warfarin and Mitral-Valve-Insufficiency

Topics: Adrenergic beta-Antagonists; Angiotensin II Type 1 Receptor Blockers; Angiotensin-Converting Enzyme Inhibitors; Anticoagulants; Cardiac Surgical Procedures; Echocardiography, Transesophageal; Heart Failure; Heart Valve Prosthesis Implantation; Humans; Hyperthermia, Induced; Mitral Valve Insufficiency; Ventricular Remodeling; Warfarin

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was what is the optimal target INR for warfarin therapy in patients who have undergone implantation of a prosthetic mechanical mitral heart valves? Altogether 894 papers were identified on Medline and 1235 on Embase using the reported search including all major international guidelines. Twelve papers and publications represented the best evidence on the topic. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses were tabulated. We conclude that after implantation of new generation prosthetic mechanical mitral valves, patients should receive warfarin to a target INR of 2.5-3.5. For older types of valve the target INR should be 3.5-4.5. Warfarin therapy should be administered to maintain stable INR values ensuring lowest possible variation in the intensity of anticoagulation. In selected patients with a history of thromboembolic disease and/or coronary artery disease warfarin therapy consideration should be given to supplementing warfarin with low-dose aspirin.

Topics: Anticoagulants; Heart Valve Prosthesis; Hemorrhage; Humans; International Normalized Ratio; Male; Middle Aged; Mitral Valve Insufficiency; Thromboembolism; Warfarin

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

We report the case of 36-year-old woman who came to us with a history of recurrent miscarriages and who was later diagnosed as having primary antiphospholipid syndrome (PAPS) and chronic hepatitis C virus (HCV) infection. The patient was referred to us with generalised seizures; cranial MRI revealed multiple embolic infarcts in both frontal lobes and a focal cortical infarct in the left frontoparietal lobe. Her echocardiography showed mitral valve vegetation and insufficiency. The patient was put on oral anticoagulant therapy and during her 8-month follow-up period no thrombotic events occurred. We report this case because it was the first in which PAPS, valvular disease, a cerebral embolic event and HCV infection were coexistent in the same patient. We also review other cases in which there was valvular vegetation and a cerebral ischaemic event associated with PAPS.

Topics: Adult; Antibodies, Anticardiolipin; Anticoagulants; Anticonvulsants; Antiphospholipid Syndrome; Carbamazepine; Echocardiography, Doppler; Endocarditis; Epilepsy; Female; Hepatitis C; Humans; Intracranial Embolism; Magnetic Resonance Imaging; Mitral Valve Insufficiency; Warfarin

We describe the case of a 67-year-old patient, who had a stroke with subsequent right hemiparesis two years before coming under our observation. Afterwards he had no more pathological manifestation until he had sudden dyspnoea and marked cyanosis, following a prolonged immobilization due to intervention for slipped disc. Symptomatology regressed rapidly, and few hours later, the patient came under our observation in relatively fair conditions. Echocardiography evidenced moderate enlargement of right heart cavities; by subcostal view we visualized the presence of thrombotic material crossing the foramen ovale. Color Doppler showed moderate tricuspid regurgitation. Pulmonary artery systolic pressure was estimated about 55 mm Hg. The patient was immediately anticoagulated firstly by heparin, and secondly by warfarin, maintaining good clinical conditions. After a treatment of two more weeks he could be discharged with prescription of indefinite anticoagulation. Before discharge an echo examination showed the thrombus was no longer present. Pulmonary systolic pressure was estimated about 40 mm Hg. This is one of the rare cases of direct visualization of impending paradoxical embolus documented in the cardiologic literature.

Topics: Aged; Cerebrovascular Disorders; Drug Therapy, Combination; Echocardiography; Heart Septum; Heparin; Humans; Male; Mitral Valve Insufficiency; Pulmonary Embolism; Thromboembolism; Tricuspid Valve Insufficiency; Warfarin

Topics: Biopsy; Drug Eruptions; Drug Interactions; Eosinophils; Erythromycin; Female; Fluocortolone; Hematoma; Humans; Leukocytes, Mononuclear; Middle Aged; Mitral Valve Insufficiency; Neutrophils; Prothrombin Time; Respiratory Tract Infections; Skin Diseases, Vesiculobullous; Trimethoprim, Sulfamethoxazole Drug Combination; Warfarin

In patients undergoing mitral valve repair (MVre), a 3-month course of anticoagulation is currently recommended. The role of the non-vitamin K antagonist oral anticoagulants has here been scarcely studied. In the present mixed cohort study, the safety and efficacy of rivaroxaban (prospective analysis) were compared with those of warfarin (retrospective analysis) in patients undergoing MVre. Anticoagulation therapy was continued for at least 3 months, and the patients were followed for 1 year following surgery. The present study recruited 736 patients undergoing MVre with or without concomitant coronary artery bypass or surgical repair on the other valves. Concomitant valvular replacement and severe chronic kidney diseases were the most important exclusion criteria. The final analysis was conducted on 153 patients treated with rivaroxaban and 144 patients treated with warfarin. Dissimilarities in baseline characteristics necessitated propensity score matching, in which 104 patients in each group were compared. No major bleeding or cerebrovascular accident occurred during the 1-year follow-up. Clinically relevant non-major bleeding was reported in 2 patients in the rivaroxaban group and 4 patients in the warfarin group, a difference non-statistically significant before and after propensity score matching (P = 0.371 and P = 0.407, respectively). The type of anticoagulation did not predict the 1-year outcome (HR 2.165, 95% CI 0.376 to 12.460; P = 0.387). In this mixed cohort study, rivaroxaban was both safe and efficient in patients with MVre. Such preliminary results should prompt larger randomized controlled trials.

Topics: Adult; Aged; Female; Follow-Up Studies; Humans; Male; Middle Aged; Mitral Valve Annuloplasty; Mitral Valve Insufficiency; Rivaroxaban; Warfarin

To compare the characteristics and outcomes of patients with atrial fibrillation (AF) and aortic stenosis (AS) with patients with AF with mitral regurgitation (MR) or aortic regurgitation (AR) and patients without significant valve disease (no SVD).. Using Rivaroxaban Once-Daily, Oral, Direct Factor Xa Inhibition Compared With Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF) data, we analysed efficacy and safety outcomes, adjusting hazard ratios (HRs) for potential confounders using Cox regression analysis.. Among 14 119 intention-to-treat ROCKET AF trial patients, a trial that excluded patients with mitral stenosis or artificial valve prosthesis, 214 had AS with or without other valve abnormalities, 1726 had MR or AR and 12 179 had no SVD. After adjusting for prognostic factors, the composite of stroke, systemic embolism or vascular death increased approximately twofold in patients with AS (AS 10.84, MR or AR 4.54 and no SVD 4.31 events per 100 patient-years, p=0.0001). All-cause death also significantly increased (AS 11.22, MR or AR 4.90 and no SVD 4.39 events per 100 patient-years, p=0.0003). Major bleeding occurred more frequently in AS (adjusted HR 1.61, confidence intervals (CI) 1.03 to 2.49, p<0.05) and MR or AR (HR 1.30, 1.07 to 1.57, p<0.01) than in no SVD, but there was no difference between AS and MR or AR (HR 1.24, 0.78 to 1.97). The relative efficacy of rivaroxaban versus warfarin was consistent among patients with and without valvular disease. Rivaroxaban was associated with higher rates of major bleeding than warfarin in patients with MR or AR (HR 1.63, 1.15 to 2.31).. We found that patients with AF and AS on oral anticoagulants may have distinctly different efficacy and safety outcomes than patients with MR or AR or no SVD.. NCT00403767; Post-results.

Topics: Administration, Oral; Aged; Aged, 80 and over; Anticoagulants; Aortic Valve Insufficiency; Aortic Valve Stenosis; Atrial Fibrillation; Drug Administration Schedule; Female; Humans; Male; Mitral Valve Insufficiency; Retrospective Studies; Rivaroxaban; Stroke; Treatment Outcome; Warfarin

We investigated clinical characteristics and outcomes of patients with significant valvular disease (SVD) in the Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF) trial.. ROCKET AF excluded patients with mitral stenosis or artificial valve prostheses. We used Cox regression to adjust comparisons for potential confounders. Among 14 171 patients, 2003 (14.1%) had SVD; they were older and had more comorbidities than patients without SVD. The rate of stroke or systemic embolism with rivaroxaban vs. warfarin was consistent among patients with SVD [2.01 vs. 2.43%; hazard ratio (HR) 0.83, 95% confidence interval (CI) 0.55-1.27] and without SVD (1.96 vs. 2.22%; HR 0.89, 95% CI 0.75-1.07; interaction P = 0.76). However, rates of major and non-major clinically relevant bleeding with rivaroxaban vs. warfarin were higher in patients with SVD (19.8% rivaroxaban vs. 16.8% warfarin; HR 1.25, 95% CI 1.05-1.49) vs. those without (14.2% rivaroxaban vs. 14.1% warfarin; HR 1.01, 95% CI 0.94-1.10; interaction P = 0.034), even when controlling for risk factors and potential confounders. In intracranial haemorrhage, there was no interaction between patients with and without SVD where the overall rate was lower among those randomized to rivaroxaban.. Many patients with 'non-valvular atrial fibrillation' have significant valve lesions. Their risk of stroke is similar to that of patients without SVD after controlling for stroke risk factors. Efficacy of rivaroxaban vs. warfarin was similar in patients with and without SVD; however, the observed risk of bleeding was higher with rivaroxaban in patients with SVD but was the same among those without SVD. Atrial fibrillation patients with and without SVD experience the same stroke-preventive benefit of oral anticoagulants.

Topics: Aged; Anticoagulants; Aortic Valve Insufficiency; Atrial Fibrillation; Factor Xa Inhibitors; Female; Hemorrhage; Humans; Male; Mitral Valve Insufficiency; Morpholines; Rivaroxaban; Stroke; Thiophenes; Treatment Outcome; Warfarin

Atrial fibrillation (AF) associated to rheumatic mitral valve disease (RMVD) increases the incidence of thromboembolism (TE), with warfarin being the standard therapy, in spite of difficulties in treatment adherence and therapeutic control.. To compare the effectiveness of Aspirin vs Warfarin in TE prevention in patients with AF and RMVD.. A total of 229 patients (pts) with AF and RMVD were followed in a prospective and randomized study. The first group consisted of 110 pts receiving Aspirin - 200 mg/day (Group Aspirin - GA) and the second group consisted of 119 pts receiving Warfarin at individually-adjusted doses (Group Warfarin - GW).. There were 15 embolic events in GA and 24 in GW (p = 0.187), of which 21 presented INR < 2.0. Thus, after excluding patients with inadequate INR, there was a higher number of embolic events in GA than in GW (15 vs 3) (p < 0.0061). The GW showed lower treatment adherence (p = 0.001). Neither group presented episodes of major bleeding. Small bleeding episodes were more frequent in the GW (p < 0.01). Increased serum levels of cholesterol and triglycerides constituted a risk factor for a higher number of thromboembolic events in the studied population, with no difference between the groups.. In patients presenting RMVD with AF for less than a year and no previous embolism, Aspirin is little effective in preventing TE. Patients with lower-risk mitral valvulopathy (mitral regurgitation and mitral biological prosthesis), especially in cases presenting contraindication to or low adherence to Warfarin, Aspirin use can present some benefit in TE prevention.

Topics: Aged; Anticoagulants; Aspirin; Atrial Fibrillation; Bioprosthesis; Heart Valve Prosthesis; Hemorrhage; Humans; Male; Medication Adherence; Mitral Valve Insufficiency; Prospective Studies; Risk Factors; Thromboembolism; Warfarin

The clinical effect of combined warfarin and antiplatelet therapy on the incidence of stroke and postoperative complications after mitral (plus aortic) valve replacement was studied and compared with that observed with warfarin therapy alone.. It has been reported that combined warfarin and antiplatelet therapy may be effective but may be associated with an increased hemorrhagic risk. Therefore, definite benefits of the treatment in patients with an implanted prosthetic valve have not been clearly documented.. Between January 1980 and December 1992, 195 patients with a St. Jude Medical valve at the mitral (plus aortic) position were assigned to receive treatment with either warfarin alone (125 patients) or warfarin plus antiplatelet agents (70 patients), such as dipyridamole (150 or 300 mg daily, 14 patients) or ticlopidine (200 or 400 mg daily, 56 patients). A minimal dose of aspirin (10 to 40 mg) was added (29 patients) if the maximal platelet aggregation rate by collagen was not reduced. The target thrombotest level was 10% to 20%.. The two treatment groups were similar with regard to gender and age distribution. The number of patients with atrial fibrillation, left atrial thrombus, history of previous stroke, simultaneous aortic valve operation and previously performed valve procedures were comparable in the two groups. Actuarial survival rate at 10 years was 98.3 +/- 1.7% (mean +/- SD) in the warfarin plus antiplatelet group and 90.3 +/- 3.2% in the warfarin group (p < 0.05 at 1 and 9 to 12 years). The actuarial stroke-free rate at 10 years was 95.3 +/- 3.4% and 84.3 +/- 3.8%, respectively (p < 0.05 by the generalized Wilcoxon test). The actuarial complication-free rate at 10 years was 89.4 +/- 4.3% and 67.9 +/- 4.8%, respectively (p < 0.05 by the generalized Wilcoxon test). No hemorrhagic complications were seen in the warfarin plus antiplatelet group.. The results strongly indicate the effectiveness and safety of combined warfarin plus antiplatelet treatment after St. Jude Medical valve replacement for mitral (plus aortic) valve disease.

Topics: Actuarial Analysis; Aortic Valve; Cerebrovascular Disorders; Drug Therapy, Combination; Female; Heart Valve Prosthesis; Humans; Male; Middle Aged; Mitral Valve; Mitral Valve Insufficiency; Mitral Valve Stenosis; Platelet Aggregation Inhibitors; Postoperative Complications; Prosthesis Design; Warfarin

Topics: Biomedical Engineering; Clinical Trials as Topic; Dipyridamole; Heart Valve Prosthesis; Humans; Mitral Valve Insufficiency; Thromboembolism; Warfarin

Patients with atrial fibrillation (AF) who have undergone mitral valve repair are at risk for thromboembolic strokes. Prior to 2019, only vitamin K antagonists were recommended for patients with AF who had undergone mitral valve repair despite the introduction of direct oral anticoagulants (DOAC) in 2010.. To characterize the use of anticoagulants in patients with AF who underwent surgical mitral valve repair (sMVR) or transcatheter mitral valve repair (tMVR).. We performed a retrospective cohort analysis of patients with AF undergoing sMVR or tMVR between 04/2014 and 12/2018 using Optum's de-identified Clinformatics® Data Mart Database. We identified anticoagulants prescribed within 90 days of discharge from hospitalization.. Overall, 1997 patients with AF underwent valve repair: 1560 underwent sMVR, and 437 underwent tMVR. The mean CHA. Among patients with AF who underwent sMVR or tMVR between 2014 and 2018, roughly 30% of patients were not treated with any anticoagulant within 90 days of discharge, despite an elevated stroke risk in the cohort. The rate of DOAC use increased steadily over the study period but did not significantly increase the rate of overall anticoagulant use in this high-risk cohort.

Topics: Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Factor Xa Inhibitors; Female; Guideline Adherence; Humans; Logistic Models; Male; Middle Aged; Mitral Valve Annuloplasty; Mitral Valve Insufficiency; Postoperative Care; Practice Guidelines as Topic; Stroke; Warfarin

When patients with extensive mitral annular calcification undergo mitral valve replacement, excessive debridement of calcification may result in fatal complications and may protract operation time. We report a case of supra-annular MVR using "the chimney technique" on a high-risk patient for severe mitral stenosis with extensive mitral annular calcification. This technique is usually used in small infants whose mitral annulus is smaller than the smallest available prosthetic valve. We apply this technique to minimize the debridement of calcification and shorten the operation time. The operation was successfully completed, and the postoperative course has been uneventful. This technique was safely and easily performed, and eliminated the need for aggressive debridement of the calcification. We believe this technique may be a good choice for high-risk patients with mitral annular calcification.

Topics: Aged; Anticoagulants; Blood Pressure; Calcinosis; Cardiopulmonary Bypass; Echocardiography; Female; Heart Defects, Congenital; Heart Valve Diseases; Heart Valve Prosthesis Implantation; Humans; Mitral Valve; Mitral Valve Insufficiency; Mitral Valve Stenosis; Tomography, X-Ray Computed; Warfarin

Hypo-attenuated leaflet thickening (HALT) in bioprosthetic aortic valve has been studied, but its equivalent in bioprosthetic mitral valve (bMV) remains uncharacterized. We sought to identify the prevalence, hemodynamic characteristics, and significance of anticoagulation therapy in bMV HALT.. A single-center cross-sectional study of 53 consecutive patients who underwent mitral valve replacement (MVR) with bMV between 2007 and 2017 was conducted. Cardiac-gated contrasted CT scans were obtained. Anticoagulant and antiplatelet therapy use were ascertained at the time of hospital discharge and CT scanning. Patient characteristics, postoperative stroke, and hemodynamic profile by echocardiogram were obtained to descriptively characterize the prevalence and characteristics associated with bMV HALT.. Three patients (5.7%) were found to have a HALT on bMV. The mean time from index MVR to CT scan was 3.4 ± 0.8 years in HALT cohort and 3.4 ± 2.7 years in non-HALT cohort. Fifty patients (94.3%) were discharged on warfarin, and 37 patients (69.8%) were on warfarin at the time of CT scans. One patient with HALT was on therapeutic warfarin at the time of the CT scan that identified HALT. All three patients were asymptomatic at the time of CT scan. In patients with HALT, mean transmitral pressure gradient were 8, 5, and 2.7 mmHg, all with trivial or mild mitral regurgitation.. In this study, the prevalence of HALT was low at 5.7%, all presenting without symptoms. One patient presented with HALT while on therapeutic oral anticoagulation, which may suggest thrombotic etiology may not adequately explain HALT.

Topics: Aged; Aged, 80 and over; Anticoagulants; Bioprosthesis; Cross-Sectional Studies; Echocardiography; Female; Heart Valve Diseases; Heart Valve Prosthesis; Hemodynamics; Humans; Male; Middle Aged; Mitral Valve; Mitral Valve Insufficiency; Platelet Aggregation Inhibitors; Postoperative Complications; Thrombosis; Tomography, X-Ray Computed; 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

Stevens-Johnson syndrome and toxic epidermal necrolysis are rare diseases that cause acute destruction of the epithelium of the skin and mucous membranes, almost always attributable to drugs. However, warfarin-induced Stevens-Johnson syndrome and toxic epidermal necrolysis is extremely rare. We report the case of 71-year-old woman who died due to destructive erosion all over her skin and mucous membranes. She had received a mitral valve prosthesis, and warfarin was prescribed for antithrombotic therapy. A lymphocyte transformation test for drug hypersensitivity and the clinical history confirmed this phenomenon as warfarin-induced toxic epidermal necrolysis.

Topics: Aged; Anticoagulants; Fatal Outcome; Female; Heart Valve Prosthesis Implantation; Humans; Mitral Valve; Mitral Valve Insufficiency; Stevens-Johnson Syndrome; Warfarin

Topics: Adrenergic beta-Antagonists; Anticoagulants; Aspirin; Cardiomyopathy, Hypertrophic; Dyspnea; Echocardiography, Transesophageal; Female; Humans; Middle Aged; Mitral Valve Insufficiency; Platelet Aggregation Inhibitors; Reoperation; Systole; Treatment Outcome; Ventricular Outflow Obstruction; Warfarin

Topics: Adult; Antibodies, Anticardiolipin; Antibodies, Antiphospholipid; Anticoagulants; Antiphospholipid Syndrome; Diagnosis, Differential; Dyspnea; Echocardiography; Endocarditis, Non-Infective; Female; Heparin; Humans; Livedo Reticularis; Mitral Valve Insufficiency; Radiography, Thoracic; Symptom Assessment; Treatment Outcome; Warfarin

Topics: Anti-HIV Agents; Anticoagulants; Aortic Valve Stenosis; Female; Heterocyclic Compounds, 3-Ring; HIV Infections; HIV Protease Inhibitors; Humans; Lopinavir; Middle Aged; Mitral Valve Insufficiency; Oxazines; Piperazines; Pyridones; Ritonavir; Warfarin

We report the case of 23-year-old man with mitral valve regurgitation and Glanzmann thrombasthenia, who underwent mechanical mitral valve replacement. Warfarin therapy was devastating, causing bilateral hemothorax, pericardial effusion, gastrointestinal bleeding, and hematuria. Redo mitral valve replacement with a biological prosthesis was required to resolve this critical situation. To our knowledge, this is the first report of mitral valve replacement in Glanzmann thrombasthenia, highlighting the danger of oral anticoagulation in this pathology.

Topics: Administration, Oral; Anticoagulants; Bioprosthesis; Blood Coagulation; Device Removal; Gastrointestinal Hemorrhage; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Hematuria; Humans; Male; Mitral Valve; Mitral Valve Insufficiency; Pericardial Effusion; Postoperative Hemorrhage; Prosthesis Design; Reoperation; Risk Factors; Thrombasthenia; Treatment Outcome; Warfarin; Young Adult

Anticoagulation with warfarin following bioprosthetic mitral valve replacement (BMVR) is recommended by multiple practice guidelines. We assessed practice variability and patient characteristics associated with warfarin prescription following BMVR.. We analyzed 7,637 patients in the Society of Thoracic Surgeons Database (January 1, 2008 to June 30, 2011) who were discharged following isolated primary nonemergent BMVR. Patients requiring preoperative warfarin, those with preoperative atrial fibrillation, or those with a contraindication to warfarin were excluded. The association between patient, hospital, and surgeon characteristics and warfarin prescription were evaluated.. Fifty-eight percent of this cohort (median age, 66 years; female sex, 58.7%) was prescribed warfarin. Patients receiving warfarin were older (67 vs 65 years; P < .0001), were less likely to have had preoperative stroke (9.3% vs 12.1%; P < .001), CHF (51.4% vs 54.1%; P < .02), or dialysis (4.9% vs 9.0%; P < 0.001), and had a longer postoperative length of stay (8.0 vs 7.0 days; P < 0.01). Warfarin was prescribed less often for patients with postoperative GI events (44.4% vs 55.6%; P < .001) but more often for patients with postoperative myocardial infarction (75.8% vs 24.2%; P < .001) or new atrial fibrillation (68% vs 32%; P < .001) and those requiring blood transfusions intraoperatively (55.7% vs 44.3%; P < .001) or postoperatively (57% vs 43%; P < .03). Similar rates of warfarin prescription were observed in patients requiring reoperation for bleeding (54.9% vs 45.1%; P = .20) and those with postoperative stroke (53.6 % vs 46.4 %; P = .30). After adjusting for patient characteristics, significant surgeon and hospital variation in warfarin prescription at hospitals was observed.. Although patient characteristics and postoperative events may be associated with the prescription of warfarin following BMVR, substantial surgeon and hospital variability remains. This variability largely ignores the established practice guidelines and warrants further study to define the optimal anticoagulation strategy in patients undergoing BMVR.

Topics: Age Factors; Aged; Anticoagulants; Atrial Fibrillation; Bioprosthesis; Blood Loss, Surgical; Blood Transfusion; Databases, Factual; Female; Guideline Adherence; Heart Failure; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Length of Stay; Male; Middle Aged; Mitral Valve; Mitral Valve Insufficiency; Multivariate Analysis; Myocardial Infarction; Patient Discharge; Postoperative Complications; Postoperative Hemorrhage; Practice Guidelines as Topic; Practice Patterns, Physicians'; Renal Dialysis; Stroke; Warfarin

Topics: Adult; Anticoagulants; Combined Modality Therapy; Female; Graft Occlusion, Vascular; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Mitral Valve Insufficiency; Prosthesis Failure; Prosthesis-Related Infections; Reoperation; Staphylococcal Infections; Tricuspid Valve; Warfarin

Topics: Adult; Anticoagulants; Antiphospholipid Syndrome; Cardiotonic Agents; Cyclophosphamide; Dobutamine; Extracorporeal Membrane Oxygenation; Female; Heparin; Humans; Immunoglobulins, Intravenous; Immunosuppressive Agents; Methylprednisolone; Mitral Valve Insufficiency; Plasmapheresis; Shock, Cardiogenic; Warfarin

Long-term warfarin therapy has been used to decrease thromboembolic events in patients with atrial fibrillation (AF) following bioprosthetic mitral valve replacement (BMVR) and left atrial appendage obliteration (LAAO). A retrospective study was conducted to investigate the efficacy of long-term warfarin or aspirin therapy in patients with AF after BMVR and LAAO.. A total of 215 patients with persistent AF were given anticoagulation therapy with warfarin for the first 3 months after BMVR and LAAO, continuing warfarin or aspirin therapy according to the surgeon's preference. A yearly follow-up with patients was performed by telephone or mail for postoperative condition, cerebrovascular, and bleeding events.. Seven patients died in the first 3 months after surgery, including 6 patients from heart failure and 1 patient from sudden death. The remaining 208 patients were divided into two groups: warfarin group (n = 84 patients) and aspirin group (n = 124). The patients in the warfarin group were older than those in the aspirin group and had a lower postoperative left ventricular ejection fraction. Other baseline and operative characteristics were similar. The two groups had similar incidence of thromboembolic events (9.5% versus 8.9%, P = .873) and bleeding events（7.1% versus 3.2%, P = .207). Each group had one intracranial hemorrhage. Eleven patients expired within three months after surgery, 4（4.8%) in the warfarin group and 10（8.1%）in the aspirin group (P = .411 by Fisher exact test). Cumulative survival was not significantly different in the two groups by Kaplan-Meier analysis (P = .55, log-rank test).. At the current time in China, long-term warfarin or aspirin therapy may have no significantly different impact on long-term prognosis after 3 months anticoagulation with warfarin in patients with AF undergoing BMVR and LAAO.

Topics: Anti-Inflammatory Agents, Non-Steroidal; Anticoagulants; Aspirin; Atrial Fibrillation; Bioprosthesis; Causality; China; Comorbidity; Female; Heart Valve Prosthesis Implantation; Humans; Longitudinal Studies; Male; Middle Aged; Mitral Valve Insufficiency; Prevalence; Retrospective Studies; Risk Factors; Survival Rate; Thromboembolism; Treatment Outcome; Turkey; Unnecessary Procedures; Utilization Review; Warfarin

The objective of this study was to evaluate the safety and efficacy of low-intensity warfarin treatment in Chinese patients after mitral valve replacement as well as the rationality of the INR standards of the hospital (The First People's Hospital of Jining City).. We retrospectively analyzed 270 cases in our hospital from January 2009 to December 2013; 239 patients completed the 5-year follow-up. There were 192 male and 78 female subjects, age 32-65 years old with a mean age 51.51 ± 12.12 years old. All eligible candidates received a Carbomedics artificial mechanical valve replacement and were anticoagulated under this hospital's current guidelines for postoperative anticoagulant therapy mitral valve replacement (INR 1.8-2.5). We analyzed the patient's regularly recorded prothrombin times (PTs) and the occurrence of anticoagulation-related complications, such as bleeding, thrombosis, and embolism.. A follow-up for 239 of 300 patients was performed for 3-60 months. Within this group, one patient died from cerebral hemorrhage, there was 1 case of subcutaneous bleeding, 1 case of epistaxis, 12 cases of gingival bleeding, in 15 menstrual quantity increased, and in 1 case we found cerebral infarction.. In conclusion, low-intensity anticoagulation after mitral Carbomedics valve replacement is therapeutically effective and safe. There is room to improve the anticoagulation standard currently used, perhaps at a slightly lower level than this standard suggests. From our research we can formulate individualized treatment plans and effectively reduce the occurrence of complications.

Topics: Adult; Aged; Anticoagulants; China; Comorbidity; Equipment Failure Analysis; Female; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Male; Middle Aged; Mitral Valve Insufficiency; Postoperative Care; Postoperative Complications; Prevalence; Prosthesis Design; Risk Factors; Thromboembolism; Treatment Outcome; Warfarin; Young Adult

Mitral valve prolapse is not commonly on the list of differential diagnosis when a patient presents in the emergency department (ED) in severe distress, presenting with non-specific features such as abdominal pain, tachycardia and dyspnea. A healthy 55-year-old man without significant past medical history arrived in the ED with a unique presentation of a primary mitral valve prolapse with an atrial septal defect uncommon in cardiology literature. Early recognition of mitral valve prolapse in high-risk patients for severe mitral regurgitation or patients with underlying cardiovascular abnormalities such as an atrial septal defect is crucial to prevent morbid outcomes such as sudden cardiac death.

Topics: Abdominal Pain; Anticoagulants; Anxiety; Cardiotonic Agents; Continuous Positive Airway Pressure; Digoxin; Dopamine; Dyspnea; Electrocardiography; Emergencies; Heart Septal Defects, Atrial; Heart Valve Prosthesis Implantation; Humans; Male; Metoprolol; Middle Aged; Mitral Valve Insufficiency; Mitral Valve Prolapse; Treatment Outcome; Warfarin

Prosthetic valve thrombosis within one year after mitral valve replacement is rarely seen in patients on warfarin therapy and without any risk factor. Here, we describe a case of a 39-year- old female, who presented with dyspnoea and shortness of breath 11 months after mitral valve replacement. The echocardiogram revealed severe valvular stenosis due to presence of clots on the mitral valve and restricted motion of the mitral leaflets. As a result of deterioration of general condition and haemodynamic un-stability, plan was made to re-operate for her valve replacement surgery. This case report highlights the diagnosis, prevention and management of patients with prosthetic valve thrombosis following mitral valve replacement.

Topics: Adult; Anticoagulants; Bioprosthesis; Female; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Mitral Valve; Mitral Valve Insufficiency; Mitral Valve Stenosis; Reoperation; Rheumatic Heart Disease; Thrombosis; Warfarin

Patients with atrial fibrillation (AF) are at risk of cardioembolism.(1,2)) Atrial thrombus formation associated with AF typically occurs in the left atrial appendage (LAA);(3)) therefore, transesophageal echocardiography (TEE) is important for detection of such a thrombus and measurement of LAA flow velocity.(4,5)) LAA closure is routinely performed during mitral valve surgery in patients with AF to prevent cardiogenic stroke.(6)) We report the case of a 65-year-old woman with severe mitral regurgitation (MR) and AF in whom a giant thrombus formed almost immediately after mitral and tricuspid valvuloplasty and concurrent LAA resection. No atrial thrombus or spontaneous echo contrast (SEC) was detected by TEE before the surgery. However, a giant intramural thrombus was detected in the left atrium 7 days after surgery. It was thought that the atrial dysfunction as well as the change in morphology of the left atrium resulting from the severe MR complicated by AF and congestive heart failure produced a thrombotic substrate. This case suggests that careful surveillance for thrombus formation and careful maintenance of anticoagulation therapy are needed throughout the perioperative period even if no SEC or thrombus is detected before surgery.

Topics: Aged; Anticoagulants; Atrial Appendage; Atrial Fibrillation; Drug Monitoring; Echocardiography, Transesophageal; Humans; Male; Mitral Valve Annuloplasty; Mitral Valve Insufficiency; Postoperative Complications; Thrombosis; Treatment Outcome; Warfarin

Topics: Coronary Angiography; Equipment Failure Analysis; Female; Humans; Medication Adherence; Middle Aged; Mitral Valve; Mitral Valve Insufficiency; Mitral Valve Stenosis; Postoperative Care; Postoperative Complications; Prosthesis Design; Reoperation; Rheumatic Heart Disease; Thrombosis; Video Recording; Warfarin

Topics: Anticoagulants; Aortic Valve Insufficiency; Atrial Fibrillation; Female; Humans; Male; Mitral Valve Insufficiency; Morpholines; Thiophenes; Warfarin

Non-bacterial endocarditis lesions associated with antiphospholipid antibodies (aPLs) in the absence of other criteria for antiphospholipid syndrome or systemic lupus erythematosus is termed an aPL-associated cardiac valve disease. Evidence regarding the management of this condition is sparse. A rare case is described of a 20-year-old female who presented with an incidental finding of 'vegetations on a heart valve'. Echocardiography revealed mitral valve leaflet thickening and echodensities with moderate mitral regurgitation. She had an elevated partial thromboplastin time that did not correct with a mixing study, and elevated levels of antiocardiolipin antibodies. Hence, a diagnosis of aPL-associated cardiac valve disease was made, and the patient commenced on warfarin, hydroxychloroquine, and a short course of oral prednisone. At one year after diagnosis the patient remained symptom-free, and follow up echocardiography revealed resolution of the vegetations with minimal mitral regurgitation. Further evidence is needed to guide the therapy of this rare condition.

Topics: Antibodies, Anticardiolipin; Anticoagulants; Drug Therapy, Combination; Endocarditis, Non-Infective; Female; Glucocorticoids; Humans; Hydroxychloroquine; Immunomodulation; Mitral Valve; Mitral Valve Insufficiency; Prednisone; Warfarin; Young Adult

Topics: Abdominal Wall; Aged; Anti-Bacterial Agents; Anticoagulants; Aza Compounds; Blood Coagulation Tests; Drug Interactions; Drug Therapy, Combination; Female; Fluoroquinolones; Heart Valve Prosthesis; Hematoma; Hemoperitoneum; Humans; Mitral Valve Insufficiency; Moxifloxacin; Pneumonia, Bacterial; Quinolines; Thromboembolism; Tomography, X-Ray Computed; Warfarin

Drug interaction between Warfarin and psychiatric agents may have important therapeutic effects for patients undergoing cardiac surgery. We present a case of a patient in whom concurrent treatment with Warfarin and valproic acid resulted in supratherapeutic international normalized ratio values. A discussion of the possible mechanisms for this interaction as well as a review of interactions between Warfarin and other psychiatric medications is the subject of this case report.

Topics: Adult; Anticoagulants; Antimanic Agents; Bipolar Disorder; Drug Interactions; Drug Therapy, Combination; Female; Follow-Up Studies; Heart Valve Prosthesis; Humans; Mitral Valve Insufficiency; Postoperative Complications; Thrombosis; Valproic Acid; Warfarin

Atrial fibrillation (AF) is the most common clinically encountered arrhythmia in adults. Because it is associated with an increased risk of atrial thrombus formation and embolism, medical and/or electrical cardioversion is the preferred treatment method in the majority of clinics. Thrombus formation in the setting of AF most commonly occurs in the left atrial appendage (LAA), left atrium (LA), right atrial appendage (RAA), and right atrium in decreasing frequency. In routine transesophageal echocardiographic evaluation for AF, examination is generally limited to LA and LAA. Although relatively rare when compared with the left side, RAA thrombus has also the potential of embolism and should be screened. A case of RAA thrombus in which the LA and LAA were spared is described. The authors aimed to underline the importance of this rare but potentially dangerous complication of AF.

Topics: Aged; Atrial Appendage; Atrial Fibrillation; Contraindications; Dyspnea; Echocardiography, Transesophageal; Electric Countershock; Embolism; Female; Humans; Mitral Valve Insufficiency; Pulmonary Embolism; Thrombosis; Warfarin

Topics: Adrenergic beta-Antagonists; Cardiomegaly; Digoxin; Diuretics; Female; Heart Atria; Humans; Middle Aged; Mitral Valve Insufficiency; Mitral Valve Stenosis; Tomography, X-Ray Computed; Ultrasonography; Warfarin

Mitral valve prolapse is a rare condition and represents a challenge for cardiac surgeons. Many techniques have been described to treat the wide spectrum of abnormalities causing mitral valve regurgitation but the low incidence of these abnormalities is the cause of the relatively poor experience of many institutions.. From April 2005 to September 2006, five patients underwent isolated mitral valve repair with the edge-to-edge technique for anterior or bileaflet prolapse. Three patients also had a Gore-Tex strip to reinforce the posterior annulus, whereas two had a 26-size soft incomplete ring annuloplasty.. There was no death and none of the patients required reoperation. None of the patients had mitral regurgitation more than 1+ at a mean follow-up of 30 months. None of the patients had mitral stenosis or any valve-related event.. The edge-to-edge technique is a well tolerated and useful technique for the anterior or bileaflet prolapse of the mitral valve. Although many techniques have been described with good results, in many anatomical settings and in small patients, edge-to-edge is a good option and might not interfere with the growth of the valve. Early results are encouraging but a longer follow-up is needed to evaluate the long-term prognosis.

Topics: Anticoagulants; Child; Child, Preschool; Female; Heart Valve Prosthesis Implantation; Humans; Male; Mitral Valve; Mitral Valve Insufficiency; Mitral Valve Prolapse; Severity of Illness Index; Time Factors; Treatment Outcome; Ultrasonography; Warfarin

Antiphospholipid syndrome (APS) is a disorder characterized by recurrent venous or arterial thrombosis and/or fetal loss; involvement of cardiac valves is also seen. A seronegative variant has been described previously. We report a case of a woman with recurrent pregnancy loss, prior strokes, and a negative workup for known antiphospholipid antibodies. During her current pregnancy, she presented with acute stroke and mitral valve vegetation. Her workup for antiphospholipid syndrome and other thrombophilias remained negative even after the stroke. Her mitral valve vegetation resolved completely with aspirin, heparin, and warfarin. We believe this to be the first report of complete resolution of valvular vegetation with antiplatelet and anticoagulant therapy alone in a patient with seronegative antiphospholipid syndrome. Moreover, this appears to be the first report of stroke associated with this condition.

Topics: Abortion, Habitual; Adult; Anticoagulants; Antiphospholipid Syndrome; Aspirin; Cesarean Section; Female; Heparin; Humans; Infant, Newborn; Male; Mitral Valve Insufficiency; Pregnancy; Pregnancy Complications, Hematologic; Stroke; Warfarin

Topics: Aged; Anticoagulants; Cardiomegaly; Coronary Thrombosis; Female; Heart Atria; Humans; Mitral Valve Insufficiency; Mitral Valve Stenosis; Thromboembolism; Ultrasonography; Warfarin

Unfractionated heparin has been a near universal anticoagulant for cardiac surgery; however it is contraindicated in heparin-induced thrombocytopenia type II. Alternative anticoagulants such as bivalirudin (a direct thrombin inhibitor) are being utilized. Bivalirudin was successfully used in an immunologically complex patient (diagnoses of heparin-induced thrombocytopenia type II, systemic lupus erythematosus, antiphospholipid syndrome, and dialysis-dependent renal failure) requiring cardiopulmonary bypass. Thrombotic events are common in antiphospholipid syndrome patients undergoing cardiac surgery utilizing high-dose heparin. This may represent unrecognized heparin-induced thrombocytopenia type II. Our patient did not experience perioperative thrombotic or bleeding complications. The possible cross-reactivity between heparin induced thrombocytopenia type II and antiphospholipid syndrome has not been investigated.

Topics: Adult; Antibody Specificity; Anticoagulants; Antiphospholipid Syndrome; Autoantibodies; Cross Reactions; Drug Evaluation; Drug Therapy, Combination; Female; Heart Failure; Heparin; Hirudins; Humans; Hypertension, Pulmonary; Kidney Failure, Chronic; Lupus Erythematosus, Systemic; Mitral Valve Insufficiency; Peptide Fragments; Platelet Count; Platelet Factor 4; Recombinant Proteins; Renal Dialysis; Thrombocytopenia; Thrombophilia; Warfarin

We have reported the short- and long-term results of mitral valve replacement in this article.. Mitral valve replacement was conducted in 276 patients in our clinic between January 1989 and March 2005. The youngest patient was 4 years old and the oldest patient was 74 years old. Mean age was 40.08 +/- 1.06 y. Of these patients, 41.3% were men and 58.7% were women. The reason for operation was mitral stenosis in 96 patients (34.78%), mitral insufficiency in 78 patients (29.26%) and mitral stenosis plus mitral insufficiency in 102 patients (36.96%). The aetiology of mitral valve lesions was acute rheumatic fever in 208 patients (75.36%). The aetiology of mitral valve lesions was degenerative in 37 patients (13.41%), ischaemic in 23 patients (8.33%) and congenital in 8 patients (2.9%).. In the 5, 10 and 15-year periods, the actual survival rates were 87.64% +/- 2.02%, 83.35% +/- 2.38% and 68.19% +/- 5.63%, respectively. Thromboembolism was observed in 38 patients (13.77%). The rates of actual freedom from thromboembolism in the 5, 10 and 15-year periods were 93.08% +/- 1.53%, 88.48% +/- 1.99% and 81.06% +/- 3.43%, respectively. Of the 276 patients who had been observed for 15 years, 5 had (1.81%) valvular thrombosis. The rates of actual freedom from valvular thrombosis in the 5, 10 and 15-year periods were 98.89% +/- 0.64%, 98.04% +/- 0.87% and 98.04% +/- 0.87%, respectively. In the 15-year period, 23 patients (8.33%) had haemorrhage due to anti-coagulation. The rates of actual freedom from haemorrhage due to anti-coagulation in the 5, 10 and 15-year periods were 95.64% +/- 1.23%, 93.40% +/- 1.56% and 87.73% +/- 2.96%, respectively. Seven patients (2.54%) had prosthetic valvular endocarditis. The rates of actual freedom from endocarditis in the 5, 10 and 15-year periods were 98.51% +/- 0.74%, 97.60% +/- 0.97% and 97.01% +/- 1.13%, respectively. Nine patients (3.27%) were re-operated. The rates of actual freedom from re-operation in the 5, 10 and 15-year periods were 97.45% +/- 0.95%, 96.58% +/- 1.12% and 96.58% +/- 1.12%, respectively.. St. Jude Medical mechanical valve prosthesis has been the valve of choice in our clinic owing to its excellent haemodynamic properties and low rates of complication.

Topics: Adolescent; Adult; Aged; Anticoagulants; Child; Child, Preschool; Female; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Male; Middle Aged; Mitral Valve Insufficiency; Mitral Valve Stenosis; Myocardial Ischemia; Prosthesis Design; Reoperation; Rheumatic Heart Disease; Survival Analysis; Time Factors; Treatment Outcome; Warfarin

Eight dogs with naturally occurring severe mitral regurgitation underwent mitral valve replacement with a mechanical valve prosthesis during cardiopulmonary bypass. Dogs received warfarin orally after surgery to maintain a prothrombin time-based international normalized ratio from 2.5 to 3.5. Seven dogs survived surgery. Left ventricular diastolic volume index decreased significantly from 206 +/- 91 mL/m2 before surgery to 121 +/- 47 mL/m2 after surgery. Left atrium-to-aorta ratio decreased significantly from 2.66 +/- 0.4 before surgery to 1.73 +/- 0.65 after surgery. Left ventricular systolic volume index was not significantly different after surgery (56 +/- 36 mL/m2), compared with before surgery (40 +/- 32 mL/m2). Median survival after surgery was 4.5 months (range, 0.75 months to 5.25 years). Six dogs died of confirmed or suspected thrombosis of the valve prosthesis. Dogs with severe mitral regurgitation tolerated mitral valve replacement well, but a high incidence of prosthetic valve thrombosis limited long-term outcome.

Topics: Animals; Anticoagulants; Dog Diseases; Dogs; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Mitral Valve; Mitral Valve Insufficiency; Surgery, Veterinary; Survival Analysis; Thrombosis; Treatment Outcome; Warfarin

We describe a pair of twins, whose mother was being treated by oral anticoagulant drugs, as a result of having received mitral heart valve implantation in the past. The male twins monochorionic, monoamniotic--but one infant showed the features of fetal warfarin syndrome. In the study we discussed the pharmacogentetics and individual variation in the human metabolism during treatment with warfarin-perinatal growth and prevalence of congenital malformations. We analysed the threats to the fetus and mother, connected with administration of anticoagulant drugs.

Topics: Abnormalities, Multiple; Adult; Anticoagulants; Diseases in Twins; Female; Fetal Death; Humans; Infant, Newborn; Male; Mitral Valve Insufficiency; Pregnancy; Pregnancy Complications, Cardiovascular; Prenatal Exposure Delayed Effects; Twins; Warfarin

Atrial fibrillation (AF) has been treated with DC shocks delivered transthoracically, but in 5-30% of patients, the procedures fail to restore sinus rhythm (SR). We hypothesized that applying high energy shock waves to the chest may overcome the inadequate penetration of electrical shock to the atrium. The aim of this study was to evaluate the efficacy of higher energy external DC shock for the treatment of refractory AF coexisting with cardiovascular disease using a synchronized double external defibrillator. Fifteen patients (mean age 65 +/- 8) with refractory AF to standard DC cardioversion (CV) underwent higher energy DC shock using a double external defibrillator. Concomitant heart disease was present in all patients. Warfarin and amiodarone (600 mg/day), were administered for at least three weeks duration before DC CV. Sedation was performed with IV midazolam. Two defibrillator paddles were positioned on the anterior and posterior chest wall in a right lateral decubitus position. Defibrillators were synchronized to the R waves and simultaneously 720 joules of energy was administered to the patients. Amiodarone (200 mg/day) was continuously administered after DC shock to maintain SR. Sinus rhythm was obtained in 13 patients. Sinus rhythm was persistent in 11 patients for six months duration. Creatine kinase MB fractions were normal at 4 (22 +/- 4 IU/L) and 12 hours (18 +/- 4 IU/L). None of the patients developed significant hemodynamic compromise or congestive heart failure, higher AV block, stroke, or transient ischemic cerebral events. The results indicate that higher energy DC shock application using a double external defibrillator is an effective and safe method for the cardioversion of refractory AF. We believe this procedure should be performed before internal atrial cardioversion.

Topics: Aged; Amiodarone; Anti-Arrhythmia Agents; Atrial Fibrillation; Cardiomyopathy, Dilated; Cardiomyopathy, Hypertrophic; Defibrillators; Electric Countershock; Humans; Middle Aged; Mitral Valve Insufficiency; Rheumatic Heart Disease; Warfarin

Controversy exists regarding the influence of mitral regurgitation (MR) on thromboembolic risk in patients with atrial fibrillation. We aimed to investigate retrospectively a reduction of risk for stroke due to MR in atrial fibrillation and to evaluate the effectiveness of low-intensity anticoagulation therapy. In 313 patients with atrial fibrillation, transthoracic echocardiography was performed and MR was graded. Between the groups with no or mild MR (n = 209) and with moderate or severe MR (n = 104), age, sex, treatment, history of diabetes, hypertension, hyperlipemia and mitral stenosis, and previous stroke were compared. No significant differences in clinical characteristics, treatment, or history were observed between the two groups. The incidence of thromboembolism was significantly higher in the group with no MR (48 patients [23%]) than in the group with MR (14 patients [13%], p < 0.05). In the MR group, previous stroke was frequently observed in patients without warfarin treatment (11 of 51 patients) compared with patients with low-dose warfarin treatment (international normalized ratio of 1.6-1.8) (3 of 53 patients, p < 0.05). Consequently, the thromboembolic event was markedly prevented by low-dose warfarin treatment.

Topics: Aged; Anticoagulants; Aspirin; Atrial Fibrillation; Cerebrovascular Circulation; Echocardiography; Female; Humans; Intracranial Embolism; Intracranial Thrombosis; Male; Middle Aged; Mitral Valve Insufficiency; Risk Factors; 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

These studies were designed to assess the effect of low-dose anticoagulation in elderly patients after mitral valve replacement.. Between 1986 and 1995, 250 patients aged > or = 50 years underwent isolated mitral valve replacement at the Cardiovascular Surgery Clinic of Turkiye Yuksek Ihtisas Hospital. The overall hospital mortality rate was 8%. Postoperatively, all patients received 2.5 mg/day warfarin, and 225 mg/day dypridamole and 250 mg/day aspirin following removal of mediastinal tubes. This regimen was continued indefinitely thereafter.. Postoperatively, the mean International Normalized Ratio (INR) was 1.4 +/- 0.67 (range: 0.9 to 4.19) and mean prothrombin time 13.33 +/- 1.98 min (range: 11.7 to 21.3 min). Mean follow up was 1.42 +/- 1.2 years (range: 2 months to 8.3 years); total cumulative follow up was 322.75 patient-years (pt-yr). During follow up, six patients (1.85% per pt-yr) developed thromboembolic complications (including mechanical valve thrombosis), two (0.62% per pt-yr) developed oral anticoagulant-related bleeding, and two (0.62% per pt-yr) developed paravalvular leak. Five patients died during follow up (late mortality rate 1.2% per pt-yr). The nine-year actuarial survival rate was 93.9 +/- 4.8% for the entire group.. Low-dose oral anticoagulation after mitral valve replacement with St. Jude Medical prosthesis in elderly patients provided satisfactory clinical results.

Topics: Actuarial Analysis; Anticoagulants; Female; Follow-Up Studies; Heart Valve Prosthesis Implantation; Hospital Mortality; Humans; Male; Middle Aged; Mitral Valve; Mitral Valve Insufficiency; Mitral Valve Stenosis; Platelet Aggregation Inhibitors; Postoperative Care; Postoperative Complications; Prosthesis Design; Time Factors; Warfarin

We report a case of profound anticoagulation caused by interaction between warfarin and danshen, a widely used Chinese herbal medicine, in a patient who had undergone mitral valve replacement. Patients taking warfarin should be warned not to take this herb. In addition, physicians should be alert to the possibility of an interaction with herbal medicine when anticoagulation control becomes difficult and no other causes are apparent.

Topics: Anticoagulants; Drug Combinations; Drug Interactions; Drugs, Chinese Herbal; Fibrinolytic Agents; Heart Valve Prosthesis Implantation; Humans; Male; Middle Aged; Mitral Valve Insufficiency; Phenanthrolines; Plant Extracts; Salvia miltiorrhiza; Warfarin

We report the case of a 74-year-old woman who underwent an elective procedure to replace her mitral valve with a 27-mm CarboMedics bileaflet valve (CarboMedics, Inc.; Austin, Tex) to correct mitral incompetence. Massive thrombosis of the prosthesis was clinically evident on the 6th postoperative day, despite administration of warfarin therapy according to our usual protocol. After an unsuccessful attempt at thrombolysis with recombinant tissue plasminogen activator, the mechanical prosthesis was replaced with a bioprosthesis. The cause of the thrombosis is unknown, but transient suboptimal anticoagulation is assumed to be responsible. Although very early massive valve thrombosis is a rare occurrence, it is a known risk of prosthetic valve implantation. Antiplatelet therapy, in addition to the usual warfarin anticoagulation, can help to prevent it. If thrombosis is diagnosed, it can be managed by thrombolysis or, when thrombolysis is unsuccessful, by reoperation. Transesophageal echocardiography is fundamental in the diagnosis and management of this sequela.

Topics: Aged; Anticoagulants; Bioprosthesis; Coronary Thrombosis; Female; Heart Valve Prosthesis Implantation; Humans; Mitral Valve Insufficiency; Postoperative Complications; Reoperation; Warfarin

A 30-year-old female whose mitral valve had been replaced with a mechanical prosthetic valve 23 years ago gave birth to a healthy baby by cesarian section under controlled anticoagulant therapy. Warfarin was replaced with intravenous heparin just one week before cesarian section and heparin administration was stopped several hours prior to the operation which was successfully carried out without excessive blood loss. Although warfarin carries a risk of teratogenecity, fortunately, the baby had not any somatic malformation. We believe that pregnancy is not contraindicated in patients with mechanical prosthetic heart valves, however, a strict observation of the cardiac function during middle and late trimesters of gestation by echocardiography and planned anticoagulant therapy are necessary in order to prevent maternal congestive heart failure and thromboembolism and protect a neonate against intracranial hemorrhage.

Topics: Adult; Biomarkers; Blood Coagulation Factors; Cerebral Hemorrhage; Cesarean Section; Echocardiography; Female; Fibrinolytic Agents; Heart Failure; Heart Valve Prosthesis; Heparin; Humans; Infant, Newborn; Mitral Valve Insufficiency; Monitoring, Physiologic; Pregnancy; Pregnancy Complications, Cardiovascular; Pregnancy Complications, Hematologic; Pregnancy Outcome; Thromboembolism; Thrombolytic Therapy; Warfarin

Two patients who had mitral valve replacement presented during the second trimester of pregnancy. Both had uneventful pregnancies ending in normal delivery of healthy female babies. Though patients who are haemodynamically stable tolerate pregnancy well, because of the substantial risks of anticoagulant therapy, it is prudent to advise against pregnancy after valve replacement.

Topics: Adult; Combined Modality Therapy; Female; Humans; Mitral Valve Insufficiency; Postoperative Period; Pregnancy; Pregnancy Complications, Cardiovascular; Rheumatic Heart Disease; Warfarin

A 66-year-old man who had undergone MVR using a ST. Jude Medical valve entered the hospital with acute heart failure and cardiogenic shock 3 months after surgery. He had had a symptom of petechiae due to macrogloburinemia after initial MVR and had been in the poor control of anticoagulation therapy because of presence of petechiae. He was diagnosed as prosthetic valve thrombosis using echocardiography and underwent emergency re-MVR using a Central Open Bioprosthesis (COB) which was developed by our department. He was doing well 8 month after re-MVR. Selection of prosthetic valve should be performed carefully in the patient with hemorrhagic disease, and careful observation and proper anticoagulant therapy should be carried out after valve replacement.

Topics: Aged; Bioprosthesis; Heart Failure; Heart Valve Prosthesis; Humans; Male; Mitral Valve; Mitral Valve Insufficiency; Prosthesis Failure; Reoperation; Thrombosis; Waldenstrom Macroglobulinemia; Warfarin

A 45-year-old woman with prosthetic valves replacement, was admitted with severe headache and vomiting one month after starting danazol treatment at 300 mg per day. She was receiving long-term anticoagulation with warfarin and dipyridamole, taking 3.5 mg and 300 mg per day respectively. The patient's thrombotest value was less than 6% at the time of admission. Cranial CT revealed subarachnoid hemorrhage. Warfarin and danazol treatment ware discontinued with replenishment of vitamin K. Recovery was uneventful. Danazol is 2, 3 isoxazol derivative of 17-alpha-ethinyl testosterone. As such, it shares the property of C 17 alkylated steroids in potentiating the action of coumarin. It is suggested that danazol affects the turnover of vitamin-K-dependent clotting factors, an impairment of synthesis being a likely mechanism. The possible hazard of the potentiating effect of danazol on warfarin should be widely appreciated.

Topics: Aortic Valve Insufficiency; Blood Coagulation; Danazol; Drug Therapy, Combination; Female; Heart Valve Prosthesis; Humans; Middle Aged; Mitral Valve Insufficiency; Subarachnoid Hemorrhage; Warfarin

The continued good results after mitral valve reconstruction prompted this retrospective study to compare operative and late results from our institutional experience since 1976 with 975 porcine mitral valve replacements (MVRs) (1976 to December 1987), 169 mechanical MVRs (1976 to December 1987), and 280 Carpentier-type mitral valve reconstructions (CVRs) (1980 to mid-1988). The operative mortality was 2.0% for isolated CVR, 6.6% for isolated mechanical MVR, and 8.5% for isolated porcine MVR. The overall operative mortality was 5.0% for CVR, 16.6% for mechanical MVR, and 10.6% for porcine MVR. The overall 5-year survival including hospital deaths was 76% for CVR, 72% for mechanical MVR, and 69% for porcine MVR. By multivariate analysis, the predictors of increased operative risk and of decreased survival were age, New York Heart Association functional class IV status, previous cardiac operation, and performance of concomitant cardiac surgical procedures. The type of valvular procedure was not predictive of operative risk or overall survival. The 5-year freedom from reoperation was 94.4% for nonrheumatic patients having CVR, 77.4% for rheumatic patients having CVR, 96.4% for mechanical MVR, and 96.6% for porcine MVR (p less than 0.05, rheumatic patients with CVR versus both MVR groups). The 5-year freedom from all valve-related morbidity and mortality was significantly better for valve reconstruction compared with both types of valve replacement. Thus, the operative risk and late survival obtained after mitral valve reconstruction were at least equivalent to those obtained after MVR. In addition, patients receiving mitral valve reconstruction had less valve-related combined morbidity than patients receiving valve replacement, thus making mitral valve reconstruction preferable in some patients with mitral insufficiency.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Bioprosthesis; Child; Endocarditis; Female; Follow-Up Studies; Heart Valve Prosthesis; Humans; Male; Middle Aged; Mitral Valve; Mitral Valve Insufficiency; Mitral Valve Stenosis; Postoperative Complications; Reoperation; 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

Topics: Age Factors; Child, Preschool; Heart Valve Prosthesis; Humans; Male; Mitral Valve; Mitral Valve Insufficiency; Prosthesis Failure; Reoperation; Thrombosis; Warfarin

Mitral valve prolapse (MVP), often the result of myxomatous degeneration of the mitral valve, is the most commonly known pathologic entity leading to pure mitral regurgitation (MR). Reconstruction of the mitral valve rather than replacement is particularly applicable to this pathologic defect, but is not often used in the U.S. Experience with reconstruction of the mitral valve for MR secondary to MVP during the period January 1970 to January 1984 was reviewed. A total of 479 patients with mitral valve disease underwent operation during this period, 82 (17%) of whom had MR secondary to MVP. Thirty-one patients (6%) had valve reconstruction by a technique of leaflet plication and posteromedial anuloplasty. Eleven of these patients had associated cardiac disease requiring correction: 2 requiring aortic valve replacement and 9 requiring coronary artery bypass grafting procedures. One hospital death (3%) and 6 late deaths (19%) occurred, of which only 3 were related to cardiac factors. Major complications included recurrent MR in 5 patients and cerebral embolus in 1 patient. The adjusted 5-year survival rate was 89 +/- 6 (mean +/- standard error of the mean), and the overall survival rate of patients free of cardiac-related complications was 73 +/- 9%. Thus, reconstruction of the mitral valve is a highly effective surgical approach to the management of symptomatic patients with MR secondary to MVP, and its use is favored over replacement in the management of these patients.

Topics: Actuarial Analysis; Chordae Tendineae; Female; Humans; Male; Middle Aged; Mitral Valve Insufficiency; Mitral Valve Prolapse; Postoperative Complications; Recurrence; Rupture, Spontaneous; Thromboembolism; Warfarin

We discussed the existence of a thrombotic tendency and the relationship between the high incidence of thromboembolism and the thrombotic tendency in patients with rheumatic heart disease (RHD). The augmentation of platelet function was detected in all kinds of rheumatic valvular disease from the finding of high values of plasma beta-thromboglobulin (72 ng/ml, normal 29 ng/ml). The existence of hypercoagulation was also detected in patients with mitral stenosis by showing low levels of plasma antithrombin III (AT III), while fibrinolytic reaction remained normal. The degree of hypercoagulation became augmented in the order of cases of mitral stenosis (MS) complicated by both atrial fibrillation and chronic congestive heart failure, MS complicated only atrial fibrillation and MS with normal sinus rhythm (AT III: 19.6, 25.0, 26.7 mg/dl, respectively). On the contrary, hypercoagulation, the degree of which was almost the same as that in the respective MS groups, also existed in comparable controls of non-RHD, accompanied by the acceleration of fibrinolytic reaction as shown by the decrease in activity of plasma alpha 2-plasmin inhibitor. Therefore, it was concluded that thrombotic tendency certainly existed in patients with MS compared to those with non RHD and that it was one of the causes of the significantly high incidence of thromboembolism in comparison with non RHD.

Topics: alpha-2-Antiplasmin; alpha-Macroglobulins; Antithrombin III; beta-Thromboglobulin; Blood Coagulation; Fibrinogen; Fibrinolysis; Humans; Mitral Valve Insufficiency; Mitral Valve Stenosis; Plasminogen; Rheumatic Heart Disease; Thromboembolism; Urokinase-Type Plasminogen Activator; Warfarin

The nature of intracardiac thrombi were studied, which were the clinical underlying conditions, relation to systemic embolism, growth of thrombus and effect of anticoagulant therapy on the size of the thrombi, in 818 patients with mitral valve disease and 1000 patients with myocardial infarction by two-dimensional echocardiography. (1) Common underlying conditions were atrial fibrillation, enlarged left atrial cavity and predominance of mitral stenosis in cases with left atrial thrombi, and apical asynergy and low ejection fraction in cases with ventricular thrombi. The blood stasis should be the major factor in the formation of intracardiac thrombi. In a condition of blood stasis, dynamic intracavitary echoes which may represent erythrocyte aggregation were observed. (2) The incidence of systemic embolism in patients with thrombi was higher than that in patients without thrombi in cardiac disease. (3) The intracardiac thrombi were living. They grew and/or reduced their size spontaneously and sometimes became detached from the cardiac wall in the form of ball thrombi. (4) The effect of anticoagulant therapy on the regression of thrombi depends on its age.

Topics: Adult; Aged; Atrial Fibrillation; Echocardiography; Embolism; Female; Humans; Male; Middle Aged; Mitral Valve Insufficiency; Mitral Valve Stenosis; Myocardial Infarction; Stroke Volume; Thrombosis; Warfarin

A low incidence rate of thromboembolism has been reported in mitral porcine valve recipients. In contrast, 5 of 22 single mitral porcine valve recipients (23 percent) followed up in our clinic for a mean of 16 months had thromboembolic events. All patients but one were receiving long-term anticoagulant therapy. One thromboembolic event resulted in death, three in permanent neurologic deficits and one in a peripheral arterial occlusion. All five patients with emboli had atrial fibrillation and left atrial enlargement. Three had thromboembolic events before porcine heart valve implantation. In addition, five mitral porcine valve recipients who were not receiving anticoagulant therapy were examined at autopsy. Thrombus was identified in the left atrium in three patients, at the tissue-valve interface (sewing ring) in two, on the porcine valve cusps in one and in the right atrium in one. Factors influencing thrombus formation such as left atrial enlargement, atrial fibrillation and a prosthetic device are present after mitral porcine valve implantation and are indications for long-term anticoagulation therapy.

Topics: Adult; Animals; California; Cardiomegaly; Female; Follow-Up Studies; Heart Atria; Heart Valve Prosthesis; Humans; Male; Middle Aged; Mitral Valve Insufficiency; Swine; Thromboembolism; Transplantation, Heterologous; Warfarin

Advanced actuarial techniques are used to analyze late results in 912 patients who had isolated mitral or aortic valve replacement with ball valve prostheses from 1965 to 1974. Experience with noncloth-covered and cloth-covered valves is compared in terms of late survival, rate of thromboembolic complications and reoperation and the influence of anticoagulation. The cloth-covered prostheses have substantially reduced the incidence of emboli after mitral valve replacement (1.9 vs. 6 emboli per 100 patient years) and have thus far eliminated emboli after aortic valve replacement in patients receiving warfarin. Patients with a cloth-covered aortic valve who did not receive warfarin had nine emboli per 100 patient years. The safety of cloth-covered valves is clearly enhanced by warfarin therapy; the efficacy of anti-platelet drugs is still uncertain. Strut cloth wear was found at reoperation in 10 patients. This should be prevented in the new model 2400 composite strut ("track") valve by a narrow metal track on the inner surface of each strut. The substantial recent reductions in operative mortality and in prosthesis-related complications pose important questions regarding timing of operations and selection of prostheses. These decisions must be individualized for each patient on the basis of a thorough analysis of late results using modern statistical methods.

Topics: Aortic Valve; Aortic Valve Insufficiency; Aortic Valve Stenosis; Evaluation Studies as Topic; Female; Follow-Up Studies; Heart Valve Diseases; Heart Valve Prosthesis; Hemolysis; Humans; Male; Mitral Valve; Mitral Valve Insufficiency; Mitral Valve Stenosis; Polyethylene Terephthalates; Polypropylenes; Polytetrafluoroethylene; Prosthesis Design; Risk; Stress, Mechanical; Thromboembolism; Time Factors; 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

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: Adult; Aged; Blood Pressure; Blood Transfusion; Cardiac Catheterization; Central Venous Pressure; Female; Glucocorticoids; Hemorrhage; Humans; Male; Mediastinal Diseases; Mediastinum; Mitral Valve Insufficiency; Neck; Pharynx; Radiography; Shock, Hemorrhagic; Vitamin K; Warfarin

Topics: Adult; Age Factors; Aged; Aortic Valve Insufficiency; Aortic Valve Stenosis; Cardiac Surgical Procedures; Female; Gastrointestinal Hemorrhage; Humans; Male; Middle Aged; Mitral Valve Insufficiency; Peptic Ulcer Hemorrhage; Postoperative Complications; Sex Factors; Warfarin

Topics: Abortion, Missed; Abortion, Spontaneous; Adult; Anticoagulants; Female; Fetal Death; Fetus; Heart Valve Prosthesis; Heparin; Humans; Mitral Valve Insufficiency; Mitral Valve Stenosis; Phenindione; Pregnancy; Pregnancy Complications, Cardiovascular; Thromboembolism; Warfarin

Topics: Adult; Corpus Luteum; Female; Heart Valve Prosthesis; Hemorrhage; Humans; Mitral Valve Insufficiency; Mitral Valve Stenosis; Ovarian Diseases; Warfarin

Topics: Anticoagulants; Dipyridamole; Heart Valve Prosthesis; Humans; Methods; Mitral Valve Insufficiency; Mitral Valve Stenosis; Physician-Patient Relations; Postoperative Care; Preoperative Care; Thromboembolism; Ventilators, Mechanical; Warfarin

Topics: Adult; Female; Heart Valve Prosthesis; Humans; Middle Aged; Mitral Valve; Mitral Valve Insufficiency; Thromboembolism; Warfarin

Topics: Abnormalities, Drug-Induced; Adult; Anticoagulants; Aortic Valve; Aortic Valve Insufficiency; Female; Fetal Death; Heart Valve Prosthesis; Heparin; Humans; Labor, Obstetric; Mitral Valve; Mitral Valve Insufficiency; Phenindione; Postoperative Complications; Pregnancy; Pregnancy Complications, Cardiovascular; Thromboembolism; Warfarin

Topics: Adult; Female; Heart Valve Prosthesis; Heparin; Humans; Mitral Valve; Mitral Valve Insufficiency; Pregnancy; Pregnancy Complications, Cardiovascular; Rheumatic Heart Disease; Sodium; Warfarin

Topics: Adult; Chlorothiazide; Drug Hypersensitivity; Female; Humans; Mitral Valve Insufficiency; Mitral Valve Stenosis; Purpura, Thrombocytopenic; Warfarin

Topics: Adolescent; Adult; Angiocardiography; Cardiac Catheterization; Electrocardiography; Extracorporeal Circulation; Female; Follow-Up Studies; Heart Valve Prosthesis; Hemorrhage; Humans; Hypothermia, Induced; Infections; Jaundice; Kidney Diseases; Male; Methods; Middle Aged; Mitral Valve Insufficiency; Myocardial Infarction; Postoperative Care; Postoperative Complications; Pulmonary Emphysema; Rheumatic Heart Disease; Suture Techniques; Thromboembolism; Warfarin