45-year-old man for Right middle finger terminalisation revision

Background

• AVR 2015 post episode of Infective endocarditis
• Ex-IVDU on methadone program
• Current smoker – 20+pack years
• Hepatitis C – treated
• PVD
• ETOH excess – intermittent 

Issues

• Anticoagulated with warfarin but self-ceased in last 6-12 months
• Multifactorial reasons – social and transport difficulties
• Unable to travel for pathology testing as no longer holds a Driver’s license  
• GP has referred to cardiology in hospital 3 times in last few months, appointment pending
• Commenced on therapeutic clexane in clinic but when called patient to check on him he had also recommenced his warfarin

Discussion

• Cardiology MDT – NOAC not an option. Requires warfarin anticoagulation.
• Current evidence – NOAC’s are inferior to warfarin for stroke and thromboembolic prevention with mechanical heart valves. NOAC’s also carry an increased bleeding risk in this population. See attached RE-ALIGN trial.
• Echocardiogram should be done urgently to assess valve
• Discussion centred around difficulties of trying to resolve long-term issues in perioperative clinic. Can be very time-consuming and patient often in the room when advice is being sought. Adds to time pressure
• May often be better to refer to GP but this has its own limitations, especially during COVID times.
• Collaborative approach after clinic appointment often works best

Plan

• Continue warfarin and cease Clexane
• Recheck INR
• Echocardiogram organised