phenprocoumon and Heart-Diseases

Oral anticoagulation and antiplatelet therapy are risk factors for gastrointestinal (GI) bleeding. GI bleeding-especially lower GI bleeding-seems to be associated with a poorer outcome. With the introduction of dabigatrane and rivaroxaban, difficulties in the management of bleeding complications arose. Thus, the goal of the authors was to establish a standard operating procedure (SOP) for the treatment of severe GI bleeding associated with rivaroxaban, dabigatrane, and antiplatelet therapy. Bleeding complications during phenprocoumon treatment should be treated with prothrombin complex concentrates and vitamin K1. Dabigatrane elimination is highly dependent to the renal function. The measurement of drug concentrations of dabigatrane and rivaroxaban is useful to indicate an increased risk of bleeding complications. Severe bleeding associated with dabigatrane or rivaroxaban therapy should trigger prothrombin complex therapy, whereby in cases with severe bleeding associated with antiplatelet therapy platelet transfusion should be initiated. Low-dose aspirin should be continued after 24 h.

Topics: Algorithms; Anticoagulants; Benzimidazoles; beta-Alanine; Blood Coagulation Factors; Dabigatran; Drug Monitoring; Gastrointestinal Hemorrhage; Heart Diseases; Humans; Metabolic Clearance Rate; Morpholines; Phenprocoumon; Platelet Aggregation Inhibitors; Platelet Transfusion; Rivaroxaban; Thiophenes; Vitamin K

Patients (pts.) with atrial fibrillation (AF) and atrial thrombi are known to have an increased risk for cerebral embolism. However, little is known about the clinical course of atrial thrombi and the incidence of cerebral embolism in those patients during anticoagulation therapy. The high sensitivity of MR imaging (MRI) including diffusion-weighted imaging (DWI) suggests that this technique could provide an improved estimate of cerebral embolism associated with the presence of left atrial thrombi. The aims of this prospective study were to evaluate 1) the prevalence of clinically silent and apparent cerebral embolism in pts. with newly diagnosed AF and atrial thrombi using MRI/DWI, 2) the long-term fate of atrial thrombi under continues anticoagulation therapy and 3) the incidence of cerebral embolism during a follow-up period of 12 months with continuous anticoagulation therapy.. The study group consisted of 32 pts. with 1) newly diagnosed AF and evidence of left atrial (LA) thrombi detected by TEE and 2) a new start of anticoagulation therapy [International Normalized Ratio (INR) 2.0 - 3.0]. 19 pts. with 1) newly diagnosed AF and no evidence of atrial thrombi and 2) an equivalent anticoagulation regimen served as the control group. In both groups a) MRI/DWI studies of the brain (weeks 0, 4, 8, 12, 20, 28, 36, 44, and 52), b) transesophageal echocardiographic studies (TEE) for assessment of LA-Thrombi (weeks 0 and 52) and c) clinical neurological assessments (weeks 0, 20 and 52) were performed.. In the study group (AF and LA-Thrombi) 11 out of 32 pts. (34 %) displayed signs of acute (n = 8) or chronic (n = 3) cerebral embolism in the initial MRI studies. In 4 out of 32 pts. (13 %), MRI/DWI depicted new or additional cerebral emboli (n = 12) during the follow-up period despite continuous anticoagulation therapy. 2 (n = 2/4; 50 %) of these patients had clinically apparent neurological deficits. In the control group 1 out of 19 pts. (5 %) showed evidence of chronic cerebral embolism as assessed by MRI/DWI at the beginning of the study (week 0). No embolic cerebral lesions were detected during the 12-month follow-up. Within 12 months only 63 % (n = 20/32) of LA thrombi in the study group resolved completely under anticoagulation.. 1. The incidence of clinically inapparent cerebral emboli in pts. with newly diagnosed AF and atrial thrombi is much higher than the incidence of clinically apparent emboli and has been underestimated in the past. 2. New cerebral embolism may occur even with continued effective anticoagulation therapy in 13 % of pts. 3. Only 63 % of atrial thrombi resolve completely within 12 months under anticoagulation therapy.

Topics: Aged; Anticoagulants; Antifibrinolytic Agents; Atrial Fibrillation; Cerebral Infarction; Diffusion Magnetic Resonance Imaging; Echocardiography, Transesophageal; Female; Follow-Up Studies; Heart Atria; Heart Diseases; Heparin; Humans; Incidence; Intracranial Embolism; Magnetic Resonance Imaging; Male; Middle Aged; Partial Thromboplastin Time; Phenprocoumon; Prospective Studies; Risk Factors; Sensitivity and Specificity; Thrombosis; Time Factors

Bioprosthetic valve replacement is the treatment of choice in older patients with symptomatic severe aortic valve disease. Thrombosis of bioprosthetic valves has been considered a rare complication; however, in the presence of valvular obstruction, therapeutic consequences for the individual patient may be dramatic including repeat valve replacement or thrombolysis. We therefore evaluated oral anticoagulation with phenprocoumon as an alternative treatment for obstructive thrombosis of bioprosthetic valves. Six of 470 patients who had received a single stented bioprosthetic aortic valve from January 2007 through December 2008 at our hospital presented with obstructive bioprosthetic valve thrombosis within 14 months postoperatively. All 6 patients (1% of study population) had received a porcine valve (p = 0.1 vs pericardial), were hemodynamically stable, were in sinus rhythm, and were taking acetylsalicylic acid 100 mg/day. Echocardiography showed an increase in mean pressure gradient early postoperatively from 23.3 ± 4 to 57.0 ± 10 mm Hg (p <0.001). Five patients were started on phenprocoumon and followed for 114 ± 54 days, when mean pressure gradient had returned to 23.5 ± 6 mm Hg. No adverse events were observed during that period. One patient presenting with dyspnea and fever underwent emergency repeat valve replacement for suspected endocarditis, with histology showing long-term thrombosis of the explanted valve. In conclusion, oral anticoagulation with phenprocoumon represents a safe and effective treatment in clinically stable patients with obstructive thrombosis of bioprosthetic aortic valves, thus obviating repeat valve surgery or thrombolysis.

Topics: Aged; Anticoagulants; Aortic Valve; Bioprosthesis; Dose-Response Relationship, Drug; Echocardiography, Doppler; Female; Follow-Up Studies; Heart Diseases; Heart Valve Diseases; Heart Valve Prosthesis; Humans; Male; Phenprocoumon; Retrospective Studies; Thrombosis; Treatment Outcome

Noninvasive echocardiographic differentiation between old and fresh left ventricular thrombi after myocardial infarction would be of clinical importance to estimate the risk for embolization and the necessity of anticoagulation.. Fifty-two patients, aged 41 to 87 years, with a thrombus after myocardial infarction were included in this 2-part study: In substudy-I, 20 patients, 10 each with a definite diagnosis of fresh or old thrombus, were included. In the subsequent prospective substudy-II, 32 consecutive patients with an incident thrombus after myocardial infarction but unknown thrombus age were started on phenprocoumon and followed for 6 months. Data on medical history, standard echocardiography, strain-rate (SR) imaging and magnetic resonance tomography were analyzed. In substudy-I, analysis of thrombus deformation revealed the most rapid change in SR during the isovolumetric relaxation period when cavity pressure decreases rapidly. Fresh (range: 5-27 days) and old thrombi (4-26 months) could be discriminated without overlap by peak SR during the isovolumetric relaxation period, using a cutoff value of 1 s(-1). Applying this threshold value in substudy-II, 17 thrombi were echocardiographically classified as fresh (=SR ≥1 s(-1)) and 15 as old. After 6 months in the fresh thrombus group, 16 of 17 thrombi had disappeared (94%), and in 1 patient the thrombus size was diminished by >50% (now presenting an old thrombus SR pattern). In contrast, 14 of the 15 old thrombi remained unchanged in size and deformation (1 thrombus disappeared).. Fresh and old intracavitary thrombi can be reliably differentiated by deformation imaging. In fresh thrombi, anticoagulation with phenprocoumon results in thrombus resolution in most patients.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Chi-Square Distribution; Diagnosis, Differential; Echocardiography, Doppler; Elastic Modulus; Elasticity Imaging Techniques; Female; Germany; Heart Diseases; Heart Ventricles; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Myocardial Infarction; Phenprocoumon; Pilot Projects; Predictive Value of Tests; Prospective Studies; Thrombosis; Time Factors

The case of a 78-year-old female patient who suffered atrial fibrillation and persistent thrombus in the left atrial appendage despite sufficient anticoagulation is reported. The case is chosen to demonstrate the complexity inherent in prophylaxis as well as risk evaluation of thromboembolism on the basis of clinical and echocardiographic criteria. We also discuss transesophageal echocardiography as the standard diagnostic procedure for detection of intracardiac thrombi prior to cardioversion as well as cardiac computer tomography as an alternative.

Topics: Administration, Oral; Adrenergic beta-Antagonists; Aged; Anticoagulants; Atrial Fibrillation; Drug Therapy, Combination; Echocardiography; Echocardiography, Transesophageal; Electric Countershock; Enoxaparin; Female; Heart Atria; Heart Diseases; Humans; International Normalized Ratio; Phenprocoumon; Risk Factors; Thromboembolism; Thrombosis; Tomography, X-Ray Computed

A serious retroperitoneal bleeding occurred in a 56-year-old male patient receiving unfractionated heparin due to multiple pulmonary embolism. After reducing the heparin dose, the patient developed a new pulmonary embolism and a large thrombus in the right atrium. Concomitantly, the platelet count dropped to a value of 29 g/l. Heparin-induced thrombocytopenia (HIT) was confirmed by a functional assay, the heparin-induced platelet activation (HIPA) assay, whereas the results of a platelet factor 4/heparin complex ELISA were repeatedly negative. This indicated that the patient's HIT antibodies were directed towards an antigen other than platelet factor 4/heparin complexes. For treatment of the atrial thrombus, an ultra-low-dose lysis with rt-PA (2 mg/h, intravenously) was administered for a period of 52 h, overlapping with systemic treatment with recombinant hirudin (Lepirudin, Refludan, 0.06-0.14 mg/kg/h intravenously). The aim was to enhance lysis of the thrombus without increasing the haematoma, and at the same time keep the risk of fulminant pulmonary embolism due to thrombus fragmentation as low as possible. The cardiac thrombus disappeared within 48 h, without new signs of pulmonary embolism. Platelet counts normalized within nine days.

Topics: Anticoagulants; Arrhythmias, Cardiac; Autoimmune Diseases; Heart Atria; Heart Diseases; Hemorrhage; Heparin; Hirudin Therapy; Hirudins; Humans; Male; Middle Aged; Phenprocoumon; Plasminogen Activators; Pulmonary Embolism; Recombinant Proteins; Retroperitoneal Space; Thrombocytopenia; Thrombolytic Therapy; Thrombosis; Tissue Plasminogen Activator; Vena Cava Filters

Over a period of several months a 33-year-old man had recurrent pulmonary emboli. No thromboses could be demonstrated in the peripheral venous system. Transoesophageal echocardiography showed two spherical space-occupying structures in the right ventricle which were removed operatively under the suspected diagnosis of multilobular myxomas. However, their histological examination revealed pure thrombi that had grown by apposition. This unusual findings of right-ventricular thrombi could not be explained pre- and intraoperatively by any local thrombi-favouring changes in the right heart. Tests of clotting mechanisms demonstrated lupus anticoagulant (kaolin-clotting-time mixture test: LA index 21.7 [normal: < 15]), as well as an increased IgG cardiolipin antibody concentration of 19.3 U/l). As no underlying disease was discovered, the diagnosis was by definition primary antiphospholipid syndrome. No further thrombo-embolism has occurred during continuing oral anticoagulation with phenprocoumon.

Topics: Adult; Antiphospholipid Syndrome; Diagnosis, Differential; Heart Diseases; Heart Neoplasms; Heart Ventricles; Humans; Lupus Coagulation Inhibitor; Male; Myxoma; Phenprocoumon; Pulmonary Embolism; Recurrence; Thrombosis

The embolic risk and changes of thrombus location and size were investigated in 29 consecutive patients with echocardiographically proven thrombi in the left atrium. Inclusion criteria were the visualization of a left atrial thrombus using transesophageal echocardiography. Transesophageal follow-up echocardiograms were performed at a mean period of 18 months. In this period 6 cases of embolism were observed at an interval of 20 days to 26 months after the detection of thrombus. Thus, the embolic rate was 14% per patient year. All patients received phenprocoumon (n = 4) or aspirin at the time of embolism. Furthermore, in two patients after cardiac thrombectomy left atrial thrombi were seen again although patients were treated with anticoagulants. On the other hand, in 12 patients (5 received oral anticoagulation, 2 received aspirin) thrombi completely resolved. It can be concluded from these data, that the majority of patients receiving anticoagulation profit from this therapy, however, a complete protection against arterial embolism or reoccurrence of thrombi cannot be reached. Left atrial spontaneous echo contrast was the only risk factor significantly associated with thromboembolism in patients with left atrial thrombi.

Topics: Aged; Aspirin; Combined Modality Therapy; Echocardiography; Echocardiography, Doppler, Color; Echocardiography, Transesophageal; Female; Follow-Up Studies; Heart Atria; Heart Diseases; Humans; Male; Middle Aged; Phenprocoumon; Recurrence; Thrombectomy; Thrombosis

To investigate risk factors for embolization in patients with echocardiographically detected left atrial thrombi and to evaluate thrombus development, we examined 29 patients with transesophageal and transthoracic echocardiography at two points during a follow-up of 18 months. We compared patients with a history of possible arterial embolization (n = 13) with those without (n = 16) in regard to age, gender, left atrial dilatation, localization of the thrombus in the left atrial cavity, spontaneous echo contrast, and atrial fibrillation. Eight patients were treated with aspirin, 20 with phenprocoumon. Only left atrial spontaneous contrast was associated with thromboembolism (10/15 patients with spontaneous contrast experienced arterial embolism; p = 0.038). In six patients arterial embolism occurred after thrombus detection (14% per patient per year). Four of these patients were treated with phenprocoumon, two with aspirin. At reexamination, one thrombus was detected in the patient without anticoagulant treatment and one thrombus was detected in the 8 patients treated with aspirin (13%), compared with ten thrombi detected in the 20 patients (50%) treated with phenprocoumon (p = NS). In 17 patients no thrombus was seen at reexamination. Since only 2 patients had undergone thrombectomy and 3 experienced arterial embolism during follow-up, thrombi disappeared under medical therapy in 12 patients. Patients with left atrial thrombi have a high risk of arterial embolization despite proper anticoagulative or antiplatelet treatment. Embolization occurs significantly more often if spontaneous echo contrast can be visualized. Left atrial thrombi can be reduced in size by the administration of antiplatelet and anticoagulative agents.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: Aged; Aspirin; Atrial Fibrillation; Dilatation, Pathologic; Echocardiography; Echocardiography, Transesophageal; Embolism; Female; Follow-Up Studies; Heart Atria; Heart Diseases; Heparin; Humans; Intracranial Embolism and Thrombosis; Male; Middle Aged; Mitral Valve Stenosis; Peripheral Vascular Diseases; Phenprocoumon; Risk Factors; Thrombosis

Topics: Adult; Age Factors; Aged; Amitriptyline; Dibenzazepines; Double-Blind Method; Drug Therapy, Combination; Electrocardiography; Exercise Test; Female; Heart Diseases; Heart Rate; Humans; Male; Mianserin; Middle Aged; Myocardial Contraction; Phenprocoumon; Sex Factors