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
 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
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 the Wisconsin
Alumni Research Foundationand the
ending "-arin", indicating its link with
coumarin.
■ Coumarins (4-hydroxycoumarin
derivatives) are also used
as rodenticides for
controlling rats and mice in residential,
industrial, and agricultural areas
■ The American Society of Health-System
Pharmacists. Retrieved 3 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

( )
Patient’s PT in Seconds ISI
INR =
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
Vitamin K IX Non Functional
X Coagulation
Factors
II

Warfarin
Warfarin: Current Indications/Intensity
Indication INR Range Target
Prophylaxis of venous thrombosis (high-risk surgery) 2.0–3.0 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) 2.5–3.5 3.0
Certain patients with thrombosis and the antiphospholipid syndrome
AMI (to prevent recurrent AMI)
Bileaflet mechanical valve in aortic position, NSR 2.0–3.0 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
■ Fibrates
■ Vitamin K rich foods
– 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:
subtherapeutic INR range normal INR range; use no
Low
or lower 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