This case involves an elderly female patient who underwent an aortic valve replacement without complications during the procedure. The patient’s medical history before the procedure had been notable for hypertension, severe obesity, and reduced kidney function. Following the procedure, the patient was sent to another facility to undergo physical therapy and rehabilitation, however her time at the facility was largely spent in bed. After a few weeks in the facility, the woman was sent back to the hospital via ambulance after she began to experience shortness of breath and was admitted. While in the hospital, the woman suffered from a pulmonary embolism that eventually proved fatal.
Question(s) For Expert Witness
- 1.How often do you perform surgeries like the one listed in the case?
- 2.What is the appropriate anticoagulation after aortic root replacement with pericardial valve and single vessel CABG?
Expert Witness Response E-088827
I perform root replacements, similar to the one described, approximately 10 times per year. At my hospital perform I CABG, with or without pericardial valve replacement, on a near daily basis. In general, we would use Lovenox for post-operative anticoagulation until the time of discharge. The patient would then be instructed to continue with a daily aspirin, in addition to other classes of post-operative medicines. I have seen post-operative Pulmonary Embolisms, and I have reviewed related cases in which the patient was not prescribed post-operative deep vein thrombosis prophylaxis as well as a failure to recognize symptoms of post-operative DVT/PE.
Expert Witness Response E-029623
Coronary artery bypasses and aortic valve replacement form the bulk of my practice. I do root replacements frequently. Appropriate anticoagulation after CABG – Aspirin alone is the standard of care. After aortic root with a tissue valve many surgeons will put the patient on anticoagulation “Coumadin” for a few months, if there are no contraindications. Many surgeons will not start the patient on Coumadin, since frequently the risk of bleeding complications is higher than the risk of thromboembolic complications related to the surgery. Also, it is the standard of care to have inpatients after heart surgeries placed on prophylaxis against DVTs. SQ Heparin is the most common way to do it. It usually gets discontinued at the time of discharge from the hospital.