Home INR Monitoring After Heart Valve Surgery: Is It Better Than Hospital Visits?

Myocardial bridging is not uncommon and is often seen on angiography. If it is asymptomatic, nothing needs to be done. If it is symptomatic, we normally do a stress thallium test — if positive, we recommend surgery; if negative, which is most of the time, only medical treatment is needed. If it is only myocardial bridging with no stenosis involved in other arteries (the circumflex or right coronary artery are normal), nothing needs to be done, but if the stress test is positive, surgery is recommended.

Tetralogy of Fallot is one of the commonest procedures in paediatric cardiac surgery, alongside ASD and VSD repair. It is a very commonly performed procedure with excellent outcomes — any paediatric cardiac centre does this routinely, and the clinical outcomes are excellent.

The patient should be referred for further evaluation at the appropriate time — not too early, but also not too late, because if it is too late the patient develops more comorbidities and the outcome may not be as good. For valve disease specifically, there are definite guidelines for mitral and aortic valve disease on when a patient should be referred for cardiac surgery; whether it can be done locally depends on whether it looks like a straightforward repair or replacement, or a more challenging one. The two important criteria are the patient's clinical symptoms — which functional class (1, 2, 3, or 4) — and the echo findings, which show the severity of stenosis or regurgitation, LV function, and pulmonary artery pressures. Together these decide whether the patient should be referred for surgical treatment, locally or elsewhere.

Cost primarily depends on two things: which valve is used — mechanical valves are significantly less expensive than tissue valves, and among tissue valves, third-generation valves cost more than second-generation ones — and the patient's clinical course, since a straightforward surgery without a long hospital stay or comorbidities costs less. The average cost generally starts from $9,000 and goes up to $15,000–$16,000.

Cardiac tumours in children are well known, though this exact pathology is not very common. The echo gives us an idea, but I would suggest also doing an MRI and a CT to further delineate it. I would like the details of this patient sent to our institute so we can forward it to our paediatric cardiac surgeon, since paediatric cardiac surgery is a separate subspecialty from the adult cardiac surgery I practise, and we do have a dedicated paediatric cardiac surgical team. This child needs very close follow-up and further investigation.

A retrospective study found that patients who monitored their INR at home had statistically significantly fewer adverse events than those monitored through office or hospital visits, indicating better clinical outcomes with home monitoring.

Devices are now available that let mechanical valve patients test their own INR at home. Well-educated and motivated patients can go a step further and manage their own anticoagulant dose based on the home reading, under guidance from their treating team.

Traditional INR monitoring requires a blood test followed by a visit to a valve clinic or hospital for dose adjustment, which can be a burden for patients who live far away, including many patients who return home after heart valve surgery in India.