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).
Rheumatic heart disease.
Congenital heart defect.
Mitral and/or aortic valve
disease.
Normal aging and wear.

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
Its 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

Types of Artificial Heart Valves

Mechanical- There are three types. The caged

ball, tilting disk, and bileaflet
Tissue(biological)- valves that are used from
animals to implant them back into humans

Desired valves
Mechanical valves - 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.g., 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.

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

What is warfarin (Coumadin /Jantoven)?

Warfarin is an anticoagulant. The
name 'warfarin' "WARF" for
theWisconsin Alumni Research
Foundationand the ending "arin", indicating its link with
coumarin.
Coumarins (4-hydroxycoumarin
derivatives) are also used
asrodenticidesfor
controllingratsandmicein
residential, industrial, and
agricultural areas
The American Society of HealthSystem Pharmacists. Retrieved3
April2011.

Prothrombin Time (PT)

Historically, 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.

INR Equation
INR =

Patients PT in Seconds
Mean Normal PT in Seconds
INR = International Normalized Ratio
ISI = International Sensitivity Index

ISI

Clotting Cascade

Warfarin Mechanism of Action

Vitamin K
Antagonism
of
Vitamin K

VII
IX
X
II

Warfarin

Synthesis of
Non Functional
Coagulation
Factors

Warfarin: Current
Indications/Intensity
Indication INR Range Target
Prophylaxis of venous thrombosis (high-risk surgery)
Treatment of venous thrombosis
Prevention of systemic embolism
Tissue heart valves
AMI (to prevent systemic embolism)
Valvular heart disease
Atrial fibrillation

2.03.0 2.5

Mechanical prosthetic valves (high risk)

2.53.5 3.0
Certain patients with thrombosis and the antiphospholipid syndrome
AMI (to prevent recurrent AMI)
Bileaflet mechanical valve in aortic position, NSR 2.03.0 2.5

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
NSAIDS
Acetaminophen > 2g/d
Amiodarone
Quinolones (e.g., Cipro),
sulfonamides,
metronidazole
Fibrates
Ginkgo, Garlic, Ginseng
Grapefruit

Decrease Warfarin
Response
Phenobarbital
Carbamazepine
Phenytoin
Vitamin K rich foods
Green leafy
vegetables

THE
MANAGEMENT

Management of Warfarin for Invasive

Procedures
Risk of Bleeding

Risk of Thrombosis

Low

Low

High

Do procedure at:
subtherapeutic INR
range or lower
Do procedure at:
therapeutic or
subtherapeutic INR
range
LD = Low dose
AdjD = Adjusted dose
FD = Full dose

High
Do procedure at:
normal INR range;
use no alternative or
use LD, AdjD or FD
Do procedure at:
normal INR range; use FD

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