warfarin and Endocarditis--Bacterial

Management of perioperative antiplatelet/anticoagulation drugs and appropriate antibiotic prophylaxis for endocarditis are two controversial issues in the safe practice of cutaneous surgery. This article highlights the current best practice based on a literature review on these topics. Antiplatelet agents should be continued perioperatively whenever clinically possible, and discontinued only after consultation with the patient's cardiologist. The exception to this is primary cardiovascular disease, when antiplatelet drugs should be stopped for 1 week before surgery. Warfarin can be continued perioperatively when the international normalised ratio is controlled at < 3. The use of antibiotics in patients at risk of endocarditis has been recently reviewed by the National Institute of Health and Clinical Excellence (NICE), the American Heart Association, and the European Society of Cardiology. The advice has changed significantly over the past few years, and the routine use of antibiotics perioperatively should occur only when there is evidence of infection perioperatively at the site of surgery.

Topics: Anti-Inflammatory Agents, Non-Steroidal; Antibiotic Prophylaxis; Anticoagulants; Aspirin; Calcium Channel Blockers; Clopidogrel; Dipyridamole; Endocarditis, Bacterial; Humans; International Normalized Ratio; Perioperative Care; Platelet Aggregation Inhibitors; Practice Guidelines as Topic; Risk Factors; Skin Diseases; Ticlopidine; Warfarin

The aim of this study was to report our experience and review the published data on argatroban administration during adult cardiac surgery.. The information on all reported cases of argatroban use in adults, during cardiac surgery was reviewed, including that of the patient described here. This analysis focused on patient characteristics, type of surgery, argatroban dosing schedule, monitoring of anticoagulation and outcomes.. Twenty-one cases have been reported. Fifteen patients underwent off-pump surgical procedures with the argatroban dose adjusted to maintain an activated clotting time (ACT) range between 200 and 300 s. Three intraoperative thrombi occurred in two patients when the ACT was <280 s. None had coagulopathy. Six cases reported the use of argatroban during on-pump cardiac surgery dosed to keep the ACT >400 s. Intraoperative thrombotic complications were not reported in this group; however, one clot in the pump was noted after the procedure when the ACT was between 300 and 350 s. All six cases required larger volumes of perioperative blood products and three had severe coagulopathy. Of the 21 cases, seven had an indication for continued anticoagulation following surgery. Four cases did not report further use of argatroban after surgery. Three patients received argatroban after surgery without complications. Recommendations for how to use argatroban during cardiac surgery are proposed.. Argatroban, with ACT monitoring, might be safely used for anticoagulation during cardiac surgery.

Topics: Adult; Aged; Anticoagulants; Arginine; Cardiac Surgical Procedures; Coronary Artery Bypass; Coronary Artery Bypass, Off-Pump; Drug Monitoring; Endocarditis, Bacterial; Female; Heart Valve Prosthesis Implantation; Heparin; Humans; Intra-Aortic Balloon Pumping; Intraoperative Complications; Male; Middle Aged; Mitral Valve; Pipecolic Acids; Postoperative Complications; Retrospective Studies; Staphylococcal Infections; Subclavian Vein; Sulfonamides; Thrombosis; Venous Thrombosis; Warfarin; Whole Blood Coagulation Time

Topics: Animals; Antibiotic Prophylaxis; Anticoagulants; Aortic Valve Insufficiency; Aortic Valve Stenosis; Bioprosthesis; Calcinosis; Defibrillators, Implantable; Echocardiography, Doppler; Endarterectomy; Endocarditis, Bacterial; Female; Heart Valve Diseases; Heart Valve Prosthesis; Heart Valves; Hemodynamics; Humans; Immunohistochemistry; Magnetic Resonance Imaging; Mitral Valve; Mitral Valve Insufficiency; Mitral Valve Stenosis; Platelet Aggregation Inhibitors; Pregnancy; Pregnancy Complications, Cardiovascular; Pulmonary Artery; Tricuspid Valve Insufficiency; Ventricular Function, Left; Warfarin

This preventive or preemptive approach to endoscopic complications is based on the premise that the knowledgeable and prepared physician can ensure that the procedure is performed under optimal conditions and results in maximal patient safety. It is obvious that a directed patient history is one of the keys to this preventive approach. This information is only a primer and requires continuous updating to improve patient outcomes.

Topics: Anti-Inflammatory Agents, Non-Steroidal; Antibiotic Prophylaxis; Anticoagulants; Aspirin; Diagnostic Tests, Routine; Dipyridamole; Endocarditis, Bacterial; Endoscopy, Gastrointestinal; Humans; Hypoglycemic Agents; Insulin; Medical History Taking; Physical Examination; Platelet Aggregation Inhibitors; Ticlopidine; Vasodilator Agents; Warfarin

Interactions between warfarin and penicillins have been infrequently reported. A case report of a single patient who experienced the effects of a warfarin-nafcillin interaction as well as a warfarin-dicloxacillin interaction is presented. Clinical effects of this interaction were documented primarily through changes in prothrombin time (PT) and the need for higher warfarin dosing. While the patient received nafcillin, warfarin doses were increased to as much as 4.5 times the previous amounts needed to provide adequate anticoagulation. During dicloxacillin therapy, warfarin doses were gradually decreased, but stabilized to a maintenance dose higher than the patient's pre-nafcillin dose. The dicloxacillin-warfarin interaction appears similar to that noted during nafcillin-warfarin combination.

Topics: Adult; Aortic Valve; Dicloxacillin; Drug Interactions; Drug Monitoring; Drug Therapy, Combination; Endocarditis, Bacterial; Heart Valve Prosthesis; Humans; Male; Nafcillin; Prosthesis-Related Infections; Prothrombin Time; Warfarin

Approximately 20,000 heart valve prostheses are inserted yearly in the United States. Even after successful heart operations, the patients who receive them cannot be regarded as healthy individuals but are a special group with special problems who need close medical attention for the rest of their lives. They are susceptible to many unusual complications because of their implanted foreign body, and it is a challenge to all physicians in contact with them to be aware of their peculiar problems in order to prevent complications if possible and to treat them immediately if they occur. General therapy, surgical complications, infection, and mechanical problems are reviewed, with means for management outlined. These difficulties can be dealt with only by careful follow-up and well-coordinated teamwork between the family physician and the institution where the operation was performed.

Topics: Activities of Daily Living; Anti-Arrhythmia Agents; Diet, Sodium-Restricted; Digitalis Glycosides; Diuretics; Embolism; Endocarditis, Bacterial; Heart Valve Prosthesis; Humans; Postoperative Care; Postoperative Complications; Thrombosis; Time Factors; Warfarin

Topics: Anti-Arrhythmia Agents; Cardiac Catheterization; Diet, Sodium-Restricted; Digitalis Glycosides; Diuretics; Endocarditis, Bacterial; Fluoroscopy; Heart Valve Prosthesis; Humans; Phonocardiography; Postoperative Complications; Postpericardiotomy Syndrome; Surgical Wound Infection; Thromboembolism; Warfarin

Topics: Anemia, Hemolytic; Anemia, Hemolytic, Autoimmune; Animals; Anticoagulants; Aortic Valve Insufficiency; Aortic Valve Stenosis; Cardiology; Cattle; Child; Dipyridamole; Dogs; Endocarditis, Bacterial; Extracorporeal Circulation; Female; Heart Valve Prosthesis; History, 15th Century; History, 16th Century; History, 19th Century; History, 20th Century; Humans; Postoperative Complications; Pregnancy; Prosthesis Design; Thromboembolism; Vascular Surgical Procedures; Venoms; Warfarin

Topics: Anticoagulants; Avitaminosis; Colon; Digestive System Abnormalities; Digestive System Surgical Procedures; Endocarditis, Bacterial; Enterococcus faecalis; Female; Heart Valve Prosthesis Implantation; Humans; Infant; International Normalized Ratio; Intestinal Atresia; Intestinal Obstruction; Mitral Valve Insufficiency; Nutrition Assessment; Parenteral Nutrition; Short Bowel Syndrome; Vitamins; Warfarin

Central venous catheter-associated bacteraemia caused by Nocardia species is very rare; the diagnosis of nocardiosis in patients with cancer is challenging because its clinical presentation is varied, sometimes mimicking metastases, and the high index of clinical suspicion is required for prompt institution of therapy. Herein, we report a case of nocardial sepsis with native aortic valve endocarditis in a patient with breast cancer in whom multidisciplinary team involvement and prompt initiation of therapy have led to successful outcome.

Topics: Amikacin; Anti-Bacterial Agents; Anticoagulants; Aortic Valve; Breast Neoplasms; Central Venous Catheters; Clopidogrel; Cough; Endocarditis, Bacterial; Fatigue; Female; Headache; Heart Valve Prosthesis Implantation; Humans; Meropenem; Middle Aged; Nocardia; Nocardia Infections; Platelet Aggregation Inhibitors; Radiography, Thoracic; Sepsis; Treatment Outcome; Warfarin

Acute ischemic stroke (AIS) is highly prevalent in patients with infective endocarditis (IE) and associated with high rates of death and disability. IE presenting as an acute ischemic stroke, especially recurrent concurrence of acute anterior and posterior circulation infarct, has rarely been reported. Herein, we report a case study of a 60-year-old man with a history of aortic valve replacement and was under warfarin, presented with recurrent acute ischemic stroke which was found to have no vegetation secondary to infective endocarditis caused by Streptococcus constellatus as the embolic source. This is the first case report of recurrent ischemic stroke secondary to IE without vegetation caused by Streptococcus constellatus involving concurrence of acute anterior and posterior circulation. We also then systematically analyze the cases with IE initially presenting as AIS reported in the literature to establish possible demographic, clinical, laboratory patterns, and prognostic features of these cases.

Topics: Aortic Valve; Brain; Brain Ischemia; Endocarditis, Bacterial; Heart Valve Prosthesis; Humans; Male; Middle Aged; Recurrence; Streptococcal Infections; Streptococcus constellatus; Stroke; Warfarin

Dengue fever is a mosquito-borne viral disease with a very high incidence in Southeast Asia. Most patients with dengue fever recover following a self-limiting febrile illness, while a small proportion may progress to develop severe disease with complications such as acute liver failure, acute kidney injury, and multiorgan failure. Secondary bacterial infections and thrombotic events are very rare.. A 38-year-old previously healthy Sri Lankan woman from Colombo, Sri Lanka, presented with dengue shock syndrome leading to acute liver failure and kidney injury. She was managed with intravenously administered fluid resuscitation with close monitoring of her hemodynamic status, and hemodialysis. Her renal and liver functions and platelet count improved gradually, but the fever persisted and there was a neutrophil leukocytosis. A clinical examination and investigations to identify a focus of secondary infection revealed staphylococcal infective endocarditis. She was started on intravenously administered vancomycin, but as the response was poor the antibiotic was changed to intravenously administered linezolid, to which the response was good. She also developed right proximal femoral deep vein thrombosis, and was commenced on subcutaneous enoxaparin and warfarin. Enoxaparin was stopped after her international normalized ratio reached the desirable range, and warfarin was continued for 3 months.. Dengue virus is known to cause endothelial dysfunction that allows bacteria to invade tissues, defective functioning and reduction in the number of cells of the immune system, and alteration of cytokines leading to immune dysregulation, predisposing patients to develop secondary bacterial infections. Evidently, patients with dengue fever who have prolonged fever (more than 5 days) and acute kidney injury are at high risk for concurrent bacteremia. Dengue virus interferes with the components of the anti-clotting pathway, such as thrombomodulin-thrombin-protein C complex. It also activates endothelial cells and increases the expression of procoagulant factors. These factors may predispose patients with dengue viral infections to develop thrombotic complications. Therefore it is important to be aware of the possibility of serious secondary bacterial infections occurring following dengue viral infections, especially in patients with prolonged fever and acute kidney injury, and to keep in mind that thrombotic events may occur as complications of dengue viral infections.

Topics: Acute Kidney Injury; Adult; Anticoagulants; Coinfection; Dengue; Endocarditis, Bacterial; Enoxaparin; Female; Fluid Therapy; Humans; Linezolid; Liver Failure, Acute; Renal Dialysis; Treatment Outcome; Venous Thrombosis; Warfarin

Cardiobacterium hominis is an uncommon cause of prosthetic valve endocarditis (PVE) and often presents insidiously. In comparison, prosthetic valve thrombosis (PVT) is a rare, but life-threatening condition that commonly occurs due to inadequate anticoagulation. Anticoagulation is relatively contraindicated in patients with endocarditis as it may prove to be lethal due to increased risk of cerebral hemorrhage. However, anticoagulation is required in patients with PVT, or for its prevention. We present a case of a 35-year-old male with a history of hypercoagulability and St. Jude's aortic valve on warfarin, who presented with chest pain andwas found to have a mass on the aorticvalve, with blood cultures revealing C. hominis.The patient was treated with appropriate antibiotics and anticoagulation was continued. No neurological complications were noted during the treatment period. This case demonstrates that carefully weighing the risks and benefits of continuing anticoagulation is essential in preventing poor outcomes.

Topics: Adult; Anti-Bacterial Agents; Anticoagulants; Cardiobacterium; Drug Therapy, Combination; Endocarditis, Bacterial; Gram-Negative Bacterial Infections; Heart Valve Prosthesis; Humans; Male; Thrombophilia; Thrombosis; Treatment Outcome; Warfarin

Aminoglycosides are useful antimicrobial agents for treating infective endocarditis; however, they occasionally cause troublesome side effects, such as nephrotoxicity and ototoxicity. We herein report a case of infective endocarditis caused by Enterococcus faecalis that was treated successfully with continuous infusion of ampicillin without adjunctive aminoglycosides. The serum ampicillin concentrations were higher than the minimal inhibitory concentration for the target strain. Although the use of ampicillin monotherapy is currently avoided because double β-lactam therapy is reportedly more effective, continuous penicillin administration remains an effective therapeutic choice for treating infective endocarditis.

Topics: Aged; Aminoglycosides; Ampicillin; Anti-Bacterial Agents; Anticoagulants; Arthroplasty, Replacement, Hip; Atrial Fibrillation; Contraindications; Diagnosis, Differential; Endocarditis, Bacterial; Enterococcus faecalis; Femoral Neck Fractures; Gram-Positive Bacterial Infections; Humans; Infusions, Intravenous; Male; Microbial Sensitivity Tests; Mitral Valve; Postoperative Complications; Practice Guidelines as Topic; Pyelonephritis; Streptomycin; Warfarin

A case of a 30-year-old woman with an end-stage renal disease and recently diagnosed with infective endocarditis, who presented with acute abdominal pain. An initial assessment of acute appendicitis was made. A CT scan of the abdomen showed a partially occluded superior mesenteric artery with radiographic evidence of ischaemia in an ileal loop. Intraoperatively, a 5-6 cm segment of the distal ileum was found to be non-viable. The segment was resected with the creation of a double-barrel ileostomy. This case report draws attention to the question of a need for anticoagulation for a septic embolus in the superior mesenteric artery. We could not find evidence on the use of postoperative anticoagulation in this scenario. In this case, the patient was started on oral anticoagulation.

Topics: Adult; Anticoagulants; Endocarditis, Bacterial; Female; Humans; Ischemia; Mesentery; Tomography, X-Ray Computed; Treatment Outcome; Ultrasonography; Warfarin

Three patients were admitted to the Imam Hospital, Tehran, Iran with a diagnosis of bacterial endocarditis. The patients had indications for valve replacement surgery and anticoagulant therapy. The administration of cloxacillin reduced the effect of warfarin, and subsequent increases in warfarin doses were unable to overcome this effect.. A decrease in warfarin anticoagulation effects was detected in our three patients following cloxacillin therapy for infective endocarditis. Penicillinase-resistant penicillins remain essential antibiotics in the treatment of severe infections caused by Staphylococcus aureus due to their bactericidal activity, safety, and cost. Thus, in situations where anticoagulants are indicated in patients with infective endocarditis, it would be better to replace warfarin with low-molecular-weight or unfractionated heparin.

Topics: Adolescent; Adult; Anti-Bacterial Agents; Anticoagulants; Blood Coagulation; Cloxacillin; Drug Interactions; Drug Monitoring; Endocarditis, Bacterial; Female; Heart Valve Prosthesis Implantation; Humans; International Normalized Ratio; Male; Mitral Valve; Warfarin; Young Adult

Topics: Adult; Anti-Bacterial Agents; Anticoagulants; Bacteremia; Brachiocephalic Veins; Defibrillators, Implantable; Drug Therapy, Combination; Echocardiography, Transesophageal; Endocarditis, Bacterial; Furunculosis; Humans; Jaw; Jugular Veins; Male; Nafcillin; Pulmonary Embolism; Reoperation; Risk Factors; Tomography, X-Ray Computed; Treatment Outcome; Venous Thrombosis; Warfarin

Anticoagulant therapy has been anticipated to increase the risk of cerebrovascular complications (CVC) in native valve endocarditis (NVE). This study investigates the relationship between ongoing oral anticoagulant therapy and the incidence of symptomatic CVC in left-sided NVE. In a prospective cohort study, the CVC incidence was compared between NVE patients with and without ongoing warfarin. Among 587 NVE episodes, 48 (8%) occurred in patients on warfarin. A symptomatic CVC was seen in 144 (25%) patients, with only three on warfarin. CVC were significantly less frequent in patients on warfarin (6% vs. 26%, odds ratio [OR] 0.20, 95% confidence interval [CI] 0.06-0.6, p = 0.006). No increase in haemorrhagic lesions was detected in patients on warfarin. Staphylococcus aureus aetiology (adjusted OR [aOR] 6.3, 95% CI 3.8-10.4) and vegetation length (aOR 1.04, 96% CI 1.01-1.07) were risk factors for CVC, while warfarin on admission (aOR 0.26, 95% CI 0.07-0.94), history of congestive heart failure (adjusted OR 0.22, 95% CI 0.1-0.52) and previous endocarditis (aOR 0.1, 95% CI 0.01-0.79) correlated with lower CVC frequency.

Topics: Administration, Oral; Aged; Anticoagulants; Endocarditis, Bacterial; Female; Humans; Incidence; Male; Meningoencephalitis; Middle Aged; Risk Factors; Staphylococcus aureus; Warfarin

Topics: Anti-Bacterial Agents; Anticoagulants; Dose-Response Relationship, Drug; Drug Interactions; Endocarditis, Bacterial; Floxacillin; Heart Valve Prosthesis; Humans; International Normalized Ratio; Male; Middle Aged; Mitral Valve; Warfarin

We report a case of a 57-year-old patient with a history of a Starr-Edwards mitral valve prosthesis and DeBakey-Surgitool aortic valve prosthesis implanted 30 years ago who presented with symptoms consistent with class IV heart failure. The patient had been on no anticoagulation for approximately 30 years secondary to recurrent epistaxis occurring two years after starting warfarin therapy postoperatively. Throughout the patient's lifetime he experienced no thromboembolic complications from the lack of anticoagulation, despite developing concomitant atrial fibrillation approximately ten years prior to admission. In place of warfarin the patient had substituted large doses of aspirin. A workup revealed normal function of the mechanical valves for this extensive period.

Topics: Anticoagulants; Aortic Valve; Aspirin; Atrial Fibrillation; Endocarditis, Bacterial; Epistaxis; Heart Failure; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Male; Middle Aged; Mitral Valve; Platelet Aggregation Inhibitors; Prosthesis Design; Self Medication; Thromboembolism; Time Factors; Treatment Outcome; Warfarin

Topics: Anticoagulants; Aortic Valve; Aspirin; Atrial Fibrillation; Endocarditis, Bacterial; Epistaxis; Heart Failure; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Mitral Valve; Platelet Aggregation Inhibitors; Prosthesis Design; Self Medication; Thromboembolism; Time Factors; Treatment Outcome; Warfarin

Infective endocarditis is an infection of the endocardium that usually involves the valves and adjacent structures. The classical fever of unknown origin presentation represents a minority of infective endocarditis. The presented case was a 21-yearold young lady presenting with acute renal failure and fever to the emergency room. Cardiac auscultation revealed a soft S1 and 4/6 apical holosystolic murmur extended to axilla. Echocardiography showed mobile fresh vegetation under the mitral posterior leaflet. She was diagnosed as having infective endocarditis. Hemodialysis was started with antimicrobial therapy. However, because of the presence of severe mitral regurgitation with left ventricle dilatation and large mobile vegetation, mitral prosthetic mechanical valve replacement was performed. Although treated with antibiotics combined with surgery, renal functions were deteriorated and progressed to chronic renal failure.

Topics: Acute Disease; Acute Kidney Injury; Adult; Anti-Infective Agents; Anticoagulants; Disease Progression; Endocarditis, Bacterial; Female; Heart Valve Prosthesis; Humans; Kidney Failure, Chronic; Renal Dialysis; Staphylococcal Infections; Staphylococcus aureus; Warfarin

Treatment of native valvular heart disease has resulted in an increasing number of patients with prosthetic valves. Although an improvement over the diseased native valve removed at surgery, prosthetic valves have suboptimal hemodynamics; mechanical valves require anticoagulation and tissue valves wear out over time. Serious complications of prosthetic valves occur at a rate of about 2% to 3% per patient-year. Complications include thromboembolism, prosthesis-patient mismatch, structural valve dysfunction, endocarditis, and hemolysis. Prosthetic valve endocarditis is a lethal disease with mortality rates of 50% to 80% even with appropriate therapy. Echocardiography now provides detailed information on valve function and hemodynamics, allowing early detection of complications. Many of these complications can be prevented by choosing the optimal valve at the time of surgery, rigorous control of anticoagulation and adherence to established anticoagulation guidelines, dental hygiene and endocarditis prophylaxis, and periodic echocardiographic monitoring by a cardiologist.

Topics: Anemia, Hemolytic; Anticoagulants; Bioprosthesis; Endocarditis, Bacterial; Guideline Adherence; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Prosthesis Design; Warfarin

Behçet's disease (BD) is a chronic relapsing systemic vasculitis in which orogenital ulceration is a prominent feature. The disease affects many systems and causes hypercoagulability. We present a 27-year-old male patient who exhibited widespread great vessel thrombosis including right atrial and ventricular thrombi in the setting of right-sided infectious endocarditis and orogenital aphthous ulcerations and erythema nodosum due to BD. We reviewed the enigmatic prothrombotic state of BD, and discuss our prior experiences in this field.

Topics: Adult; Anti-Bacterial Agents; Anticoagulants; Axillary Vein; Behcet Syndrome; Drug Therapy, Combination; Endocarditis, Bacterial; Endothelium, Vascular; Erythema Nodosum; Heart Atria; Heart Diseases; Heart Ventricles; Heparin; Humans; Male; Pulmonary Veins; Stomatitis, Aphthous; Streptokinase; Superior Vena Cava Syndrome; Thrombectomy; Thrombolytic Therapy; Thrombophilia; Thrombosis; Tissue Plasminogen Activator; Tricuspid Valve; Venous Thrombosis; Warfarin

Pregnant women who have valvular disease represent a major challenge for physicians involved in their care. Careful history taking and physical examination, along with a judicious use of diagnostic tools (mainly echocardiography), can lead to better management and ultimately to excellent outcomes for both mother and baby.

Topics: Antibiotic Prophylaxis; Anticoagulants; Aortic Valve Stenosis; Endocarditis, Bacterial; Female; Heart Valve Diseases; Heart Valve Prosthesis; Hemodynamics; Humans; Mitral Valve Insufficiency; Mitral Valve Stenosis; Pregnancy; Pregnancy Complications, Cardiovascular; Warfarin

Since July 1978, 1,284 patients have received the St. Jude Medical prosthesis (425 aortic, 636 mitral, and 223 double aortic-mitral), and the results in these patients were reviewed according to guidelines of the Society of Thoracic Surgeons. Follow-up was complete in 98%. Of 80 late deaths, 29% were valve related. The actuarial survival rate, including operative deaths, at 12 years was 81.7% and 87.1%, respectively, for aortic and mitral valve replacement, and it was 82.6% at 11 years after double valve replacement. All patients were anticoagulated with warfarin to maintain the thrombotest value between 10% and 25%, which is equivalent to between 2.8 and 1.6 times the control according to the international normalized ratio of the prothrombin time. The linearized rate of complication for aortic, mitral, and double valve replacement, respectively (expressed as the percent per patient-year), was as follows: structural deterioration, 0; non-structural dysfunction, 0.16, 0.30, and 0.20; valve thrombosis, 0.05, 0.09, and 0; thromboembolism, 1.35, 1.63, and 0.79; anticoagulant-related hemorrhage, 0.10, 0.18, and 0.10; and prosthetic valve endocarditis, 0.21, 0.06, and 0.20. Reoperation was performed in 16 patients. The freedom from reoperation rate at 12 years was 99.5% and 98.0% for aortic and mitral valve replacement, respectively, and it was 99.1% at 11 years for double valve replacement. Thus, during the 12-year follow-up in patient who received the St. Jude Medical prosthesis, the valve performed satisfactorily and with an acceptable risk of late complication even though patients were anticoagulated using a lower dose of warfarin.

Topics: Actuarial Analysis; Adolescent; Adult; Aged; Aortic Valve; Endocarditis, Bacterial; Female; Follow-Up Studies; Heart Valve Prosthesis; Humans; Male; Middle Aged; Mitral Valve; Prosthesis Failure; Prosthesis-Related Infections; Reoperation; Survival Rate; Thromboembolism; Warfarin

to audit anticoagulant control and endocarditis prophylaxis following heart valve surgery.. retrospective review of all 190 patients living in Canterbury who had heart valve surgery between January 1981 and December 1986 to determine the incidence of endocarditis and complications of anticoagulation.. there were 35 late deaths, of which nine were attributed to thromboembolism (3), major bleeding (2), or endocarditis (4). The rate of thromboembolic events, and major bleeding was 4.6 and 3.3/100 patient years of warfarin therapy respectively, while the incidence of late endocarditis was 0.96/100 patient years. Two episodes of endocarditis occurred after minor dental procedures performed without antibiotic prophylaxis. Many dentists indicated that they would not have recommended prophylactic therapy for these procedures. Some patients had inadequate recall of important details of anticoagulant control or endocarditis prophylaxis. Only 24% knew their latest prothrombin ratio, yet a survey of general practitioners revealed that, in their view, the majority of patients may be capable of monitoring their own anticoagulant therapy.. the incidence of potentially preventable long term complications of heart valve surgery is comparable to other series. Nevertheless, these complications could be reduced by better patient education possibly enhanced by greater involvement of the patient in their anticoagulant control. The indications for antibiotic prophylaxis for dental procedures should be broadened for this group of patients.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Dental Care; Endocarditis, Bacterial; Evaluation Studies as Topic; Female; Follow-Up Studies; Heart Valve Diseases; Hemorrhage; Humans; Male; Medical Audit; Middle Aged; New Zealand; Patient Education as Topic; Postoperative Care; Postoperative Complications; Prothrombin Time; Retrospective Studies; Thromboembolism; Warfarin

There have been few relatively complete follow-up studies of long-term mitral valve function after Carpentier-type surgical reconstruction. Between January 1980 and May 1986, 148 patients underwent Carpentier reconstruction for mitral valve disease (43% degenerative and 30% rheumatic). Operative mortality was 5.4% overall (1.2% for isolated mitral reconstruction), and follow-up (mean, 26 months) was completed for all survivors. Five-year survival from late cardiac death was 90.0%, as was 5-year freedom from postreconstruction mitral valve replacement. Postreconstruction mitral replacement was needed in eight patients, in only five for failure of repair. Follow-up echocardiographic studies on 83.2% (104 of 125) of eligible patients showed 92.3% were free of significant (3+ or 4+) mitral regurgitation. Freedom from mitral valve replacement or recurrent severe (4+) insufficiency was 84.4% at 5 years overall, but was lower for the rheumatic type of mitral disease than for the degenerative type (71.6% vs. 88.3%). At 5 years, 95.2% of patients were free from thromboembolism without the necessity for long-term warfarin (Coumadin) therapy. At follow-up, 95.3% of survivors had improved to New York Heart Association Class I or II. The functional durability of mitral reconstruction and consistently high level of freedom from late endocarditis and thromboembolic and anticoagulant complications support the value of the Carpentier method of mitral reconstruction for mitral insufficiency, especially insufficiency due to degenerative disease.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Child; Child, Preschool; Echocardiography; Endocarditis, Bacterial; Follow-Up Studies; Humans; Methods; Middle Aged; Mitral Valve; Mitral Valve Insufficiency; Platelet Aggregation Inhibitors; Postoperative Care; Postoperative Complications; Thromboembolism; Warfarin

Enhanced clinical awareness of infective endocarditis, along with improved microbiologic methodology and more aggressive surgical intervention, has favorably influenced the outcome of the disease. The evolving nature of infective endocarditis over the past decade is described, as are the changing epidemiologic factors, microbiologic techniques, and echocardiographic contributions in the clinical management of patients with infective endocarditis.

Topics: Adult; Anti-Bacterial Agents; Echocardiography; Endocarditis, Bacterial; Female; Humans; Male; Middle Aged; Mitral Valve Prolapse; Warfarin

A total of 479 valve replacements were performed in 469 patients for aortic, mitral, and tricuspid disease. A total of 529 valves were implanted (311 Carpentier-Edwards, 118 Hancock, 94 Björk-Shiley, and six other mechanical valves). Of the 479 operations, 51.1% (245) were carried out in male patients and 48.9% (234) were carried out in female patients. The mean age was 57.6 years; however, 28.6% (137) of the operations were performed in patients over 65 years of age. One hundred five patients (21.9%) had had previous cardiac operations of one type or another. Follow-up was 99.6% and the average length of follow-up was 36.2 months. The overall operative mortality was 5.6%. The operative mortality in the isolated aortic valve replacement group was 2.0% and that in the mitral valve replacement group, 4.4%. There was a 5.9% valve explant rate in the Hancock series; however, no valve explants were required because of valve dysfunction in either the Carpentier-Edwards or the Björk-Shiley groups. The thromboembolic rate in the aortic valve position was 2.4, 1.1, and 2.1 emboli per 100 patient-years in the Hancock, Carpentier-Edwards, and Björk-Shiley groups, respectively. The thromboembolic rate in the mitral valve position was 2.8, 2.2, and 1.0 emboli per 100 patient-years in the Hancock, Carpentier-Edwards, and Björk-Shiley groups, respectively.

Topics: Aged; Aortic Valve; Bioprosthesis; Endocarditis, Bacterial; Female; Follow-Up Studies; Heart Valve Diseases; Heart Valve Prosthesis; Humans; Male; Middle Aged; Mitral Valve; Postoperative Complications; Reoperation; Sex Factors; Thromboembolism; Time Factors; Tricuspid Valve; Warfarin

We reviewed the experience with infective endocarditis at some major US Army Medical Centers. One hundred patients were studied, comparing 82 patients who had native valve endocarditis (NVE) with 18 patients who had prosthetic valve endocarditis (PVE). Among patients with PVE, four had porcine valves and 14 had synthetic. None of the patients with NVE had received anticoagulants; 14 of 18 patients with PVE had received anticoagulants. The major causes of death were central nervous system hemorrhage, congestive heart failure, uncontrolled infection, and embolic phenomena. The principal cause of death in patients with PVE was CNS hemorrhage. Of the patients with PVE, 36% had symptomatic cerebral hemorrhage while receiving anticoagulants and 80% of them died.

Topics: Anti-Bacterial Agents; Anticoagulants; Aortic Valve; Cerebral Hemorrhage; Drug Evaluation; Endocarditis, Bacterial; Heart Failure; Heart Valve Prosthesis; Humans; Mitral Valve; Postoperative Complications; Premedication; Prothrombin Time; Retrospective Studies; Thromboembolism; Warfarin

Bacterial adherence as a result of specific surface properties may be a contributory factor in the pathogenesis of bacterial endocarditis giving certain types of bacteria a selective advantage to cause this disease. Adherence could interact with other pathogenetic mechanisms, and this interaction could promote or hamper the development of endocarditis. Dextran production by streptococci, the activation of the clotting system by monocyte tissue thromboplastin, and phagocytic removal of bacteria from the vegetational surface by granulocytes and monocytes are examples of interacting mechanisms that could contribute to the pathogenesis of bacterial endocarditis.

Topics: Adhesiveness; Animals; Aortic Valve; Bacterial Infections; Bacterial Physiological Phenomena; Dogs; Endocarditis, Bacterial; Etoposide; Fibrin; Humans; In Vitro Techniques; Mechlorethamine; Rabbits; Staphylococcus; Streptococcus; Virulence; Warfarin

Topics: Abnormalities, Drug-Induced; Abortion, Therapeutic; Endocarditis, Bacterial; Female; Heart Diseases; Heart Failure; Heart Valve Prosthesis; Humans; Pregnancy; Pregnancy Complications, Cardiovascular; Warfarin

Topics: Adolescent; Adult; Barbiturates; Endocarditis, Bacterial; Female; Heart Valve Prosthesis; Hemorrhage; Humans; Male; Middle Aged; Oral Hemorrhage; Postoperative Complications; Thrombosis; Tooth Extraction; Warfarin

The role of blood monocytes in the attachment of streptococci to endocardial vegetations was investigated in an experimental Streptococcus sanguis endocarditis by depletion of blood monocytes with the cytostatic drug VP 16-213 alone and combined with anticoagulant treatment with warfarin sodium. The numbers of streptococci in the vegetations of control, monocytopenic, and monocytopenic/anticoagulated rabbits were comparable. In the vegetations streptococci were found mainly in areas free of phagocytic cells. It is concluded that streptococci do not have to be phagocytosed by monocytes in the circulation before being deposited on the surface of endocardial vegetations. Even the vegetations of intensively anticoagulated/monocytopenic rabbits showed colonies of streptococci embedded in polymerized fibrin and cellular material, this matrix possibly being held together by streptococcal dextran.

Topics: Animals; Endocarditis, Bacterial; Endocardium; Etoposide; Granulocytes; Leukocyte Count; Male; Microscopy, Electron; Monocytes; Podophyllotoxin; Rabbits; Streptococcal Infections; Streptococcus sanguis; Warfarin

The effect of warfarin treatment on an experimental Staphylococcus epidermidis endocarditis was studied. Warfarin was found to affect both the induction and course of the infection of catheter-induced endocardial vegetations. In warfarin-treated rabbits, larger bacterial inocula were needed to induce an infection, and the degree of infection of the vegetations was also significantly lower, eventually resulting in the total elimination of the bacteria from the vegetations. Thus, warfarin treatment seems to have an inhibitory effect on the induction and development of an S. epidermidis infection of the endocardium. The results differ from previous findings in studies done with Streptococcus anguis, where warfarin was found to have no effect on the induction or course of the infection of endocardial vegetations, which suggests that different mechanisms are involved in the pathogenesis of endocarditis caused by these two species of bacteria.

Topics: Animals; Endocarditis, Bacterial; Male; Rabbits; Sepsis; Staphylococcal Infections; Staphylococcus; Warfarin

The effect of warfarin treatment on an experimental endocarditis was studied in rabbits. Warfarin had no effect on the induction of a Streptococcus sanguis infection in catheter-induced endocardial vegetations, and the course of this infection was also unaltered. However, warfarin treatment resulted in rapidly progressive bacteremia, probably due to impaired circulation in clearing organs such as the lungs, liver, and spleen. Warfarin also reduced the survival time of the infected rabbits, in which pulmonary edema and extensive lung hemorrhages may have been a contributory factor.

Topics: Animals; Endocarditis, Bacterial; Endocardium; Male; Penicillin G; Rabbits; Sepsis; Streptococcus sanguis; Warfarin

From March 1971 through April 1975, one hundred twenty patients underwent mitral valve replacement with a Hancock "stabilized glutaraldehyde process" porcine aortic xenograft. A simultaneous canine experimental series was also carried out. In the clinical series, the early mortality was 8.3%. Actuarial analyses of all patients predicts survival at two years of 81.0% and at four years of 70.0%. The predicted survival for patients without coronary disease or prior prosthetic valve replacement is 87.5% at two years and 77.5% at four years. There were four thromboembolic episodes, a rate of 2.4% per patient-year. None were fatal. No valve failure were noted. Histologic examination and shrink temperature analysis of recovered valves show excellent tissue preservation at 40 months. The data indicate that the Hancock valve is durable, enjoys a low incidence of thromboembolism, and may be the valve of choice for mitral valve replacement.

Topics: Adult; Aged; Aldehydes; Animals; Aortic Valve; Brain Diseases; Cardiac Surgical Procedures; Coronary Disease; Dogs; Endocarditis, Bacterial; Evaluation Studies as Topic; Female; Gastrointestinal Hemorrhage; Glutaral; Hematoma; Humans; Male; Methods; Middle Aged; Mitral Valve; Mitral Valve Insufficiency; Mitral Valve Stenosis; Postoperative Complications; Swine; Thromboembolism; Thrombophlebitis; Transplantation, Heterologous; Warfarin

Twenty-one patients with prosthetic cardiac valves successfully underwent transurethral prostatic resection at the Mayo Clinic. Temperature elevation in 4 patients was the only postoperative complication; in particular, neither congestive heart failure nor thromboembolic complications developed and there were no operative deaths. Preoperative evaluation and clinical management of potential complications are based on the recognition of the complications that are peculiar to these patients. Particularly important is the proper use of antibiotics and anticoagulants and avoidance of overloading the circulation with fluid from open prostatic venous sinuses.

Topics: Aged; Aortic Valve; Endocarditis, Bacterial; Heart Failure; Heart Valve Diseases; Heart Valve Prosthesis; Humans; Male; Middle Aged; Mitral Valve; Preoperative Care; Prostatectomy; Sodium; Thromboembolism; Urethra; Vitamin K 1; Warfarin

Topics: Blood Pressure; Cardiac Catheterization; Computers; Endocarditis, Bacterial; Follow-Up Studies; Heart Valve Prosthesis; Heparin; Humans; Mitral Valve; Postoperative Care; Postoperative Complications; Prognosis; Pulmonary Artery; Surveys and Questionnaires; Thromboembolism; Warfarin

Topics: Adolescent; Adult; Aortic Valve Insufficiency; Atrial Fibrillation; Cerebral Hemorrhage; Child; Death, Sudden; Endocarditis, Bacterial; Female; Follow-Up Studies; Heart Valve Diseases; Heart Valve Prosthesis; Humans; Male; Middle Aged; Mitral Valve Insufficiency; Mitral Valve Stenosis; Myocardial Infarction; Postoperative Complications; Thromboembolism; Tricuspid Valve Insufficiency; Warfarin

Topics: Animals; Endocarditis, Bacterial; Erysipelothrix Infections; Female; Fish Products; Heart Auscultation; Hemoglobins; Humans; Lung; Middle Aged; Occupational Diseases; Penicillins; Radiography; Sepsis; Warfarin

Topics: Adolescent; Adult; Aged; Anemia, Hemolytic; Aortic Valve; Aortic Valve Stenosis; Endocarditis, Bacterial; Evaluation Studies as Topic; Female; Follow-Up Studies; Heart Valve Prosthesis; Hemorrhage; Humans; Male; Middle Aged; Mitral Valve; Thromboembolism; Tricuspid Valve; Warfarin

Aortic valve replacement with the University of Cape Town lenticular prosthesis was performed in 149 patients during a six-year period, almost all patients being severely disabled with advanced heart disease. There was a hospital mortality of 12 per cent. Bacterial endocarditis was a serious complication and accounted for three hospital and five long-term deaths. The survivors were followed for periods of up to 72 months (average 24), the minimum period of observation being six months. There were 23 late deaths due to heart disease, of which 5 where due to myocardial failure. Myocardial failure unrelieved or only temporarily alleviated by the operation occurred in three surviving patients. The main problems have been sudden death and systemic embolism. Some of the cases of sudden death were due to coronary artery embolism, but in a number the cause could not be determined even at necropsy, and they were presumed to be due to arrhythmia. Both complications appeared to be related to valve design. A bare steel seat was associated with a high incidence of both complications, whereas a woven Dacron-velour cloth-covered seat almost eliminated embolism and reduced the incidence of sudden death. Long-term anticoagulant therapy appears to be of no real value with the cloth-covered valve. Gratifying results were obtained in the surviving patients with loss of all symptoms in 80 per cent and improvement in almost all patients. This improvement or relief of symptoms was maintained in most patients throughout the period of study.

Topics: Adolescent; Adult; Aged; Alloys; Anemia, Hemolytic; Angina Pectoris; Aortic Valve; Aortic Valve Insufficiency; Aortic Valve Stenosis; Arrhythmias, Cardiac; Cardiovascular Diseases; Child; Endocarditis, Bacterial; Female; Follow-Up Studies; Heart Valve Prosthesis; Humans; Male; Middle Aged; Phenindione; Polymers; Postoperative Complications; Thromboembolism; Warfarin

Topics: Aged; Aortic Valve; Aortic Valve Stenosis; Arrhythmias, Cardiac; Cardiac Catheterization; Cardiac Surgical Procedures; Digoxin; Endocarditis; Endocarditis, Bacterial; Heart Failure; Heart Valve Diseases; Heart Valve Prosthesis; Heart, Artificial; Humans; Isoproterenol; Methicillin; Middle Aged; Postoperative Complications; Psychoses, Substance-Induced; Psychotic Disorders; Thoracic Surgery; Warfarin