembolism; Warfarin

Venous autografts were prepared in jugular veins of rabbits as a test model to determine the usefulness of antiplatelet and anticoagulant agents (aspirin and warfarin sodium) alone or in combination for maintaining patency in the reconstruction of small veins. Graft patency was determined by periodic venography and postmortem examination. The grafts clotted in all of the untreated controls, five of six animals receiving aspirin, and three of four receiving warfarin, but in none of the animals receiving the combination of aspirin and warfarin.

Topics: Animals; Aspirin; Drug Therapy, Combination; Female; Jugular Veins; Male; Platelet Aggregation; Postoperative Complications; Prothrombin Time; Rabbits; Radiography; Thrombosis; Transplantation, Autologous; Warfarin

Topics: Arthroplasty; Aspirin; Dextrans; Femoral Neck Fractures; Heparin; Hip Joint; Humans; Postoperative Complications; Pulmonary Embolism; Warfarin

Nineteen cardiac patients were given warfarin sodium to prevent thrombosis and embolism. Empirical dosage resulted in long hospital stays to obtain a stable therapeutic prothrombin time. Using a dosage of 0 therefore 5-0 therefore 7 mg/kg, therapeutic levels were achieved in a much shorter time. When prothrombin time was excessive, it was successfully reduced with vitamin K or plasma. A haematoma in one case and haematuria in another were easily controlled. Warfarin sodium appears to be appropriate and effective for children requiring anticoagulants within the above dosage limits and with meticulous follow-up.

Topics: Administration, Oral; Adolescent; Child; Female; Heart Valve Diseases; Humans; Male; Postoperative Complications; Prothrombin Time; Thromboembolism; Warfarin

The efficacy of two antithrombotic regimens, combined dextran and aspirin and combined dextran and warfarin, was analyzed by comparing the incidence of thromboembolism following total hip replacement in two groups of similar patients. Of the 427 who received dextran and aspirin, 7 per cent had thromboembolic complications, including one case of fatal pulmonary embolus and one case of recurrent emboli that required vena caval ligation, and 15 per cent had wound-healing complications. Of the 197 patients who received dextran and warfarin, 5 per cent had thromboembolism and 24 per cent had wound healing complications. Although both prophylactic regimens seemed effective, dextran and aspirin appeared less effective in reducing thromboembolic complications than dextran and warfarin, but there were fewer wound complications in that group. One-fourth of the patients on dextran-warfarin were not adequately anticoagulated despite close supervision. In forty-five patients with a history of thromboembolism who were excluded from the study and analyzed separately, warfarin alone and the two described regimens were equally ineffective in preventing thromboembolism, and the incidence of thromboembolic complications was high. Dextran-aspirin and dextran-warfarin appear to be satisfactory and relatively simple methods of thromboembolic prophylaxis.

Topics: Arthroplasty; Aspirin; Dextrans; Drug Therapy, Combination; Female; Hip Joint; Humans; Joint Prosthesis; Male; Middle Aged; Postoperative Complications; Pulmonary Embolism; Risk; Thromboembolism; Thrombophlebitis; Warfarin

Two patients, who suffered from pericardial tamponade in the course of prophylactic anticoagulant treatment, are reported. The mitral valve had been replaced by a prosthesis in both cases. The diagnosis was suspected clinically and radiologically and proven by pericardiocentesis. One of the patients was treated by a percutaneously inserted small polyethylene tube for continous drainage and the other by thoracotomy and partial pericardiectomy. Both patients recovered and are at present asymptomatic. Th mechanism of bleeding patients receiving anticoagulant therapy is briefly discussed.

Topics: Adult; Female; Heart Valve Prosthesis; Humans; Male; Mitral Valve; Pericardial Effusion; Postoperative Complications; Radiography; Time Factors; Warfarin

This report is based on information obtained from a questionnaire sent to major cardiac centres in the United Kingdom. This produced details of 39 pregnancies in 34 patients after valve replacement. The 39 pregnancies gave rise to 30 healthy babies. The small size of the series probably reflects both the increasing rarity of young women with rheumatic heart disease in this country and the cautious attitude of their cardiologists. This makes it likely that these women represented the best end of the spectrum of cardiac function after valve replacement. Twenty-four pregnancies in 20 women who were not given anticoagulants producted 23 healthy babies and 1 spontaneous abortion. This group comprised 6 patients with free aortic homografts, 1 patient with a fascia lata mitral valve, 1 with a Beall tricuspid prosthesis, 1 with a combined mitral homograft and Starr Edwards aortic prosthesis, and 1 with mitral and aortic frame-mounted fascia lata valves. There were no maternal deaths or thromboembolic complications in this group which included 5 patients who were in atrial fibrillation. Fifteen pregnancies in 14 women who received anticoagulants gave rise to 7 healthy babies. The fetal losses were one stillbirth, one intrauterine death at 34 weeks, and 3 spontaneous abortions; one surviving child has hydrocephalus as a result of blood clot and there were 2 maternal deaths. This group included 13 patients with Starr Edwards valves, 11 mitral and 2 aortic. A patient with a Hammersmith mitral valve was the only one to have been treated with heparin and her valve thrombosed. One patient with a mounted mitral homograft had a cerebral embolus. Nine of these patients were in atrial fibrillation. In 3 additional patients the valve replacement was carried out during pregnancy. Two of the patients survived operation. In one of these who was treated with warfarin the pregnancy well, but there is an increased fetal wastage in patients pregnancy gave rise to a congenitally malformed baby who died in the neonatal period. The baby born to the mother who did not receive anticoagulants has a hare-lip and talipes. Women with artificial valves can tolerate the haemodynamic load of pregnancy well, but there is an increased fetal wastage in patients taking oral anticoagulants. This is probably largely attributable to fetal haemorrhage but there is also a risk of malformation caused by a teratogenic effect of warfarin. Experience gained in non-pregnant patients suggests that withholdin

Topics: Abnormalities, Drug-Induced; Abortion, Spontaneous; Adolescent; Adult; Anticoagulants; Female; Fetal Death; Heart Valve Prosthesis; Heparin; Humans; Intracranial Embolism and Thrombosis; Postoperative Complications; Pregnancy; Pregnancy Complications, Cardiovascular; Warfarin

Cardiac tamponade occurring late after open-heart surgery is a frequently fatal complication. Of the 13 cases previously reported in the literature, there were seven deaths. In this report, three additional patients with late cardiac tamponade successfully treated are presented. Postoperative anticoagulation with Coumadin appeared to contribute to this complication. Increased awareness of late cardiac tamponade allowing prompt recognition and immediate decompression of the pericardial sac should lower the high mortality rate previously associated with the condition.

Topics: Adult; Cardiac Surgical Procedures; Cardiac Tamponade; Coronary Artery Bypass; Female; Heart Valve Prosthesis; Humans; Male; Middle Aged; Postoperative Care; Postoperative Complications; Time Factors; Warfarin

Clinically suspect but nonfatal pulmonary embolism followed vein surgery in 16 of 4,080 patients operated on over a 10-year period from 1962 to 1971, an incidence of 0.39%. The presence of superficial thrombophlebitis, previous or recent thromboembolic disease, or chronic deep venous insufficiency was a statistically significant factor in patients who had embolism. Prophylactic postoperative anticoagulant treatment in those with a thrombotic background appears justified.

Topics: Adult; Aged; Female; Heparin; Humans; Male; Middle Aged; Postoperative Complications; Pulmonary Embolism; Varicose Veins; Warfarin

Topics: Aged; Anticoagulants; Dicumarol; Heparin; Humans; Ligation; Postoperative Complications; Pulmonary Embolism; Recurrence; Vena Cava, Inferior; Warfarin

A 54-yr-old woman presented with a 23-yr history of repeated life-threatening thromboembolism. The presence of a qualitatively abnormal fibrinogen was suggested by the demonstration of delayed and incomplete coagulation of plasma or partially purified fibrinogen by thrombin or Reptilase. Two brothers showed a similar in vitro defect but were clinically not affected. The plasma fibrinogen concentration was 0.50-1.64 mg/ml when estimated by heat turbidity, clottability, or immunologic techniques. The serum contained 80-820 mug/ml of unclottable fibrinogen-related materials even after 24 hr exposure to thrombin. The fibrinogen-related material in the serum showed faster anodal mobility an immunoelectrophoresis than that of normal plasma. Immunodiffusion studies with rabbit antihuman fibrinogen antiserum showed lines of identity between control plasma and the patient's plasma and serum. Studies of the kinetics of thrombin action on fibrinogen demonstrated impaired release of fibrinopeptide A and B and defective polymerization of preformed fibrin monomers. The maximum amount of fibrinopeptide A released by exhaustive treatment with thrombin was similar (per milligram protein) for both the patient's and control fibrinogen. This abnormal fibrinogen varient is tentatively designated fibrinogen "New York"; its possible identity with one of the previously described abnormal fibrinogens has not been excluded.

Topics: Aprotinin; Blood Coagulation Tests; Carbon Radioisotopes; Female; Fibrinogen; Heparin; Hirudins; Humans; Hydrogen-Ion Concentration; Immunodiffusion; Immunoelectrophoresis; Iodine Radioisotopes; Mastectomy; Middle Aged; Peptides; Platelet Aggregation; Postoperative Complications; Serotonin; Thromboembolism; Warfarin

From March 1971 through April 1975, one hundred twenty patients underwent mitral valve replacement with a Hancock "stabilized glutaraldehyde process" porcine aortic xenograft. A simultaneous canine experimental series was also carried out. In the clinical series, the early mortality was 8.3%. Actuarial analyses of all patients predicts survival at two years of 81.0% and at four years of 70.0%. The predicted survival for patients without coronary disease or prior prosthetic valve replacement is 87.5% at two years and 77.5% at four years. There were four thromboembolic episodes, a rate of 2.4% per patient-year. None were fatal. No valve failure were noted. Histologic examination and shrink temperature analysis of recovered valves show excellent tissue preservation at 40 months. The data indicate that the Hancock valve is durable, enjoys a low incidence of thromboembolism, and may be the valve of choice for mitral valve replacement.

Topics: Adult; Aged; Aldehydes; Animals; Aortic Valve; Brain Diseases; Cardiac Surgical Procedures; Coronary Disease; Dogs; Endocarditis, Bacterial; Evaluation Studies as Topic; Female; Gastrointestinal Hemorrhage; Glutaral; Hematoma; Humans; Male; Methods; Middle Aged; Mitral Valve; Mitral Valve Insufficiency; Mitral Valve Stenosis; Postoperative Complications; Swine; Thromboembolism; Thrombophlebitis; Transplantation, Heterologous; Warfarin

Topics: Aged; Female; Gastrointestinal Hemorrhage; Heart Valve Prosthesis; Hematoma; Humans; Intestinal Obstruction; Postoperative Complications; Thrombosis; Warfarin

In the prevention of thromboembolic complications following elective total hip operations, warfarin is a safe and effective agent which causes minimal bleeding complications, if the drug is first administered on the first postoperative day and thereafter continued in various dosages to maintain a prothrombin time between one and one and one-half and two times that of the control. Dextran also is effective in preventing thromboembolic complications but causes more bleeding problems, especially when administered intraoperatively.

Topics: Aged; Anticoagulants; Dextrans; Female; Hematoma; Hemorrhage; Hip Joint; Humans; Joint Prosthesis; Male; Middle Aged; Osteoarthritis; Postoperative Complications; Pulmonary Embolism; Rheumatic Diseases; Surgical Wound Infection; Thromboembolism; Thrombophlebitis; Warfarin

Advanced actuarial techniques are used to analyze early and late results in a closely followed series of 396 patients who received a cloth-covered, composite-seat aortic prosthesis. Late mortality and various complications are carefully assessed, and most late deaths are seen to be unrelated to the prosthesis. One hundred sixteen patients with Model 2310-2320 prostheses who received warfarin postoperatively had no thromboembolic complications in 360 patient-years of follow-up (average, 3.1 years per patient); 134 patients who had the same prosthesis but did not receive warfarin had 9 emboli per 100 patient-years (average follow-up, 1.7 years per patient; total, 228 patient-years). By comparison, in 9 years' experience with non-cloth-covered Model 1200-1260 valves, 132 patients had 4.0 emboli per 100 patient-years (average follow-up, 5.1 years; total, 673 patient-years). The safety of cloth-covered valves is clearly enhanced by concomitant use of anticoagulants; the possibility that antiplatelet drugs may suffice has not yet been demonstrated. Strut cloth wear was found at reoperation in 10 patients. The Model 2400 composite strut ("track") valve with a narrow metal track on the inner surface of each strut prevents this complication.

Topics: Adolescent; Adult; Aged; Aortic Valve Insufficiency; Aortic Valve Stenosis; Female; Follow-Up Studies; Heart Valve Prosthesis; Humans; Male; Middle Aged; Postoperative Complications; Thromboembolism; Warfarin

Topics: Adolescent; Adult; Age Factors; Aged; Aneurysm; Arteries; Arteriovenous Fistula; Aspirin; Blood Vessels; Child; Child, Preschool; Colorado; Female; Heparin; Humans; Infant; Male; Methods; Middle Aged; Postoperative Complications; Radiography; Sex Factors; Thrombosis; Veins; Warfarin; Wounds and Injuries

Eleven patients with deep venous thrombosis were treated with streptokinase. Lysis of thrombi and prevention of pulmonay embolism were achieved in eight patients. Bleeding from the operative wound necessitated transfusions in seven patients. Fibrinolytic treatment of deep venous thrombosis lyses the floating portion of the thrombi. Protection against pulmonary embolism may be expected. The fibrinolytic effect of streptokinase is rapid; its value can be answered only by follow-up examinations.

Topics: Adult; Aged; Female; Hemorrhage; Heparin; Humans; Infant; Infusions, Parenteral; Male; Middle Aged; Phlebography; Postoperative Complications; Streptokinase; Thrombophlebitis; Warfarin

A case is presented of sudden deafness following cardio-pulmonary bypass surgery. Microembolism is believed to be the most likely cause as this is common following the use of pump oxygenator systems. There was no response to anticoagulants.

Topics: Animals; Aortic Valve Stenosis; Cardiopulmonary Bypass; Deafness; Extracorporeal Circulation; Heparin; Humans; Male; Middle Aged; Postoperative Complications; Warfarin

Topics: Adult; Follow-Up Studies; Humans; Jejunum; Male; Mesenteric Vascular Occlusion; Mesenteric Veins; Pneumatosis Cystoides Intestinalis; Postoperative Care; Postoperative Complications; Recurrence; Sex Factors; Sodium; Surgical Wound Infection; Thrombophlebitis; Thrombosis; Warfarin

Topics: Dextrans; Female; Fibrinogen; Genital Diseases, Female; Heparin; Humans; Hysterectomy; Injections, Intravenous; Injections, Subcutaneous; Iodine Radioisotopes; Postoperative Complications; Pulmonary Embolism; Thrombophlebitis; Warfarin

Topics: Exercise Therapy; Female; Hematoma; Hematuria; Hip; Hip Joint; Humans; Male; Melena; Postoperative Care; Postoperative Complications; Prothrombin Time; Pulmonary Embolism; Thrombophlebitis; Warfarin

Topics: Anticoagulants; Dextrans; Fibrinogen; Heparin; Humans; Iodine Radioisotopes; Phenindione; Postoperative Complications; Pulmonary Embolism; Thromboembolism; Warfarin

Topics: Aspirin; Dextrans; Female; Hemorrhage; Heparin; Hip Joint; Humans; Injections, Subcutaneous; Joint Prosthesis; Male; Middle Aged; Molecular Weight; Postoperative Complications; Prospective Studies; Pulmonary Embolism; Radiography; Thromboembolism; Thrombophlebitis; Warfarin

Topics: Adolescent; Adult; Blood Coagulation; Female; Heart Valve Prosthesis; Humans; Male; Middle Aged; Postoperative Care; Postoperative Complications; Thrombosis; Time Factors; Warfarin

Topics: Adult; Aged; Anesthesia, Inhalation; Blood Pressure; Blood Transfusion; Female; Gastrointestinal Hemorrhage; Halothane; Heart Arrest; Hip; Humans; Hypotension, Controlled; Joint Prosthesis; Male; Methylmethacrylates; Middle Aged; Myocardial Infarction; Osteotomy; Pentolinium Tartrate; Postoperative Complications; Pulmonary Embolism; Respiratory Insufficiency; Sodium; Thromboembolism; Thrombophlebitis; Warfarin

Topics: Anticoagulants; Fibrinolytic Agents; Heparin; Humans; Postoperative Complications; Pulmonary Embolism; Thromboembolism; Thrombophlebitis; Warfarin

Topics: Adult; Age Factors; Aged; Aspirin; Clothing; Dextrans; Dipyridamole; Exercise Therapy; Heparin; Humans; Iodine Radioisotopes; Middle Aged; Phlebography; Plethysmography, Impedance; Postoperative Complications; Pulmonary Embolism; Radionuclide Imaging; Thrombophlebitis; Ultrasonography; Warfarin

Topics: Adenosine Diphosphate; Aortic Valve; Blood Platelets; Cell Survival; Chromium Radioisotopes; Collagen; Heart Valve Diseases; Heart Valve Prosthesis; Heart Valves; Humans; Mitral Valve; Platelet Adhesiveness; Postoperative Complications; Prognosis; Prosthesis Design; Sulfinpyrazone; Thromboembolism; Time Factors; Transplantation, Homologous; Warfarin

Topics: Aged; Animals; Cattle; Diabetic Angiopathies; Female; Femoral Artery; Humans; Intermittent Claudication; Knee; Leg Ulcer; Male; Middle Aged; Pain; Popliteal Artery; Postoperative Complications; Radiography; Rest; Thrombosis; Transplantation, Heterologous; Warfarin

Topics: Anti-Bacterial Agents; Aortic Valve; Aspergillosis; Bacterial Infections; Calcinosis; Diagnosis, Differential; Embolism; Endocarditis; Furosemide; Heart Auscultation; Heart Valve Prosthesis; Heparin; Humans; Kidney; Lanatosides; Leg; Male; Middle Aged; Morphine; Myocardial Infarction; Myocardium; Oxygen; Postoperative Complications; Renal Artery; Thrombosis; Tooth Extraction; Warfarin

The high incidence of pulmonary embolism is well documented. At first suspicion of an embolism attack, adequate anticoagulant therapy was administered to 86% of the patients in this study. With failure of anticoagulants preoperatively, 30 patients received partial interruption of the IVC, 26 patients had their IVC ligated. Postoperatively, anticoagulants were administered to 64% of the patients who subsequently suffered recurrent attacks of embolism or new episodes of acute thrombophlebitis. These patients also had a substantial hazard of hemorrhage since 48% of the patients on heparin required transfusion. Postoperative mortality for the ligation group was associated with underlying conditions of the patients. These patients subjected to IVC plication had more deaths due to recurrence of pulmonary emboli and were demonstrated to have a substantially higher recurrence rate of pulmonary embolus. Reasons for this recurrence in both groups are discussed. Severe leg sequlae problems often associated with ligation were not encountered but were present in several patients subjected to plication.

Topics: Female; Hemorrhage; Heparin; Humans; Ligation; Male; Methods; Postoperative Care; Postoperative Complications; Preoperative Care; Pulmonary Embolism; Recurrence; Surgical Equipment; Thrombophlebitis; Vena Cava, Inferior; Warfarin

Topics: Aged; Animals; Blood Coagulation; Drug Therapy, Combination; Female; Femoral Fractures; Fibrinogen; Heparin; Hip; Hip Joint; Humans; Iodine Radioisotopes; Postoperative Complications; Pulmonary Artery; Pulmonary Embolism; Radiography; Radionuclide Imaging; Thromboembolism; Thrombophlebitis; Warfarin

Topics: Blood Pressure; Cardiac Catheterization; Computers; Endocarditis, Bacterial; Follow-Up Studies; Heart Valve Prosthesis; Heparin; Humans; Mitral Valve; Postoperative Care; Postoperative Complications; Prognosis; Pulmonary Artery; Surveys and Questionnaires; Thromboembolism; Warfarin

Topics: Adult; Blood Urea Nitrogen; Female; Heparin; Humans; Kidney Transplantation; Male; Middle Aged; Phlebography; Postoperative Complications; Proteinuria; Pulmonary Embolism; Renal Veins; Thrombosis; Transplantation, Homologous; Warfarin

Topics: Adult; Aged; Arthritis, Rheumatoid; Cloxacillin; Female; Hematoma; Hip; Hip Dislocation; Hip Joint; Humans; Joint Prosthesis; Male; Middle Aged; Ossification, Heterotopic; Osteoarthritis; Postoperative Complications; Pulmonary Embolism; Staphylococcal Infections; Streptomycin; Surgical Wound Infection; Thromboembolism; Warfarin

Topics: Adolescent; Adult; Aged; Anticoagulants; Arthritis, Rheumatoid; Female; Femoral Fractures; Follow-Up Studies; Gastrointestinal Hormones; Hematoma; Hip; Hip Dislocation; Hip Joint; Humans; Iatrogenic Disease; Joint Prosthesis; Male; Middle Aged; Ossification, Heterotopic; Osteoarthritis; Postoperative Complications; Thromboembolism; Warfarin

Topics: Adult; Age Factors; Cholecystitis; Chromium Alloys; Follow-Up Studies; Gastrointestinal Hemorrhage; Hepatitis; Hip; Hip Dislocation; Hip Joint; Humans; Joint Prosthesis; Middle Aged; Molecular Weight; Peripheral Nervous System Diseases; Polyethylenes; Postoperative Complications; Prosthesis Design; Surgical Wound Infection; Thromboembolism; Urinary Tract Infections; Warfarin

Topics: Aged; Dextrans; Female; Femoral Neck Fractures; Gastrointestinal Hemorrhage; Humans; Male; Postoperative Complications; Pulmonary Embolism; Thrombophlebitis; Warfarin

Topics: Acute Disease; Anticoagulants; Blood Coagulation Tests; Cardiac Surgical Procedures; Coronary Artery Bypass; Dextrans; Female; Fibrinolytic Agents; Hemorrhage; Heparin; Humans; Infusions, Parenteral; Injections, Subcutaneous; Postoperative Complications; Pregnancy; Pregnancy Complications, Hematologic; Prothrombin; Prothrombin Time; Pulmonary Embolism; Surgical Procedures, Operative; Thromboembolism; Thrombophlebitis; Thrombosis; Vascular Surgical Procedures; Warfarin

Topics: Administration, Oral; Aged; Dextrans; Female; Femoral Neck Fractures; Follow-Up Studies; Humans; Male; Middle Aged; Phlebography; Postoperative Care; Postoperative Complications; Premedication; Thromboembolism; Time Factors; Warfarin

Topics: Administration, Oral; Adult; Aged; Follow-Up Studies; Fractures, Bone; Hip; Hip Injuries; Humans; Middle Aged; Phlebography; Postoperative Care; Postoperative Complications; Preoperative Care; Thromboembolism; Time Factors; Warfarin

Topics: Adolescent; Adult; Aortic Valve Insufficiency; Atrial Fibrillation; Cerebral Hemorrhage; Child; Death, Sudden; Endocarditis, Bacterial; Female; Follow-Up Studies; Heart Valve Diseases; Heart Valve Prosthesis; Humans; Male; Middle Aged; Mitral Valve Insufficiency; Mitral Valve Stenosis; Myocardial Infarction; Postoperative Complications; Thromboembolism; Tricuspid Valve Insufficiency; Warfarin

Topics: Adult; Aspirin; Blood Coagulation Tests; Cholelithiasis; Diabetes Complications; Female; Heparin; Humans; Postoperative Complications; Pulmonary Embolism; Radiography; Radionuclide Imaging; Thrombophlebitis; Thrombosis; Warfarin

Topics: Aged; Female; Heparin; Humans; Postoperative Complications; Prostheses and Implants; Pulmonary Embolism; Radiography; Radionuclide Imaging; Recurrence; Thrombosis; Vena Cava, Inferior; Warfarin

Topics: Adult; Amides; Anticoagulants; Fibrinogen; Hematoma; Hemorrhage; Heparin; Hip Joint; Humans; Iodine Radioisotopes; Joint Prosthesis; Leg; Phlebography; Physical Examination; Postoperative Complications; Radionuclide Imaging; Thiazines; Thiazoles; Thrombophlebitis; Ultrasonography; Warfarin

Topics: Adolescent; Adult; Aged; Aortic Valve; Child; Evaluation Studies as Topic; Extracorporeal Circulation; Female; Follow-Up Studies; Heart Valve Prosthesis; Humans; Hypothermia, Induced; Male; Methods; Middle Aged; Mitral Valve; Polytetrafluoroethylene; Postoperative Complications; Prosthesis Design; Thromboembolism; Warfarin

Topics: Arthritis, Juvenile; Arthritis, Rheumatoid; Arthroplasty; Female; Follow-Up Studies; Hematoma; Heparin; Hip; Hip Joint; Humans; Joint Prosthesis; Male; New York City; Osteoarthritis; Paralysis; Peroneal Nerve; Postoperative Care; Postoperative Complications; Pulmonary Embolism; Splints; Surgical Wound Infection; Thromboembolism; Warfarin; Wound Healing

Topics: Arthroplasty; Blood Coagulation Tests; Hip; Humans; Postoperative Complications; Prospective Studies; Pulmonary Embolism; Thrombophlebitis; Warfarin

Topics: Aged; Gastrointestinal Hemorrhage; Hematoma; Humans; Intestinal Obstruction; Intestine, Small; Laparotomy; Male; Necrosis; Postoperative Complications; Warfarin

Topics: Adult; Age Factors; Aged; Aortic Valve Insufficiency; Aortic Valve Stenosis; Cardiac Surgical Procedures; Female; Gastrointestinal Hemorrhage; Humans; Male; Middle Aged; Mitral Valve Insufficiency; Peptic Ulcer Hemorrhage; Postoperative Complications; Sex Factors; Warfarin

Topics: Adult; Aged; Anticoagulants; Blood Coagulation; Blood Coagulation Tests; Edema; Female; Heparin; Humans; Leg; Male; Middle Aged; Postoperative Complications; Thrombophlebitis; Warfarin

Topics: Aged; Anticoagulants; Arteriosclerosis; Arthritis; Breast Diseases; Female; Gangrene; Humans; Hypertension; Mastectomy; Middle Aged; Necrosis; Penicillins; Postoperative Complications; Thrombophlebitis; Warfarin

Topics: Adolescent; Adult; Aortic Valve; Blood Platelets; Dipyridamole; Female; Heart Valve Prosthesis; Humans; Male; Middle Aged; Mitral Valve; Platelet Adhesiveness; Postoperative Complications; Thromboembolism; Warfarin

Topics: Angina Pectoris; Aorta; Cardiac Surgical Procedures; Central Nervous System Diseases; Coronary Disease; Coronary Vessels; Electrocardiography; Extracorporeal Circulation; Heart Ventricles; Humans; Hypoxia; Intubation, Intratracheal; Methods; Postoperative Complications; Recurrence; Ventricular Fibrillation; Warfarin

Topics: Aorta, Abdominal; Dextrans; Endarterectomy; Female; Femoral Artery; Follow-Up Studies; Hematoma; Hemorrhage; Humans; Intermittent Claudication; Ischemia; Leg; Male; Popliteal Artery; Postoperative Complications; Pulmonary Embolism; Saphenous Vein; Surgical Wound Infection; Thrombosis; Vascular Surgical Procedures; Warfarin

Patients with disorders of hemostasis who undergo surgical procedures are in danger of hemorrhage. While the careful medical history remains the most sensitive test of a bleeding tendency, some such patients can give no suggestive history. In three patients with coagulopathy-one with mild classical hemophilia, one with Christmas disease, and one with warfarin toxicity-the abnormality was missed by routine preoperative history but promptly detected by the routine preoperative use of the activated coagulation time (act). Either this test or the activated partial thromboplastin time should be included in the routine preoperative work-up, along with appropriate additional tests of the hemostatic mechanism.

Topics: Adult; Blood Coagulation Disorders; Blood Coagulation Tests; Child; Female; Hemophilia A; Hemophilia B; Humans; Male; Middle Aged; Postoperative Complications; Preoperative Care; Warfarin

Topics: Adult; Aged; Female; Filtration; Heparin; Humans; Iliac Vein; Laryngeal Nerve Injuries; Male; Middle Aged; Postoperative Complications; Pulmonary Embolism; Renal Veins; Vascular Surgical Procedures; Vena Cava, Inferior; Warfarin

Topics: Animals; Arteries; Arthroplasty; Aspirin; Blood Platelets; Dextrans; Dipyridamole; Hemorrhage; Hip; Humans; Joint Prosthesis; Postoperative Complications; Pulmonary Embolism; Thromboembolism; Thrombophlebitis; Veins; Warfarin

Topics: Abnormalities, Drug-Induced; Adult; Anticoagulants; Aortic Valve; Aortic Valve Insufficiency; Female; Fetal Death; Heart Valve Prosthesis; Heparin; Humans; Labor, Obstetric; Mitral Valve; Mitral Valve Insufficiency; Phenindione; Postoperative Complications; Pregnancy; Pregnancy Complications, Cardiovascular; Thromboembolism; Warfarin

Topics: Adult; Age Factors; Aged; Angiography; Blood Vessel Prosthesis; Diabetes Complications; Dicumarol; Female; Femoral Artery; Fluorocarbon Polymers; Follow-Up Studies; Heparin; Humans; Iliac Artery; Intermittent Claudication; Ischemia; Leg; Male; Methods; Middle Aged; Popliteal Artery; Postoperative Complications; Sex Factors; Thrombosis; Transplantation, Autologous; Transplantation, Homologous; Vascular Diseases; Veins; Warfarin

Topics: Adult; Aged; Anticoagulants; Female; Femoral Fractures; Fractures, Bone; Hemorrhage; Humans; Male; Middle Aged; Pelvic Bones; Postoperative Complications; Spinal Injuries; Thromboembolism; Warfarin

Aortic valve replacement with the University of Cape Town lenticular prosthesis was performed in 149 patients during a six-year period, almost all patients being severely disabled with advanced heart disease. There was a hospital mortality of 12 per cent. Bacterial endocarditis was a serious complication and accounted for three hospital and five long-term deaths. The survivors were followed for periods of up to 72 months (average 24), the minimum period of observation being six months. There were 23 late deaths due to heart disease, of which 5 where due to myocardial failure. Myocardial failure unrelieved or only temporarily alleviated by the operation occurred in three surviving patients. The main problems have been sudden death and systemic embolism. Some of the cases of sudden death were due to coronary artery embolism, but in a number the cause could not be determined even at necropsy, and they were presumed to be due to arrhythmia. Both complications appeared to be related to valve design. A bare steel seat was associated with a high incidence of both complications, whereas a woven Dacron-velour cloth-covered seat almost eliminated embolism and reduced the incidence of sudden death. Long-term anticoagulant therapy appears to be of no real value with the cloth-covered valve. Gratifying results were obtained in the surviving patients with loss of all symptoms in 80 per cent and improvement in almost all patients. This improvement or relief of symptoms was maintained in most patients throughout the period of study.

Topics: Adolescent; Adult; Aged; Alloys; Anemia, Hemolytic; Angina Pectoris; Aortic Valve; Aortic Valve Insufficiency; Aortic Valve Stenosis; Arrhythmias, Cardiac; Cardiovascular Diseases; Child; Endocarditis, Bacterial; Female; Follow-Up Studies; Heart Valve Prosthesis; Humans; Male; Middle Aged; Phenindione; Polymers; Postoperative Complications; Thromboembolism; Warfarin

The outcome of 185 consecutive autogenous vein bypass grafts for femoro-popliteal occlusions carried out between January 1962 and June 1968 has been reviewed. One patient died at operation and 21 late deaths have occurred since. The overall five-year patency was 61.5%, but was much lower when the popliteal-tibial runoff arteries were diseased. Distal anastomosis of the graft to the popliteal artery below the level of the knee joint also impaired the results, and if this was performed with a graft of minimal diameter less than 5 mm. sustained patency was obtained in only a quarter of the limbs. Nevertheless, where major amputation was imminent owing to advanced ischaemia three out of four limbs were salvaged.

Topics: Adult; Aged; Arteriosclerosis; Electrocardiography; Female; Femoral Artery; Follow-Up Studies; Humans; Ischemia; Male; Middle Aged; Phenindione; Popliteal Artery; Postoperative Complications; Transplantation, Autologous; Vascular Diseases; Veins; Warfarin

Topics: Adult; Aged; Factor IX; Female; Genital Diseases, Female; Genital Neoplasms, Female; Hemorrhage; Humans; Middle Aged; Postoperative Complications; Preoperative Care; Thromboembolism; Time Factors; Warfarin

Topics: Administration, Oral; Adult; Dextrans; Female; Fibrinolytic Agents; Humans; Injections, Intravenous; Postoperative Complications; Radiography; Thrombosis; Vertebral Artery; Warfarin

Topics: Adenocarcinoma, Papillary; Blood Coagulation Tests; Blood Platelet Disorders; Blood Transfusion; Chromium Isotopes; Colectomy; Colonic Neoplasms; Gastrointestinal Hemorrhage; Hematoma; Humans; Male; Middle Aged; Postoperative Complications; Staphylococcus; Thrombocytopenia; Thrombophlebitis; Warfarin

Topics: Acenocoumarol; Aged; Anticoagulants; Ethyl Biscoumacetate; Female; Humans; Male; Middle Aged; Postoperative Complications; Prothrombin; Thromboembolism; Warfarin

Topics: Adenocarcinoma; Animals; Mammary Neoplasms, Experimental; Mice; Postoperative Complications; Sarcoma, Experimental; Warfarin

Review of the 74 patients undergoing aortic valve replacement with a Starr-Edwards ball-valve prosthesis between October 1963 and December 1967 showed that 16 died during surgery or within the first month after operation, usually owing to myocardial failure; and there were nine late deaths. The remaining patients developed few major complications, and the long-term results of operation are considered satisfactory, no patient being grossly incapacitated and most of them are leading active, symptom-free lives.

Topics: Adolescent; Adult; Aged; Aortic Rupture; Aortic Valve Insufficiency; Aortic Valve Stenosis; Cardiac Tamponade; Female; Heart Valve Prosthesis; Humans; Male; Middle Aged; Myocardial Infarction; Postoperative Complications; Thrombosis; Warfarin

Topics: Hip; Humans; Methods; Postoperative Complications; Pulmonary Embolism; Thrombophlebitis; Warfarin

Topics: Adolescent; Adult; Angiocardiography; Cardiac Catheterization; Electrocardiography; Extracorporeal Circulation; Female; Follow-Up Studies; Heart Valve Prosthesis; Hemorrhage; Humans; Hypothermia, Induced; Infections; Jaundice; Kidney Diseases; Male; Methods; Middle Aged; Mitral Valve Insufficiency; Myocardial Infarction; Postoperative Care; Postoperative Complications; Pulmonary Emphysema; Rheumatic Heart Disease; Suture Techniques; Thromboembolism; Warfarin

Topics: Animals; Benzopyrans; Blood Coagulation Tests; Female; Hemorrhagic Disorders; Incisor; Injections, Intravenous; Ointments; Oral Hemorrhage; Postoperative Complications; Powders; Rats; Thrombosis; Tooth Extraction; Warfarin

Topics: Adolescent; Adult; Aged; Biliary Tract Diseases; Child; Female; Gastrointestinal Diseases; Humans; Infusions, Parenteral; Male; Middle Aged; Postoperative Complications; Thromboembolism; Warfarin

Topics: Female; Humans; Postoperative Care; Postoperative Complications; Preoperative Care; Probability; Thromboembolism; Warfarin

Topics: Adult; Dextrans; Female; Heparin; Humans; Leg; Male; Middle Aged; Phlebitis; Postoperative Complications; Pulmonary Embolism; Thrombophlebitis; Vascular Surgical Procedures; Vena Cava, Inferior; Warfarin

Topics: Heart Valve Diseases; Heart Valve Prosthesis; Hemorrhage; Humans; New York City; Postoperative Complications; Prothrombin Time; Thromboembolism; Warfarin

Topics: Abdomen; Coumarins; Dicumarol; Humans; Postoperative Complications; Thromboembolism; Warfarin

Topics: Dicumarol; Humans; Postoperative Care; Postoperative Complications; Pulmonary Embolism; Thrombophlebitis; Warfarin

Topics: Animals; Anti-Infective Agents, Local; Benzalkonium Compounds; Carbon; Cattle; Dextrans; Heart Valve Prosthesis; Heparin; Postoperative Complications; Thrombosis; Tricuspid Valve; Warfarin

Topics: Adult; Angiocardiography; Blood Pressure Determination; Cineangiography; Female; Heart Atria; Heart Valve Prosthesis; Heparin; Humans; Male; Middle Aged; Mitral Valve Stenosis; Postoperative Complications; Thrombosis; Warfarin

Topics: Adult; Aged; Female; Genital Diseases, Female; Humans; Middle Aged; Postoperative Complications; Thromboembolism; Warfarin

Topics: Acenocoumarol; Anticoagulants; Dicumarol; Drug Therapy; Heparin; Phenindione; Postoperative Complications; Preventive Medicine; Pulmonary Embolism; Thrombophlebitis; Toxicology; Venous Thrombosis; Vitamin K 1; Warfarin

Topics: Aqueous Humor; Cataract Extraction; Diabetes Mellitus; Diagnosis, Differential; Eye Neoplasms; Geriatrics; Glaucoma; Humans; Macula Lutea; Macular Degeneration; Pathology; Postoperative Complications; Retinal Detachment; Retinal Hemorrhage; Warfarin

Topics: Animals; Cardiac Surgical Procedures; Cattle; Dextrans; Heart Valve Prosthesis; Postoperative Complications; Thrombosis; Tricuspid Valve; Warfarin

Topics: Blood Coagulation Tests; Factor VII; Humans; Postoperative Complications; Prothrombin; Thromboembolism; Thrombosis; Toxicology; Warfarin

Topics: Dicumarol; Enzyme Inhibitors; Heparin; Phenindione; Postoperative Complications; Prothrombin; Thrombophlebitis; Warfarin

Topics: Atrial Fibrillation; Embolectomy; Embolism; Gastrointestinal Hemorrhage; Heparin; Humans; Mesenteric Artery, Superior; Mesenteric Vascular Occlusion; Postoperative Care; Postoperative Complications; Preoperative Care; Radiography; Rheumatic Heart Disease; Vascular Surgical Procedures; Warfarin

Topics: Anticoagulants; Coronary Disease; Dicumarol; Embolism; Ethyl Biscoumacetate; Hemorrhage; Humans; Postoperative Complications; Prothrombin Time; Thrombophlebitis; Toxicology; Warfarin

Topics: Aged; Aortic Valve; Aortic Valve Stenosis; Arrhythmias, Cardiac; Cardiac Catheterization; Cardiac Surgical Procedures; Digoxin; Endocarditis; Endocarditis, Bacterial; Heart Failure; Heart Valve Diseases; Heart Valve Prosthesis; Heart, Artificial; Humans; Isoproterenol; Methicillin; Middle Aged; Postoperative Complications; Psychoses, Substance-Induced; Psychotic Disorders; Thoracic Surgery; Warfarin

Topics: Anticoagulants; Artificial Organs; Cardiac Catheterization; Cardiac Surgical Procedures; Heart Failure; Heart, Artificial; Heparin; Humans; Mitral Valve; Mitral Valve Stenosis; Pathology; Postoperative Complications; Prostheses and Implants; Radiography, Thoracic; Thoracic Surgery; Thrombosis; Warfarin

Topics: Anesthesia; Anesthesia, Inhalation; Aortic Valve; Cardiac Surgical Procedures; Cyclopropanes; Heart Valve Diseases; Humans; Nitrous Oxide; Pathology; Postoperative Complications; Prostheses and Implants; Protamines; Thoracic Surgery; Thromboembolism; Thrombosis; Warfarin

Topics: Anti-Bacterial Agents; Anticoagulants; Drug Therapy; Female; Fever; Genital Diseases, Female; Heparin; Humans; Hysterectomy; Pelvis; Postoperative Complications; Puerperal Disorders; Thrombophlebitis; Warfarin