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 Health-
System 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

ISI
INR = ( Patients 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
 Warfarin: Current
Indications/Intensity
Indication INR Range Target
Prophylaxis of venous thrombosis (high-risk surgery) 2.03.0 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) 2.53.5 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 Decrease Warfarin

NSAIDS Response
Acetaminophen > 2g/d Phenobarbital
Amiodarone Carbamazepine
Quinolones (e.g., Cipro), Phenytoin
sulfonamides,
metronidazole Vitamin K rich foods
Fibrates Green leafy
Ginkgo, Garlic, Ginseng vegetables
Grapefruit
 THE
MANAGEMENT
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;
range or lower use no alternative or
use LD, 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
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