warfarin and Mitral-Valve-Stenosis

Direct oral anticoagulants (DOACs) are increasingly prescribed instead of warfarin for chronic anticoagulation for ease of dosing, fewer interactions, and less stringent monitoring. However, it is important to consider indications and comorbidities for which warfarin is still the preferred anticoagulant. This review aims to capture these clinical scenarios in which warfarin may still be preferred over DOACs.. We undertook a comprehensive literature search using the PubMed database. Key search terms were based on DOAC clinical trial exclusion criteria, as well as indications and conditions in which the use of DOACs for anticoagulation has suggested harm. Society guidelines and tertiary literature were used to inform expert opinion where necessary. Studies were included if they investigated the use of DOACs or warfarin in the identified indications or conditions.. Currently, evidence for the use of warfarin over DOACs for anticoagulation is strongest for patients with prosthetic valves, antiphospholipid syndrome, or a high risk of gastrointestinal bleeding. For several clinical situations, including mitral stenosis, obesity, altered gastrointestinal anatomy, pulmonary arterial hypertension, renal or hepatic impairment, and left ventricular thrombus, evidence is lacking but may eventually support the use of DOACs. Depending on indication and condition, appropriateness of DOAC use may vary by agent.. New evidence continues to support new indications and conditions in which DOACs may be appropriate to use for anticoagulation. There are key clinical scenarios, however, in which emerging literature continues to support warfarin as the preferred anticoagulant.

Topics: Anticoagulants; Antiphospholipid Syndrome; Atrial Fibrillation; Blood Coagulation; Comorbidity; Drug Interactions; Factor Xa Inhibitors; Gastrointestinal Hemorrhage; Heart Valve Prosthesis; Humans; Liver Failure; Medication Adherence; Mitral Valve Stenosis; Overweight; Pulmonary Arterial Hypertension; Renal Insufficiency; Stroke; Warfarin

Topics: Cardiac Catheterization; Cardiac Surgical Procedures; Diagnostic Imaging; Digitalis Glycosides; Diuretics; Heart Failure; Heart Valve Prosthesis Implantation; Humans; Mitral Valve; Mitral Valve Stenosis; Rheumatic Fever; 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

An interesting case of spontaneous bleeding from an ependymoma of the filum terminale is presented.. To document a rare case of rapid neurologic deterioration as a consequence of spinal tumoral hemorrhage and to highlight important issues regarding tumor histologic subtype and the impact of anticoagulation that have emerged from an illuminating review of the literature.. To our knowledge, there have been only 8 reported cases of hemorrhage from an ependymoma of the filum terminale or conus medullaris causing acute cauda equina syndrome. Bleeding is described in the pathology texts as being a consequence of the vascular architecture of the myxopapillary subtype and so postulated to be more common in this group. Anticoagulation is recognized to increase the frequency of tumoral bleeding, but no studies report its effect of severity of clinical presentation.. We report the case of a 57-year-old woman who developed nontraumatic acute cauda equina syndrome, including sphincter compromise. She underwent a lumbosacral laminectomy for evacuation of a hematoma, at which stage a filum terminale ependymoma was excised. Histopathologic analysis demonstrated it to be of a nonmyxopapillary subtype.. The patient demonstrated gradual improvement of the neurologic deficit. At 12-month follow-up, her saddle area sensory deficit has resolved, her right lower limb is much stronger allowing her to walk long distances, and she is successfully performing intermittent self-catheterization of her bladder.. The possibility of an underlying tumor should always be borne in mind so that adequate preoperative planning can be undertaken. The presence of the myxopapillary subtype should not prevent a clinician from excluding other reasons for hemorrhage, and counseling when reinstituting anticoagulation must include warning against a worse prognosis from any future hemorrhage.

Topics: Anticoagulants; Atrial Fibrillation; Cauda Equina; Ependymoma; Female; Hematoma; Hemorrhage; Humans; Laminectomy; Magnetic Resonance Imaging; Middle Aged; Mitral Valve Stenosis; Polyradiculopathy; Rheumatic Heart Disease; Rupture, Spontaneous; Spinal Neoplasms; Thrombophilia; Warfarin

Left atrial appendage obliteration was historically ineffective for the prevention of postoperative stroke in patients with rheumatic atrial fibrillation who underwent operative mitral valvotomy. It is, however, a routine part of modern "curative" operations for nonrheumatic atrial fibrillation, such as the maze and corridor procedures.. To assess the potential of left atrial appendage obliteration to prevent stroke in nonrheumatic atrial fibrillation patients, we reviewed previous reports that identified the etiology of atrial fibrillation and evaluated the presence and location of left atrial thrombus by transesophageal echocardiography, autopsy, or operation.. Twenty-three separate studies were reviewed, and 446 of 3,504 (13%) rheumatic atrial fibrillation patients, and 222 of 1,288 (17%) nonrheumatic atrial fibrillation patients had a documented left atrial thrombus. Anticoagulation status was variable and not controlled for. Thrombi were localized to, or were present in the left atrial appendage and extended into the left atrial cavity in 254 of 446 (57%) of patients with rheumatic atrial fibrillation. In contrast, 201 of 222 (91%) of nonrheumatic atrial fibrillation-related left atrial thrombi were isolated to, or originated in the left atrial appendage (p < 0.0001).. These data suggest that left atrial appendage obliteration is a strategy of potential value for stroke prophylaxis in nonrheumatic atrial fibrillation.

Topics: Aged; Atrial Fibrillation; Cerebrovascular Disorders; Contraindications; Heart Atria; Heart Diseases; Humans; Mitral Valve Stenosis; Postoperative Complications; Thrombosis; Warfarin

Patients with moderate-to-severe mitral stenosis (MS) have bee excluded from all major randomized controlled trials (RCTs) comparing non-vitamin K antagonist oral anticoagulants (NOACs) with warfarin in patients with atrial fibrillation (AF).. In this pilot RCT, 40 patients were randomized to rivaroxaban 20 mg daily or warfarin. No patients experienced symptomatic ischemic strokes and systemic embolic events (the primary composite study outcome) during a 12-month follow-up. No major bleeding was reported. During the follow-up, 18.2% of patients in both groups showed echocardiographic signs of increased thrombogenicity in the left atrial appendage. The rate of silent cerebral ischemia was 13.3% in the rivaroxaban group and 17.6% in the warfarin group at brain magnetic resonance imaging.. Our results suggest acceptable efficacy and safety for rivaroxaban in patients with AF and moderate-to-severe MS and are encouraging for larger RCTs in this so far neglected setting (NCT03926156).

Topics: Administration, Oral; Animals; Anticoagulants; Atrial Fibrillation; Humans; Mitral Valve Stenosis; Pilot Projects; Rivaroxaban; Stroke; Treatment Outcome; Warfarin

Mitral stenosis (MS) in association with atrial fibrillation (AF) is a clinical condition at high risk for systemic thromboembolism. Although oral anticoagulants greatly reduce the incidence of thromboembolism in these patients, the optimal intensity of treatment has never been tested in specific clinical trials, and current recommendations are derived from studies of nonrheumatic AF. In this study we tested the effectiveness of two different intensities. The study design was carried out as an open randomized prospective study in an anticoagulation clinic. We randomized 103 patients with MS and AF to a low (target INR = 2) or moderate (target INR = 3) anticoagulation regimen. The primary end points were systemic thromboembolism, major bleeding and vascular death. During a mean follow-up of 4.5 years, 1 systemic embolism occurred in the low intensity group (0.41 per 100 pt/yrs, CI 0.01-2.3), and 1 minor stroke occurred in the moderate intensity group (0.40 per 100 pt/yrs, CI 0.01-2.3; p = ns). Major bleeding occurred in 8 patients, with 3 in the low intensity (1.25 per 100 pt/yrs) and 5 in the moderate intensity group (2.0 per 100 pt/yrs, Incidence Rate Ratio 0.6, CI 0.1-3.1; p = ns). Total events (systemic embolism, major bleeding and vascular death) occurred in 7 low intensity patients and 8 moderate intensity patients. As expected, minor bleeding was more frequent in the moderate intensity group of patients, who actually had more intense treatment and required closer monitoring of oral anticoagulant treatment. These data suggest that low intensity anticoagulation, as performed in an anticoagulation clinic, is effective and safe in high risk patients with MS and AF.

Topics: Acenocoumarol; Administration, Oral; Adult; Age Factors; Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Female; Follow-Up Studies; Humans; Male; Middle Aged; Mitral Valve; Mitral Valve Stenosis; Random Allocation; Thromboembolism; Time Factors; Warfarin

The comparative study of the efficacy of coumadin and aspirin in primary cardioembolic stroke prevention of chronic rheumatic heart disease (mitral stenosis) with atrial fibrillation was conducted at Siriraj Hospital, Mahidol University, Bangkok, Thailand. Seventy-nine patients were enrolled in the trial. Allocation of patients into coumadin or aspirin groups depended upon the patients' choice. Nineteen patients were given coumadin at the adjusted dosage to maintain the therapeutic range of International Normalised Ratio between 1.5-3. Sixty patients were given aspirin at the fixed dosage of 75 mg per day. Six patients were lost to follow-up over the 3 yr period; four in the aspirin group and 2 in the coumadin group. There were three patients with nonfatal cardioembolic stroke in the aspirin group but none in the coumadin group after three years of follow-up. Six patients had mitral valve replacement during the study (i.e. three patients in each group). There were complications in 12 patients, 10 in the aspirin (16.6 per cent) and 2 in the coumadin (10.5 per cent) group. The complications in coumadin group were minor bleeding over the thigh in one patient and generalised ecchymosis over the whole body in one other. In the aspirin group, the complication was gastrointestional symptoms, mainly epigastric pain, but no frank bleeding was observed. Primary prevention of cardioembolic stroke in chronic rheumatic heart disease was found to be more effective with coumadin than aspirin. Our study does not support the use of aspirin in primary prevention of cardiac embolism in chronic rheumatic heart disease.

Topics: Adolescent; Adult; Aspirin; Atrial Fibrillation; Cerebrovascular Disorders; Chi-Square Distribution; Chronic Disease; Female; Humans; Male; Middle Aged; Mitral Valve Stenosis; Rheumatic Heart Disease; Survival Rate; 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

This study aimed to develop and validate a new bleeding risk score to predict warfarin-associated major bleeding for patients with mitral valve stenosis with atrial fibrillation (MSAF) or mechanical heart valves (MHV).. A multicentre, retrospective cohort study was conducted at 3 hospitals in Thailand. Adult patients with MSAF or MHV receiving warfarin for ≥3 months during 2011-2015 were identified. Data collection and case validation were performed electronically and manually. Potential variables were screened using the least absolute shrinkage and selection operator. Multivariate logistic regression analysis using stepwise backward selection was used to construct a risk score. Predictive discrimination of the score was evaluated using the C-statistic. Calibration was assessed using the Hosmer-Lemeshow goodness-of-fit test.. There were 1287 patients (3903.41 patient-year of follow-up), with 192 experiencing bleeding (4.92 event/100 patient-year) in the derivation cohort. A new bleeding risk score termed, the HEARTS-60 + 3 score (hypertension/history of bleeding; external factors, e.g., alcohol/drugs [aspirin or nonsteroidal anti-inflammatory drugs]; anaemia/hypoalbuminaemia; renal/hepatic insufficiency; time in therapeutic range of <60%; stroke; age ≥60 y; target international normalized ratio of 3.0 [2.5-3.5]), was developed and showed good predictive performance (C-statistic [95% confidence interval] of 0.88 [0.85-0.91]). In the external validation cohort of 832 patients (2018.45 patient-year with a bleeding rate of 4.31 event/100 patient-year), the HEARTS-60 + 3 score showed a good predictive performance with a C-statistic (95% confidence interval) of 0.84 (0.81-0.89).. The HEARTS-60 + 3 score shows a potential as a bleeding risk prediction score in MSAF or MHV patients.

Topics: Adult; Anticoagulants; Atrial Fibrillation; Heart Valves; Hemorrhage; Humans; Mitral Valve Stenosis; Retrospective Studies; Risk Assessment; Risk Factors; Stroke; Warfarin

Rheumatic valve disease is present in 0.4 % of the word population, mainly in lowincome countries. Rheumatic mitral stenosis affects more women and between 40 to 75 % of patients may have atrial fibrillation (AF), more frequently in upper-middle income countries. This rhythm disturbance is due to increased atrial pressure, chronic inflammation, fibrosis, and left atrial enlargement. There is also an increase in the prevalence of AF with age in patients with mitral stenosis. The risk of stroke is 4 % per year. Success rates for cardioversion, Cox-Maze procedure, and catheter ablation are low. Therefore, anticoagulation with vitamin K antagonist is mandatory for Evaluated Heart valves, Rheumatic or Artificial (EHRA) classification type 1. However, this anticoagulation is used by less than 80 % of those eligible and less than 30 % have the international normalized ratio in the therapeutic range. The safety and efficacy of using rivaroxaban, a direct factor Xa inhibitor anticoagulant, were demonstrated in the RIVER trial with a sample of 1005 patients with AF and bioprosthetic mitral valve. The indication for valve replacement, that is, if severe mitral stenosis or severe mitral regurgitation, was not specified. A randomized, open-label study (DAVID-MS) is underway to compare the effectiveness and safety of dabigatran and warfarin therapy for stroke prevention in patients with AF and moderate or severe mitral stenosis. Thus, the applicability of the use of direct anticoagulants in patients with AF and mitral stenosis and also in those undergoing mitral bioprostheses surgery will be the subject of further studies. The findings may explain if specific atrial changes of mitral stenosis even after the valve replacement will influence thromboembolic events with direct anticoagulants.

Topics: Administration, Oral; Anticoagulants; Atrial Fibrillation; Dabigatran; Factor Xa Inhibitors; Female; Humans; Mitral Valve Stenosis; Rivaroxaban; Stroke; Vitamin K; Warfarin

The aim of this study was to investigate the frequency of oral anticoagulant drugs and time in therapeutic range in patients receiving warfarin in addition to the epi-demiological trial of non-valvular atrial fibrillation previously conducted in Turkey (The Atrial Fibrillation: Epidemiological Registry trial). Furthermore, the prevalence of major adverse events and mortality rates of the patients were evaluated during the long-term follow-up period.. We created a national data registry for non-valvular atrial fibrillation patients, reflecting all geographic regions by population density. In that context, the study included all consecutive atrial fibrillation patients older than 18 years of age who were admitted to the cardiology outpatient clinic except for patients those with prosthetic heart valvesand rheumatic mitral valve stenosis.. This study included 2592 patients from 35 different centers. The mean age was 68.7 ± 11.1 years, and 55.5% of the patients were female. The most common comorbid diseases were chronic kidney disease (69%) and hypertension (65.5%). The time in ther- apeutic range rate in the general population was 40%, and the mortality rate at 5-year follow-up was 29.4%.. The Atrial Fibrillation: Epidemiological Registry 2 study showed higher use of anticoagulant in non-valvular atrial fibrillation patients than in previous national stud-ies. Furthermore, this study demonstrated that most of the non-valvular atrial fibrilla- tion patients are in the high-risk group and the time in therapeutic range rates are still low in Turkey. As a result, this is a significant reason for switching from warfarin to non-K vitamin-dependent new oral anticoagulant treatments.

Topics: Aged; Anticoagulants; Atrial Fibrillation; Female; Follow-Up Studies; Humans; Male; Middle Aged; Mitral Valve Stenosis; Turkey; 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

The typical cause of bioprosthetic valve dysfunction over years is calcification of leaflets, pannus formation, or tears due to structural degeneration. Thrombosis is rare as the valves get endothelialized early on, and, hence, anticoagulation is not recommended beyond 6 months after valve replacement. While bioprosthetic valve thrombosis is unusual (0.03% to 0.34%/year), it can be associated with significant mortality and morbidity. Here, we present a case of a middle-aged man with history of bioprosthetic mitral valve who presented with syncopal episode and was referred to us for mitral valve replacement for tentative bioprosthetic valve degeneration and stenosis. However, preoperative work up revealed prosthetic valve thrombosis which was successfully treated with anticoagulation.

Topics: Anticoagulants; Bioprosthesis; Echocardiography, Transesophageal; Heart Valve Prosthesis; Humans; Male; Middle Aged; Mitral Valve; Mitral Valve Stenosis; Postoperative Complications; Prosthesis Failure; Severity of Illness Index; Thrombosis; Treatment Outcome; Warfarin

Topics: Anticoagulants; Atrial Fibrillation; Humans; Mitral Valve Stenosis; Warfarin

Topics: Anticoagulants; Atrial Fibrillation; Humans; Mitral Valve Stenosis; Stroke; Warfarin

Lutembacher syndrome is characterized by a congenital ostium secundum atrial septal defect and an acquired mitral valve stenosis. We present a similar case in a 31-year old male who came in with orthopnoea, central cyanosis and pedal oedema. Examination revealed cardiac murmurs in tricuspid and apical regions. Chest x-ray showed signs of pulmonary congestion and ventricular enlargement. Electrocardiogaphy (ECG) revealed right axis deviation and right bundle branch block along with atrial fibrillation and Transthoracic Echocardiography (TTE) showed abnormal valves (mitral stenosis with calcification and tricuspid regurgitation) and dilated cardiac chambers. The patient was consequently treated with beta-blockers and diuretics and scheduled for valvular and septal repair via open heart surgery. The purpose of this case report is to assist cardiologists in diagnosing this syndrome accurately on the basis of symptoms and investigations.

Topics: Adrenergic beta-Antagonists; Adult; Amiloride; Anticoagulants; Atrial Fibrillation; Bundle-Branch Block; Calcinosis; Cardiac Surgical Procedures; Cardiomegaly; Cyanosis; Diuretics; Echocardiography; Edema; Electrocardiography; Foot; Furosemide; Heart Septal Defects, Atrial; Humans; Lutembacher Syndrome; Male; Mitral Valve Annuloplasty; Mitral Valve Stenosis; Tricuspid Valve Insufficiency; Warfarin

BACKGROUND Coronary artery embolization is an exceedingly rare cause of myocardial infarction, but a few cases in association with prosthetic mechanical valves have been reported. We report a case of embolic myocardial infarction caused by a thrombus in the left atrium with deranged coagulation profile in a patient with critical mitral stenosis under warfarinization. CASE REPORT A 22-year-old woman was taken to the catheterization lab for early coronary intervention in lieu of non-ST elevation myocardial infarction. Electrocardiography showed T↓ in V1 to V4, and atrial fibrillation with controlled ventricular rate. Coronary angiography showed total occlusion of the mid-left anterior descending artery with thrombus. After upstream treatment with tirofiban, the apparent thrombus was dislodged distally while passing a BMW wire. No abnormalities were seen by intravascular ultrasound study. Echocardiography revealed critical mitral stenosis, and left atrial clot with mild left ventricular dysfunction. Coagulation profile revealed sub-therapeutic international normalized ratio levels. The sequential angiographic images, normal intravascular ultrasound study, and presence of atrial fibrillation are confirmatory of coronary embolism as the cause of myocardial infarction. Anticoagulation and treatment of acute coronary syndrome were initiated and she was referred for closed mitral valvulotomy. CONCLUSIONS Coronary artery thromboembolism as a nonatherosclerotic cause of acute coronary syndrome is rare. The treatment consists of aggressive anticoagulation, antiplatelet therapy, and interventional options, including simple wiring when possible. In this context, primary prevention in the form of patient education on optimal anticoagulation with oral vitamin K antagonist and medical advice about imminent thromboembolic risks are of extreme importance.

Topics: Acute Coronary Syndrome; Anticoagulants; Atrial Fibrillation; Coronary Occlusion; Coronary Vessels; Electrocardiography; Female; Humans; Mitral Valve Stenosis; Thromboembolism; Warfarin; Young Adult

Topics: Anticoagulants; Atrial Fibrillation; Echocardiography, Doppler; Embolectomy; Humans; Lower Extremity; Male; Mitral Valve Stenosis; Pain; Rheumatic Diseases; Treatment Outcome; Venous Thromboembolism; Warfarin

Pregnant women with severe mitral stenosis tend to experience clinical decompensation with approximately 50% mortality and they may experience adverse effects of the medication they are taking, notably congenital malformations from warfarin exposure. Corrective heart surgery may increase the risk of pregnancy loss. We present 2 cases of RHD in pregnancy. The first case was a 27-year-old patient in her first pregnancy with severe mitral stenosis. Caesarean section was done for foetal distress and she delivered a small for gestational age baby. She was closely monitored postpartum and was stable on discharge. She presented with supraventricular tachycardia and died in the coronary care unit 4 weeks postpartum. The second case was a 28-year-old who was on warfarin for a mechanical mitral valve. A foetal anomaly scan done at 20 weeks showed severe congenital malformations which were not compatible with extra-uterine life. The pregnancy was terminated and she recovered well. The first case illustrates the significant mortality risk with uncorrected severe rheumatic heart disease. The second case highlights the risks of warfarin on the foetus and the need to avoid mechanical heart valves if possible in young women. RHD patients require preconception counselling so they can make informed reproductive choices.

Topics: Adult; Anticoagulants; Cesarean Section; Female; Heart Valve Prosthesis; Humans; Mitral Valve Stenosis; Pregnancy; Pregnancy Complications, Cardiovascular; Pregnancy Outcome; Rheumatic Heart Disease; Warfarin

Topics: Anticoagulants; Aortic Valve; Aortic Valve Stenosis; Cardiac Surgical Procedures; Cardiac Valve Annuloplasty; Echocardiography; Endarterectomy; Female; Heart Atria; Heart Diseases; Heart Valve Prosthesis Implantation; Humans; Middle Aged; Mitral Valve Stenosis; Rheumatic Heart Disease; Thrombosis; Treatment Outcome; Tricuspid Valve; Tricuspid Valve Insufficiency; Warfarin

We describe a case of reversible thrombotic mitral valve stenosis following a valve-in-ring transcatheter mitral valve replacement. Life-long oral anticoagulation in patients who underwent transcatheter mitral valve replacement might be beneficial.

Topics: Aged; Anticoagulants; Aspirin; Bioprosthesis; Cardiac Catheterization; Clopidogrel; Female; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Mitral Valve; Mitral Valve Stenosis; Postoperative Complications; Thrombosis; Ticlopidine; Treatment Outcome; Warfarin

A 57-year-old woman with known moderate-to-severe mitral stenosis and atrial fibrillation (AF) presented to the emergency department with acute onset right loin pain after having a coronary angiogram and left and right heart catheterisation through the right femoral route about 28 h ago. The cardiac catheterisation was done after she presented with one episode of troponin-negative chest pain and progressive shortness of breath. She had anterior wall myocardial infarction (MI) 25 years ago, which was thought to be due to coronary artery embolism. Her mitral stenosis was diagnosed at that stage.Her warfarin was stopped for 5 days before cardiac catheterisation and international normalised ratio (INR) on the day of the procedure was 1.1. No bridging heparin/low molecular weight heparin (LMWH) was used and warfarin was restarted on the evening of the procedure at the usual dose. Clinical examination revealed some guarding in the right iliac fossa and some tenderness in the right loin. She was not feverish and there was no dysuria or frequency. There was no lump at the puncture site.On presentation to the emergency department, a contrast-enhanced CT scan of the abdomen was performed (figures 1 and 2).. Which of the following is the aetiology of the pain? Abdominal aortic dissectionRenal artery embolismRetroperitoneal haematomaUreteric stone.

Topics: Administration, Intravenous; Anticoagulants; Atrial Fibrillation; Cardiac Catheterization; Coronary Angiography; Drug Administration Schedule; Embolism; Female; Flank Pain; Heparin; Humans; International Normalized Ratio; Middle Aged; Mitral Valve Stenosis; Renal Artery Obstruction; Tomography, X-Ray Computed; Treatment Outcome; Warfarin

Topics: Aged; Anticoagulants; Aortic Valve; Aortic Valve Stenosis; Echocardiography; Female; Heart Valve Prosthesis Implantation; Heparin; Humans; Infusions, Intravenous; International Normalized Ratio; Mitral Valve; Mitral Valve Stenosis; Rheumatic Heart Disease; Thrombosis; Vitamin K; Warfarin

Many cases of cardiac masses have been reported in the literature, but in this case report we described a rare case of biatrial cardiac mass that represented a challenge for diagnosis and therapy. The differentiation between cardiac masses such as thrombi, vegetations, myxomas and other tumors is not always straightforward and an exact diagnosis is important because of its distinct treatment strategy. Transthoracic/esophageal echocardiography and cardiac magnetic resonance play an important role in establishing the diagnosis of cardiac masses. However, no current noninvasive diagnostic tool has the ability to absolutely diagnose cardiac masses; obtaining a pathological specimen by surgical resection of cardiac masses is the only reliable method to diagnose cardiac masses accurately. Our case report is an exception in that the final diagnosis was affirmed by empirical anticoagulation therapy based on clinical judgment and noninvasive characterization of biatrial mass.. We described a 54-year-old Malay man with severe mitral stenosis and atrial fibrillation who presented with a biatrial mass. Transthoracic/esophageal echocardiography and cardiac magnetic resonance detected a large, homogeneous right atrial mass typical of a thrombus, and a left atrial mass adhering to interatrial septum that mimicked atrial myxoma. The risk factors, morphology, location, and characteristics of the biatrial cardiac mass indicated a diagnosis of thrombi. However, our patient declined surgery. As a result, the nature of his cardiac masses was not specified by histology. Of note, his left atrial mass was completely regressed by long-term warfarin, leaving a residual right atrial mass. Thus, we affirmed the most probable diagnosis of cardiac thrombi. During the course of treatment, he had an episode of non-fatal ischemic stroke most probably because of a thromboembolism.. Noninvasive characterization of cardiac mass is essential in clarifying the diagnosis and directing treatment strategy. Anticoagulation is a feasible treatment when the clinical assessment, risk factors, and imaging findings indicate a diagnosis of thrombi. After prolonged anticoagulation therapy, complete resolution of biatrial thrombi was achievable in our case.

Topics: Antihypertensive Agents; Atrial Fibrillation; Bisoprolol; Diagnosis, Differential; Directive Counseling; Echocardiography; Echocardiography, Doppler; Humans; Male; Middle Aged; Mitral Valve Stenosis; Patient Compliance; Stroke; Venous Thromboembolism; Warfarin

Topics: 2-Pyridinylmethylsulfinylbenzimidazoles; Administration, Ophthalmic; Anticoagulants; Drug Substitution; Endoscopy, Gastrointestinal; Esophageal Diseases; Female; Follow-Up Studies; Heart Valve Prosthesis Implantation; Hematoma; Humans; Middle Aged; Mitral Valve; Mitral Valve Stenosis; Pantoprazole; Radiography, Thoracic; Rheumatic Diseases; Tomography, X-Ray Computed; 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

Topics: Anticoagulants; Female; Heart Valve Prosthesis; Humans; Lupus Coagulation Inhibitor; Middle Aged; Mitral Valve Stenosis; Monitoring, Physiologic; Thrombosis; 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

A free-floating thrombus in the left atrium is very rare in mitral stenosis. Such a thrombus can lead to sudden circulatory arrest and syncope or can cause severe cerebral or peripheral thromboembolic events. Clinical diagnosis is difficult, but left atrial thrombus should be suspected if patients with mitral stenosis and atrial fibrillation have intermittent or changing murmurs, emboli, or syncope. We describe the case of a patient with mild mitral stenosis under warfarin therapy, and a left atrial pedunculated thrombus discovered during the investigation for syncope attacks.

Topics: Aged; Anticoagulants; Atrial Fibrillation; Coronary Thrombosis; Diagnosis, Differential; Echocardiography, Transesophageal; Female; Heart Atria; Humans; Mitral Valve Stenosis; Syncope; Warfarin

Prosthetic valve thrombosis is an uncommon, life-threatening complication that often mandates urgent repeat surgery or thrombolytic therapy. We present an alternative approach in a patient with rheumatic heart disease who presented with subacute thrombosis of a recently implanted On-X mechanical mitral valve (On-X Life Technologies Inc, Austin, TX), diagnosed on echocardiography and valve fluoroscopy. The patient refused surgery, hence we elected to treat the patient with high-dose antithrombotic therapy alone. Echocardiographic monitoring demonstrated complete reabsorption of the thrombus within 6 months without any embolic complications. Endogenous fibrinolysis with appropriate antithrombotic therapy might be a suitable option for select, high-risk patients with mechanical mitral valve thrombosis.

Topics: Anticoagulants; Aspirin; Echocardiography; Female; Heart Valve Prosthesis; Humans; Middle Aged; Mitral Valve; Mitral Valve Stenosis; Platelet Aggregation Inhibitors; Rheumatic Heart Disease; Thrombosis; Warfarin

Topics: Anticoagulants; Atrial Fibrillation; Benzimidazoles; beta-Alanine; Dabigatran; Drug Substitution; Echocardiography; Female; Humans; Magnetic Resonance Imaging; Middle Aged; Mitral Valve Stenosis; Rheumatic Heart Disease; Thrombosis; Treatment Outcome; Warfarin

Topics: Amiodarone; Anti-Arrhythmia Agents; Anticoagulants; Blood Coagulation; Child, Preschool; Chromatography, High Pressure Liquid; Drug Interactions; Drug Monitoring; Drug Resistance; Female; Genotype; Heart Valve Prosthesis Implantation; Humans; International Normalized Ratio; Mitral Valve Stenosis; Mixed Function Oxygenases; Phenotype; Polymorphism, Single Nucleotide; Vitamin K Epoxide Reductases; Warfarin

Topics: Aged; Anticoagulants; Atrial Fibrillation; Coronary Thrombosis; Echocardiography; Heparin; Humans; Male; Mitral Valve Stenosis; Pacemaker, Artificial; Rheumatic Heart Disease; Warfarin

Atrial fibrillation is one of the most important causes of ischemic stroke. The purposes of this study were to recognize the incidence of ischemic stroke, the use of antithrombotic agents, the predictors of ischemic stroke, and prescription of warfarin during the three-years after atrial fibrillation was diagnosed.. This was a descriptive design and chart review study, comprised of 1211 subjects at two hospitals in Northern Taiwan who were aged ≥ 60 at their first diagnosis of atrial fibrillation. Chi-square and logistic regression were used for data analysis.. The incidence of ischemic stroke was 46.2% during the three-years after atrial fibrillation was diagnosed, with 86.3% of those occurring in the first year. The prescription rate was 53.3% in antithrombotic therapy, which included 42.5% antiplatelet agents and 10.8% warfarin. The positive predictors of ischemic stroke were age ≥ 75 (odds ratio = 1.48) and a history of ischemic stroke (odds ratio = 3.19); the negative predictors were continued use of warfarin (odds ratio = 0.01), transient use of warfarin (odds ratio = 0.25), alternating use of warfarin and antiplatelet agents (odds ratio = 0.04), and use of antiplatelet agents alone (odds ratio = 0.13). The positive predictors of prescribing warfarin were a history of ischemic stroke (odds ratio = 2.32), thromboembolism (odds ratio = 31.06), mitral stenosis (odds ratio = 10.02), and mechanical valve replacement (odds ratio = 136.02). The negative predictor of prescribing warfarin was age ≥ 75 (odds ratio = 0.62).. It is important in prevention of ischemic stroke to give antithrombotic therapy to newly diagnosed atrial fibrillation patients. Underuse of antithrombotic therapy and warfarin were more severe in our study than in Western countries.

Topics: Aged; Aged, 80 and over; Anticoagulants; Atrial Fibrillation; Brain Ischemia; Drug Utilization; Female; Fibrinolytic Agents; Heart Valve Prosthesis; Humans; Male; Middle Aged; Mitral Valve Stenosis; Platelet Aggregation Inhibitors; Prognosis; Retrospective Studies; Risk Factors; Stroke; Thromboembolism; Warfarin

There is high incidence of rheumatic valvular heart disease in developing countries like Bangladesh, for which large number of young females undergo valve replacement with mechanical prosthetic heart valve. Pregnancy with mechanical heart valve carries risk of warfarin embryopathy and increased incidence of maternal thrombo-embolism. We had successful outcome of pregnancy of a patient with mechanical prosthetic heart valve with home heparin therapy.

Topics: Abnormalities, Drug-Induced; Adult; Anticoagulants; Female; Heart Valve Prosthesis; Heparin, Low-Molecular-Weight; Humans; Mitral Valve; Mitral Valve Stenosis; Nasal Bone; Pregnancy; Pregnancy Complications, Cardiovascular; Self Administration; Warfarin

A 76 -year-old lady with a recent diagnosis of rheumatic heart disease (RHD), and a history of repeated lower respiratory tract infections, came with symptoms of gastritis unrelated to the primary disease but further diagnostic study in the hospital revealed poorly controlled atrial fibrillation, grossly dilated left atrium with two large left atrial thrombi and mitral valve area<1 cm(2). It was decided that the best approach in our patient would be mitral valve replacement with mechanical prosthesis. Despite the usual trend of using bioprosthesis in the elderly, our decision was influenced by the fact that the patient would need chronic anticoagulation for atrial fibrillation in any case. The purpose of our case presentation is to illustrate a late-presenting case of RHD with unusual associations and the challenges to choose the best possible management.

Topics: Aged; Anti-Arrhythmia Agents; Anticoagulants; Atrial Fibrillation; Cardiomegaly; Female; Gastritis; Heart Diseases; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Mitral Valve Stenosis; Radiography; Rheumatic Fever; 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

Free-floating left atrial ball thrombus is rare. We describe a case of a 48-year-old man who had free-floating left atrial ball thrombus that was not accompanied by mitral stenosis and that was treated aggressively with anticoagulants. Echocardiography revealed dramatic disappearance of the thrombus.

Topics: Anticoagulants; Coronary Thrombosis; Echocardiography; Heart Atria; Heparin; Humans; Male; Middle Aged; Mitral Valve Stenosis; Treatment Outcome; Urokinase-Type Plasminogen Activator; Warfarin

We report on a patient who was referred for percutaneous transvenous mitral commissurotomy for symptomatic mitral stenosis. However, transthoracic and transesophageal echocardiography both revealed a large mobile left atrial thrombus, occupying almost half of the left atrial body. Because the patient strongly declined surgical mitral treatment, he was administered warfarin for 2 years. Complete resolution of left atrial thrombus was confirmed by follow-up transesophageal echocardiography. Successful percutaneous transvenous mitral commissurotomy was undertaken without complications.

Topics: Adult; Anticoagulants; Catheterization; Echocardiography, Transesophageal; Heart Atria; Humans; Male; Mitral Valve Stenosis; Thrombosis; Warfarin

Topics: Anticoagulants; Atrial Appendage; Atrial Fibrillation; Echocardiography, Transesophageal; Female; Humans; Middle Aged; Mitral Valve Stenosis; Rheumatic Heart Disease; Thrombosis; Warfarin; Withholding Treatment

Warfarin, an oral anticoagulant, is the therapy of choice to maintain anticoagulation. An individual requiring five- to 20-fold higher dosage than average for anticoagulation may be considered as having resistance to warfarin. In order to evaluate a subtherapeutic response to high-dose warfarin, the clinician must consider many possible causes of resistance, such as non-compliance, drug interactions, or pharmacokinetic changes. When these factors have been eliminated, an hereditary warfarin resistance might be considered responsible. The case is reported of a 49-year-old woman who received warfarin after mitral valve replacement and experienced mechanical mitral valve thrombosis due to inadequate anticoagulation, possibly caused by warfarin resistance.

Topics: Anticoagulants; Bioprosthesis; Drug Resistance; Female; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Middle Aged; Mitral Valve Stenosis; Reoperation; Thrombosis; Ultrasonography; Warfarin

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

Thromboembolic events are serious complications of atrial fibrillation (AF). We histologically investigated intraatrial thrombogenesis in a 52-year-old woman with mitral stenosis and chronic AF who had recurrent attacks of cerebral infarction despite continuous warfarin therapy. She underwent cardiac surgery for mitral valve replacement and maze procedure including left atrial thrombectomy. Macroscopic thrombi were found on the endocardium and their surfaces appeared rough and dark red in most areas. Histological examination showed that a single thrombus mass was composed of several tissue layers or blocks on the endocardium. Immunohistochemistry revealed stratum-like accumulations of small platelet aggregate/fibrin clot complexes in the superficial, fresh thrombus layers and multiple neovessel formation in the basal organized tissue layers. This case study suggests that intraatrial thrombi may develop in a stepwise fashion on the endocardium involving platelet aggregate/fibrin clot complex formation.

Topics: Adult; Atrial Fibrillation; Coronary Thrombosis; Drug Resistance; Female; Humans; Immunohistochemistry; Middle Aged; Mitral Valve Stenosis; Platelet Aggregation; Thrombectomy; Warfarin

Topics: Acenocoumarol; Aged; Anticoagulants; Aspirin; Atrial Fibrillation; Dose-Response Relationship, Drug; Drug Therapy, Combination; Female; Humans; International Normalized Ratio; Male; Middle Aged; Mitral Valve Stenosis; Platelet Aggregation Inhibitors; Randomized Controlled Trials as Topic; Salicylates; Warfarin

Topics: Aged; Aged, 80 and over; Anticoagulants; Atrial Function, Left; Catheterization; Echocardiography; Echocardiography, Transesophageal; Electrocardiography; Heart Block; Heart Valve Prosthesis Implantation; Humans; Male; Mitral Valve Stenosis; Risk Factors; Thrombosis; Warfarin

Transesophageal echocardiography (TEE) is the method of choice for the evaluation of the left atrium and of left atrial appendage (LAA) thrombosis. However, the anatomy of the left appendage is complex and reverberations from anatomical structures may create images and ghosting which mimic left atrial thrombosis. The purpose of this study was to investigate whether a systematic approach through TEE may facilitate the recognition of LAA anatomical variants and artifacts.. One hundred and sixty-four consecutive patients scheduled for cardioversion of atrial fibrillation (study population) and 30 patients (control group) undergoing mitral valve surgery were submitted to TEE using a multiplane probe in order to obtain a systematic evaluation of the LAA. The number of LAA lobes and the presence of thrombi and artifacts were evaluated.. The majority of the study patients had a bilobed (53.1%) or single-lobed (34.1%) LAA. Thrombi were identified in 6%. Artifacts were found in 38 cases (23.2%) and their position was localized precisely at a distance from the transducer which was twice that from the partition-bend between the left upper pulmonary vein and left appendage, suggesting a reverberation. No differences in echocardiographic parameters were found in patients with (group 1) or without (group 2) artifacts. Cardioversion was successful in a similar percentage of cases in the two groups (group 1 68%, group 2 76%) without complications. In controls, the percentages of a single-(33%) and bilobed (40%) left appendage were similar to those found in the study population. Artifacts were identified in 11 controls (37%); no thrombi were detected during surgical left appendage inspection in these cases.. A systematic approach with multiplane TEE facilitates the evaluation of the LAA anatomy and the recognition of artifacts, thus reducing the likelihood of false positive or negative diagnoses of left appendage thrombi.

Topics: Adult; Aged; Anticoagulants; Artifacts; Atrial Fibrillation; Atrial Flutter; Diagnosis, Differential; Echocardiography; Echocardiography, Transesophageal; Electric Countershock; Female; Heart Atria; Humans; Male; Middle Aged; Mitral Valve; Mitral Valve Prolapse; Mitral Valve Stenosis; Prevalence; Prospective Studies; Thrombosis; Treatment Outcome; Warfarin

Topics: Anticoagulants; Female; Heart Valve Prosthesis Implantation; Hemorrhage; Humans; Middle Aged; Mitral Valve Stenosis; Warfarin

Topics: Adult; Anticoagulants; Echocardiography, Doppler; Female; Fibrinolytic Agents; Heart Valve Prosthesis; Heparin; Humans; Mitral Valve; Mitral Valve Stenosis; Pregnancy; Pregnancy Complications, Cardiovascular; Pregnancy Outcome; Prosthesis Failure; Pulmonary Edema; Rheumatic Heart Disease; Shock, Cardiogenic; Thrombosis; Tissue Plasminogen Activator; Treatment Outcome; 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

Percutaneous balloon mitral valvuloplasty (PBMV) described by Inoue et al, is a safe FDA (Food and Drug Administration) approved procedure in patients with severe mitral stenosis. One of the contraindications of the procedure is presence of a left atrial thrombus; however, it has been reported that intense warfarin therapy may led to dissolution of the thrombus. The authors report a patient who was referred for PBMV and was found to have a left atrial thrombus. After intense warfarin therapy, successful PBMV was undertaken without complications.

Topics: Anticoagulants; Catheterization; Contraindications; Echocardiography, Transesophageal; Female; Follow-Up Studies; Heart Atria; Heart Diseases; Humans; International Normalized Ratio; Middle Aged; Mitral Valve Stenosis; Rheumatic Heart Disease; Thrombosis; Warfarin

The authors report a case of angiographically documented multiple coronary neovascularizations originating from the left circumflex artery (LCX) and coursing toward multiple thrombi located in the left atrium in a patient with severe mitral stenosis. The thrombi as well as the neovascularizations underwent near-complete resolution with 4 weeks' anticoagulation therapy with warfarin maintaining an international normalization ratio of 3.5. Percutaneous mitral balloon valvuloplasty was performed successfully without complications.

Topics: Anticoagulants; Catheterization; Coronary Angiography; Coronary Vessels; Echocardiography, Transesophageal; Female; Follow-Up Studies; Heart Atria; Heart Diseases; Humans; International Normalized Ratio; Middle Aged; Mitral Valve Stenosis; Neovascularization, Pathologic; Remission Induction; Thrombosis; Warfarin

This study assesses the efficacy of oral anticoagulation in resolving left atrial appendage (LAA) thrombi and evaluates clinical outcomes of percutaneous mitral valvuloplasty after resolution of LAA thrombi compared with mitral valve replacement. Warfarin therapy is successful in resolving LAA thrombi; percutaneous mitral valvuloplasty after resolution of LAA thrombi is an effective alternative to surgical treatment.

Topics: Aged; Anticoagulants; Catheterization; Contraindications; Disease-Free Survival; Echocardiography, Transesophageal; Female; Follow-Up Studies; Heart Atria; Heart Diseases; Heart Valve Prosthesis Implantation; Humans; Male; Middle Aged; Mitral Valve Stenosis; Thrombosis; Treatment Outcome; Warfarin

We report the first case in which a fluid-blood interface was identified at autopsy in a patient with acute intracerebral hematoma on anticoagulant therapy. Anticoagulation may be one of the major factors contributing to the production of an intracerebral blood sedimentation level.

Topics: Aged; Anticoagulants; Blood Sedimentation; Blood-Brain Barrier; Brain; Cerebral Hemorrhage; Fibrin; Heart Valve Prosthesis Implantation; Hematoma; Humans; Male; Mitral Valve Stenosis; Postoperative Complications; 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

Topics: Anticoagulants; Atrial Fibrillation; Cost-Benefit Analysis; Decision Support Techniques; Decision Trees; Fibrinolytic Agents; Heart Diseases; Hemorrhage; Humans; Mitral Valve Stenosis; Quality-Adjusted Life Years; Thromboembolism; Warfarin

By 1992, several prospective trials established the efficacy of anticoagulation (AC) and to some extent antiplatelet (AP) agents in the prevention of stroke in the setting of atrial fibrillation (AF). The objective of this study was to determine whether practice patterns in AF stroke prophylaxis reflect the findings of clinical trials and whether stroke prophylaxis in AF differs between community hospitals and tertiary teaching hospitals.. Retrospectively, 1250 hospital charts were reviewed. After patients who had undergone recent surgery, received treatment for malignancy, or were not in chronic AF on discharge were eliminated, 651 remaining records were analyzed for the presence of 26 clinical factors influencing the selection of thromboembolism prophylaxis. Descriptive statistics and logistic regression were used to analyze the association between clinical and demographic factors and the decision to treat with AC, AP, or no specific antiembolic therapy.. Of the 651 patients in AF, 273 (42%) received noemboli prophylaxis while 219 (34%) were treated with AC (warfarin), 146 (22%) were treated with AP, and 13 (2%) received both agents. Patients discharged in AF from community hospitals were significantly less likely to be treated with either AC or AP agents than patients discharged from tertiary centers. A strong bias against thromboembolism prophylaxis with either AC or AP agents in AF existed with age over 45 years. Multivariate logistic regression indicated that the decision to treat was associated only with the presence of prosthetic valve, history of prior stroke, mitral disease, and absence of a recent gastrointestinal bleed or occult blood in stool. Even after adjustment for these factors, a significant bias against treatment with either AC or AP agents with advancing age and discharge from community hospitals remained.. Thromboembolism prophylaxis with either AC or AP agents is underutilized in the setting of AF. Furthermore, factors known to increase the risk of embolization in AF such as age, hypertension, diabetes, and heart disease were not associated with decisions to treat with either AP or AC agents. This study suggests that the use of clinical guidelines suggested by trials of thromboembolism prophylaxis in AF could reduce the incidence of stroke.

Topics: Aged; Anticoagulants; Atrial Fibrillation; Cerebrovascular Disorders; Contraindications; Gastrointestinal Hemorrhage; Heart Valve Prosthesis; Hospitals, Community; Hospitals, Teaching; Humans; Intracranial Embolism and Thrombosis; Medical Records; Middle Aged; Mitral Valve Stenosis; Multivariate Analysis; New York; Occult Blood; Platelet Aggregation Inhibitors; Regression Analysis; Retrospective Studies; Warfarin

Increased regional left atrial (LA) coagulation activity has recently been implicated in the pathophysiology of LA thrombus and systemic embolism in mitral stenosis (MS). Anticoagulation with warfarin reduces the risk of such thromboembolism, but the effect of warfarin on LA coagulation activity is unknown. We have addressed this question in MS patients with normal or prolonged clotting times. Peripheral venous and LA coagulation activities were measured in MS patients on long-term oral anticoagulation, who were predisposed to increased LA coagulation activity because of the presence of LA spontaneous echo contrast. Patients ceased warfarin 4 days before percutaneous balloon mitral valvuloplasty, and had either a normal (n = 15) or prolonged (n = 8) International Normalized Ratio (INR) at valvuloplasty. Coagulation activity was assessed during the valvuloplasty procedure, but before valve dilation, by measuring levels of prothrombin fragment 1 + 2 (F1 + 2), a marker of thrombin generation. The LA F1 + 2 level exceeded the peripheral venous level in patients with a normal INR (p <0.001), but these levels were similar in patients with a prolonged INR (p = 0.16). Moreover, the LA (p <0.005) and peripheral venous (p <0.03) F1 + 2 levels, as well as the LA-peripheral venous F1 + 2 difference (p <0.03) were lower in patients with a prolonged INR. These results suggest that anticoagulation with warfarin in MS not only reduces systemic coagulation activity but is associated with a greater reduction in LA coagulation activity. The latter may contribute to the reduced risk of LA thrombus formation that accompanies warfarin therapy in MS.

Topics: Aged; Anticoagulants; Blood Coagulation; Catheterization; Echocardiography; Female; Heart Atria; Humans; Male; Middle Aged; Mitral Valve Stenosis; Warfarin

Topics: Adenocarcinoma; Antineoplastic Combined Chemotherapy Protocols; Bone Neoplasms; Cyclophosphamide; Drug Interactions; Female; Fluorouracil; Humans; Methotrexate; Middle Aged; Mitral Valve Stenosis; Prothrombin Time; Time Factors; Warfarin

To study the cardiac function, mode of delivery and anticoagulant therapy in 13 pregnant women after cardiac valves replacement (CVR) and percutaneous transluminal mitral commissuroplasty (PTMC).. Retrospective data analysis.. Patients with cardiac function of degree I to III can accomplish pregnancy and delivery safely after cardiac operation one and a half years. Using warfarin during pregnancy and delivery safely. Using warfarin during pregnancy and heparin during delivery did not increase the blood loss in both mothers and neonates, and congenital malformation either. It is more appropriate for pregnant women who had CVR to deliver by cesarean section and those who had PTMC to deliver vaginally.. Women after cardiac operation can accomplish pregnancy and delivery if their cardiac function belong to degree I-III with or without digoxin treatment before delivery. Using anticoagulant therapy correctly according to prothrombin time (PT) test during pregnancy does not increase delivery complications to both mothers and neonates.

Topics: Adult; Anticoagulants; Catheterization; Cesarean Section; Female; Heart Valve Prosthesis; Humans; Mitral Valve; Mitral Valve Stenosis; Pregnancy; Pregnancy Complications, Cardiovascular; Retrospective Studies; Rheumatic Heart Disease; Warfarin

Recent evidence suggests that regional left atrial coagulation activity may be increased in mitral stenosis and perhaps contribute to the pathophysiology of left atrial thrombus. However, the relation of left atrial coagulation activity to factors that predispose to left atrial thrombus formation is unknown, and the relation between left atrial and systemic coagulation activities is unresolved.. Left atrial and peripheral venous levels of the coagulation marker prothrombin fragment 1 + 2 (F1 + 2) were measured in 32 patients with mitral stenosis with normal clotting times and no left atrial thrombus who were undergoing percutaneous balloon mitral valvuloplasty. Baseline peripheral venous F1 + 2 levels, measured at the beginning of the valvuloplasty procedure, did not differ from those of 30 age-matched control patients. Prevalvuloplasty left atrial F1 + 2 levels, obtained immediately after transseptal puncture, were similar to femoral venous levels in patients without left atrial spontaneous echo contrast (LASEC) (0.81 +/- 0.32 versus 0.81 +/- 0.27 nmol/L, n = 7) but greater than femoral venous levels in patients with LASEC and either sinus rhythm (1.57 +/- 0.86 versus 0.99 +/- 0.38 nmol/L, n = 16, P < .001) or atrial fibrillation (1.52 +/- 0.69 versus 0.85 +/- 0.33 nmol/L, n = 9, P < .003). Furthermore, LASEC emerged as the only significant predictor of increased regional left atrial coagulation activity (P = .005) on stepwise multivariate logistic regression analysis.. Increased regional left atrial coagulation activity in mitral stenosis occurs in the presence of LASEC, is evident in either sinus rhythm or atrial fibrillation, and is associated with normal systemic coagulation activity.

Topics: Adult; Aged; Atrial Function, Left; Blood Coagulation; Echocardiography, Transesophageal; Female; Heart Atria; Heart Rate; Humans; Male; Middle Aged; Mitral Valve Stenosis; Peptide Fragments; Prothrombin; Veins; Warfarin

A 50-year-old man experienced acute heart failure four years after initial mitral valve replacement (MVR) for left atrial thrombosis using a CarboMedics prosthesis, despite satisfactory coagulation control with warfarin. After initial MVR, late cardiac tamponade occurred twice and left circumflex branch stenosis was treated with percutaneous transluminal coronary angioplasty (PTCA). Re-MVR with an Edwards-TEKNA valve was performed after echocardiography and cineradiography showed mitral valve thrombosis, with thrombi on both mitral valve leaflets and covering most of the left atrial wall. Post-surgery progress was favorable with warfarin and dipyridamole therapy. After six weeks cardiac catheter revealed complete right external iliac artery occlusion. Cardiac dysfunction and atrial flutter apparently accelerated thrombosis after a common cold activated coagulation. Cardiac tamponade, circumflex branch stenosis, and right external iliac artery occlusion occurred despite satisfactory coagulation control by warfarin. Warfarin suppresses some coagulation factors but cannot always correct hypercoagulability. Two months after re-MVR, coagulation tests showed normal TT, F1 + 2, and D-Dimer but an increase in TAT, suggesting involvement of additional coagulation factors. After artificial valve replacement, therapy should achieve a PT-INR level of 3.0-4.5, with close follow-up using other indices of fibrinolysis and coagulation activity in addition to TT.

Topics: Acute Disease; Blood Coagulation; Blood Coagulation Factors; Fibrinolysis; Heart Failure; Heart Valve Prosthesis; Humans; Male; Middle Aged; Mitral Valve; Mitral Valve Stenosis; Prosthesis Failure; Thrombosis; Warfarin

Topics: Catheterization; Diagnosis, Differential; Echocardiography, Transesophageal; Female; Heart Diseases; Humans; Middle Aged; Mitral Valve Stenosis; Thrombosis; Warfarin

The presence of a left atrial thrombus is considered to be a relative contraindication to percutaneous transvenous mitral commissurotomy (PTMC) in patients with rheumatic mitral stenosis. However, resolution of left atrial thrombus after anticoagulant therapy with warfarin makes PTMC possible. From July 1989 to June 1991, a total of 70 patients with rheumatic mitral stenosis received PTMC at National Taiwan University Hospital. Of these, four patients underwent PTMC uneventfully after resolution of left atrial thrombi with anticoagulant therapy. The prothrombin time was kept at around 1.5 times that for the normal controls and transesophageal echocardiography (TEE) was used for follow-up. The time for resolution of left atrial thrombi was 1.5, 11, 12, and 2 months. In all four patients with chronic atrial fibrillation, TEE revealed the presence of left atrial thrombi; in only two of these cases was there a suspicion of left atrial thrombi on transthoracic echocardiography. It is concluded that: (1) left atrial thrombi may be resolved after anticoagulant therapy with warfarin, but the time required varies for different patients; and (2) TEE is better than conventional transthoracic echocardiography for detecting a left atrial thrombus and is recommended as the tool of choice for observing the response of a left atrial thrombus to anticoagulant therapy.

Topics: Adult; Anticoagulants; Coronary Thrombosis; Echocardiography; Female; Heart Atria; Humans; Male; Middle Aged; Mitral Valve; Mitral Valve Stenosis; Rheumatic Heart Disease; Warfarin

A case of rheumatic heart disease, mitral stenosis, large left atrium, and chronic atrial fibrillation is reported and discussed. This patient was shown, by means of two-dimensional echocardiography, to have a massive left atrial thrombus, and after the initiation of anticoagulation with warfarin, complete resolution of the clot was seen in less than two months. The use of two-dimensional echocardiography was valuable in the follow-up of this patient, and it is suggested that further prospective studies are necessary for better understanding the natural history of left atrial thrombus.

Topics: Aged; Atrial Fibrillation; Chronic Disease; Echocardiography; Female; Heart Atria; Heart Diseases; Humans; Mitral Valve Stenosis; Remission Induction; Thrombosis; Warfarin

Left atrial (LA) thrombi sometimes occur in patients with mitral stenosis (MS) and the systemic embolization due to thrombi causes a serious, occasionally fatal complication. Several clinical techniques have been used to estimate the presence of LA thrombi. However, the hitherto available methods, even an echocardiography which has been most widely used, still have some drawbacks, depending on the size and location of thrombi. The author measured D-dimer, fibrinopeptide A (FPA) and thrombin-antithrombin III complex (TAT) in the patients with MS and evaluated the diagnostic value of these molecular markers to estimate the presence of LA thrombi. Twenty six patients with MS who had undergone cardiac operation were studied. Atrial fibrillation was found in all the patients. Episode of obvious thromboembolic diseases is a criteria of exclusion. Blood was drawn from the brachial vein several days (3 +/- 1 days: mean +/- SD) before the operation. The presence or absence of thrombus was confirmed at the surgery in all the cases. 1) Both levels of D-dimer and TAT were significantly higher in the patients with thrombi than those in the patients without thrombus or those in normal controls (mean: 378, 93 and 64 ng/ml, respectively; p less than 0.01 for both and 9.1, 2.0 and 1.7 ng/ml, respectively; p less than 0.01 for both). However, levels of FPA were not significantly different among the three groups (mean: 7.9, 4.9 and 3.7 ng/ml, respectively; NS for both). 2) both levels of D-dimer and TAT were significantly correlated with the weights of LA thrombus (r = 0.87, p less than 0.01: r = 0.79, p less than 0.01, respectively). 3) LA thrombi (ca. greater than or equal to 2 g) were always confirmed at the surgery in the patients who had levels of D-dimer higher than 200 ng/ml and/or TAT higher than 4 ng/ml. The plasma levels of D-dimer and TAT were further followed after the surgery in the same 18 patients (8 patients who had thrombus, the rest who didn't). 1) In the patients who had thrombi, levels of D-dimer were significantly decreased after the surgery (mean: from 267 ng/ml to 73 ng/ml, p less than 0.05). Levels of TAT were slightly but not significantly decreased (mean: from 82 ng/ml to 76 ng/ml, NS).(ABSTRACT TRUNCATED AT 400 WORDS)

Topics: Aged; Antithrombin III; Female; Fibrin Fibrinogen Degradation Products; Fibrinopeptide A; Heart Atria; Heart Diseases; Heart Valve Prosthesis; Humans; Male; Middle Aged; Mitral Valve Stenosis; Peptide Hydrolases; Thrombosis; Warfarin

Topics: Adult; Echocardiography; Female; Heart Atria; Heart Diseases; Humans; Middle Aged; Mitral Valve Stenosis; Thrombosis; Time Factors; Warfarin

A case of mitral stenosis with left atrial thrombus which rapidly arose and reduced within a month was reported. A 61-year-old female was admitted to our hospital on November 14, 1986 because of a syncopal attack due to ventricular tachycardia. On admission she had typical auscultatory signs of mitral stenosis, mild hepatomegaly and no neurological abnormality. Laboratory findings included coagulation studies were normal, and atrial fibrillation was noted on ECG. Heart catheterization revealed low cardiac output, the mitral orifice area to be 2.4 cm2 and left ventriculography showed mild mitral regurgitation. Ventricular tachycardia was controlled following improvement of heart failure. On two-dimensional echocardiography performed on December 24, left atrial thrombus was revealed which was not detected on December 3. Through the continuous administration of warfarin and aspirin to prevent the thrombus' growth, it markedly reduced in size, from 3 x 2 x 4.5 cm on December 24, 1986 to 1.5 x 1 x 2.5 cm on January 30, 1987 without systemic embolism. Then a mitral valve replacement and a left atrial thrombectomy were performed on February 3, with the removal of a red thrombus, partially organized, measuring 1 x 0.7 x 2.5 cm. This case is unique in its clinical outcome and further investigation is necessary for the management of patients as our case.

Topics: Aspirin; Female; Heart Atria; Heart Diseases; Humans; Middle Aged; Mitral Valve Stenosis; Thrombosis; Ultrasonography; 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

Topics: Adult; Catheterization; Echocardiography; Female; Heart Diseases; Humans; Middle Aged; Mitral Valve Stenosis; Thrombosis; Warfarin

The difficulty in the treatment of patients undergoing Warfarin therapy for mitral stenosis, is underlined and cases treated with Danazol in sideropenic anaemia caused by menometrorrhagia are reported.

Topics: Anemia, Hypochromic; Danazol; Drug Evaluation; Drug Interactions; Female; Heart Valve Prosthesis; Humans; Menorrhagia; Mitral Valve; Mitral Valve Stenosis; Pregnadienes; Warfarin

Percutaneous transatrial mitral valvotomy with a double-balloon technique produced striking symptomatic improvement in 7 of 9 patients with severe mitral stenosis. In 7 patients the mitral valve area (Gorlin formula) increased significantly and the mitral end-diastolic gradient fell significantly. Similar improvements were noted in follow-up haemodynamic studies at 6 weeks. There were no procedure-related complications. It is concluded that percutaneous double-balloon mitral valvotomy may be an alternative to surgical treatment for mitral stenosis.

Topics: Adolescent; Adult; Angioplasty, Balloon; Blood Pressure; Echocardiography; Female; Follow-Up Studies; Hemodynamics; Heparin; Humans; Infusions, Parenteral; Male; Methods; Mitral Valve; Mitral Valve Stenosis; Phonocardiography; Premedication; Rheumatic Heart Disease; 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

Topics: Adult; Aortic Valve Insufficiency; Aortic Valve Stenosis; Heart Valve Prosthesis; Hematoma, Subdural; Humans; Male; Mitral Valve Stenosis; Postoperative Complications; Warfarin

Topics: Aged; Atrial Fibrillation; Digoxin; Echocardiography; Electrocardiography; Female; Fluoroscopy; Heart Ventricles; Humans; Mitral Valve Prolapse; Mitral Valve Stenosis; Radionuclide Imaging; Warfarin

Topics: Hemorrhage; Humans; Lung Diseases; Male; Middle Aged; Mitral Valve Stenosis; Postoperative Care; Warfarin

Topics: Anticoagulants; Atrial Fibrillation; Blood Platelets; Humans; Mitral Valve Stenosis; Sex Ratio; 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

Porcine aortic valve xenografts stabilized with glutaraldehyde have been implanted in 91 patients with acquired and congenital valvular heart disease. The indications for use of this valve have included age, previous sensitivity to anticoagulants, or a concomitant condition contraindicating anticoagulant therapy. There were two operative deaths and three late deaths in 44 mitral, 25 aortic, 16 aortic-mitral, 5 mitral-tricuspid, and one aortic-mitral-tricuspid replacements. There were no valve failures from cusp rupture, although one valve was replaced because of annular disproportion. There was one inhospital stroke but no late emboli in a 3 to 33 month followup period, 16.5; 72 patients are functional class 1, 10 class 2, and one patient is class 3. In appropriate patients this biologic tissue valve relieves the hemodynamic abnormalities of valvular heart disease, is associated with a low embolization rate without anticoagulant therapy and, to date, has been durable.

Topics: Adolescent; Adult; Aged; Animals; Aortic Valve; Boston; Child; Child, Preschool; Female; Glutaral; Heart Valve Diseases; Heart Valve Prosthesis; Humans; Male; Middle Aged; Mitral Valve Stenosis; Swine; Transplantation, Heterologous; 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

Eighty-four patients with mitral stenosis and cerebral embolism have been followed up for 20 years. Half of the series (those treated in the early years) had no anticoagulant treatment and half were given long-term warfarin therapy. Mortality rate and causes of death have been reviewed, and comparison of survival times of treated and untreated groups by life-table analysis bears out the immediate need for anticoagulants when a diagnosis of systemic embolism is established. It is wise to continue the treatment for six months but it may be reasonable to discontinue it after one year with patients who can be assured of regular review.

Topics: Adult; Aged; Atrial Fibrillation; Female; Follow-Up Studies; Heart Failure; Humans; Intracranial Embolism and Thrombosis; Male; Middle Aged; Mitral Valve Stenosis; Phenindione; Pneumonia; Recurrence; 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: 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: Atrial Fibrillation; Atropine; Digoxin; Electric Countershock; Humans; Male; Middle Aged; Mitral Valve Stenosis; Myocardial Infarction; Ouabain; Warfarin

Topics: Angiocardiography; Animals; Blood Glucose; Blood Proteins; Blood Volume; Body Composition; Body Weight; Cachexia; Calcium; Carbon Dioxide; Chlorides; Creatinine; Dogs; Hydrogen-Ion Concentration; Magnesium; Mitral Valve Stenosis; Penicillins; Potassium; Potassium Isotopes; Sodium; Sodium Isotopes; Streptomycin; Thyroxine; Urea; Warfarin; Water

Topics: Atrial Fibrillation; Esophageal Diseases; Esophagoscopy; Female; Hematoma; Humans; Middle Aged; Mitral Valve Stenosis; Warfarin

Fourteen patients were treated with anticoagulants during 15 pregnancies. Eleven had venous thrombosis, three with pulmonary embolism; three had prosthetic heart valves; and one had mitral stenosis with pulmonary hypertension. All 15 were treated with heparin and 10 with warfarin. The mean duration of heparin therapy was 4.5 weeks and of warfarin 14 weeks. There were two minor episodes of recurrent thromboembolism and three minor haemorrhagic episodes during anticoagulant therapy. No fetal or neonatal complications occurred.There appears to be no ideal anticoagulant regimen for treating thromboembolic disease in pregnancy. A compromise approach based on experimental and clinical findings is suggested, which is considered to offer reasonable protection to the mother without undue risk to the fetus. This is heparin when an anticoagulant is indicated in the first trimester, after 37 weeks' gestation, and for the treatment of the initial thromboembolic episodes. Oral anticoagulants are used at other times when long-term anticoagulant therapy is indicated.

Topics: Adolescent; Adult; Female; Fetal Diseases; Fetus; Heart Valve Prosthesis; Hemorrhage; Heparin; Humans; Hypertension, Pulmonary; Infant, Newborn; Mitral Valve Stenosis; Pregnancy; Pregnancy Complications, Cardiovascular; Pulmonary Embolism; Thrombophlebitis; Warfarin

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

Topics: Anticoagulants; Corpus Luteum; Female; Hematoma; Humans; Mitral Valve Stenosis; Postoperative Care; Warfarin

Topics: Adult; Chlorpropamide; Digoxin; Female; Fetal Death; Furosemide; Gestational Age; Heart Valve Prosthesis; Humans; Mitral Valve Stenosis; Pregnancy; Pregnancy Complications, Cardiovascular; Pregnancy in Diabetics; Warfarin

Topics: Adult; Angiocardiography; Blood Pressure Determination; Cineangiography; Female; Heart Atria; Heart Valve Prosthesis; Heparin; Humans; Male; Middle Aged; Mitral Valve Stenosis; Postoperative Complications; Thrombosis; Warfarin

Topics: Anticoagulants; Artificial Organs; Cardiac Catheterization; Cardiac Surgical Procedures; Heart Failure; Heart, Artificial; Heparin; Humans; Mitral Valve; Mitral Valve Stenosis; Pathology; Postoperative Complications; Prostheses and Implants; Radiography, Thoracic; Thoracic Surgery; Thrombosis; Warfarin