A mechanical heart valve is the best choice

The choice of prosthesis type in patients with valvular heart disease should always be individualised. The treating heart team must weigh the concerns surrounding durability of bioprosthetic valves compared with mechanical valves and the need for lifelong anticoagulation required with mechanical valves. In general, guidelines recommend that patients under the age of 60 would benefit from a mechanical valve, and those over 70 would benefit from a bioprosthetic valve. We would argue, in this context, that the most appropriate choice for this patient would be undertaking a mitral valve replacement with a mechanical prosthesis. This recommendation is based on two considerations: first, there is a high likelihood of failure of a bioprosthesis within an unacceptably short period of time, which would then necessitate a higher risk reoperation. Second, there is high likelihood of needing long-term anticoagulation in a patient with severe mitral stenosis due to the development of atrial fibrillation. While we do acknowledge the difficulty in managing long-term anticoagulation of patients in rural settings, there have nonetheless been significant advancements in this realm with the use of pharmacist-led thrombosis clinics and point of care international normalised ratio (INR) devices in the treatment of rural patients in low-income and middle-income countries. For these reasons, therefore, we would strongly advocate for a mechanical valve in this 44-year-old patient from a rural setting.

Left atrial volume index and prediction of events in acute coronary syndrome: Solar Registry

Background

According to some international studies, patients with acute coronary syndrome (ACS) and increased left atrial volume index (LAVI) have worse long-term prognosis. However, national Brazilian studies confirming this prediction are still lacking.

Objective

To evaluate LAVI as a predictor of major cardiovascular events (MCE) in patients with ACS during a 365-day follow-up.

Methods

Prospective cohort of 171 patients diagnosed with ACS whose LAVI was calculated within 48 hours after hospital admission. According to LAVI, two groups were categorized: normal LAVI (≤ 32 mL/m²) and increased LAVI (> 32 mL/m²). Both groups were compared regarding clinical and echocardiographic characteristics, in- and out-of-hospital outcomes, and occurrence of ECM in up to 365 days.

Results

Increased LAVI was observed in 78 patients (45%), and was associated with older age, higher body mass index, hypertension, history of myocardial infarction and previous angioplasty, and lower creatinine clearance and ejection fraction. During hospitalization, acute pulmonary edema was more frequent in patients with increased LAVI (14.1% vs. 4.3%, p = 0.024). After discharge, the occurrence of combined outcome for MCE was higher (p = 0.001) in the group with increased LAVI (26%) as compared to the normal LAVI group (7%) [RR (95% CI) = 3.46 (1.54-7.73) vs. 0.80 (0.69-0.92)]. After Cox regression, increased LAVI increased the probability of MCE (HR = 3.08, 95% CI = 1.28-7.40, p = 0.012).

Conclusion

Increased LAVI is an important predictor of MCE in a one-year follow-up.