Ultraslow thrombolytic therapy in stuck mechanical aortic valve, case report, and review of the literature

Background

Stuck mechanical heart valves had a debate about the management plan. There is debate regarding the type, dose, and rate of administration of various thrombolytic agents. We report a case with successful thrombolysis using an ultraslow regimen.

Case summary

A 43-year-old female with a history of aortic valve (AV) and mitral valve replacement (bi-leaflet metallic valves), and tricuspid valve repair (MINI band) at October 2017. Physical examination showed normal metallic first heart sound and weak metallic second heart sound. Laboratory investigations were normal except low INR, hematocrit, and hemoglobin level (9 gm/L due to iron deficiency anemia). Transthoracic echocardiogram (TTE) and Transoesophageal echocardiogram (TEE) confirmed stuck aortic valve leaflet, with a high mean pressure gradient across prosthetic AV (34 mmHg). The mechanical mitral valve was working well. Fluoroscopy showed stuck one of the AV leaflets in a closed position. The treating physician decided to give her the chance for thrombolytic therapy. This case was treated with ultraslow thrombolytic therapy (Alteplase, 1 mg, every hour) with follow up transthoracic echocardiogram every 24 h to check the pressure gradient on the AV. She was young, asymptomatic, and hemodynamically stable. After 48 h of Alteplase, the stuck leaflet was released. The mean pressure gradient dropped to 16 mmHg.

Discussion

Ultraslow thrombolytic regimen advised to be tried in stuck mechanical valves and hemodynamically stable patients.

Treatment of severe aortic stenosis and left ventricular outflow tract mass with transcutaneous aortic valve implantation: a case report

Background

Percutaneous implantation of aortic valve for severe aortic stenosis (AS) in the presence of pedunculated mobile left ventricular outflow tract (LVOT) mass not reported before. In this case report, we address the feasibility of this procedure.

Case summary

An 80-year-old patient who presented with presyncope, transthoracic echocardiogram (TTE), and transoesophageal echocardiography (TOE) revealed severe calcific AS and LVOT mass measuring 2.1*1.5 cm. The patient was turned down for surgery. It was decided that transcatheter aortic valve implantation (TAVI) be performed because the valve compresses the mass against the proximal part of the interventricular septum. The mass peduncle was 1.4 cm, and it was 4 mm away from the annulus. This meant the valve was needed to be deployed 18 mm below the annulus to cover the mass completely. Gentle manipulation and direct valve deployment without preballoon dilation to decrease the possibility of fragment embolization were necessary. Self-expandable core valve deployed as low as possible, after initial deployment, the distance of LVOT covered by the valve measured by TOE 1.66 cm, the whole mass was covered, then the valve was fully deployed. The patient was extubated in the catheterization room; there was no clinical evidence of embolization. The patient was discharged home after 2 days. A follow-up TTE after 6 months showed a well-functioning valve and the LVOT mass then disappeared.

Discussion

Pedunculated LVOT mass should be resected surgically. In high-risk surgical patients, direct TAVI to compress the mass is feasible in experienced canters. The safety issues need more research and more cases to judge. Transoesophageal echocardiography during the procedure is mandatory to guide the valve position.

Transcatheter Closure of Aorta to Left Atrium Fistula during Active Prosthetic Valve Endocarditis as a Bridge for Surgery: A Case Report

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Early diagnosis of ALAFs and immediate management are mandatory to reduce mortality.

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Transcatheter closure of ALAF is an option to stabilize the patient as a bridge for surgery.

Big Data Based m-Health Application to Prevent Health Hazards: A Design Science Framework

BACKGROUND

Every year about three million Muslims visit the Holy City of Makkah in Saudi Arabia to perform the Hajj. Because of the large number of people present during this period, pilgrims can be subjected to many health hazards. An adequate system to minimize these health hazards is needed to support the pilgrims who attend the Hajj. This study justifies the need for developing a large data-based m-Health application to identify the health hazards encountered during the Hajj.

MATERIALS AND METHODS

In developing a big data-based m-Health application, this study follows the framework suggested by Hevner. The design of the science framework allows the development of a technological solution (i.e., design artifact) of the problem through a series of actions. The design involves rigorous knowledge of the environmental factors, including knowledge of the construction and evaluation of technological solutions, that are important and relevant to an existing problem.

RESULTS

Based on the design science framework, the process of artifact development can be classified into Artifact Design, Artifact Implementation, and Artifact Evaluation. This paper presents the Artifact Design step for the design of the big data-based m-Health application, which has an Environmental Relevance Cycle, a Knowledge-based rigor Cycle, and an Artifice development and design cycle. The big data-based m-Health application is a prototype and must be evaluated using the evaluation-and-feedback loop process until the optimum artifact is completely built and integrated into the system.

CONCLUSION

Development of a big data-based m-Health application using a design science framework can support the effective and comprehensive plan of the government of Saudi Arabia for preventing and managing Hajj-related health issues. Our proposed model for developing and designing a big data-based m-Health application could provide direction for developing the most advanced solution for dealing with the Hajj-related health issues in the future.

Playing polo during mitosis: PLK1 takes the lead

Polo-like kinase 1 (PLK1), the prototypical member of the polo-like family of serine/threonine kinases, is a pivotal regulator of mitosis and cytokinesis in eukaryotes. Many layers of regulation have evolved to target PLK1 to different subcellular structures and to its various mitotic substrates in line with its numerous functions during mitosis. Collective work is starting to illuminate an important set of substrates for PLK1: the mitotic kinases that together ensure the fidelity of the cell division process. Amongst these, recent developments argue that PLK1 regulates the activity of the histone kinases Aurora B and Haspin to define centromere identity, of MPS1 to initiate spindle checkpoint signaling, and of BUB1 and its pseudokinase paralog BUBR1 to coordinate spindle checkpoint activation and inactivation. Here, we review the recent work describing the regulation of these kinases by PLK1. We highlight common themes throughout and argue that a major mitotic function of PLK1 is as a master regulator of these key kinases.