THE USE OF WARFARIN

IN PROSTHETIC HEART
VALVE PATIENTS
Stanley Santosa Kamadjaja drg. (SLA)
Oral and Maxillofacial Surgery
Residents
Batch XV
Airlangga University

Why do you need a valve
replacement?
Valves control the flow of blood by making it move in one direction through the
different chambers or parts of the heart.
■ If a valve is not working correctly, blood flow is impaired.
■ if a valve does not close properly, blood may leak between the chambers or
flow backwards, a condition known as valve regurgitation, insufficiency, or
incompetence.
■ If a valve is narrowed (also called stenosed), blood flow through the heart may
be restricted.
■ If the valve problem is minor, it may be treated with medication. But if the
heart valve damage is severe, a procedure may be required to repair or replace
the malfunctioning valve.

Indications for valve repair or replacement Valve repair or replacement may be required if a valve has been damaged by: ■ Infection (endocarditis). ■ Normal aging and wear. ■ Rheumatic heart disease. ■ Congenital heart defect. ■ Mitral and/or aortic valve disease. .

Approach in valve correction ■ Valve repair – Surgical – Minimally invasive valve repair – Non-surgical valve repair ■ Valve Replacement ■ Non-surgical valve replacement .

THE REPLACEMENT .

Artificial heart valve  An artificial heart valve is a mechanism that mimics the function of a human heart valve  It’s used for patients with a heart valvular disease or have a damaged valve  Heart valves are used to provide the heart with a unidirectional blood flow  They act as pumps .

Ideal valve ■Good hemodynamic ■Quiet ■Require no anticoagulation ■Last for life time ■Cheap ■Easy to implant .

There are three types. and bileaflet  Tissue(biological). The caged ball.Types of Artificial Heart Valves  Mechanical.valves that are used from animals to implant them back into humans . tilting disk.

.preferred in young patients who have a life expectancy of more than 10 to 15 years who require long-term anticoagulant therapy for other reasons (e..Desired valves ■ Mechanical valves . atrial fibrillation) ■ Bioprosthetic valves preferred in patients who are elderly have a life expectancy of less than 10 to 15 years who cannot take long-term anticoagulant therapy ■ A bileaflet-tilting-disk or homograft prosthesis is most suitable for a patient with a small valvular annulus in whom a prosthesis with the largest possible effective orifice area is desired.g.

THE MEDICATION .

Antithrombotic ■An antithrombotic agent is a drug that reduces the formation of blood clots (thrombi). – Anticoagulants: prevent clot formation and extension – Antiplatelet drugs: interfere with platelet activity – Thrombolytic agents: dissolve existing thrombi .

indicating its link with coumarin. The name 'warfarin' "WARF" for the Wisconsin Alumni Research Foundationand the ending "- arin". Retrieved 3 April2011. industrial. ■ Coumarins (4-hydroxycoumarin derivatives) are also used as rodenticides for controlling rats and mice in residential. and agricultural areas ■ The American Society of Health- System Pharmacists.What is warfarin (Coumadin® /Jantoven)? ■ Warfarin is an anticoagulant. .

. a most reliable and “relied upon” clinical test However: – Proliferation of thromboplastin reagents with widely varying sensitivities to reduced levels of vitamin K-dependent clotting factors has occurred – Concept of correct “intensity” of anticoagulant therapy has changed significantly (low intensity) – Problem addressed by use of INR (International Normalized Ratio) – The INR is a mathematical correction that normalizes the PT ratio by adjusting for the variability in the sensitivity of the different thromboplastins.Prothrombin Time (PT) ■ Historically.

INR Equation ISI INR = ( Patient’s PT in Seconds Mean Normal PT in Seconds ) INR = International Normalized Ratio ISI = International Sensitivity Index .

Clotting Cascade .

Warfarin Mechanism of Action Vitamin K Antagonism VII of Synthesis of IX Non Functional Vitamin K X Coagulation Factors II Warfarin .

NSR 2.5 .0–3.0 2.0–3. Warfarin: Current Indications/Intensity Indication INR Range Target Prophylaxis of venous thrombosis (high-risk surgery) 2.5–3.0 Certain patients with thrombosis and the antiphospholipid syndrome AMI (to prevent recurrent AMI) Bileaflet mechanical valve in aortic position.0 2.5 Treatment of venous thrombosis Prevention of systemic embolism Tissue heart valves AMI (to prevent systemic embolism) Valvular heart disease Atrial fibrillation Mechanical prosthetic valves (high risk) 2.5 3.

Relative Contraindications to Warfarin Therapy ■ Pregnancy ■ Situations where the risk of hemorrhage is greater than the potential clinical benefits of therapy – Uncontrolled alcohol/drug abuse – Unsupervised dementia/psychosis .

Warfarin: Major Adverse Effect— Hemorrhage ■ Factors that may influence bleeding risk: – Intensity of anticoagulation – Concomitant clinical disorders – Concomitant use of other medications – Quality of management .

Drug Interactions Increase Warfarin Response Decrease Warfarin ■ NSAIDS Response ■ Acetaminophen > 2g/d ■Phenobarbital ■ Amiodarone ■Carbamazepine ■ Quinolones (e. Garlic.. Cipro).g. ■Phenytoin sulfonamides. Ginseng vegetables ■ Grapefruit . metronidazole ■Vitamin K rich foods ■ Fibrates – Green leafy ■ Ginkgo.

THE MANAGEMENT .

AdjD or FD Do procedure at: Do procedure at: High therapeutic or normal INR range. use FD subtherapeutic INR range LD = Low dose AdjD = Adjusted dose FD = Full dose . range or lower use no alternative or use LD.Management of Warfarin for Invasive Procedures Risk of Bleeding Low High Risk of Thrombosis Do procedure at: Do procedure at: Low subtherapeutic INR normal INR range.

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Low risk of valve thrombosis Bileaflet aortic valve Normal LV function Sinus rhythm Stop warfarin 48-72 hours before procedure Restart warfarin within 24 hours after .

High risk of valve thrombosis: mitral valve tricuspid valve Aortic valve AND atrial fibrillation prior thromboembolism hypercoagulable older generation valve LVEF < 30% a second mechanical valve Therapeutic unfractionated heparin when INR < 2.0 Restart as soon as possible .

Questions? .

THANK YOU .