What to do with a patient on clopidogrel (Plavix) after a mitral valve replacement (MVR) who is scheduled for fracture tibia and radius plating?

Management of Clopidogrel in Post-MVR Patient Requiring Orthopedic Surgery

For this patient on clopidogrel after mitral valve replacement who requires tibia and radius fracture plating, proceed with surgery while continuing clopidogrel, as the thrombotic risk from discontinuation outweighs the bleeding risk in orthopedic procedures. 1

Immediate Pre-Surgical Assessment

Determine the indication for clopidogrel:

• If the patient has a coronary stent (especially drug-eluting stent), never discontinue clopidogrel as abrupt cessation dramatically increases risk of stent thrombosis, MI, and death 2
• If clopidogrel is for stroke prevention or peripheral arterial disease without stent, there is more flexibility but continuation is still preferred 1
• Contact the patient's cardiologist before making any changes to antiplatelet therapy 2

Assess surgical bleeding risk:

• Orthopedic fracture plating does not fall into high-risk bleeding categories that mandate clopidogrel discontinuation 3
• High-risk procedures requiring discontinuation include: intracranial surgery, spinal surgery in the medullary canal, and posterior chamber eye surgery 3
• Peripheral arterial surgery data shows no increased bleeding complications when continuing clopidogrel 4

Recommended Management Strategy

Continue clopidogrel 75mg daily through surgery:

• The FDA label states clopidogrel should be discontinued 5 days before surgery "when possible" for major bleeding risk procedures, but emphasizes that discontinuation increases cardiovascular event risk 1
• Multiple studies demonstrate that orthopedic and peripheral vascular procedures can be safely performed on clopidogrel 4, 5
• The thrombotic risk from withdrawal exceeds the bleeding risk in most surgical settings 3

Maintain aspirin if patient is on dual antiplatelet therapy:

• If the patient is on both aspirin and clopidogrel (dual antiplatelet therapy), continue aspirin 75-100mg daily throughout the perioperative period 2
• Minimize the duration of any P2Y12 inhibitor interruption if discontinuation is absolutely necessary 2

Intraoperative Hemostasis Planning

Prepare for potential increased bleeding:

• Ensure availability of platelet transfusions, though they are less effective within 4 hours of clopidogrel loading dose or 2 hours of maintenance dose 1
• Consider prophylactic use of tranexamic acid or aminocaproic acid 6
• Clopidogrel increases chest tube drainage and transfusion requirements in cardiac surgery, but orthopedic procedures show lower bleeding risk 7, 4

Optimize surgical technique:

• Meticulous hemostasis is essential as clopidogrel inhibits platelet aggregation for 7-10 days (platelet lifespan) 1
• Fresh platelet transfusion before wound closure can help restore hemostasis if needed 7
• At least 20% of circulating platelets must have normal function for adequate hemostasis 3

Postoperative Management

Resume clopidogrel immediately if temporarily held:

• If clopidogrel was discontinued, restart within 12-24 hours postoperatively once hemostasis is achieved 1, 3
• The FDA label emphasizes restarting "as soon as possible" after temporary discontinuation 1

Monitor for thrombotic complications:

• Patients with stents who discontinue clopidogrel face risk of stent thrombosis presenting as STEMI 8
• The highest thrombotic risk period is within 30 days of stent placement, with ongoing risk of 0.2-0.6% per year thereafter 8

Critical Pitfalls to Avoid

Never discontinue clopidogrel without cardiology consultation in stent patients:

• Abrupt discontinuation is the leading cause of stent thrombosis with potentially fatal consequences 2, 8
• Even for elective procedures, surgery should ideally be postponed beyond 12 months after drug-eluting stent implantation 2

Do not substitute heparin or LMWH for clopidogrel:

• Antiplatelet treatment replacement with heparin does not provide protection against coronary artery or stent thrombosis 3

Avoid regional/neuraxial blockade considerations overriding thrombotic risk:

• The thrombotic risk of preoperative clopidogrel withdrawal overwhelms any benefit of regional anesthesia 3

Do not delay urgent/emergent orthopedic surgery:

• Meta-analysis of 22,584 CABG patients showed no significant mortality difference in ACS patients continuing clopidogrel (OR 1.44,95% CI 0.97-2.1, P=0.07) 5
• Fracture surgery should proceed without delay, as surgical expertise with antiplatelet therapy has grown substantially 5