A 56-year-old man comes to the office due to a 3-month history of upper abdominal discomfort. CT scan of the abdomen reveals a cystic pancreatic lesion; an endoscopic ultrasound-guided biopsy is planned. Medical history is significant for hypertension, hyperlipidemia, and a bicuspid aortic valve that was diagnosed at age 24. The patient underwent an aortic valve replacement with a bileaflet mechanical aortic valve at age 44 due to symptomatic aortic regurgitation. He takes warfarin daily and attends regular follow-up visits at an anticoagulation clinic. He had an episode of epistaxis a year ago that required nasal packing for 2 days.
ECG is unremarkable. An echocardiogram 2 months ago showed normal left ventricular size and function with an ejection fraction of 60%. The mechanical aortic valve prosthesis had normal leaflet motion, and there was mild mitral and tricuspid regurgitation. The aortic root size was normal.
Which of the following is the best next step in management of this patient?

Question

A 56-year-old man comes to the office due to a 3-month history of upper abdominal discomfort.  CT scan of the abdomen reveals a cystic pancreatic lesion; an endoscopic ultrasound-guided biopsy is planned.  Medical history is significant for hypertension, hyperlipidemia, and a bicuspid aortic valve that was diagnosed at age 24.  The patient underwent an aortic valve replacement with a bileaflet mechanical aortic valve at age 44 due to symptomatic aortic regurgitation.  He takes warfarin daily and attends regular follow-up visits at an anticoagulation clinic.  He had an episode of epistaxis a year ago that required nasal packing for 2 days.
ECG is unremarkable.  An echocardiogram 2 months ago showed normal left ventricular size and function with an ejection fraction of 60%.  The mechanical aortic valve prosthesis had normal leaflet motion, and there was mild mitral and tricuspid regurgitation.  The aortic root size was normal.
Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_973b_5c25_853d_6313d920e27c_MD0002_00 This patient on warfarin due to his mechanical valve is scheduled for a high-bleeding-risk procedure (ie, endoscopic ultrasound with biopsy). A mechanical bileaflet aortic valve is considered either a moderate-thrombotic-risk condition or, when accompanied by ≥1 additional risk factor for stroke (eg, hypertension), a high-thrombotic-risk condition. The generally recommended approach in patients with moderate or high thrombotic risk is to hold warfarin for 5 days until the INR falls <1.5 and then perform the procedure. Warfarin can usually be resumed the evening following the procedure with no need for bridging. high-bleeding-risk procedure In contrast to the high rate of blood flow through the aortic valve, the relatively stagnant blood flow surrounding the mitral valve creates very high thrombotic risk in patients with a mechanical mitral valve. For patients with a very-high-risk thrombotic condition, perioperative bridging with low-molecular-weight or unfractionated heparin is indicated; warfarin is typically held 5 days prior to the procedure, and heparin is started once the INR is <2.0 (rather than <1.5) (Choice D). Heparin should be stopped the day of the procedure and then restarted 24-48 hours afterward, in combination with warfarin, when adequate hemostasis has been achieved. (Choice A) Patients undergoing low-bleeding-risk procedures (eg, carpal tunnel repair, tooth extraction, endoscopy without biopsy) can often proceed without any change in anticoagulation regimen. (Choice B) This patient is symptomatic and has signs of possible malignancy requiring tissue diagnosis. Ultrasound-guided biopsy is appropriate and can be performed safely with temporary interruption of warfarin. (Choice C) Vitamin K administration is not recommended as it leads to a prolonged lag phase before the INR reaches therapeutic range after warfarin is restarted. Educational objective: In patients with a high-risk condition for perioperative thrombosis (eg, mechanical bileaflet aortic valve) managed with warfarin, it is recommended that warfarin be held until the INR is <1.5 and then the procedure may be performed; bridging therapy is not indicated. However, patients with a very-high-risk thrombotic condition (eg, mechanical mitral valve) should undergo perioperative bridging with low-molecular-weight or unfractionated heparin. __________ References: 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. (http://www.ncbi.nlm.nih.gov/pubmed/24589852) Management of antithrombotic agents for endoscopic procedures. (http://www.ncbi.nlm.nih.gov/pubmed/19889407)

A 56-Year-Old Man Comes to the Office Due to a 3-Month