Discontinuation Of Warfarin Research Articles

Outcomes of different perioperative management strategies of patients on chronic anticoagulation in elective total hip and knee arthroplasty: a systematic review.

There are currently different management guidelines for patients undergoing elective total hip arthroplasty (THA) or total knee arthroplasty (TKA) that are on long-term anticoagulation. The timing of discontinuation and restarting the anticoagulation is challenging during the postoperative care, which often involves general practitioners and physiotherapists. The systematic review followed the PRISMA guidelines and included 3 databases: PubMed/MEDLINE, EMBASE, and Web of Science Core Collection. It was registered in the International Prospective Register for Systematic Reviews and Meta-analysis (PROSPERO) under the registration number: CRD42023408906. The risk of bias assessment was performed using the Methodological index for non-randomized studies (MINORS) criteria. Six retrospective studies involving 727 patients with therapeutic anticoagulation (1,540 controls) for elective THA, TKA and revision arthroplasty have been included. The follow-up ranged from 30 days to 1 year postoperatively. All studies evaluated outcomes of warfarin therapeutic anticoagulation versus prophylactic dosages of one or more of the following: warfarin, aspirin, low-molecular-weight heparin (LMWH) and unfractionated low-dose heparin (UFH). One study did not discontinue therapeutic anticoagulation. Two studies reported no significant differences in complications between groups, whilst 3 studies had significantly higher rates of superficial wound infections, revision surgeries, postoperative haematomas, and prosthetic joint infections (PJI). Different anticoagulation-related perioperative management strategies achieve different outcomes following elective arthroplasty in patients with therapeutic chronic anticoagulation. There is contradictory evidence regarding the need for the discontinuation of therapeutic warfarin. Retrospective data showed that individual risk stratification with multi-modal prophylaxis resulted in minimal complications. Systematic Review of Level III studies.

Anticoagulation decision-making before non-cardiac surgery in patients with mechanical heart valve: A retrospective study

ObjectiveTo clarify the timing of warfarin discontinuation at different ranges of INR. Improve anticoagulation management in non-cardiac surgical patients with MHV. DesignThis is a single-center retrospective observational study. Settingand participants This study used data from the Hospital Information System, and the Surgery and Anesthesia Information System of the Second Affiliated Hospital of Army Military Medical University. Participants included 121 adult patients with MHV who underwent non-cardiac surgery from 2012 to 2021. ResultsOverall, 121 patients with MHV (15 aortic valve only, 56 mitral valve only, and 50 with multiple valves) underwent non-cardiac surgery. When the duration of warfarin discontinuation was ≤ 3 days, 3−5 days, and≥5 days, the INR was 1.45, 1.15, and 1.09, respectively. Bleeding between INR ≤1.2 and INR >1.2 groups was not statistically significant using Student's t-test (95% CI −0.57, 0.14 P = 0.24). Multivariate regression analysis revealed that Intraoperative bleeding volume correlated with preoperative albumin levels (OR = 0.68，95% CI 0.49, 0.89). ConclusionsWhen need preoperative INR is less than 1.5 in patients with MHV undergoing non-cardiac surgery, preoperative warfarin discontinuation for 3 days is sufficient. If INR less than 1.2, preoperative warfarin discontinuation for 3–5 days is appropriate. And in patients with MHV underwent abdominal surgery, intraoperative bleeding is not significant reduced by lower INR after preoperative warfarin discontinuation. Furthermore, the effect of albumin levels on coagulation function cannot be ignored in patients with MHV. Strengths and limitationsThis study was derived from real-world clinical data. It's a retrospectively study to describe the INR changed according to the duration of warfarin discontinuation in patients with MHV and compared intraoperation of bleeding volume between INR>1.2 and INR ≤ 1.2after warfarin discontinuation. To clarify the timing of warfarin discontinuation at different ranges of INR. Improve anticoagulation management in non-cardiac surgical patients with MHV, while providing clinicians with a reference for preoperative warfarin adjustment. This study does have a few limitations. The number of cases is small because patients undergoing repeat noncardiac surgery after heart valve surgery are a special case population. And the patients were not followed up after non-cardiac surgery. The impact of changes in INR on postoperative complications could not be assessed in patients with MHV.

Interventional treatment of haemorrhoids in anticoagulated patients

Anticoagulants are currently widely used for cardiological reasons, stroke prevention and in other vascular diseases. Colorectal surgeons face patients suffering from haemorrhoids who are put on anticoagulant therapy in their everyday practice. Anticoagulation strategy for patients undergoing interventional treatment of haemorrhoids has not been discussed in detail in the literature so far. Standard management of grade 1-3 haemorrhoids includes rubber band ligation (RBL), sclerotherapy (SCL) and infrared coagulation (IRC) after unsuccessful conservative treatment. The rates of postprocedural bleeding range from 0.9-2.8% after rubber band ligation, 0-2.7% after sclerotherapy and 5% after infrared coagulation. Surgical procedures including dearterialization, haemorrhoidectomy and stapled haemorrhoidopexy are indicated in more advanced degrees as the third line of treatment and are complicated by postoperative bleeding in 1.4-5.9% and 2-7.9% patients, respectively. Haemorrhoidectomy is the best option in grade 4 haemorrhoids and is associated with 6.2-8.4% risk of bleeding. However, closed haemorrhoidectomy, Ligasure technique and/or anal tamponade can reduce this risk. Surgical guidelines recommend continuing acetylsalicylic acid in low bleeding risk procedures, including haemorrhoidal surgery. However, postoperative bleeding after rubber band ligation was more common in the aspirin group. On the other hand, haemorrhage incidence after sclerotherapy did not differ significantly between the group on anticoagulation compared with the group without anticoagulation. Haemorrhoidectomy should be postponed for 6 months in patients receiving dual antiplatelet therapy. According to the guidelines, vitamin K antagonists should be discontinued 5 days before haemorrhoidal surgery. Minimal bleeding risk procedures do not require discontinuation of anticoagulation,but this option seems to be hazardous for patients undertaking rubber band ligation. Sclerotherapy, on the other hand, could not require warfarin discontinuation if the international normalized ratio (INR) is within therapeutic range. Novel oral anticoagulants (NOACs) should be discontinued 1 day before low bleeding risk operations, including haemorrhoidectomy and resumed 1 day after the procedure. In conclusion, all anticoagulants should be ceased prior to operation except for aspirin. There are not clear recommendations on the perioperative protocols for continuation or discontinuation of blood thinners in patients undergoing minimally invasive procedures.

S3197 Warfarin-Induced Skin Necrosis Following Routine Endoscopy in a Patient With Cirrhosis

Introduction: Warfarin-induced skin necrosis (WISN) is rare, and most cases are caused by inherited deficiencies of protein C. Acquired protein C deficiency has been associated with advanced liver disease, ulcerative colitis (UC), and malignancies. Due to its rarity, clinicians must have a high index of suspicion for WISN to avoid delays in diagnosis or treatment. Case Description/Methods: A 67-year-old male with UC, cirrhosis due to primary biliary cholangitis, and prior pulmonary embolism on warfarin underwent surveillance EGD and colonoscopy. Warfarin was held for five days prior to the procedures without bridging. EGD was unremarkable and colonoscopy revealed active UC. He resumed warfarin therapy the next day. Two days later, he developed significant tenderness and bruising on his abdomen, flank, and outer thighs. After evaluation by multiple providers, his pain was attributed to central sensitization, and he was prescribed gabapentin. Over the next several days, he developed extensive painful retiform purpura and expanding areas of superficial necrosis (Figure 1). He was admitted to the hospital for multidisciplinary evaluation. Extensive workup assessed potential causes, such as WISN, sepsis, vasculitis, disseminated intravascular coagulation (DIC), thrombotic thrombocytopenic purpura (TTP), or cryoglobulinemia. Given the characteristic appearance and temporal association with restarting warfarin, WISN was thought to be the most likely etiology. Protein C activity was low at 22% (normal 70-150%). Genetic testing for inherited protein C deficiency was negative, confirming an acquired deficiency. For management of WISN, warfarin was discontinued, heparin was initiated, and protein C was repleted with fresh frozen plasma (FFP). He was discharged on warfarin after bridging with heparin. He later had recurrence of his necrotic rash, and an excisional biopsy confirmed WISN. Warfarin was then discontinued in favor of lifelong enoxaparin. Discussion: Our case highlights a rare but devastating complication of warfarin use. In WISN, protein C is depleted prior to other vitamin K-dependent factors, leading to a transient hypercoagulable state, microvascular occlusion, and tissue necrosis. Despite our patient’s risk factors (liver disease and active UC) and characteristic presentation, diagnosis of WISN was delayed. Prompt recognition and treatment (discontinuation of warfarin, IV heparin, vitamin K and FFP) is crucial for tissue preservation and avoidance of morbid surgical interventions.Figure 1.: Images of the patient’s abdomen and right thigh (left) and left hip (right). The skin is extensively involved with painful retiform purpura and areas of superficial necrosis with associated hemorrhagic bullae.

Warfarin Discontinuation in Patients with HeartMate3 Left Ventricular Assist Device

<h3>Purpose</h3> The standard of care for management in patients with Heartmate 3 (HM3) left ventricular assist devices (LVAD) involves anticoagulation with warfarin for thromboprophylaxis. To date, there have been no major prospective studies that evaluate outcomes of patients with HM3 LVAD off anticoagulation. We aimed to review cases of patients with HM3 LVAD in which warfarin was discontinued for various reasons. <h3>Methods</h3> A multicenter retrospective review was done of patients implanted with a HM3 LVAD. Patients who were initially on anticoagulation after implantation but later discontinued were identified. The primary outcome evaluated was the presence of a pump related thrombotic adverse event defined as pump thrombosis, stroke, or systemic embolism. Additional characteristics including echocardiographic parameters, hematologic lab values, and LVAD parameters were assessed. <h3>Results</h3> A total of eight patients were identified at three advanced heart failure centers. LVAD therapy was implemented for a median of 556 days (67-1113 days, range). Warfarin was discontinued in five patients due to substantial bleeding (recurrent GI bleeds, intracranial bleeds/subdural hematoma) and discontinued in the other three patients due to self-discontinuation/non-adherence. Warfarin was discontinued for a median of 180 days (43-567 days, range). Of the identified patients, 50% of the patients were not on aspirin. None of the patients reviewed had pump related thromboembolic or thrombotic events after discontinuing warfarin. One patient died due to cirrhosis and right ventricular failure. There was no observed change in echocardiographic parameters, lab values, or LVAD parameters after cessation of warfarin. <h3>Conclusion</h3> In this multicenter case review, warfarin discontinuation in patients with HM3 LVAD did not result in an increase of pump related thrombotic events. In select cases, it is reasonable to discontinue anticoagulation however close monitoring is required. Further investigation is required to understand the long term safety and hemocompatibility of discontinuing anticoagulation in patients with HM3 LVAD.

Přímé náklady na léčbu pacientů s nevalvulární fibrilací síní nově indikovaných k léčbě apixabanem: retrospektivně prospektivní jednoramenná kohortová studie

Atrial fibrillation (AF) affects 46.3 million people; its prevalence has tripled over the last 50 years. AF leads to formation of blood clots increasing four-fold the risk of a stroke. Preventive anticoagulant therapy with warfarin has been well established for over 50 years but has efficacy and safety limitations. New anticoagulants do not require laboratory monitoring of prothrombin time, have low risk of adverse events, yet are more costly.This non-interventional (Act 378/2007 Coll.) retrospective-prospective single-arm cohort study consisted of 3 visits. The primary objective was to compare the total direct cost of treatment with warfarin and apixaban. Patients with non-valvular AF were enrolled at the time of discontinuation of warfarin and switching to apixaban. Costs were derived from the care provided and the list of medical procedures (Decrees 268/ 2019 Coll.). Satisfaction was assessed using SAFUCA® questionnaire.Between February 2017 and June 2019, 499 patients were enrolled in 29 Czech internal medicine clinics. The mean age of the patients was 73.6 ± 10.2 years, 36.5% were at high risk of bleeding (HAS-BLED score). Previous warfarin treatment lasted 5.9 ± 2.7 months, 63% were unable to achieve target prothrombin time, 18% switched due to adverse reactions. New apixaban treatment was followed for the first 6 months. Treatment with warfarin was associated with higher rates of major bleeding and adverse events (22 vs. 2), stroke (17 vs. 0), ischemic heart attack (11 vs. 0), and minor bleeding (173 vs. 2). The average daily cost following the switch to apixaban decreased from CZK 65.2 to CZK 4.8 (p.

Using a Simple Prescription Gap to Determine Warfarin Discontinuation Can Lead to Substantial Misclassification.

Warfarin remains widely used and a key comparator in studies of other direct oral anticoagulants. As longer-than-needed warfarin prescriptions are often provided to allow for dosing adjustments according to international normalized ratios (INRs), the common practice of using a short allowable gap between dispensings to define warfarin discontinuation may lead to substantial misclassification of warfarin exposure. We aimed to quantify such misclassification and determine the optimal algorithm to define warfarin discontinuation. We linked Medicare claims data from 2007 to 2014 with a multicenter electronic health records system. The study cohort comprised patients ≥65 years with atrial fibrillation and venous thromboembolism initiating warfarin. We compared results when defining warfarin discontinuation by (1) different gaps (3, 7, 14, 30, and 60 days) between dispensings and (2) having a gap ≤60 days or bridging larger gaps if there was INR ordering at least every 42 days (60_INR). Discontinuation was considered misclassified if there was an INR ≥2 within 7 days after the discontinuation date. Among 3,229 patients, a shorter gap resulted in a shorter mean follow-up time (82, 95, 117, 159, 196, and 259 days for gaps of 3, 7, 14, 30, 60, and 60_INR, respectively; p < 0.001). Incorporating INR (60_INR) can reduce misclassification of warfarin discontinuation from 68 to 4% (p < 0.001). The on-treatment risk estimation of clinical endpoints varied significantly by discontinuation definitions. Using a short gap between warfarin dispensings to define discontinuation may lead to substantial misclassification, which can be improved by incorporating intervening INR codes.

Clinical outcomes in lower extremity deep vein thrombosis treated with a direct oral anticoagulant: A retrospective cohort study

Background/Aim: Rivaroxaban and apixaban were shown to be non-inferior and somewhat superior to warfarin in preventing pulmonary embolization and venous complications. However, there is still a need for further evidence concerning the efficacy and safety of direct oral anticoagulants in the treatment of patients with deep vein thrombosis (DVT) and pulmonary embolism (PE). This study aimed to analyze patients with DVT and PE who received a direct oral anticoagulant (apixaban) during their hospitalization and thereafter. Methods: Data of all consecutive subjects admitted for lower limb DVT who received apixaban for DVT treatment in our department between January 2015-April 2019 were analyzed. Apixaban was directly administered after the diagnosis of DVT in 68 subjects, following discontinuation of warfarin due to the lack of success in maintaining appropriate INR values in 56 subjects and following the discontinuation of the rivaroxaban due to gastrointestinal complications in 7 subjects. Results: Apixaban was administered for a median duration of 12.0 (12.0-24.0) months. The most common predisposing factors for venous thromboembolism were thrombophilia and major surgery history. Among all, 62.59% of the DVT were at and proximal to the femoral vein. Concomitant PE was encountered in 16.03% of the study subjects. Those with distal DVT and those who received apixaban immediately after diagnosis of the DVT less frequently developed PE compared to those who received post-rivaroxaban or post-warfarin apixaban. Treatment with apixaban leads to a significant decline in D-dimer levels from the first month of the treatment (P<0.001). Recurrent DVT and PE occur in 10% and 16%, respectively, under apixaban treatment. Conclusions: Among patients with proximal DVT, those receiving apixaban following a period of treatment with rivaroxaban or warfarin compared to direct administration constitute the majority of the PE cases. Apixaban seems like an effective treatment option in patients with DVT and PE.

Rebleeding in patients with delayed bleeding after endoscopic submucosal dissection for early gastric cancer.

Delayed bleeding is a major adverse event in endoscopic submucosal dissection (ESD) for early gastric cancer (EGC). Some patients may experience rebleeding after successful hemostasis for delayed bleeding, yet the details of rebleeding remain unclear. We aimed to clarify the frequency and risk factors of rebleeding. Among 11,452 patients who underwent ESD for EGC at 33 institutions in Japan between 2013 and 2016, we analyzed 489 patients showing delayed bleeding. The rate of rebleeding was investigated. Subsequently, 15 candidate variables were evaluated for their influence on the risk of rebleeding via logistic regression analysis. Rebleeding occurred in 11.2% (55/489) of the enrolled patients. Multivariate analysis revealed that warfarin [odds ratio (OR), 2.71; 95% confidence interval (CI), 1.26-5.84] and a resection size >40mm (OR, 1.99; 95% CI, 1.08-3.67) were independent risk factors for rebleeding. In the analysis of the management of warfarin after index bleeding, only warfarin discontinuation (OR, 3.66; 95% CI, 1.37-9.78) was significantly associated with rebleeding in comparison with no use of warfarin. However, many rebleeding events (75.0%) occurred following the resumption of warfarin. The rebleeding rate during discontinuation status and that in taking warfarin (continuation or resumption) were 6.1% and 20.0%, respectively. Rebleeding was not a rare event in patients experiencing delayed bleeding after ESD for EGC. In addition to having a resection size >40mm, warfarin usage placed patients at high risk for rebleeding, especially at the timing of its resumption following discontinuation as well as its continuation.

Nonatrial Fibrillation Patients With Complete P Wave Disappearance: An Overlooked Population With High Stroke Risk.

Complete P wave disappearance (CPWD) in patients without atrial fibrillation is an uncommon clinical phenomenon. We aimed to study the relationship between CPWD and thromboembolism. Between July 2007 and December 2018, consecutive patients with CPWD on surface ECG and 24-hour Holter recording were recruited into the study from 4 centers in China. All recruited patients underwent transesophageal echocardiography or cardiac computed tomography to screen for atrial thrombus. Atrial electrical activity and scar were assessed by electrophysiological study (EPS) and 3-dimensional electroanatomic mapping. Cardiac structure and function were assessed by multimodality cardiac imaging. Twenty-three consecutive patients (8 male; mean age 48.5±14.7 years) with CPWD were included. Only 3 patients demonstrated complete atrial electrical silence with atrial noncapture. Thirteen patients who had invasive atrial endocardial mapping demonstrated extensive scar. Pulse-wave mitral inflow Doppler demonstrated absent and dampened A waves in 18 and 5 patients, respectively. Pulse-wave tricuspid inflow Doppler showed absent and dampened A waves in 19 and 4 patients, respectively. Upon recruitment, 8 patients had previous stroke and 3 patients had atrial thrombus. Warfarin was prescribed to all patients. During median follow-up of 42.0 months, 2 patients developed massive ischemic stroke due to warfarin discontinuation. Our study suggested that CPWD reflects extensive atrial electrical silence and significantly impaired atrial mechanical function. It was strongly associated with thromboembolism and the clinical triad of CPWD-atrial paralysis-stroke was proposed. Anticoagulation should be recommended in such patients.

Premature permanent discontinuation of apixaban or warfarin in patients with atrial fibrillation

AimsThe ARISTOTLE (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation) trial randomised patients with atrial fibrillation at risk of stroke to apixaban or warfarin. We sought...

Effect of warfarin discontinuation on the incidence of postoperative bleeding in tooth extraction.

ObjectivesThe number of patients undergoing oral anticoagulant therapy for cardiovascular and cerebrovascular disease is increasing. However, the risk of bleeding after tooth extraction in patients receiving warfarin is unclear. Here, we assess the risk of bleeding after tooth extraction in patients on warfarin.Materials and MethodsThe study included 260 patients taking warfarin who underwent tooth extraction (694 teeth). The patients were divided into those whose teeth were extracted while they were taking warfarin, those who discontinued warfarin before extraction, and those who underwent extraction while receiving heparin bridging therapy. Bleeding complications in the two groups were compared.ResultsOf the 260 patients, 156 underwent extraction while taking warfarin, 70 stopped taking warfarin before extractions, and 34 received heparin bridging therapy and stopped taking either medication before extractions. Bleeding complications occurred in 9 patients (3.5%) and 9 tooth sites (1.3%). Among the 9 patients with bleeding complications, 6 underwent extraction while taking warfarin, 2 stopped warfarin before extraction, and 1 underwent extraction after receiving heparin bridging therapy. No significant difference was seen between patient groups regarding bleeding after extractions (P=0.917).ConclusionWarfarin use does not increase the risk of post-extraction bleeding and can therefore be continued during tooth extraction.

Assessment of the attitude, awareness and practice of periprocedural warfarin management among health care professional in Qatar. A cross sectional survey

It is estimated that 10–15% of oral anticoagulant (OAC) patients, would need to hold their OAC for scheduled surgery. Especially for warfarin, this process is complex and requires multi-layer risk assessment and decisions across different specialties. Clinical guidelines deliver broad recommendations in the area of warfarin management before surgery which can lead to different trends and practices among practitioners. To evaluate the current attitude, awareness, and practice among health care providers (HCPs) on warfarin periprocedural management. A multiple-choice questionnaire was developed, containing questions on demographics and professional information and was completed by187 HCPs involved in warfarin periprocedural management. The awareness median (IQR) score was moderate [64.28% (21.43)]. The level of awareness was associated with the practitioner’s specialty and degree of education (P = 0.009, 0.011 respectively). Practice leans to overestimate the need for warfarin discontinuation as well as the need for bridging. Participants expressed interest in using genetic tests to guide periprocedural warfarin management [median (IQR) score (out of 10) = 7 (5)]. In conclusion, the survey presented a wide variation in the clinical practice of warfarin periprocedural management. This study highlights that HCPs in Qatar have moderate awareness. We suggest tailoring an educational campaign or courses towards the identified gaps.

Outcomes Following Discontinuation of Warfarin in Heartmate 3 Patients: A Multi-Center Review

Bleeding complications during left ventricular assist device (LVAD) support pose anticoagulation challenges as risk of discontinuation of anticoagulation, even in the setting of bleeding, may pose an increased risk of subsequent LVAD hemolysis or thrombosis. We assessed whether discontinuation of anticoagulation in HM3 patients whose bleeding concerns preventing anticoagulation would adversely impact outcomes. This multi-center, retrospective review included HeartMate 3 patients implanted between November 2016 and July 2019 for whom warfarin was discontinued. Patient characteristics, reason for anticoagulation discontinuation and subsequent adverse events were collected for all patients. The primary outcome was incidence of pump thrombosis. Secondary outcomes included bleeding events and overall survival. Ten patients were analyzed (80% male, 70% ischemic cardiomyopathy and 80% destination therapy). Preopertively, three patients required warfarin and 3 had a prior history of gastrointestinal bleeding (GIB). Reasons for anticoagulation discontinuation post HM3 placement included: GIB (N=5), hemorrhagic CVA (N=3), gross hematuria (N=1), hemothorax (N=1), and allergy (N=1). Four patients had concomitant Aspirin discontinuation. Time supported with HM3 off anticoagulation ranged from 69 to 961 days, representing 4,869 patient-days in total (Figure 1A). During this follow-up time, one patient experienced an embolic CVA attributed to left atrial appendage clot with subsequent hemorrhagic transformation, and one patient required device exchange for thrombosis. Bleeding also remained a common adverse event (N=5) despite the lack of anticoagulation. These data highlight the complicated hemocompatibility challenges associated with long-term LVAD support in a sub-group of patients. Discontinuation of both Aspirin and Warfarin can be considered in a select group of HM3 patients, but with judicious monitoring for early signs of adverse events.

Evaluation of Patients with Ineffective Anticoagulation after Left Ventricular Assist Device (LVAD) Implantation: Early and mid term follow up

Reports about discontinuation of anticoagulant therapy in LVAD patients are very limited. We reported that our experience of discontinuation of warfarin and aspirin therapy due to bleeding and ineffective international normalized ratio (INR) in patients with LVAD. From June 2013 to June 2019, hundred and forty seven patients that underwent LVAD implantation at our department. We analyzed outcomes of patients in whom warfarin and aspirin therapy had to be discontinued due to bleeding and temporary warfarin resistance during ongoing support with LVAD. None of these patients received any anticoagulation therapy until their bleeding event was over. INR <2 was defined as ineffective INR. We collected baseline and follow-up data, including patient characteristics, history of atrial fibrillation, history of heparin-induced thrombocytopenia, renal function at time of discontinuation. We checked speed, flow rates and power consumption parameters of pump, lactate dehydrogenase (LDH), creatinine, total bilirubin and INR level daily. After patients were discharged from the hospital, they returned to our center for follow-up, device review and clinical assessment. Of thirty five (23.8%) patients, mean age was 41 ± 16 (19-65) years, mean follow up time was 645.7 ± 430 (52-1315) days. Thirty patients had to discontinue warfarin due to bleeding and ineffective INR due to warfarin resistance in five patients. Mean duration of ineffective INR was 24.5 ± 12.1 (9-45) days. In one of the patient with intracranial hemorrhage, pump thrombosis was encountered, and his pump had to be exchanged with an urgent operation. There were not any other adverse events in this patient population. Mean follow-up time after ineffective INR situation was 344 ± 417 (94-1240) days. No delayed rehemorrhages or pump complications were observed after resuming aspirin and warfarin therapy. Despite advances in device technology and treatment strategies, prospective, controlled studies are needed to determine the new anticoagulation regimen that most effectively balances bleeding and thrombosis in LVAD patients.

Warfarin Accelerates Medial Arterial Calcification in Humans.

Warfarin is associated with medial arterial calcification in humans, but the magnitude and specificity of this effect and the role of other risk factors are unknown. Using serial mammograms, progression of arterial calcification was compared in women receiving no anticoagulants, warfarin, or other anticoagulants, and before, during, and after warfarin use. Approach and Results: Warfarin users with mammograms were identified by computerized searches of medical records that included renal function and diabetes mellitus. Lengths of calcified arterial segments were measured, with progression expressed as millimeters per breast per year and presented as medians and interquartile range (IQR). In women with normal renal function (estimated glomerular filtration rate >60 mL/minute per 1.73 m2), progression was 3.9-fold greater in warfarin users: 9.9 (3.8-16) versus 2.5 (0.7-6.7) in controls, P=0.0003, but not increased in users of other anticoagulants. In longitudinal analyses, progression increased from 2.1 (IQR, 0.3-3.9) to 13.8 (IQR, 7.8-38.7; P=0.011) after starting warfarin (n=11) and decreased from 8.8 (IQR, 1.1-10) to 1.9 (IQR, -10 to 6.7; P=0.024) after discontinuation of warfarin (n=13). Progression of calcification was similar in warfarin users with chronic kidney disease (7.3 [IQR, 3.6-17], n=29) but markedly accelerated in warfarin users with end-stage renal disease (47 [IQR, 31-183], n=11; P=0.0002). Progression was similar in diabetic and nondiabetic warfarin users (10.1 [IQR, 3.8-24] versus 7.8 [IQR, 3.6-15]) and did not correlate with age (r=0.09) or duration of warfarin therapy (r=0.12). Warfarin significantly accelerates medial arterial calcification in humans. This effect is markedly augmented in end-stage renal disease.

The safe and risk assessment of perioperative antiplatelet and anticoagulation therapy in inguinal hernia repair, a systematic review.

There is a lack of consensus on the continuation or cessation of perioperative antiplatelet and anticoagulation therapies in inguinal hernia repair, therefore, the local hospital protocols dealing with these agents vary. The aim of this study is to investigate the risk and safety of perioperative antiplatelet and anticoagulation therapies in patients undergoing elective inguinal hernia repair. The major databases (PubMed, Embase, Springer, and Cochrane Library) were searched, and all studies published through January 2019 were identified, using the keywords Aspirin, Clopidogrel, Warfarin, antiplatelet, anticoagulation, inguinal hernia repair, bleeding, hematoma, complications. All relevant articles and reference lists in these original studies were also obtained from the above databases. Thirteen articles were identified, ten studies reported the results of perioperative application of antiplatelet therapy during inguinal hernia repair, nine trials reported the outcomes perioperative use of anticoagulation therapy in inguinal hernia repair, and six articles reported the results of both agents. One study did not indicate the perioperative cessation or continuation of the corresponding agents. Cessation of antiplatelets was reported in three studies and continuation of antiplatelets was used in six studies, they all demonstrated similar incidence of the bleeding complications, as compared with controls. Continued perioperative anticoagulation with Warfarin was reported in six studies and Warfarin discontinuation 3days prior to operation was examined in two studies, both reported similar postoperative bleeding-related complication rates providing international normalized ratio (INR) < 3, and the postoperative hematoma incidence increased in the condition of INR > 3. Our results indicated that, for both open and laparoscopic inguinal hernia repair, there is no need to stop the antiplatelet therapy (Aspirin or Clopidogrel), and due to the limited evidence and the complexity of each patient' condition, the continuation or cessation of anticoagulation with Warfarin should be tailored on a case-by-case basis.

Interruption of long-term warfarin is not necessary in patients undergoing total hip arthroplasty

IntroductionThe management of anticoagulation in patients undergoing arthroplasty remains a challenge. Guidelines for perioperative management of long-term warfarin recommend discontinuation of warfarin preoperatively in low risk patients. We hypothesised that patients who had their warfarin continued during the perioperative period would have shorter hospital stay and no significant increase risk of surgical complications compared to patients who had their warfarin interrupted. MethodsThis was a retrospective review of 20 consecutive patients receiving long-term warfarin who underwent total hip replacement without stopping warfarin. As a control group, we collected same data from 20 age and gender matched patients also on long term warfarin but their warfarin was stopped prior to surgery and restarted postoperatively. ResultsThere was no significant difference in age, BMI or comorbidities between the 2 groups. There was a statistically significant difference between the two groups in postoperative INR (P < 0.0001) levels. The mean drop in Hb postoperatively was 25.95 g/L in the warfarin group and 35.7 g/L in the control group, which was statistically significant (P = 0.0066). Hospital stay was statistically significant with shorted stay observed in the warfarin group (P = 0.0447). The odds ratio for developing a postoperative complication was 1.5882 which was not statistically significant (P = 0.6346). ConclusionOur results support the hypothesis that it is safe to continue warfarin in patients on long term anticoagulation undergoing total hip replacement. Continuation of warfarin was associated with significantly shorter hospital stay and less INR fluctuations. There was no significant increase in the risk of complications or blood transfusion.

Warfarin Induced Necrosis of The Breast: A Case Report

Background: Warfarin induced breast necrosis is a rare complication of oral anticoagulant therapy. Although it can be related to protein C, S, and antithrombin III deficiency; the pathogenesis of necrosis is still unknown.&#x0D; Case presentation: We report a case of a 38-year-old woman with extensive left breast necrosis after receiving warfarin for treatment of deep vein thrombosis. Simple mastectomy was performed and the wound was closed secondarily with an abdominal advancement flap. Rivaroxaban was prescribed after discontinuation of warfarin.&#x0D; Conclusion: Although breast necrosis following warfarin usage is uncommon, it should be considered in women presenting with breast symptoms after initiation of warfarin. Early diagnosis and appropriate management are essential to prevent extensive loss of breast tissue.

Warfarin Induced Necrosis of The Breast: A Case Report

Background: Warfarin induced breast necrosis is a rare complication of oral anticoagulant therapy. Although it can be related to protein C, S, and antithrombin III deficiency; the pathogenesis of necrosis is still unknown.&#x0D; Case presentation: We report a case of a 38-year-old woman with extensive left breast necrosis after receiving warfarin for treatment of deep vein thrombosis. Simple mastectomy was performed and the wound was closed secondarily with an abdominal advancement flap. Rivaroxaban was prescribed after discontinuation of warfarin.&#x0D; Conclusion: Although breast necrosis following warfarin usage is uncommon, it should be considered in women presenting with breast symptoms after initiation of warfarin. Early diagnosis and appropriate management are essential to prevent extensive loss of breast tissue.