Progress Note Template for a Patient with SAVR-Mechanical Valve
A comprehensive progress note for a patient who has undergone Surgical Aortic Valve Replacement (SAVR) with a mechanical valve should include specific elements focused on valve function, anticoagulation management, and monitoring for complications to optimize morbidity and mortality outcomes.
Chief Complaint/Subjective
- Document presence/absence of symptoms: dyspnea, chest pain, palpitations, syncope
- Activity tolerance and functional capacity
- Mechanical valve sounds (patient's awareness/concerns)
- Bleeding symptoms (epistaxis, gum bleeding, hematuria, melena)
- Medication adherence, especially anticoagulation
- Any missed doses of warfarin
Objective Assessment
Vital Signs
- Blood pressure (target ranges)
- Heart rate and rhythm
- Temperature
- Respiratory rate
- Oxygen saturation
Physical Examination
- Cardiac auscultation: mechanical valve clicks, murmurs
- Signs of heart failure (JVD, peripheral edema, pulmonary rales)
- Evidence of bleeding or thromboembolism
- Neurological assessment for signs of stroke/TIA
Laboratory Data
- Current INR value and trend (target INR 2.5-3.5 for mitral position; 2.0-3.0 for aortic position) 1
- Complete blood count (hemoglobin/hematocrit)
- Renal function tests
- Liver function tests (if on warfarin)
Diagnostic Studies
- Most recent echocardiogram findings:
- Valve function (gradient, regurgitation)
- Left ventricular size and function
- Chamber dimensions
- Pulmonary artery pressure estimates 2
Assessment
- Mechanical aortic valve status (functioning vs. dysfunction)
- Anticoagulation status (therapeutic vs. sub/supratherapeutic)
- Heart failure status (if applicable)
- Complications assessment:
- Bleeding
- Thromboembolism
- Prosthetic valve endocarditis
- Paravalvular leak
Plan
Anticoagulation Management
- Warfarin therapy with target INR of 2.0-3.0 for aortic position mechanical valves or 2.5-3.5 for mitral position mechanical valves 3, 1
- Dose adjustments based on current INR
- Addition of low-dose aspirin (75-100 mg) if high risk for thrombotic complications 3
- Next INR check timing
- Instructions for dose adjustments
Medication Review
- Anticoagulation (warfarin)
- Antiplatelets (if indicated)
- Heart failure medications (if applicable)
- Endocarditis prophylaxis recommendations
Follow-up Imaging
- Schedule for next echocardiogram (typically annually if stable)
- Other cardiac imaging as indicated 2
Education
- Signs/symptoms requiring immediate medical attention:
- Bleeding complications
- Symptoms of valve thrombosis (dyspnea, heart failure)
- Signs of stroke or TIA
- Importance of anticoagulation adherence
- INR monitoring schedule
- Dietary considerations with warfarin
- Endocarditis prophylaxis situations
Follow-up Planning
- Next cardiology appointment
- Next INR check
- Coordination with primary care
Important Considerations and Pitfalls
- Never use direct oral anticoagulants (DOACs) for mechanical valves as they are contraindicated 3
- Recognize that subtherapeutic INR increases thromboembolism risk while supratherapeutic INR increases bleeding risk 1, 4
- Document any planned procedures requiring temporary anticoagulation interruption with appropriate bridging plan 3
- Consider higher INR targets (2.5-3.5) for patients with additional risk factors for thromboembolism 5
- Document any concurrent cardiac conditions requiring management (e.g., atrial fibrillation) 2
- Include assessment of valve sounds - absence of previously audible mechanical valve sounds may indicate valve thrombosis
- Monitor for signs of hemolysis which may indicate paravalvular leak
This template ensures comprehensive documentation and management of patients with mechanical aortic valves, focusing on the critical aspects that impact morbidity, mortality, and quality of life.