deamino-arginine-vasopressin and Aortic-Valve-Stenosis

Patients with severe aortic valve stenosis have a markedly reduced platelet function as measured by a prolonged collagen adenosine diphosphate closure time (CADP-CT) determined by the platelet function analyzer PFA-100. We hypothesized that such patients may benefit from desmopressin when they present with prolonged CADP-CT due to the specific action of desmopressin on von Willebrand factor (VWF) and CADP-CT.. In this double-blind, randomized placebo controlled trial, 43 patients undergoing aortic valve replacement (due to severe aortic valve stenosis with CADP-CT>170 seconds) were given desmopressin 0.3 μg/kg or saline intravenously after induction of anesthesia. Measurement of CADP-CT, factor VIII activity, von Willebrand factor antigen, GpIb binding activity, ristocetin cofactor activity, collagen-binding activity, and multimers were performed after induction of anesthesia, one hour after desmopressin infusion, and 24 hours postoperatively.. In the majority of patients, baseline values of von Willebrand factor related indices were normal, but increased one hour after infusion of desmopressin by 73% to 90% as compared with placebo. Selective loss of high molecular weight multimers was seen only in a minority of patients. The CADP-CT was greater than 170 seconds in 92% of screened patients, and desmopressin shortened CADP-CT by 48% versus baseline and reduced postoperative blood loss by 42% (p<0.001).. Prolonged CADP-CT indicates platelet dysfunction in severe aortic valve stenosis, and can guide the use of desmopressin as an effective prohemostatic agent in patients with severe aortic valve stenosis.

Topics: Aged; Aged, 80 and over; Aortic Valve Stenosis; Blood Platelet Disorders; Deamino Arginine Vasopressin; Double-Blind Method; Echocardiography, Doppler; Female; Follow-Up Studies; Heart Valve Prosthesis Implantation; Hemostatics; Hospital Mortality; Humans; Infusions, Intravenous; Male; Middle Aged; Postoperative Hemorrhage; Preoperative Care; Reference Values; Risk Assessment; Severity of Illness Index; Survival Analysis; Time Factors; Treatment Outcome

Topics: Angiodysplasia; Aortic Valve; Aortic Valve Stenosis; Deamino Arginine Vasopressin; Female; Gastrointestinal Hemorrhage; Heart Valve Prosthesis Implantation; Hemostatics; Humans; Middle Aged; Postoperative Care; Postoperative Hemorrhage

Cardiac surgery in Jehovah's Witness patients remains a challenge in the presence of concomitant congenital or acquired coagulation disorders and anaemia. We report a case of a 66-year-old female Jehovah's Witness suffering from severe calcified aortic valve stenosis requiring aortic valve replacement. The anaemic patient suffered from concomitant platelet dysfunction and deficiency of factors V and VII due to gammopathy of immunoglobulin G. The patient was preoperatively treated with recombinant erythropoietin in combination with folic acid and iron, which resulted in an increase of the haematocrit from 0.335 to 0.416 after 22 days of treatment. Haemostasis was improved by high dose aprotinin and additional desmopressin, which could be demonstrated to be effective by a preoperative test. The patients intra- and postoperative course was uneventful, her total chest tube loss was 130 ml, and she was able to be discharged without the need of any blood transfusions. The beneficial properties of erythropoietin and desmopressin in Jehovah's Witness patients are discussed.

Topics: Aged; Anemia; Aortic Valve Stenosis; Blood Coagulation Disorders; Blood Loss, Surgical; Blood Transfusion; Deamino Arginine Vasopressin; Erythropoietin; Female; Heart Valve Prosthesis Implantation; Hemostatics; Humans; Jehovah's Witnesses; Preoperative Care; Recombinant Proteins; Religion and Medicine

The majority of cases of central diabetes insipidus are still pathogenetically unclear (idiopathic). Atherosclerotic cholesterol emboli might be partly responsible for some of these idiopathic cases. A 54-year-old woman with known aortic valve stenosis and a history of a transitory ischemic attack presented with sudden-onset polyuria and polydipsia of up to eight l/d, which had started acutely with headaches. She had been treated with lithium for 3 years because of cyclothymic depression. Plasma sodium was in the upper normal range (142-148 mmol/l). Hypertonic saline infusion during lithium therapy revealed a normal threshold of thirst and resetting of vasopressin secretion (osmotic threshold > 300 mosmol/l), whereas vasopressin reserve was normal. Lithium withdrawal led to an even greater delay of vasopressin release upon hypertonic saline infusion (> 310 mosmol/l). Pituitary function tests revealed a normal anterior pituitary function. MR imaging of the hypothalamo-hypophyseal region showed a normal hypothalamic region and a highly intensive neurohypophyseal signal in the T1-weighted image. The patient responded well to desmopressin. We suggest that in this rare case clinical symptoms as well as biochemical findings like impairment of AVP release might be related to a minor structural hypothalamic damage by a vascular lesion, caused, for example, by an atheromatous (cholesterol) embolism in the hypothalamic region responsible for integration of osmoreceptor function and AVP-secretion. The patient's atherosclerosis and aortic stenosis might be responsible for this event.

Topics: Aortic Valve Stenosis; Arginine Vasopressin; Arteriosclerosis; Deamino Arginine Vasopressin; Diabetes Insipidus; Drinking; Female; Humans; Magnetic Resonance Imaging; Middle Aged; Polyuria; Saline Solution, Hypertonic