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What should be the management of post operative aortic valve?

Q: Four years ago, my wife underwent a surgery for severe aortic regurgitation (AR) at the age of 36 years. Her aortic valve was replaced with a prosthetic valve along with the aortic root. She has been prescribed Acitrom 4 mg/day, Cardace 2.5 mg/BD, Ecosprin 150/OD, Avas 10 mg/OD and Co-enzyme Q 10 100 mg/BD. Her body weight is around 87 kg. Ever since the surgery, her prothrombin time (PT) remains in the range of 17-19 and the INR at 1.99. We get a lipid profile done before every review and her triglycerides are around 247. The surgeon says that he wants to keep the PT around 19 and INR at the level of 2 but I am confused, because everywhere on the net I have read that the ideal INR for a post operative aortic valve patient should be around 2.3 to 3.0. Is the INR of 1.99 OK or should it be more? Is the cardiothoracic surgeon who operated her or another cardiologist is the best person to review her medication? Does the body weight have any affect on the amount of anticoagulant required (Acitrom)? What should be the ideal interval for review of medication? The CT surgeon normally calls us after 6 months. Shall we get an ECHO done every time we go for review to rule out any vegetation on the prosthetic valve?

A:1. The INR is a more reliable index of anticoagulation than prothrombin time. The INR recommended for aortic valve replacement in the US is higher than what surgeons in India have found from their experience to be necessary. Many of the experienced surgeons in India share the feeling that the clotting tendency with prosthetic valves in Indian patients is less than that in American patients. Therefore I would agree with your surgeon’s view that INR of 2 is quite acceptable. 2. The best person to review valve related medications is the surgeon who operated on your wife. 3. Yes, weight does have a bearing on the doze of anticoagulants and indeed other medications. Suppose the weight comes down to 70 Kg from the present 87 Kg, the dose would then have to be reviewed and possibly reduced. 4. After four years of valve replacement, six monthly reviews are acceptable. However, extra reviews may be necessary if the patients status changes e.g.. weight reduction, systemic illness, accidental injuries etc. 5. Echocardiography is not essential but desirable during six monthly reviews.

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