Orthopedic DVT Prophylaxis with aortic valve

[xcnellie]

So I know this is a hot-debated topic. I am putting in a call to our cardiologists who cover our hospital clinic, but they are on the other side of the world right now (ok well only across the metro area) to get there input as well. But I wanted to see what others had for knowledge or data.

 

Here's my patient

-75yo w/ cad, copd, fibrosis, chf (ef 40%), and remote s/p st. jude aortic valve. No afib, stroke, or DVT/PE hx. He is POD 1 s/p L TKA. He was bridged pre-op with 1mg/kg q12 Lovenox and holding coumadin. Now ortho who did his procedure yesterday, and conveniently isn't here now today since they got called to another hospital for call. Put him back on warfarin and Lovenox 30mg twice daily.

 

What should he be on? Treatment or prophylactic dose lovenox? This ortho group has no docs at all who use Lovenox post-op, all use coumadin for 2 weeks, then asa for 6 weeks and stick firm to that. In fact some of there older docs who don't come to our hospital still use ASA only for prophy!!

 

The other ortho group in the past few months had an elderly guy who they refused anything but Lovenox 40 qday with warfarin post-op. He had a complex past hx of mech mitral valve with replacement 6 weeks later due to a sternal infection followed by clotting of his valve.

 

Any opinions or data to support would be extremely helpful!!!

[andersenpa]

The breaking point is his thrombosis risk profile.

The guidelines endorse LV dysfunction, AF, hypercoaguable state, older mechanical valves (cage-ball models etc), and h/o thromboembolism as risk factors.

His CHF hx probably requires therapeutic heparin/LMWH until INR is in range.

A conservative apporach would be IV UFH or lovenox 1 mg/kg q 12 until the INR is up.