Coumadin Implicated in Cardiac Ablation Patient’s Death

Joseph O'Neill

Written by
— Updated on April 11, 2018

CoumadinThis case takes place in Oregon and involves a 60-year-old overweight male patient who required a cardiac ablation. The patient had a past medical history of obesity and atrial fibrillation, and he had been prescribed Coumadin. During the ablation procedure, the treating surgeons recognized that the patient required an emergent cholecystectomy – which had to be converted to open technique, due to complications intra-operatively. Post-operatively, physicians had a difficult time controlling the patient’s PTT. The patient was given a large dose of Heparin on post op day 5. He coded and died due to hemorrhaging.

Question(s) For Expert Witness

  • 1. If given the necessary material, can you make a decision on whether or not the Coumadin dosage was appropriate for this patient?

Expert Witness Response E-005901

Based on the initial information provided to me, this patient was prescribed coumadin (i.e., warfarin) prior to a routine cardiac ablation for treatment of atrial fibrillation. This is routine for these types of procedures; however, it is essential that warfarin be stopped a few days (usually 3 days) prior to ablation to minimize the risk of bleeding during the procedure. This is based on the pharmacokinetic profile of warfarin, a drug that has a mean half-life of 40 hours and a duration of anticoagulant action of 2-5 days. From the preliminary information provided, it is not clear if warfarin was stopped at an appropriate time prior to surgery. If not, the patient would have been anti-coagulated at the time of the emergent cholecystectomy and, therefore, at a high risk of bleeding. This would have suggested a need to reverse warfarin-based anticoagulation using vitamin K. Additionally, it is critical to know if warfarin was started in this patient at any time point following surgery. Use of heparin in the postoperative period for anticoagulation is associated with an increased risk of bleeding in patients that have had recent surgery, as is the case in this particular patient. I could certainly assess the pharmacological basis of anticoagulant therapy in this patient, particularly with respect to appropriateness of dose and possible drug-drug interactions that may have contributed to mortality in this patient, if provided with detailed medical records that include i) patient history, ii) medications provided and duration of therapy, iii) pre, intra, and post-operative notes, and iv) medical records obtained immediately following surgery up until the time of death 5 days later. Furthermore, I’d be happy to review this matter on behalf of the plaintiff.

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