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Balaji N, Olukayode O, Faiz F, Dixit P, Bhavsar V. Periprocedural Bridging Therapy in Patients With Mechanical Heart Valves. Cureus 2024; 16:e56465. [PMID: 38638777 PMCID: PMC11024885 DOI: 10.7759/cureus.56465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2024] [Indexed: 04/20/2024] Open
Abstract
Mechanical heart valves (MHVs) are thrombogenic and require lifelong anticoagulation with vitamin K antagonists (VKAs) such as warfarin. Periprocedural bridging with unfractionated heparin (UFH) and low-molecular-weight heparin (LMWH) aims to reduce the risk of thromboembolic events in patients. Currently, there are no definitive class I recommendations for anticoagulation management in patients with MHVs. In this report, we present the case of a 77-year-old female who was perioperatively bridged with enoxaparin and subsequently developed an acute thrombus.
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Affiliation(s)
- Nivedha Balaji
- Internal Medicine, Northeast Georgia Medical Center Gainesville, Gainesville, USA
| | - Oluwafemi Olukayode
- Internal Medicine, Northeast Georgia Medical Center Gainesville, Gainesville, USA
| | - Fardeen Faiz
- Cardiology, Northeast Georgia Medical Center Gainesville, Gainesville, USA
| | | | - Vedang Bhavsar
- Cardiology, Northeast Georgia Medical Center Gainesville, Gainesville, USA
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2
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AlSawy NS, ElKady EF, Mostafa EA. AGREE and ESA for Greenness Assessment of a Novel Validated RP-HPLC Method for Simultaneous Determination of Aspirin, Warfarin and Clopidogrel in Rat Plasma: Application to Pharmacokinetic Study of the Possible Interaction between the Three Drugs. J Chromatogr Sci 2023:bmad078. [PMID: 37791421 DOI: 10.1093/chromsci/bmad078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 07/23/2023] [Accepted: 09/07/2023] [Indexed: 10/05/2023]
Abstract
The green profile of the developed method is assessed and compared with previously reported methods. Percutaneous coronary intervention is a procedure where a catheter is utilized to place a stent in order to facilitate opening of the blood vessels in the heart. Triple antithrombotic therapy includes oral anticoagulation as warfarin and dual antiplatelet therapy (composed of aspirin and clopidogrel bisulfate). The aim of the current study was to evaluate the pharmacokinetic parameters of ASP, WAR and CLP and to investigate the possible interaction between the three drugs upon co-administration in rats. A selective and precise RP-HPLC method was developed for the simultaneous determination of ASP, WAR and CLP in rat plasma. Pharmacokinetic study was conducted in rats that received ASP, WAR and CLP as an application of the developed method. From the statistical evaluation of the pharmacokinetic parameters, it was observed that the co-administration of ASP, WAR and CLP significantly increased the ASP and CLP bioavailability in rats. A significant drug-drug interaction was confirmed in the current study. The elevated Cmax of ASP and CLP upon the co-administration of ASP, WAR and CLP may explain the reported bleeding.
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Affiliation(s)
- Norhan S AlSawy
- Pharmaceutical Chemistry, Kasr El-Aini Hospital, Kasr El-Aini St., Cairo 11562, Egypt
| | - Ehab F ElKady
- Pharmaceutical Chemistry Department, Faculty of Pharmacy, Cairo University, Kasr El-Aini St., Cairo 11562, Egypt
| | - Eman A Mostafa
- Pharmaceutical Chemistry Department, Faculty of Pharmacy, Cairo University, Kasr El-Aini St., Cairo 11562, Egypt
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3
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Ababneh M, Al-Kasasbeh A, Algorani E. Mechanical Aortic Valve Thrombosis with Heart Failure Successfully Treated with Oral Anticoagulation: A Case Report. Vasc Health Risk Manag 2023; 19:617-620. [PMID: 37727781 PMCID: PMC10506610 DOI: 10.2147/vhrm.s425525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 08/27/2023] [Indexed: 09/21/2023] Open
Abstract
Background The use of anticoagulation is mandatory for prevention of prosthetic valve thrombosis (PVT) worldwide, regardless of the valve type or position in the heart. In case a thrombosis causes symptomatic dysfunction, treatment usually includes the use of thrombolytic therapy or surgery. We report a case of PVT involving a patient with a mechanical aortic valve which was treated entirely with the use of anticoagulation therapy (warfarin). Case Presentation A 58-year-old man had an aortic valve replacement using a Carbomedics® mechanical valve due to severe aortic stenosis as a result of a calcific bicuspid native aortic valve. He was commenced on warfarin after surgery which was continued thereafter. He presented to our hospital after three years with shortness of breath at rest. On clinical examination, his condition was poor with a New York Heart Association functional classification of IV. He was in sinus rhythm and had an enlarged heart shadow on chest X-ray. Transesophageal echocardiography (TEE) revealed aortic valve regurgitation with vegetations on the anterior valve leaflet causing reduced hemi leaflet motility and a mean pressure gradient of 50 mmHg. Cinefluoroscopy revealed a dysfunctional mechanical valve leaflet. Surgery was at high risk of mortality due to the patient's clinical status and he was continued on warfarin therapy with close monitoring. Cinefluoroscopy and echocardiography done six months later revealed complete dissolution of thrombus and a normally functioning mechanical aortic valve. Conclusion Only a few cases of symptomatic, thrombotic mechanical aortic valve were entirely treated with anticoagulation only. Our patient is one such case who had resolution of symptoms and improvement on NYHA functional classification (IV to I).
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Affiliation(s)
- Muhannad Ababneh
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Abdullah Al-Kasasbeh
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Emad Algorani
- Department of Internal Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
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4
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Alessiani M, Bonura A, Iaccarino G, Mangiardi M, Pezzella FR, Bravi MC, Crupi D, Galluzzo M, Anticoli S. Recurrent paraneoplastic cerebral hemorrhage in lung cancer: A case report. Brain Circ 2023; 9:99-102. [PMID: 37576582 PMCID: PMC10419736 DOI: 10.4103/bc.bc_78_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 12/14/2022] [Accepted: 12/23/2022] [Indexed: 08/15/2023] Open
Abstract
Cerebral hemorrhage management in a patient requiring anticoagulant therapy is a therapeutic challenge also due to the absence of guidelines that convincingly define the best therapeutic strategy. Although the occurrence of cerebral hemorrhage in a patient with anticoagulant therapy seems to make the bleeding etiology obvious, sometimes, it is better to reflect on other possible causes and set up an adequate diagnostic workup. Herein, we describe a case of a 73-year-old male patient with atrial fibrillation, mechanical heart valve, and pacemaker that experienced an ischemic minor stroke during steady anticoagulation therapy with recurrent intracerebral haemorrhages (ICHs).
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Affiliation(s)
- Michele Alessiani
- Department of Medicine, Neurology, Neurophysiolohy and Neurobiology Unit, Campus Bio-Medico University Hospital, Rome, Italy
| | - Adriano Bonura
- Department of Medicine, Neurology, Neurophysiolohy and Neurobiology Unit, Campus Bio-Medico University Hospital, Rome, Italy
| | - Gianmarco Iaccarino
- Department of Medicine, Neurology, Neurophysiolohy and Neurobiology Unit, Campus Bio-Medico University Hospital, Rome, Italy
| | - Marilena Mangiardi
- Head, Neck and Neuroscience Department, Stroke Unit, San Camillo-Forlanini Hospital, Rome, Italy
| | | | - Maria Cristina Bravi
- Head, Neck and Neuroscience Department, Stroke Unit, San Camillo-Forlanini Hospital, Rome, Italy
| | - Domenica Crupi
- Head, Neck and Neuroscience Department, Stroke Unit, San Camillo-Forlanini Hospital, Rome, Italy
| | - Michele Galluzzo
- Department of Emergency Radiology, San Camillo Forlanini Hospital, Rome, Italy
| | - Sabrina Anticoli
- Head, Neck and Neuroscience Department, Stroke Unit, San Camillo-Forlanini Hospital, Rome, Italy
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5
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Carapinha JL, Iliescu VA, Dorobantu LF, Turcu-Stiolica A, Deckert J, White A, Salem A, Parasca C. Budget impact analysis of a bovine pericardial aortic bioprosthesis versus mechanical aortic valve replacement in adult patients with aortic stenosis in Romania. J Med Econ 2023; 26:998-1008. [PMID: 37505934 DOI: 10.1080/13696998.2023.2242188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 07/15/2023] [Accepted: 07/25/2023] [Indexed: 07/30/2023]
Abstract
AIMS An analysis of the budget impact of using a bovine pericardial aortic bioprosthesis (BPAB) or a mechanical valve (MV) in aortic stenosis (AS) patients in Romania. MATERIALS AND METHODS A decision-tree with a partitioned survival model was used to predict the financial outcomes of using either a BPAB (the Carpentier-Edwards Perimount Magna Ease Valve) or MV in aortic valve replacement (AVR) procedure over a 5-year period. The budget impact of various resource consumption including disabling strokes, reoperations, minor thromboembolic events, major bleeding, endocarditis, anticoagulation treatment and monitoring, and echocardiogram assessments were compared for both types of valves. One-way sensitivity analyses (OWSA) were conducted on the input costs and probabilities. RESULTS The use of BPAB compared to MV approaches budget neutrality due to incremental savings year-on-year. The initial surgical procedure and reoperation costs for BPAB are offset by savings in acenocoumarol use, disabling strokes, major bleeding, minor thromboembolic events, and anticoagulation complications. The cost of the initial procedure per patient is 460 euros higher for a BPAB due to the higher valve acquisition cost, although this is partially offset by a shorter hospital stay. The OWSA shows that the total procedure costs, including the hospital stay, are the primary cost drivers in the model. LIMITATIONS Results are limited by cost data aggregation in the DRG system, exclusion of costs for consumables and capital equipment use, possible underestimation of outpatient complication costs, age-related variations of event rates, and valve durability. CONCLUSIONS Adopting BPAB as a treatment option for AS patients in Romania can lead to cost savings and long-term economic benefits. By mitigating procedure costs and increasing anticoagulation treatment costs, BPAB offers a budget-neutral option that can help healthcare providers, policymakers, and patients alike manage the growing burden of AS in Romania.
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Affiliation(s)
- João L Carapinha
- Northeastern University School of Pharmacy, Boston, United States of America
- Syenza, Anaheim, United States of America
| | - Vlad A Iliescu
- University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
| | | | | | | | | | - Adham Salem
- Edwards Lifesciences, Dubai, United Arab Emirates
| | - Catalina Parasca
- "Prof. Dr. C.C. Iliescu" Institute for Cardiovascular Diseases, Bucharest, Romania
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6
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Jenneker M, Ramnarain H, Sebitloane H. A clinical conundrum: review of anticoagulation in pregnant women with mechanical prosthetic heart valves. Cardiovasc J Afr 2022; 33:322-328. [PMID: 36162856 PMCID: PMC10031849 DOI: 10.5830/cvja-2022-028] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 05/28/2022] [Indexed: 10/08/2023] Open
Abstract
In South Africa, maternal mortality from cardiovascular disease remains high. The recent Saving Mothers report 2017-2019 from the Confidential Enquiries into Maternal Deaths revealed that indirect maternal death from medical and surgical disorders is the fourth commonest cause of maternal death, accounting for 16.9% of deaths, with cardiac disease accounting for one-third of this. The burden of rheumatic heart disease (RHD) is a significant contributor to maternal morbidity and mortality. The true burden is unknown due to limited data. The natural history of RHD confers additional risk as many cases may remain undiagnosed, with first presentation occurring during pregnancy. This undiagnosed subset of women may be the result of poor accessibility to healthcare facilities and primary healthcare interventions for acute rheumatic fever. RHD causes progressive damage to the heart valves, especially the left-sided valves, which eventually require surgical correction with mechanical prosthetic valves.
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Affiliation(s)
- M Jenneker
- Department of Obstetrics and Gynaecology, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa; Department of Obstetrics and Gynaecology, High Risk Obstetrics, Inkosi Albert Luthuli Central Hospital, Cator Manor, Durban, South Africa.
| | - H Ramnarain
- Department of Obstetrics and Gynaecology, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa; Department of Obstetrics and Gynaecology, High Risk Obstetrics, Inkosi Albert Luthuli Central Hospital, Cator Manor, Durban, South Africa
| | - H Sebitloane
- Department of Obstetrics and Gynaecology, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
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7
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Motta SE, Zaytseva P, Fioretta ES, Lintas V, Breymann C, Hoerstrup SP, Emmert MY. Endothelial Progenitor Cell-Based in vitro Pre-Endothelialization of Human Cell-Derived Biomimetic Regenerative Matrices for Next-Generation Transcatheter Heart Valves Applications. Front Bioeng Biotechnol 2022; 10:867877. [PMID: 35433657 PMCID: PMC9008229 DOI: 10.3389/fbioe.2022.867877] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 03/14/2022] [Indexed: 01/22/2023] Open
Abstract
Hemocompatibility of cardiovascular implants represents a major clinical challenge and, to date, optimal antithrombotic properties are lacking. Next-generation tissue-engineered heart valves (TEHVs) made from human-cell-derived tissue-engineered extracellular matrices (hTEMs) demonstrated their recellularization capacity in vivo and may represent promising candidates to avoid antithrombotic therapy. To further enhance their hemocompatibility, we tested hTEMs pre-endothelialization potential using human-blood-derived endothelial-colony-forming cells (ECFCs) and umbilical vein cells (control), cultured under static and dynamic orbital conditions, with either FBS or hPL. ECFCs performance was assessed via scratch assay, thereby recapitulating the surface damages occurring in transcatheter valves during crimping procedures. Our study demonstrated: feasibility to form a confluent and functional endothelium on hTEMs with expression of endothelium-specific markers; ECFCs migration and confluency restoration after crimping tests; hPL-induced formation of neo-microvessel-like structures; feasibility to pre-endothelialize hTEMs-based TEHVs and ECFCs retention on their surface after crimping. Our findings may stimulate new avenues towards next-generation pre-endothelialized implants with enhanced hemocompatibility, being beneficial for selected high-risk patients.
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Affiliation(s)
- Sarah E. Motta
- Institute for Regenerative Medicine (IREM), University of Zurich, Zurich, Switzerland
- Wyss Translational Center Zurich, University and ETH Zurich, Zurich, Switzerland
| | - Polina Zaytseva
- Institute for Regenerative Medicine (IREM), University of Zurich, Zurich, Switzerland
| | - Emanuela S. Fioretta
- Institute for Regenerative Medicine (IREM), University of Zurich, Zurich, Switzerland
| | - Valentina Lintas
- Institute for Regenerative Medicine (IREM), University of Zurich, Zurich, Switzerland
| | - Christian Breymann
- Department of Obstetrics and Gynaecology, University Hospital Zurich, Obstetric Research, Feto- Maternal Haematology Research Group, Zurich, Switzerland
| | - Simon P. Hoerstrup
- Institute for Regenerative Medicine (IREM), University of Zurich, Zurich, Switzerland
- Wyss Translational Center Zurich, University and ETH Zurich, Zurich, Switzerland
| | - Maximilian Y. Emmert
- Institute for Regenerative Medicine (IREM), University of Zurich, Zurich, Switzerland
- Wyss Translational Center Zurich, University and ETH Zurich, Zurich, Switzerland
- Department of Cardiovascular Surgery, Charité Universitätsmedizin Berlin, Berlin, Germany
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
- *Correspondence: Maximilian Y. Emmert,
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8
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Butany J, Schoen FJ. Cardiac valve replacement and related interventions. Cardiovasc Pathol 2022. [DOI: 10.1016/b978-0-12-822224-9.00010-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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9
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Huda SA, Kahlown S, Jilani MH, Chaudhuri D. Management of Life-Threatening Bleeding in Patients With Mechanical Heart Valves. Cureus 2021; 13:e15619. [PMID: 34277237 PMCID: PMC8276624 DOI: 10.7759/cureus.15619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2021] [Indexed: 11/12/2022] Open
Abstract
Valvular heart disease is common in the United States, with a number of patients undergoing valve replacement procedures every year. The two types of valve prostheses include mechanical and bioprosthetic valves. Mechanical heart valves require lifelong anticoagulation with vitamin K antagonists like warfarin. The clinicians are often faced with the dilemma of major bleeding episodes such as intracranial hemorrhage or gastrointestinal bleeding in these patients. The management includes reversing warfarin-induced coagulopathy with vitamin K supplementation, fresh frozen plasma, or prothrombin complex concentrate (PCC), with PCC being the treatment of choice. With regard to the safe resumption of anticoagulation, guidelines are silent, and data is limited to case reports/series. This article reviews the present literature for the management of bleeding in patients with mechanical heart valves and the safe duration for holding off anticoagulation with minimal risk of valve thrombosis/thromboembolism.
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Affiliation(s)
- Syed A Huda
- Internal Medicine, State University of New York (SUNY) Upstate Medical University, Syracuse, USA
| | - Sara Kahlown
- Internal Medicine, United Health Services Wilson Medical Center, Johnson City, USA
| | | | - Debanik Chaudhuri
- Interventional Cardiology, State University of New York (SUNY) Upstate Medical University, Syracuse, USA
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10
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Eltheni R, Schizas N, Michopanou N, Fildissis G. Effects of a Personalized Nurse-Led Educational Program for New Patients Receiving Oral Anticoagulant Therapy after Mechanical Heart Valve Prosthesis Implantation on Adherence to Treatment. J Chest Surg 2021; 54:25-30. [PMID: 33767008 PMCID: PMC7946524 DOI: 10.5090/kjtcs.20.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 10/15/2020] [Accepted: 10/18/2020] [Indexed: 11/16/2022] Open
Abstract
Background Life-long anticoagulant therapy is mandatory for patients who undergo heart valve replacement with implantation of a mechanical prosthesis. The aim of this study was to investigate the effects of a nurse-led patient educational program concerning oral anticoagulant therapy intake after heart valve replacement surgery on patients’ knowledge of important parameters of anticoagulant administration. Methods In this single-center study, 200 patients who underwent surgical implantation of a mechanical prosthesis were divided into 2 groups. The control group received the basic education concerning oral anticoagulants, while the intervention group received a personalized educational program. Results Personalized education was correlated with a better regulation of therapeutic international normalized ratio (INR) levels and adequate knowledge among patients. Therapeutic levels of INR were achieved in 45% of the patients during the first month, 71% in the third month, and 89% in the sixth month after discharge in the intervention group, compared to 25%, 47%, and 76% in the control group, respectively. Patients’ satisfaction with the information was higher in the intervention group than in the control group. The percentage of satisfaction reached 80% for the intervention group versus 37% for the patients of the control group. Conclusion The implementation of the nurse-led educational programs was associated with improved clinical results and increased adherence to oral anticoagulant treatment.
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Affiliation(s)
- Rokeia Eltheni
- Cardiac Surgery Intensive Care Unit, "Evangelismos" General Hospital of Athens, Greece
| | - Nikolaos Schizas
- Cardiac Surgery Intensive Care Unit, "Evangelismos" General Hospital of Athens, Greece
| | - Nektaria Michopanou
- Cardiac Surgery Intensive Care Unit, "Evangelismos" General Hospital of Athens, Greece
| | - Georgios Fildissis
- Faculy of Nursing, School of Healthcare Sciences, National and Kapodistrian University of Athens, Athens, Greece
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11
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Yaghi C, Masson R, Yamada K, Zhu S, Fong C, Shirazi A, LaPunzina P, Mok K. Risks and benefits of concurrent treatment with antiplatelet and anticoagulation therapy in post-op bioprosthetic aortic valve replacement patients. J Card Surg 2021; 36:879-885. [PMID: 33442916 DOI: 10.1111/jocs.15314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 12/13/2020] [Accepted: 01/02/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIM Among patients receiving surgical bioprosthetic aortic valve replacement (bAVR), there is an elevated risk of thromboembolic events postoperatively. However, the risks and benefits of varying anticoagulation strategies remain controversial. The aim of this study is to compare the risks and benefits of aspirin monotherapy to aspirin plus warfarin ("concurrent therapy") in patients receiving bAVR. METHODS A retrospective cohort study was conducted using patients' data from Kaiser Permanente Northern California, including those who underwent bAVR with or without coronary artery bypass grafting between 2009 and 2018. Patients were identified as having been discharged with aspirin only or concurrent therapy. The outcomes were mortality, thromboembolic events, and clinically relevant bleeding during a 6-month follow-up. The event rates were compared using the Kaplan-Meier method. Multivariable survival analysis, incorporating propensity scores, was used to estimate adjusted hazard ratios (aHRs) for each outcome. RESULTS The cohort consisted of 3047 patients. Approximately 58% of patients received aspirin only and 42% received concurrent therapy. Patients who received concurrent therapy were more likely to be older, have hypertension, previous stroke, and longer hospital stays. After adjustment using multivariable analysis, concurrent therapy was associated with a higher risk of clinically relevant bleeding (aHR, 2.33; 95% confidence interval, 1.67-3.25). There was no significant difference in the risk of thromboembolic events or mortality between the two groups. CONCLUSION Patients who underwent bAVR and were discharged on concurrent therapy compared to aspirin only had a significantly increased risk of bleeding without a significant difference in thromboembolic events.
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Affiliation(s)
- Carma Yaghi
- Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
| | - Rajeev Masson
- Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
| | - Kyoko Yamada
- Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
| | - Shiyun Zhu
- Kaiser Permanente Division of Research, Oakland, California, USA
| | - Christine Fong
- Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
| | - Aida Shirazi
- Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
| | - Paul LaPunzina
- Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
| | - Kenny Mok
- Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
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12
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Aikins J, Koomson A, Ladele M, Al-Nusair L, Ahmed A, Ashry A, Harky A. Anticoagulation and antiplatelet therapy in patients with prosthetic heart valves. J Card Surg 2020; 35:3521-3529. [PMID: 32939828 DOI: 10.1111/jocs.15034] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 09/05/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND The choice of antithrombotic therapy, anticoagulants or antiplatelets, after prosthetic heart valve replacement or repair, remains a disputed topic in the literature. Antithrombotic therapies are used after heart valve intervention to reduce the rates of thromboembolic events, therefore improving patient outcomes. Different interventions may require different therapeutic regimens to achieve the most efficacious clinical outcome for patients. METHODS AND DISCUSSION This review aims to summarize and critique the available literature concerning therapeutic agents used for bioprosthetic and mechanical valves as well as for valve repair, so as to assist clinicians and researchers in making decisions with regard to their patients and research endeavors.
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Affiliation(s)
- Joel Aikins
- Imperial College School of Medicine, Faculty of Medicine, Imperial College London, London, UK
| | - Abeku Koomson
- Imperial College School of Medicine, Faculty of Medicine, Imperial College London, London, UK
| | - Mofolaoluwami Ladele
- Imperial College School of Medicine, Faculty of Medicine, Imperial College London, London, UK
| | - Lana Al-Nusair
- Imperial College School of Medicine, Faculty of Medicine, Imperial College London, London, UK
| | - Amna Ahmed
- Imperial College School of Medicine, Faculty of Medicine, Imperial College London, London, UK
| | - Amr Ashry
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest, Liverpool, UK.,Department of Cardiothoracic Surgery, Assiut University Hospital, Assiut, Egypt
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest, Liverpool, UK.,Department of Integrative Biology, Faculty of Life Science, University of Liverpool, Liverpool, UK.,Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital, Liverpool, UK
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13
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Zhang H, Dong Y, Ao X, Zhu D, Dong L. Optimal oral anticoagulant therapy in Chinese patients with mechanical heart valves. Eur J Pharm Sci 2019; 144:105202. [PMID: 31866562 DOI: 10.1016/j.ejps.2019.105202] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 11/25/2019] [Accepted: 12/18/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND The oral administration of anticoagulants is an effective means of preventing thromboembolic complications in patients implanted with mechanical valves. This treatment strategy, however, entails a dose-dependent in the risk of hemorrhage that is a cause for concern in China. As such, in this study, we sought to better determine what the ideal oral anticoagulant therapy intensity is in a Chinese population of patients implanted with mechanical valves. METHODS In the present observational cohort study, we observed the outcomes of eligible enrolled patients that had been implanted with St. Jude Medical prosthetic valves and who had been treated at our institution from 2013 onwards. All enrolled patients were followed for between 1 and 6 years through outpatient visits or telephone interviews following discharge. Study endpoints included instances of thromboembolism and major hemorrhage. We calculated the international normalized ratio (INR)-specific incidence of such adverse events as a means of determining optimal anticoagulant therapeutic intensity in patients with these bileaflet mechanical valve prostheses. RESULTS In total this study enrolled 3176 patients, of whom 3017 were followed for 12,746.08 total person-years (4.22 mean years per patient), while the remaining 159 patients (5%) were lost during follow-up. A total of 182 patients suffered from adverse events, with a roughly 1.43% annual incidence rate of such adverse events (95% confidence interval [CI], 1.22-1.64). Of these, 54 patients suffered from episodes of major bleeding (0.42% per patient-year, 95% CI, 0.31-0.53), while 131 suffered from thromboembolism (1.03% per patient-year, 95% CI, 0.85-1.21). Based on these analyses, we determined that the ideal low-intensity anticoagulant treatment regimen for patients with bileaflet mechanical heart valve prostheses was an INR between 1.5 and 2.5. In those patients that had undergone aortic valve replacement (AVR), the optimal INR was between 1.5 and 2.0 regardless of any thromboembolism risk factors in these patients. In contrast, in patients that had undergone mitral valve replacement (MVR) who were not at risk for thromboembolism, the optimal INR was between 1.5 and 2.0, whereas in those at risk of thromboembolism the optimal INR was between 2.0 and 2.5. The ideal anticoagulant intensity in patients undergoing both AVR and MVR (DVR) was the same as in patients undergoing MVR alone. CONCLUSIONS In order to achieve optimal outcomes by maintaining effective anticoagulant dosing while entailing minimal risk in Chinese patients that have undergone a bileaflet mechanical valve replacement, the target INR range should be between 1.5 and 2.5, with the final intensity of this anticoagulant regimen being determined based on a given patient's risk of thromboembolism.
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Affiliation(s)
- Heng Zhang
- Department of Cardiovascular Surgery, West China Hospital of Sichuan University, No. 37, Guoxue Alley, Chengdu 610041, China
| | - Yijun Dong
- Department of Thoracic Neoplasm, West China Hospital of Sichuan University, Chengdu, China
| | - Xuelian Ao
- Department of Ultrasound, West China Hospital of Sichuan University, Chengdu, China
| | - Da Zhu
- Department of Cardiovascular Surgery, West China Hospital of Sichuan University, No. 37, Guoxue Alley, Chengdu 610041, China
| | - Li Dong
- Department of Cardiovascular Surgery, West China Hospital of Sichuan University, No. 37, Guoxue Alley, Chengdu 610041, China.
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Modified Bentall procedure: Mechanical vs biological valved conduits in patients older than 65 years. Int J Cardiol 2019; 296:38-42. [DOI: 10.1016/j.ijcard.2019.07.053] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 06/20/2019] [Accepted: 07/15/2019] [Indexed: 01/10/2023]
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Javan L, Kazemnejad A, Nomali M, Zakerimoghadam M. Effect of Self-Management Program on Self-efficacy and Medication Adherence in Patients with Mechanical Heart Valve: a Randomized Clinical Trial. J Caring Sci 2019; 8:207-211. [PMID: 31915622 PMCID: PMC6942652 DOI: 10.15171/jcs.2019.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 10/22/2018] [Indexed: 11/28/2022] Open
Abstract
Introduction: Patients with mechanical heart valve need anticoagulant therapy to prevent thrombotic events. The treatment interacts with some foods and drugs. The aim was to evaluate the effect of self- management program on self-efficacy and medication adherence in patients with mechanical heart valve. Methods: This was a randomized controlled trial. eighty eligible patients, with the ability to read and speak in Farsi, aged between 15 to 60, were included in the study from the cardiac surgery clinic in Imam Khomeini hospital affiliated to Tehran University of Medical Sciences (Tehran, Iran) and randomly allocated to intervention and control groups. The participants had no history of psychiatric disorders, had undergone valve replacement surgery at least one year before the study, and were being treated with Warfarin. The intervention was a combination of 2 one- hour self-management education via small groups with 3 to 5 members, self-management educational booklets, and weekly call follow- ups for 8 weeks about 10- 15 minutes. The control group received no intervention. Self- efficacy was the primary outcome and medication adherence, Prothrombin Time (PT), and International Normalized Ratio (INR) were secondary outcomes. Data were analyzed using spss13. Results: Although the mean of self-efficacy and medication adherence, PT, and INR values were not different between the two groups at baseline, they improved significantly following the program. Conclusion: Self-management program had a positive effect on self-efficacy and medication adherence of patients with mechanical heart valve.
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Affiliation(s)
- Leila Javan
- Department of Critical Care Nursing, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
| | - Anoshirvan Kazemnejad
- Department of Biostatistics, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | - Mahin Nomali
- Department of Critical Care Nursing, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
| | - Masoumeh Zakerimoghadam
- Department of Critical Care Nursing, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
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Chang WT, Ho CH, Chang CL, Cheng BC, Wu NC, Chen ZC. Influence of warfarin on cardiac and cerebrovascular events following bioprosthetic aortic valve replacement: A nationwide cohort study. J Thorac Cardiovasc Surg 2019; 159:1730-1739.e1. [PMID: 31208804 DOI: 10.1016/j.jtcvs.2019.04.096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 04/13/2019] [Accepted: 04/20/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The need for anticoagulation treatment following bioprosthetic aortic valve replacement remains controversial. We investigated the associations of warfarin treatment with the risks of major adverse cardiac and cerebrovascular events, including mortality, bleeding incidents, and reoperation requirement after bioprosthetic aortic valve replacement surgery. METHODS We identified 1086 patients who received first bioprosthetic aortic valve replacement between 2001 and 2010 using Taiwan's National Health Insurance Database. Patients were excluded for prior use of warfarin, warfarin use for >3 months, dual valve procedures, prior valve surgeries, or concomitant surgeries. Enrolled patients were divided into 2 groups according to whether they were warfarin-naïve or received warfarin for <3 months postsurgery. After propensity score matching, 282 patients not receiving warfarin were matched to 282 patients receiving warfarin for <3 months. Patients were followed-up for minimum 36 months. RESULTS Patients receiving warfarin were younger and showed less frequent kidney disease than those who did not use warfarin. The warfarin group demonstrated a gross decrease in major adverse cardiac and cerebrovascular events. Patients receiving warfarin for <30 days were at an even lower risk for major adverse cardiac and cerebrovascular events than those treated for ≥30 days. No significant difference in bleeding or reoperation risk was observed between warfarin users and warfarin nonusers. Similar findings remained after propensity-score matching but the benefit of short-term warfarin use diminished in a younger population. CONCLUSIONS Short-term use of postoperative warfarin (especially <30 days) following bioprosthetic aortic valve replacement may be associated with a reduction in MACCE compared with nonuse.
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Affiliation(s)
- Wei-Ting Chang
- Department of Cardiology, Chi Mei Medical Center, Tainan, Taiwan; Department of Biotechnology, Southern Taiwan University of Science and Technology, Tainan, Taiwan; Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chung-Han Ho
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan; Department of Hospital and Health Care Administration, Chia Nan University of Pharmacy and Science, Tainan City, Taiwan
| | - Chia-Li Chang
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
| | - Bor-Chih Cheng
- Department of Cardiovascular Surgery, Chi Mei Medical Center, Tainan, Taiwan
| | - Nan-Chun Wu
- Department of Hospital and Health Care Administration, Chia Nan University of Pharmacy and Science, Tainan City, Taiwan; Department of Cardiovascular Surgery, Chi Mei Medical Center, Tainan, Taiwan
| | - Zhih-Cherng Chen
- Department of Cardiology, Chi Mei Medical Center, Tainan, Taiwan; Department of Pharmacy, Chia Nan University of Pharmacy and Science, Tainan City, Taiwan.
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Dahal K, Mustafa U, Sharma SP, Apte N, Bogabathina H, Hanna M, Watti H, Azrin M, Lee J, Mina G, Katikaneni P, Modi K. Ischemic and bleeding outcomes of triple therapy in patients on chronic anticoagulation undergoing percutaneous coronary intervention: A meta-analysis of randomized trials. JRSM Cardiovasc Dis 2019; 8:2048004019885572. [PMID: 31700620 PMCID: PMC6826915 DOI: 10.1177/2048004019885572] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 08/07/2019] [Accepted: 10/08/2019] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Triple therapy (TT) that includes oral anticoagulation and dual antiplatelet therapy is recommended in patients who are on chronic anticoagulation and undergo percutaneous coronary intervention (PCI). The randomized clinical trials (RCTs) comparing the effectiveness and safety of TT compared to double therapy (DT), which consists of an oral anticoagulation and one of the P2Y12 inhibitors, have shown increased risk of bleeding; however, none of the individual studies were powered to show a difference in ischemic outcomes. To compare the clinical outcomes of TT and DT, we performed this meta-analysis of RCTs. METHODS Electronic search of PubMed, EMBASE and Cochrane CENTRAL databases was performed for RCTs comparing TT and DT in patients who were on oral anticoagulation (Vitamin K antagonist or non-vitamin K antagonist oral anticoagulant) who underwent PCI. All-cause and cardiovascular mortality, myocardial infarction (MI), stroke, stent thrombosis (ST) and TIMI major and minor bleeding were the major outcomes. RESULTS An analysis of 5 trials including 10,592 total patients showed that TT, compared to DT, resulted in non-significant difference in risk of all-cause [odds ratio (OR); 1.14;95% confidence interval (CI):(0.80-1.63); P = 0.46) and cardiovascular mortality [1.43(0.58-3.36); P = 0.44], MI [0.88 (0.64-1.21); P = 0.42], stroke [1.10(0.75-1.62); P = 0.63] and ST [0.82(0.46-1.45); P = 0.49]. TT, compared to DT resulted in higher risk of TIMI major bleeding [1.61(1.09-2.37); P = 0.02], TIMI minor bleeding [1.85(1.23-2.79); P = 0.003] and TIMI major and minor bleeding [1.81 (1.38-2.38); P < 0.0001; I2 = 52%]. CONCLUSION Compared to DT, the patients receiving TT are at a higher risk of major and minor bleeding with no survival benefit or impact on thrombotic outcomes.
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Affiliation(s)
- Khagendra Dahal
- Division of Cardiology, Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, LA, USA
- Division of Cardiology, Calhoun Cardiovascular Center, University of Connecticut Health Center, Farmington, CT, USA
| | - Usman Mustafa
- Division of Cardiology, Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Sharan P Sharma
- Division of Cardiology, Garden City Hospital, Michigan State University, Garden City, MI, USA
| | - Nachiket Apte
- Division of Cardiology, Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Hari Bogabathina
- Division of Cardiology, Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Magdy Hanna
- Division of Cardiology, Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Hussam Watti
- Division of Cardiology, Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Michael Azrin
- Division of Cardiology, Calhoun Cardiovascular Center, University of Connecticut Health Center, Farmington, CT, USA
| | - Juyong Lee
- Division of Cardiology, Calhoun Cardiovascular Center, University of Connecticut Health Center, Farmington, CT, USA
| | - Goerge Mina
- Division of Cardiology, Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Pavan Katikaneni
- Division of Cardiology, Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Kalgi Modi
- Division of Cardiology, Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, LA, USA
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Recurrent Hemorrhagic Conversion of Ischemic Stroke in a Patient with Mechanical Heart Valve: A Case Report and Literature Review. Brain Sci 2018; 8:brainsci8010012. [PMID: 29316662 PMCID: PMC5789343 DOI: 10.3390/brainsci8010012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 12/25/2017] [Accepted: 12/25/2017] [Indexed: 12/03/2022] Open
Abstract
The authors present a unique case of recurrent stroke, discovered to be secondary to hemorrhagic conversion of microemboli from a mechanical aortic valve despite anticoagulation with Coumadin. The complexity of this case was magnified by the patient’s young age, a mechanical heart valve (MHV), and a need for anticoagulation to maintain MHV patency in a setting of potentially life-threatening intracranial hemorrhage. Anticoagulant and antiplatelet therapy are risk factors for hemorrhagic conversion post-cerebral ischemia; however, the pathophysiology underlying endothelial cell dysfunction causing red blood cell extravasation is an active area of basic and clinical research. The need for randomized clinical trials to aid in the creation of standardized treatment protocol continues to go unmet. Consequently, there is marked variation in therapeutic approaches to treating intracranial hemorrhage in patients with an MHV. Unfortunately, patients with an MHV are considered at high thromboembolic (TE) risk, and these patients are often excluded from clinical trials of acute stroke due to their increased TE potential. The authors feel this case represents an example of endothelial dysfunction secondary to microthrombotic events originating from an MHV, which caused ischemic stroke with hemorrhagic conversion complicated by the need for anticoagulation for an MHV. This case offers a definitive treatment algorithm for a complex clinical dilemma.
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Dangas GD, Weitz JI, Giustino G, Makkar R, Mehran R. Prosthetic Heart Valve Thrombosis. J Am Coll Cardiol 2016; 68:2670-2689. [DOI: 10.1016/j.jacc.2016.09.958] [Citation(s) in RCA: 256] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 09/19/2016] [Accepted: 09/20/2016] [Indexed: 01/28/2023]
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Hwang TW, Kim SO, Lee SY, Kim SH, Choi EY, Jang SI, Park SJ, Kwon HW, Lim HB, Lee CH, Choi ES. Impact of postoperative duration of Aspirin use on longevity of bioprosthetic pulmonary valve in patients who underwent congenital heart disease repair. KOREAN JOURNAL OF PEDIATRICS 2016; 59:446-450. [PMID: 27895692 PMCID: PMC5118504 DOI: 10.3345/kjp.2016.59.11.446] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/07/2016] [Revised: 09/06/2016] [Accepted: 09/12/2016] [Indexed: 11/27/2022]
Abstract
Purpose Generally, aspirin is used as a protective agent against thrombogenic phenomenon after pulmonary valve replacement (PVR) using a bioprosthetic valve. However, the appropriate duration of aspirin use is unclear. We analyzed the impact of postoperative duration of aspirin use on the longevity of bioprosthetic pulmonary valves in patients who underwent repair for congenital heart diseases. Methods We retrospectively reviewed the clinical data of 137 patients who underwent PVR using a bioprosthetic valve between January 2000 and December 2003. Among these patients, 89 were included in our study and divided into groups I (≤12 months) and II (>12 months) according to duration of aspirin use. We analyzed echocardiographic data from 9 to 11 years after PVR. Pulmonary vale stenosis and regurgitation were classified as mild, moderate, or severe. Results The 89 patients consisted of 53 males and 36 females. Their mean age was 14.3±8.9 years (range, 2.6–48 years) and body weight was 37.6±14.7 kg (range, 14–72 kg). The postoperative duration of aspirin use was 7.3±2.9 months in group I and 32.8±28.4 months in group II. However, no significant difference in sex ratio, age, body weight, type of bioprosthetic valve, and number of early redo-PVRs. In the comparison of echocardiographic data about 10 years later, no significant difference in pulmonary valve function was found. The overall freedom rate from redo-PVR at 10 years showed no significant difference (P=0.498). Conclusion Our results indicated no benefit from long-term aspirin medication (>6 months) in patients who underwent PVR with a bioprosthetic valve.
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Affiliation(s)
- Tae-Woong Hwang
- Department of Pediatrics, Sejong General Hospital, Bucheon, Korea
| | - Sung-Ook Kim
- Department of Pediatrics, Sejong General Hospital, Bucheon, Korea
| | - Sang-Yun Lee
- Department of Pediatrics, Sejong General Hospital, Bucheon, Korea
| | - Seong-Ho Kim
- Department of Pediatrics, Sejong General Hospital, Bucheon, Korea
| | - Eun-Young Choi
- Department of Pediatrics, Sejong General Hospital, Bucheon, Korea
| | - So-Ick Jang
- Department of Pediatrics, Sejong General Hospital, Bucheon, Korea
| | - Su-Jin Park
- Department of Pediatrics, Sejong General Hospital, Bucheon, Korea
| | - Hye-Won Kwon
- Department of Pediatrics, Sejong General Hospital, Bucheon, Korea
| | - Hyo-Bin Lim
- Department of Pediatrics, Sejong General Hospital, Bucheon, Korea
| | - Chang-Ha Lee
- Department of Thoracic and Cardiovascular Surgery, Sejong General Hospital, Bucheon, Korea
| | - Eun-Seok Choi
- Department of Thoracic and Cardiovascular Surgery, Sejong General Hospital, Bucheon, Korea
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Scotten LN, Siegel R. Are anticoagulant independent mechanical valves within reach-fast prototype fabrication and in vitro testing of innovative bi-leaflet valve models. ANNALS OF TRANSLATIONAL MEDICINE 2015; 3:197. [PMID: 26417581 DOI: 10.3978/j.issn.2305-5839.2015.08.18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Exploration for causes of prosthetic valve thrombogenicity has frequently focused on forward or post-closure flow detail. In prior laboratory studies, we uncovered high amplitude flow velocities of short duration close to valve closure implying potential for substantial shear stress with subsequent initiation of blood coagulation pathways. This may be relevant to widely accepted clinical disparity between mechanical and tissue valves vis-à-vis thrombogenicity. With a series of prototype bi-leaflet mechanical valves, we attempt reduction of closure related velocities with the objective of identifying a prototype valve with thrombogenic potential similar to our tissue valve control. This iterative design approach may find application in preclinical assessment of valves for anticoagulation independence. METHODS Tested valves included: prototype mechanical bi-leaflet BVs (n=56), controls (n=2) and patented early prototype mechanicals (n=2) from other investigators. Pulsatile and quasi-steady flow systems were used for testing. Projected dynamic valve area (PDVA) was measured using previously described novel technology. Flow velocity over the open and closing periods was determined by volumetric flow rate/PDVA. For the closed valve interval, use was made of data obtained from quasi-steady back pressure/flow tests. Performance was ranked by a proposed thrombogenicity potential index (TPI) relative to tissue and mechanical control valves. RESULTS Optimization of the prototype valve designs lead to a 3-D printed model (BV3D). For the mitral/aortic site, BV3D has lower TPI (1.10/1.47) relative to the control mechanical valve (3.44/3.93) and similar to the control tissue valve (ideal TPI ≤1.0). CONCLUSIONS Using unique technology, rapid prototyping and thrombogenicity ranking, optimization of experimental valves for reduced thrombogenic potential was expedited and simplified. Innovative mechanical valve configurations were identified that merit consideration for further development which may bring the anti-coagulation independent mechanical valve within reach.
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Affiliation(s)
- Lawrence N Scotten
- 1 ViVitro Systems Inc. (VSI), Victoria, BC, Canada ; 2 Lake Oswego, OR, USA
| | - Rolland Siegel
- 1 ViVitro Systems Inc. (VSI), Victoria, BC, Canada ; 2 Lake Oswego, OR, USA
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Almeida ED, Guimarães RB, Stephan LS, Medeiros AK, Foltz K, Santanna RT, Pires LM, Kruse ML, Lima GGD, Leiria TLL. Clinical Differences between Subtypes of Atrial Fibrillation and Flutter: Cross-Sectional Registry of 407 Patients. Arq Bras Cardiol 2015; 105:3-10. [PMID: 26016782 PMCID: PMC4523282 DOI: 10.5935/abc.20150049] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Accepted: 02/09/2015] [Indexed: 01/03/2023] Open
Abstract
Introduction Atrial fibrillation and atrial flutter account for one third of hospitalizations
due to arrhythmias, determining great social and economic impacts. In Brazil, data
on hospital care of these patients is scarce. Objective To investigate the arrhythmia subtype of atrial fibrillation and flutter patients
in the emergency setting and compare the clinical profile, thromboembolic risk and
anticoagulants use. Methods Cross-sectional retrospective study, with data collection from medical records of
every patient treated for atrial fibrillation and flutter in the emergency
department of Instituto de Cardiologia do Rio Grande do Sul during the first
trimester of 2012. Results We included 407 patients (356 had atrial fibrillation and 51 had flutter).
Patients with paroxysmal atrial fibrillation were in average 5 years younger than
those with persistent atrial fibrillation. Compared to paroxysmal atrial
fibrillation patients, those with persistent atrial fibrillation and flutter had
larger atrial diameter (48.6 ± 7.2 vs. 47.2 ± 6.2 vs. 42.3 ± 6.4; p < 0.01) and
lower left ventricular ejection fraction (66.8 ± 11 vs. 53.9 ± 17 vs. 57.4 ± 16; p
< 0.01). The prevalence of stroke and heart failure was higher in persistent
atrial fibrillation and flutter patients. Those with paroxysmal atrial
fibrillation and flutter had higher prevalence of CHADS2 score of zero when
compared to those with persistent atrial fibrillation (27.8% vs. 18% vs. 4.9%; p
< 0.01). The prevalence of anticoagulation in patients with CHA2DS2-Vasc ≤ 2
was 40%. Conclusions The population in our registry was similar in its comorbidities and demographic
profile to those of North American and European registries. Despite the high
thromboembolic risk, the use of anticoagulants was low, revealing difficulties for
incorporating guideline recommendations. Public health strategies should be
adopted in order to improve these rates.
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Affiliation(s)
- Eduardo Dytz Almeida
- Fundação Universitária de Cardiologia, Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre, RS, BR
| | - Raphael Boesche Guimarães
- Fundação Universitária de Cardiologia, Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre, RS, BR
| | - Laura Siga Stephan
- Fundação Universitária de Cardiologia, Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre, RS, BR
| | - Alexandre Kreling Medeiros
- Fundação Universitária de Cardiologia, Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre, RS, BR
| | - Katia Foltz
- Fundação Universitária de Cardiologia, Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre, RS, BR
| | - Roberto Tofani Santanna
- Fundação Universitária de Cardiologia, Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre, RS, BR
| | - Leonardo Martins Pires
- Fundação Universitária de Cardiologia, Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre, RS, BR
| | - Marcelo Lapa Kruse
- Fundação Universitária de Cardiologia, Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre, RS, BR
| | - Gustavo Glotz de Lima
- Fundação Universitária de Cardiologia, Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre, RS, BR
| | - Tiago Luiz Luz Leiria
- Fundação Universitária de Cardiologia, Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre, RS, BR
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Fiorentino F, Rogers CA, Bryan AJ, Angelini GD, Reeves BC. Implications of using different methods to characterise anticoagulant control in patients with second generation mechanical heart valve prostheses. PLoS One 2014; 9:e98323. [PMID: 24988447 PMCID: PMC4079318 DOI: 10.1371/journal.pone.0098323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 05/01/2014] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Characterisation of anticoagulant control is fundamental to investigations of its association with clinical outcome. Anticoagulant control depends on several factors. This paper aims to illustrate the implications of different methods for measuring and analysing anticoagulant control in patients with second generation mechanical heart valve prostheses. METHODS International normalised ratio (INR) data collected during the 10-year follow-up of a randomised controlled trial were analysed. We considered the influence of: 3 different target INR ranges; anticoagulant control expressed as the proportion of INR readings (PoR) vs. anticoagulant control follow-up time (PoT); 3 ways of describing the profile of anticoagulant control over time. RESULTS Different target INR ranges dramatically influenced derived measures of anticoagulant control; the PoT within the target range varied from 88% for the widest to 28% for narrowest range. Overall distributions of PoR and PoT observations were similar but differed by up to ± 20% for individuals; PoT exceeded PoR when control was good but was less than PoR when control was poor. Classifying PoT outside the target range showed that widely varying combinations of PoT too high and too low are possible across individuals. CONCLUSIONS Researchers' choices about methods for measuring and quantifying anticoagulant control markedly influence the values derived from INR readings. The use of different methods across studies makes it difficult or impossible to compare findings and to establish an evidence base for clinical practice. Methods for quantifying anticoagulant control should be standardised.
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Affiliation(s)
- Francesca Fiorentino
- National Heart & Lung Institute, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Chris A. Rogers
- Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Bristol, United Kingdom
| | - Alan J. Bryan
- Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Bristol, United Kingdom
| | - Gianni D. Angelini
- Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Bristol, United Kingdom
- National Heart & Lung Institute, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Barnaby C. Reeves
- Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Bristol, United Kingdom
- * E-mail:
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Affiliation(s)
- Patricia A Howard
- Professor and Vice Chair, Department of Pharmacy Practice, University of Kansas Medical Center , Mailstop 4047, 3901 Rainbow Boulevard, Kansas City, KS 66160 ; phone: 913-588-5391 ; fax: 913-588-2355 ; e-mail:
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Ewen S, Rettig-Ewen V, Mahfoud F, Böhm M, Laufs U. Drug adherence in patients taking oral anticoagulation therapy. Clin Res Cardiol 2013; 103:173-82. [PMID: 23999974 DOI: 10.1007/s00392-013-0616-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Accepted: 08/27/2013] [Indexed: 10/26/2022]
Abstract
Oral anticoagulation has proven to reduce mortality and morbidity of thromboembolic events. One of the most important determinants of the effectiveness and safety of anticoagulation therapy is the adherence to the prescribed therapy. Vitamin K antagonists are characterized by under-utilization, a narrow therapeutic window and multiple food and drug interactions which contribute to a variable dose-response relationship with the risk of insufficient protection and/or increased bleeding risk. The "new" direct oral anticoagulants have demonstrated equal or superior protection and reduced bleeding risks compared to warfarin and are easier to use because of fixed dosing without monitoring of anticoagulation. Controlling of adherence to the direct oral anticoagulants is difficult. Therefore, continuous and regular medication intake represents a pre-requisite for achieving optimal protection. The present review aims to give an overview about the factors that affect drug adherence in patients taking oral anticoagulation drugs and discusses strategies to improve drug adherence.
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Affiliation(s)
- Sebastian Ewen
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Kirrberger Str., Geb. 40, 66421, Homburg/Saar, Germany,
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van der Sand CR, Leiria TLL, Kalil RAK. Assessment of the adherence of cardiologists to guidelines for the treatment of atrial fibrillation. Arq Bras Cardiol 2013; 101:127-33. [PMID: 23877745 PMCID: PMC3998160 DOI: 10.5935/abc.20130148] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Revised: 11/14/2012] [Accepted: 03/15/2013] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND No local studies evaluating the knowledge of cardiologists on the management of atrial fibrillation (AF) and their adherence to these guidelines are available. OBJECTIVE To evaluate the knowledge of cardiologists on the guidelines and clinical practices for the treatment of AF, correlating it to the time since medical graduation. METHODS Cross-sectional study randomly including cardiologists affiliated to the Society of Cardiology of the State of Rio Grande do Sul (Sociedade de Cardiologia do Estado do Rio Grande do Sul - SOCERGS). The physicians were divided into two groups, according to time since graduation: those graduated for more (G1) or less (G2) than 25 years. RESULTS Of the 859 SOCERGS members, 150 were interviewed, and six refused to participate in the study. G1 comprised 71 physicians, and G2, 73. Differences were observed in regard to the following variables: use of betablockers as the first-choice drug for the control of AF response in 59.2% (G1) vs 91.8% (G2) (p<0.0001); use of digoxin as the preferred drug for the control of AF response in 19.7% (G1) vs 0% (G2) (p< 0.0001); warfarin as the preferred anticoagulant in 71.8% (G1) vs 93.2% (G2) (p=0.009); application of a risk score for anticoagulation in 73.2% (G1) vs 87.7% (G2) (p=0.02). In questions regarding the knowledge about the Brazilian Society of Cardiology's guideline for AF, the overall percentage of right answers was 82.3%. CONCLUSION Most of the clinical measures regarding the management of AF comply with the guidelines, and the clinical practice differs according with the time since graduation.
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Affiliation(s)
- Cézar R. van der Sand
- Instituto de Cardiologia/Fundação Universitária de Cardiologia - Programa de
Pós Graduação em Ciências da Saúde: Cardiologia, Porto Alegre, RS - Brazil
| | - Tiago Luiz Luz Leiria
- Instituto de Cardiologia/Fundação Universitária de Cardiologia - Programa de
Pós Graduação em Ciências da Saúde: Cardiologia, Porto Alegre, RS - Brazil
| | - Renato Abdala Karam Kalil
- Instituto de Cardiologia/Fundação Universitária de Cardiologia - Programa de
Pós Graduação em Ciências da Saúde: Cardiologia, Porto Alegre, RS - Brazil
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Bajaj R, Karthikeyan G, Sinha N, Lokhandwala Y, Rao D, Kaushik SK, Jain SL, Narayanan S, Seth A, Satyamurthi I, Sawhney JPS, Saran RK, Sharma S, Haridas KK, Gohkroo RK, Omar AK, Dwivedi SK, Modi S, Kapur KK, Dalvi B, Bharani A, Wander GS, Venugopal K, Mahant TS. CSI consensus statement on prosthetic valve follow up. Indian Heart J 2012. [PMID: 23186628 DOI: 10.1016/j.ihj.2012.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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28
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Stapf C. Hemostatic Therapy Should Not Be Used for Acute Treatment of Anticoagulation-Related Intracerebral Hemorrhage. Stroke 2012; 43:2537-8. [DOI: 10.1161/strokeaha.111.636738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Christian Stapf
- From the Neurovascular Unit, Department of Neurology, APHP–Hôpital Lariboisière, Paris, France; and Université Paris Diderot-Sorbonne Paris Cité, Paris, France
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29
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First 102 Patients With the Biovalsalva Conduit for Aortic Root Replacement. Ann Thorac Surg 2012; 94:72-7. [DOI: 10.1016/j.athoracsur.2012.03.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2012] [Revised: 03/09/2012] [Accepted: 03/19/2012] [Indexed: 11/17/2022]
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30
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Lopes RD, Becker RC, Newby LK, Peterson ED, Hylek EM, Granger CB, Crowther M, Wang T, Carvalho AC, Berwanger O, Giraldez RR, Feitosa GS, Ribeiro JP, Darze E, Kalil RAK, Andrande M, Boas FV, Andrade J, Rocha AT, Harrington RA, Lopes AC, Garcia DA. Highlights from the IV International Symposium of Thrombosis and Anticoagulation (ISTA), October 20-21, 2011, Salvador, Bahia, Brazil. J Thromb Thrombolysis 2012; 34:143-63. [PMID: 22427055 DOI: 10.1007/s11239-012-0700-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
To discuss and share knowledge about advances in the care of patients with thrombotic disorders, the Fourth International Symposium of Thrombosis and Anticoagulation was held in Salvador, Bahia, Brazil, from October 20-21, 2011. This scientific program was developed by clinicians for clinicians and was promoted by three major clinical research institutes: the Brazilian Clinical Research Institute, the Duke Clinical Research Institute of the Duke University School of Medicine, and Hospital do Coração Research Institute. Comprising 2 days of academic presentations and open discussion, the symposium had as its primary goal to educate, motivate, and inspire internists, cardiologists, hematologists, and other physicians by convening national and international visionaries, thought-leaders, and dedicated clinician-scientists. This paper summarizes the symposium proceedings.
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Affiliation(s)
- Renato D Lopes
- Duke Clinical Research Institute, Duke University Medical Center, Box 3850, 2400 Pratt Street, Room 0311 Terrace Level, Durham, NC 27705, USA.
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31
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Wilke A, Wende CM, Horst M, Steverding D. Thrombosis of A Prosthetic Mitral Valve After Withdrawal of Phenprocoumon Therapy. Cardiol Res 2011; 2:298-300. [PMID: 28352399 PMCID: PMC5358259 DOI: 10.4021/cr124w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2011] [Indexed: 11/11/2022] Open
Abstract
Patients with prosthetic heart valves require lifelong oral anticoagulant therapy based on vitamin K antagonists. These patients may need interruption of their anticoagulant therapy if they have to undergo surgery. The clinical challenge is to identify patients who can safely undergo surgery while continuing their vitamin K antagonist treatment and those who have to take short-acting heparin as part of a bridging therapy. Here we present a case of a patient with a prosthetic mitral valve whose oral anticoagulant therapy was unnecessarily discontinued by the GP prior to an upcoming cataract surgery. As a result, the patient developed thrombosis of the prosthetic mitral valve which needed to be surgically replaced.
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Affiliation(s)
| | - Christian M Wende
- Abteilung Kardiologie, Marienkrankenhaus Papenburg, Papenburg, Germany
| | - Michael Horst
- Abteilung Kardiochirugie, Städtische Kliniken Oldenburg, Oldenburg, Germany
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