warfarin and Rheumatic-Heart-Disease

Although guidelines give preference to direct oral anticoagulants (DOACs) over vitamin K antagonists (VKAs) for stroke prevention in most patients with atrial fibrillation (AF), DOACs are not recommended in those with rheumatic heart disease or mechanical heart valves. The results of the INVICTUS trial (Investigation of Rheumatic AF Treatment Using Vitamin K Antagonists, Rivaroxaban or Aspirin Studies), which compared rivaroxaban with a VKA in patients with rheumatic heart disease-associated AF, and the PROACT Xa trial (A Trial to Determine if Participants with an On-X Aortic Valve Can be Maintained Safely on Apixaban), which compared apixaban with warfarin in patients with an On-X valve in the aortic position, support the use of VKAs for these indications. In this paper, we review the results of these trials, provide perspective on why VKAs were superior to DOACs, and discuss future directions for anticoagulation in these disorders.

Topics: Administration, Oral; Anticoagulants; Atrial Fibrillation; Dabigatran; Fibrinolytic Agents; Humans; Pyridones; Rheumatic Heart Disease; Rivaroxaban; Stroke; Vitamin K; 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

Atrial Fibrillation (AF) is a common cardiac arrhythmia and stroke is its most devasting complication. The rate of ischemic stroke among people with AF is approximately six times that of people without AF and varies importantely with coexistent cardiovascular diseases; therefore stratification of AF patients into those at high and low risk of thromboembolism has become a crucial determinant of optimal antithrombotic prophylaxis. Multivaria-te analyses of prospective studies consistently show prior TIA/stroke, diabetes, age, heart failure to be independently predictive of stroke; left ventricular dysfunction is also strongly associated with stroke risk. Several randomized clinical trials demonstrated that treatment with adjusted-dose warfarin reduces the risk of stroke in AF patients by about two thirds. The efficacy of aspirin for prevention of stroke is controversial, but supported by pooled results of 3 placebo-controlled trials yelding a 21% reduction in stroke. The inherent risk of stroke should be considered in selection of AF patients for lifelong anticoagulation. Patients with AF and a recent stroke or TIA or multiple risk factors for stroke are likely to benefit from anticoagulation therapy; at present a target INR 2,5 appears optimal for most patients, although INR closer to 2.0 may be safer for patients at increased risk for bleeding events. The addition of aspirin to low- dose warfarin regimen does not provide any significant benefits and should be avoided. Therapy with aspirin is appropriate for patients who are at low risk of stroke or are unable to receive anticoagulants. AF patients treated with aspirin, should be periodically evaluated for development of high-risk features favoring anticoagulation.

Topics: Age Factors; Aged; Aged, 80 and over; Anticoagulants; Aspirin; Atrial Fibrillation; Controlled Clinical Trials as Topic; Electric Countershock; Fibrinolytic Agents; Humans; Middle Aged; Multivariate Analysis; Platelet Aggregation Inhibitors; Prevalence; Prospective Studies; Randomized Controlled Trials as Topic; Rheumatic Heart Disease; Risk Factors; Stroke; Thromboembolism; Warfarin

Topics: Algorithms; Anticoagulants; Atrial Fibrillation; Cardiac Output, Low; Contraindications; Heart Diseases; Hemorrhage; Heparin; Humans; Myocardial Infarction; Rheumatic Heart Disease; Risk Factors; Thromboembolism; Warfarin

Topics: Calcinosis; Endocarditis; Fibrinolytic Agents; Heart Septal Defects, Atrial; Heart Valve Diseases; Humans; Mitral Valve Prolapse; Rheumatic Heart Disease; Thromboembolism; Warfarin

The role of antithrombotic therapy in reducing thromboembolic complications in patients with chronic atrial fibrillation has been clarified by the results of four major randomized and placebo-controlled trials. Patients with rheumatic heart disease complicated by atrial fibrillation should receive long-term warfarin therapy to reduce the risk of stroke unless an absolute contraindication exists. Patients with nonrheumatic atrial fibrillation should also be treated with low-dose warfarin therapy, especially if high-risk features for thromboembolism exist. In patients who have contraindications to warfarin therapy and in young patients with lone atrial fibrillation or paroxysmal atrial fibrillation, therapy with 325 mg of aspirin a day is preferred. Ongoing trials directly comparing aspirin and warfarin will provide additional insight into the optimal role of these antithrombotic agents in patients with atrial fibrillation.

Topics: Acute Disease; Aspirin; Atrial Fibrillation; Cerebrovascular Disorders; Chronic Disease; Electric Countershock; Hemorrhage; Humans; Randomized Controlled Trials as Topic; Research Design; Rheumatic Heart Disease; Risk Factors; Warfarin

Topics: Administration, Oral; Anticoagulants; Cardiovascular Diseases; Cerebrovascular Disorders; Coronary Disease; Heart Valve Diseases; Hemorrhage; Humans; Ischemic Attack, Transient; Mitral Valve; Myocardial Infarction; Rheumatic Heart Disease; Warfarin

Topics: Acenocoumarol; Angina Pectoris; Anticoagulants; Cerebrovascular Disorders; Dicumarol; Heparin; Humans; Myocardial Infarction; Phlebitis; Rheumatic Heart Disease; Thromboembolism; Thrombophlebitis; Warfarin

Testing of factor Xa inhibitors for the prevention of cardiovascular events in patients with rheumatic heart disease-associated atrial fibrillation has been limited.. We enrolled patients with atrial fibrillation and echocardiographically documented rheumatic heart disease who had any of the following: a CHA. Of 4565 enrolled patients, 4531 were included in the final analysis. The mean age of the patients was 50.5 years, and 72.3% were women. Permanent discontinuation of trial medication was more common with rivaroxaban than with vitamin K antagonist therapy at all visits. In the intention-to-treat analysis, 560 patients in the rivaroxaban group and 446 in the vitamin K antagonist group had a primary-outcome event. Survival curves were nonproportional. The restricted mean survival time was 1599 days in the rivaroxaban group and 1675 days in the vitamin K antagonist group (difference, -76 days; 95% confidence interval [CI], -121 to -31; P<0.001). A higher incidence of death occurred in the rivaroxaban group than in the vitamin K antagonist group (restricted mean survival time, 1608 days vs. 1680 days; difference, -72 days; 95% CI, -117 to -28). No significant between-group difference in the rate of major bleeding was noted.. Among patients with rheumatic heart disease-associated atrial fibrillation, vitamin K antagonist therapy led to a lower rate of a composite of cardiovascular events or death than rivaroxaban therapy, without a higher rate of bleeding. (Funded by Bayer; INVICTUS ClinicalTrials.gov number, NCT02832544.).

Topics: Anticoagulants; Atrial Fibrillation; Echocardiography; Factor Xa Inhibitors; Female; Hemorrhage; Humans; Male; Middle Aged; Rheumatic Heart Disease; Rivaroxaban; Stroke; Treatment Outcome; Vitamin K; Warfarin

Patients with mechanical heart valves are critically dependent upon adequate anticoagulation. The present patients are young, geographically dispersed and socioeconomically deprived. Hospital attendance is erratic, and compliance with conventional anticoagulation difficult. The need exists for an alternative method of anticoagulation that requires neither regular visits nor adjustment of the warfarin dose.. A five-year prospective randomized double-blind study was undertaken to compare the efficacy and safety of a predetermined, individualized fixed-dose versus adjusted-dose warfarin. Postopoeratively, 296 patients, after an initial dose-finding phase (International Normalized Ratio (INR) 2.0 - 3.5), were randomized to either fixed-dose or adjusted-dose warfarin.. For the intention-to-treat analysis, the groups were well-matched with regard to baseline characteristics. Among patients on fixed-dose warfarin, 63% of INRs were in the range 2.0 - 4.5 compared with 64% in patients on adjusted-dose warfarin. The mean follow up period was 2.4 years in both groups; total follow up was 725 patient-years. There were seven deaths in the fixed-dose warfarin group, and five in the adjusted-dose group (p = 0.52). Thirteen major thrombotic events, occurred in the fixed-dose warfarin group, and four in the adjusted-dose group (p = 0.02). Twelve major hemorrhagic events occurred in each group.. In this predominantly young, impoverished population, despite similar overall INR control, fixed-dose warfarin was associated with an increase in thromboembolic events, but no significant increase in mortality or hemorrhagic events. Fixed-dose warfarin may be an acceptable option where conventional anticoagulation is impracticable. In particular, the study highlighted the difficulties of adequate anticoagulation in a population where compliance is erratic and often non-existent.

Topics: Adolescent; Adult; Aged; Anticoagulants; Bioprosthesis; Developing Countries; Dose-Response Relationship, Drug; Double-Blind Method; Drug Administration Schedule; Female; Follow-Up Studies; Heart Valve Diseases; Heart Valve Prosthesis; Humans; Male; Middle Aged; Patient Compliance; Postoperative Care; Poverty; Probability; Prospective Studies; Reference Values; Rheumatic Heart Disease; Risk Factors; South Africa; Survival Analysis; Thromboembolism; Treatment Outcome; Warfarin

Transesophageal echocardiography was used to assess cardiac abnormalities associated with embolization in patients who had completed the Department of Veterans Affairs Cooperative Study of Stroke Prevention in Nonrheumatic Atrial Fibrillation at the Minneapolis and West Haven Department of Veterans Affairs Medical Centers without an embolic event. Patients were men, 71 +/- 7 years old, with atrial fibrillation of 6.2 +/- 4.3 years' duration who had received warfarin (n = 32) or placebo (n = 23) for 2 years. Thrombi were found in 5 of 55 patients (warfarin 4 and placebo 1; p = 0.39); spontaneous echo contrast was seen in 4 of 5 patients. Other abnormalities identified included spontaneous echo contrast (47%), patent foramen ovale (54%), atrial septal aneurysm (7.3%), and left ventricular thrombus (3.6%). During 34 months of posttreatment follow-up, 5 patients had a stroke (1 fatal), and 10 died. Potential sources of emboli did not predict subsequent outcome. Thus warfarin therapy did not preclude the presence of thrombi. Stroke reduction likely involves the prevention of emboli from sources in addition to the atrial appendage.

Topics: Aged; Atrial Fibrillation; Blood Flow Velocity; Chi-Square Distribution; Chronic Disease; Echocardiography, Transesophageal; Follow-Up Studies; Heart Aneurysm; Heart Atria; Heart Diseases; Heart Septal Defects, Atrial; Heart Septum; Heart Ventricles; Humans; Male; Middle Aged; Prevalence; Rheumatic Heart Disease; Thrombosis; 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 safety of a very low level of anticoagulation combined with dipyridamole in a rheumatic population (mean age 31 +/- 13 years) with the St. Jude Medical (SJM) prosthesis has not yet been tested. Furthermore, no data are available on the safety of relatively infrequent monitoring of anticoagulation levels and of the necessity for different therapeutic targets according to valve position, number of risk factors, and other baseline risk factors for thromboembolism. In this study, the performance of the SJM prosthesis was tested using a target international normalized ratio (INR) of 2.0 to 2.5 combined with dipyridamole 300 mg/day applied uniformly to all patients. Clinical, biochemical, and echocardiographic data were acquired prospectively in 200 consecutive patients at 3-month intervals. Follow-up (mean 27 +/- 13 months) was complete in 95% of patients. Thirteen patients died (2.9%/patient year). Severe left ventricular dysfunction was the cause of death in 10 of 13 patients. Probability of survival (Kaplan-Meier) was 0.92 at 36 months and of event-free survival 0.84 at 36 months. The median INR was 2.0 +/- 0.9. Valve obstruction did not occur, and there were 3 thromboembolic events (0.6%/patient year). Incidence of bleeding was 1.6%/patient year (n = 7) and was major (hemorrhagic stroke) in 1 (0.2%/patient year). Thus, the SJM prosthesis performs very well despite the use of very low level warfarin anticoagulation combined with dipyridamole. A 3-month assessment of the anticoagulation level is safe. Left ventricular dysfunction rather than valve-related complications is the leading cause of mortality in this population.

Topics: Adult; Dipyridamole; Drug Administration Schedule; Drug Therapy, Combination; Female; Heart Valve Prosthesis; Humans; Incidence; Male; Middle Aged; Proportional Hazards Models; Prospective Studies; Rheumatic Heart Disease; Thromboembolism; Warfarin

Topics: Adult; Aged; Blood Coagulation; Blood Coagulation Tests; Chlordiazepoxide; Clinical Trials as Topic; Coronary Disease; Drug Synergism; Female; Hemostasis; Humans; Male; Middle Aged; Placebos; Rheumatic Heart Disease; Time Factors; Warfarin

Rheumatic heart disease (RHD) remains an important cause of morbidity and mortality in New Zealand. Factors associated with the choice of surgical treatment for advanced RHD in young adults are poorly understood. We sought to review our local experience with the surgical management of young adults with rheumatic mitral valvular disease.. From 2003 to 2016, all patients aged 15-24 years undergoing mitral valve surgery for rheumatic disease at Auckland City Hospital, New Zealand were retrospectively reviewed.. During the 13-year study period, 73 young adults underwent mitral surgery; 85% were Maori or Pacific Islanders. Mitral repair was performed in 32 patients and replacement in 41 patients. Isolated mitral valve surgery was performed in 36%, double valve procedures in 47%, and triple valve procedures in 17% of patients. The 30-day mortality rate and stroke rate were 1.4% and 2.7% respectively. The medium-term mortality rate was 11.9% across a mean follow-up of 6 years (6.9% in the repair group, 15.8% in the replacement group, p = 0.25). There were increased bleeding complications (p = 0.04) in patients with mechanical mitral valve replacement. For patients on warfarin, across medium-term follow-up, the INR was in the therapeutic range only 23% of the time.. Most young adults in New Zealand with severe RHD requiring surgery are of indigenous Maori or Pacific Island ethnicity. There is a trend towards improved survival with mitral repair. There is a significant tendency towards increased bleeding complications in patients on warfarin for mechanical mitral replacement. Warfarin compliance is poor.

Topics: Cohort Studies; Heart Valve Prosthesis Implantation; Humans; Mitral Valve; New Zealand; Retrospective Studies; Rheumatic Heart Disease; Treatment Outcome; Warfarin; Young Adult

Warfarin is one of the most commonly used anticoagulants in the management of thromboembolic events. Herein we report a rare case of warfarin induced leukocytoclastic vasculitis in a patient with history of rheumatic heart disease and a mechanical mitral valve prosthesis who presented with heart failure and palpable purpura. Upon clinical suspicion of cutaneous small vessel vasculitis, a comprehensive laboratory panel was performed. Warfarin induced vasculitis was suspected when withdrawal of warfarin, due to rising INR, led to improvement of the skin lesions. The diagnosis was finally confirmed when re-instatement of warfarin reproduced the skin lesions and a skin biopsy showed evidence for leukocytoclastic vasculitis with eosinophilic infiltration. A third of cases of leukocytoclastic vasculitis are due to drug hypersensitivity which being a diagnosis of exclusion with varying manifestations, requires a high index of clinical suspicion. Since drug induced leukocytoclastic vasculitis may affect multiple organ systems and even cause mortality, clinicians must be aware of this rare adverse event, promptly discontinue the drug, and commence anti-inflammatory or immunosuppressive treatment when necessary.

Topics: Adult; Drug Eruptions; Humans; Male; Rheumatic Heart Disease; Skin; Vasculitis, Leukocytoclastic, Cutaneous; Warfarin

We report a case of atrial fibrillation with rheumatic heart disease (RHD) who had intracardiac thrombus and cardiogenic cerebral embolism with rivaroxaban therapy. Intracardiac thrombus disappeared after switching from rivaroxaban to warfarin. Patients of RHD have the possibility of gradual progression of valvular disease even if they are old, so we need to distinguish nonvalvular atrial fibrillation from RHD before starting direct oral anticoagulants.

Topics: Administration, Oral; Aged; Anticoagulants; Atrial Fibrillation; Brain Infarction; Drug Substitution; Factor Xa Inhibitors; Humans; Intracranial Embolism; Male; Rheumatic Heart Disease; Rivaroxaban; Thrombosis; Treatment Outcome; Warfarin

The most frequently used oral anti-coagulant warfarin has been implicated in inducing calcification of aortic valve interstitial cells (AVICs), whereas the mechanism is not fully understood. The low-level activation of p53 is found to be involved in osteogenic transdifferentiation and calcification of AVICs. Whether p53 participates in warfarin-induced AVIC calcification remains unknown. In this study, we investigated the role of low-level p53 overexpression in warfarin-induced porcine AVIC (pAVIC) calcification. Immunostaining, quantitative PCR, and Western blotting revealed that p53 was expressed in human and pAVICs and that p53 expression was slightly increased in calcific human aortic valves compared with non-calcific valves. Terminal deoxynucleotidyltransferase-mediated dUTP nick end labeling staining indicated that apoptosis slightly increased in calcific aortic valves than in non-calcific valves. Warfarin treatment led to a low-level increase of p53 mRNA and protein in both pAVICs and mouse aortic valves. Low-level overexpression of p53 in pAVICs via an adenovirus vector did not affect pAVIC apoptosis but promoted warfarin-induced calcium deposition and expression of osteogenic markers. shRNA-mediated p53 knockdown attenuated the pAVIC calcium deposition and osteogenic marker expression. Moreover, ChIP and luciferase assays showed that p53 was recruited to the

Topics: Animals; Anticoagulants; Antifibrinolytic Agents; Aortic Valve; Atrial Fibrillation; Calcinosis; Cells, Cultured; Disease Models, Animal; Epigenesis, Genetic; Gene Expression Regulation; Genes, Reporter; Heart Valve Diseases; Humans; Male; Mice, Inbred C57BL; Promoter Regions, Genetic; Recombinant Proteins; Rheumatic Heart Disease; RNA Interference; Snail Family Transcription Factors; Sus scrofa; Tumor Suppressor Protein p53; Vitamin K 1; Warfarin

Warfarin-related nephropathy.. Warfarin.. A 31-year-old female, managed with warfarin for rheumatic heart disease with atrial fibrillation.. There were no alternative causes of nephropathy that could have caused the adverse event in this patient.. Shifting the drug from warfarin to acenocoumarol.. Difference in renal elimination between warfarin and acenocoumarol.. Clinicians should be aware of this rare adverse effect of warfarin, and acenocoumarol can be considered as an alternative therapy for this condition.. Further prospectively designed studies are needed to consider acenocoumarol as an alternative therapy in warfarin-related nephropathy.

Topics: Acenocoumarol; Adult; Anticoagulants; Atrial Fibrillation; Female; Humans; Kidney Diseases; Rheumatic Heart Disease; 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

To investigate the contribution of brain natriuretic peptide (BNP) promoter DNA methylation to the risk of rheumatic heart disease (RHD) and the influence of warfarin anticoagulant therapy on BNP methylation levels for RHD patients after surgery. BNP methylation levels were determined by bisulfite pyrosequencing from plasma samples of RHD patients compared with healthy controls. Several factors influencing the RHD patients were included like age, smoking and cholesterol levels. A fragment of five CG sites (CpG1-5) in the promoter region of BNP gene was measured. BNP gene hypermethylation was found in CpG4 and CpG5 in RHD patients compared with non-RHD controls. A significant difference was also observed between RHD patients with long-term administration of warfarin and RHD patients who had recently undergone an operation. Moreover, single CpG4 and CpG5 analysis revealed a significant increase in methylation levels in men. BNP gene body hypermethylation is associated with the risk of RHD, and also influenced by the warfarin anticoagulant therapy of RHD patients after surgery, which could represent novel and promising targets for therapeutic development.

Topics: Adult; Age Factors; Aged; Anticoagulants; Cholesterol; DNA Methylation; Female; Genetic Predisposition to Disease; Humans; Male; Middle Aged; Natriuretic Peptide, Brain; Promoter Regions, Genetic; Rheumatic Heart Disease; Risk Factors; Sex Factors; Smoking; Time Factors; 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

Fetal exposure to maternal ingestion of warfarin is known to produce certain dysmorphic features in the neonate, known as fetal warfarin syndrome (FWS). There is a general consensus that maternal intake of warfarin at a daily dose of 5 mg or less is safe both for the infant and the mother.. We report four cases of FWS born to mothers with rheumatic heart disease on warfarin prophylaxis during pregnancy at a dose less than 5 mg/day.. Along with typical facial features of FWS and multiple epiphyseal stippling in skeletal x-ray, Case 1 had Dandy-Walker malformation and Case 2 had laryngo-tracheomalacia and patent ductus arteriosus.. We emphasize the need for optimizing the choice and dosage schedule of anticoagulants during pregnancy, least harmful for the mother and her developing fetus.

Topics: Abnormalities, Drug-Induced; Abnormalities, Multiple; Adult; Anticoagulants; Dandy-Walker Syndrome; Ductus Arteriosus, Patent; Female; Heart Valve Prosthesis; Humans; Nasal Bone; Pregnancy; Prenatal Exposure Delayed Effects; Rheumatic Heart Disease; 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

Lack of adherence to international normalised ratio (INR) monitoring in rheumatic heart disease (RHD) patients is a contributor to cardio-embolic complications. This population-based observational study investigated whether the distance between home and an INR clinic affects the maintenance of therapeutic INR in RHD patients on warfarin.. Residential addresses, INR clinics, and INR results of patients with RHD were extracted from the Cape Town component of the Global Rheumatic Heart Disease Registry (REMEDY) database. Addresses of homes and INR clinics were converted to geographical coordinates and verified in ArcGIS 10®. ArcGIS 10® and Google Maps® were used for spatial mapping and obtaining shortest road distances respectively. The travel distance between the home and INR clinic was correlated with time within therapeutic range (TTR) using the Rosendaal linear interpolation method, and with the fraction of INR within range, based on an average of three INR readings of patients and compared with recommended therapeutic ranges.. RHD patients (n = 133) resided between 0.2 km and 50.8 km (median distance, 3.60 km) from one of 33 INR clinics. There was no significant difference in the achievement of the therapeutic INR between patients who travelled a shorter distance compared to those who travelled a longer distance (in range = 3.50 km versus out of range = 3.75 km, p = 0.78). This finding was the same for patients with mechanical valve replacement (n = 105) (3.50 km versus 3.90 km, p = 0.81), and native valves (3.45 km versus 2.75 km, p = 0.84).. There is no association between the maintenance of INR within therapeutic range amongst RHD patients in Cape Town and distance from patients' residence to the INR clinic.

Topics: Adolescent; Adult; Aged; Anticoagulants; Female; Geographic Information Systems; Health Facilities; Health Services Accessibility; Humans; International Normalized Ratio; Male; Middle Aged; Registries; Rheumatic Heart Disease; South Africa; Warfarin; Young Adult

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: 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: Adult; Africa South of the Sahara; Female; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Infant, Newborn; Male; Mitral Valve; Pregnancy; Pregnancy Complications, Cardiovascular; Rheumatic Heart Disease; Thrombosis; Uganda; Ultrasonography; Warfarin

Topics: Anticoagulants; Aortic Valve; Aortic Valve Insufficiency; Aortic Valve Stenosis; Aspirin; Female; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Male; Mitral Valve; Rheumatic Heart Disease; Thromboembolism; 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

A retrospective analysis of the records of all the patients of heart disease with pregnancy at AIIMS, New Delhi, India, to find out the maternal and fetal outcome.. A retrospective analysis was carried out of 100 pregnancies in women with heart disease who delivered at ≥28 weeks of gestation from July 2009 through August 2012.. Cardiac disease was found to complicate 3.8 % of pregnancies. Rheumatic heart disease (n = 64, 64 %) was the predominant cardiac disease. Congenital heart disease was found to complicate 36 pregnancies (n = 36, 36 %).Cardiac complications were seen in 32 (32 %) and fetal complications in 18 (18 %) pregnancies. Fewer cardiac and postpartum complications were present in NYHA class I/II patients compared to NYHA III/IV patients (P < 0.05). Pregnancy outcome was better in rheumatic heart disease patients who had undergone cardiac intervention prior to pregnancy (n = 29, 45.2 %) compared to those whose heart disease remained uncorrected (n = 35, 54.8 %) but the difference was not statistically significant. There was one maternal mortality in a patient with Eisenmenger syndrome. Two of the newborns of the 17 women who had received anticoagulants had features of warfarin embryopathy.. Pregnancy in women in NYHA class III/IV is associated with significantly higher maternal morbidity and cardiac interventions before pregnancy, when indicated may improve pregnancy outcome.

Topics: Adult; Anticoagulants; Aortic Valve; Birth Weight; Female; Fetal Diseases; Fetal Growth Retardation; Heart Defects, Congenital; Heart Valve Diseases; Humans; Mitral Valve; Pregnancy; Pregnancy Complications, Cardiovascular; Pregnancy Outcome; Retrospective Studies; Rheumatic Heart Disease; Severity of Illness Index; Warfarin; Young Adult

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

It is recommended that warfarin therapy should be managed through an anticoagulation monitoring service to minimize the risk of bleeding and subsequent thromboembolic events. There are few studies in Sub-Saharan Africa that describe warfarin management in spite of the high incidence of venous thromboembolism (VTE) and rheumatic heart disease.. To examine the feasibility of the Moi Teaching and Referral Hospital anticoagulation monitoring service and compare its performance with clinics in resource-rich settings.. A retrospective chart review compared the percentage time in the therapeutic range (TTR) and rates of bleeding and thromboembolic events to published performance targets using the inference on proportions test. Wilcoxon's rank sum analyses were used to establish predictors of TTR.. For the 178 patients enrolled, the mean TTR was 64.6% whereas the rates of major bleeds and thromboembolic events per year were 1.25% and 5%, respectively. In the primary analysis, no statistically significant differences were found between the results of TTR, major bleeds and thromboembolic events for the clinic and published performance rates. In the secondary analysis, having an artificial heart valve and a duration of follow-up of > 120 days were positively associated with a higher TTR (P < 0.05) whereas venous thromboembolism, history of tuberculosis, HIV and a duration of follow-up of < 120 days were associated with having a lower TTR (P < 0.05).. The performance of the MTRH anticoagulation clinic is non-inferior to published metrics on the performance of clinics in resource-rich settings.

Topics: Anticoagulants; Drug Monitoring; Health Resources; Humans; Kenya; Pharmacists; Retrospective Studies; Rheumatic Heart Disease; Rural Population; Venous Thromboembolism; Warfarin

Topics: Adrenergic beta-Antagonists; Adult; Anticoagulants; Drug Therapy, Combination; Female; Fetal Death; Heart Valve Prosthesis; Humans; Mitral Valve; Pregnancy; Pregnancy Complications, Cardiovascular; Pulmonary Edema; Rheumatic Heart Disease; Treatment Outcome; Warfarin

Topics: Drug Interactions; Food-Drug Interactions; Humans; Patient Education as Topic; Practice Guidelines as Topic; Rheumatic Heart Disease; Therapeutic Equivalency; Warfarin

Vitamin K is an essential factor for carboxylation of bone matrix protein. Low vitamin K may be associated with reduced bone mineral density (BMD). The issue of whether long-term sodium warfarin therapy as oral anticoagulant that antagonizes vitamin K, results in decreased bone density, is controversial. Our purpose in this study was to assess the effects of warfarin on BMD.. We performed a case control study survey of bone density in 70 patients with rheumatic valvular heart disease 'mechanical valve replacement' on long-term warfarin compared with 103 randomly selected matched controls.. There was a marked reduction in BMD (g/cm(2)) and T-score of lumbar spine between patients and controls (P = 0.048, 0.005). Duration of warfarin use was the only risk factor of significant importance respectively on spinal T-score (P < 0.03).. Screening of patients on long-term warfarin for reduced bone density should be considered. We strongly suggest the prophylactic use of calcium-vitamin D supplements for these patients.

Topics: Absorptiometry, Photon; Adult; Anticoagulants; Bone Density; Case-Control Studies; Female; Femur; Health Surveys; Heart Valve Prosthesis; Humans; Lumbar Vertebrae; Male; Middle Aged; Osteoporosis; Rheumatic Heart Disease; Vitamin K; Warfarin

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

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

A follow-up study was performed to assess long-term survival, valve-related complications, and pregnancy outcomes in young rheumatic women undergoing isolated mitral mechanical replacement. The influence of prosthetic type on outcomes was also investigated.. Between 1975 and 2003, 267 isolated mitral mechanical prostheses were implanted. Follow-up reached 3707.8 patient-years.. Actuarial survival at 1, 5, 10, 15, 20, and 25 years was 97% +/- 0.01%, 90.4% +/- 0.017%, 85.3% +/- 0.023%, 82.3% +/- 0.025%, 71.7% +/- 0.036%, and 70.2% +/- 0.038%, respectively. At multivariate analysis, atrial fibrillation at follow-up was identified as an independent risk factor for late mortality, whereas left ventricular ejection fraction at 12 postoperative months proved to be a protective factor. Freedom from thromboembolism at 1, 5, 10, 15, 20, and 25 years was 98.1% +/- 0.01%, 94.1% +/- 0.015%, 89.1% +/- 0.021%, 85.9% +/- 0.025%, 81.1% +/- 0.031%, and 75.3% +/- 0.063%, respectively. Atrial fibrillation and Carbomedics device were significantly associated with an increase in thromboembolic events. Freedom from reoperation at 1, 5, 10, 15, 20, and 25 years was 99.2% +/- 0.005%, 95% +/- 0.014%, 91.6% +/- 0.018%, 88.6% +/- 0.022%, and 85.7% +/- 0.041%. Type of prosthesis (tilting disc) was identified as a predictor of reoperation. At the end of the study, 208 patients were still alive: 94.7% were in New York Heart Association class I or II. When receiving warfarin therapy, no patient undertaking pregnancy (n = 35) experienced adverse cardiac or valve-related events. Fetal events were significantly less frequent with a daily warfarin dose less than 5 mg.. Mechanical devices provided excellent performance, safety, and durability. The prognostic role of left ventricular function and atrial fibrillation overwhelmed any differences that might exist between different prosthetic designs. Pregnancies entail virtually no maternal risk and predictable fetal complications.

Topics: Adolescent; Adult; Anticoagulants; Female; Follow-Up Studies; Heart Valve Diseases; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Mitral Valve; Multivariate Analysis; Pregnancy; Pregnancy Outcome; Prosthesis Design; Reoperation; Retrospective Studies; Rheumatic Heart Disease; Risk Factors; Warfarin

Topics: Aged; Anticoagulants; Atrial Fibrillation; Dose-Response Relationship, Drug; Drug Therapy, Computer-Assisted; Female; Follow-Up Studies; Hemorrhage; Humans; Incidence; Male; Retrospective Studies; Rheumatic Heart Disease; Risk Factors; Stroke; Thromboembolism; Time Factors; Treatment Outcome; 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

A 43-year-old woman developed tenderness and induration of her thighs and lower abdomen, 56 days after commencing warfarin for aortic and mitral valve replacements. Investigations showed elevated inflammatory markers, mild renal impairment, normal echocardiogram and low protein C and S levels consistent with warfarin therapy. Three weeks later, purpuric areas evolved into large tender haemoserous bullae, which broke down to form ulcers. Histology confirmed the clinical impression of warfarin-induced skin necrosis with dermal and subcutaneous venular thrombi. Despite cessation of warfarin and commencement of heparin, the lesions progressed. When the patient became febrile, blood cultures grew Pseudomonas aeruginosa, which was treated with intravenous imipenem and vancomycin. Wound swabs grew methycillin-resistant Staphylococcus aureus and the antibiotics were changed. The patient developed septic shock and, despite intensive care management, her condition deteriorated and she died 9 weeks after the onset of the skin symptoms.

Topics: Adult; Aortic Valve; Biopsy, Needle; Disease Progression; Dose-Response Relationship, Drug; Drug Administration Schedule; Fatal Outcome; Female; Heart Valve Prosthesis; Humans; Mitral Valve; Necrosis; Postoperative Care; Rheumatic Heart Disease; Severity of Illness Index; Skin Ulcer; Time Factors; Warfarin

A 51-year-old female underwent redo mitral valve replacement with a pericardial bioprosthesis because of acute thrombotic obstruction of a mechanical valve, in spite of adequate anticoagulation with warfarin. Her protein C level was 24% of the normal value and protein S was reduced to 54% of normal.

Topics: Acute Disease; Anticoagulants; Bioprosthesis; Female; Heart Valve Diseases; Heart Valve Prosthesis; Humans; Middle Aged; Mitral Valve; Protein C; Recurrence; Reoperation; Rheumatic Heart Disease; Thromboembolism; 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

To evaluate the effect of lower intensity anticoagulation therapy in patients with mechanical prosthetic valves, laboratory-based hematological assays including prothrombin time (PT), activity of factor X, antithrombin III (AT III), D-dimer, fibrinogen (Fg) and platel et al pha-granular membrane protein (GMP-140) were performed in 65 patients who had been on warfarin treatment for over one month. The patients were assigned to 3 groups on the basis of their International Normalized Ratios (INR), ranging from 2.00 to 2.50; 2.51 to 3.00; 3.01 to 4.50, respectively. The results showed that the D-dimer, Fg, GMP-140 levels were higher after mechanical valve replacement than those before operation, indicating the activation of coagulation and fibrinolysis system and the damage of platelets. Lower intensity anticoagulation therapy (INR 2.00 to 2.50) could effectively inhibit the activity of factor X and increase the level of AT III. There were no appreciable differences among D-dimer, Fg, GMP-140 and AT III in the 3 anticoagulation intensity groups. These results suggest that in patients with new generation mechanical prosthetic valves, target anticoagulation level (INR 2.00 to 2.50) may result in good protection from thrombo-embolism.

Topics: Adolescent; Adult; Anticoagulants; Factor X; Female; Heart Valve Diseases; Heart Valve Prosthesis Implantation; Humans; Male; Middle Aged; P-Selectin; Postoperative Complications; Rheumatic Heart Disease; Thromboembolism; 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

This study assesses the long-term (mean 52+/-24 months) performance of the St. Jude Medical (SJM) valve in 200 young (mean age 31+/-13 years) rheumatic patients on low-level warfarin anticoagulation combined with dipyridamole. Follow-up was 95% complete and comprised 867 patient-years. There were 33 deaths (3.8%/patient-year). Death was valve related in 12 cases and due to left ventricular dysfunction in 10. Death due to left ventricular dysfunction occurred earlier after surgery than death due to other causes (10+/-7 vs 29+/-18 months, p <0.005); these patients had larger preoperative left ventricular dimensions than the rest of the group (end-systolic diameter 51+/-13 vs 37+/-16 mm, end-diastolic diameter 66+/-13 vs 50+/-19 mm, p = 0.006). Actuarial probability of survival was 81% at 86 months and probability of event-free survival was 71%. The median international normalized ratio was 1.88+/-0.54. Thromboembolism (13 events) occurred at a linearized rate of 1.5%/patient-year. There were 11 major bleeding episodes (1.3%/patient-year), 4 cases of prosthetic valve endocarditis (0.8%/patient-year), and 12 paraprosthetic leaks (1.4%/patient-year). No valve obstructions or reoperations occurred. Thus, the SJM valve performs well on low-level anticoagulation combined with dipyridamole. Left ventricular dysfunction was a common cause of death in the early postoperative period.

Topics: Actuarial Analysis; Adult; Anticoagulants; Cause of Death; Endocarditis; Female; Follow-Up Studies; Heart Valve Diseases; Heart Valve Prosthesis; Hemorrhage; Humans; Male; Middle Aged; Postoperative Complications; Rheumatic Heart Disease; Survival Analysis; Thromboembolism; Time Factors; Treatment Outcome; Warfarin

Chinese patients are reportedly more sensitive than Caucasians to the anticoagulant effect of warfarin. We examined warfarin dose requirements and their determinants in 151 Chinese out-patients on stable maintenance dose of warfarin with international normalized ratio of 2 to 2.5. Mean daily warfarin requirement was 3.3 +/- 1.4 mg, much lower than reported doses in Caucasian patients. The most important determinant was age (r = -0.43, p < 0.001), with progressively lower warfarin requirement with increasing age (p = 0.0001). There was a weaker association with body weight (r = 0.20, p = 0.01). Patients with chronic rheumatic heart disease tended to require a smaller dose than those with heart valve replacements (2.94 +/- 1.24 vs. 3.69 +/- 1.42 mg, p < 0.01). We confirm that Chinese patients require a smaller dose of warfarin for the same degree of anticoagulation. Age is the most important factor affecting dose requirement, although body weight and underlying disease also play a role.

Topics: Adult; Age Factors; Aged; Aged, 80 and over; Anticoagulants; Asian People; Blood Coagulation Disorders; Body Weight; Cardiovascular Diseases; Drug Administration Schedule; Female; Heart Valve Prosthesis; Hong Kong; Humans; Male; Middle Aged; Rheumatic Heart Disease; Sex Factors; Thrombophlebitis; 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

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

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

We have described two cases of spontaneous intracerebral hematoma, characterized by sedimentation level seen on unenhanced cerebral CT, in patients receiving anticoagulation therapy. Anticoagulation or coagulopathy may be important in producing sedimentation levels. The "sedimentation level" is a more accurate term than the commonly used "blood-fluid level" or "hematocrit effect."

Topics: Aged; Body Fluids; Cerebral Hemorrhage; Fatal Outcome; Hematocrit; Hematoma; Hemoglobins; Humans; Male; Middle Aged; Rheumatic Heart Disease; Thrombophlebitis; Tomography, X-Ray Computed; Warfarin

A retrospective analysis of 21 cases with 23 pregnancies after cardiac valve replacement from August 1979 to March 1992. In 11 cases mechanical and in 10 biological valves were used, and in 18 cases with mitral valve replacement was done (MVR), in 1 case aortic valve replacement (AVR) and in 2 cases, both MVR and AVR were carried out 22 pregnancies in 20 cases with cardiac function grading I and II (New York Heart Association, NYHA) before pregnancy resulted in normal term deliveries and 1 case with grading III prior to pregnancy died of heart failure in the third trimester. All the cases treated with mechanical valve replacement received warfarin derivatives throughout pregnancy, and no malformation was found in their neonates. Issues related to pregnancy after cardiac valve replacement were discussed.

Topics: Adult; Bioprosthesis; Female; Heart Valve Prosthesis; Humans; Mitral Valve; Postoperative Period; Pregnancy; Pregnancy Complications, Cardiovascular; Pregnancy Outcome; Retrospective Studies; Rheumatic Heart Disease; Warfarin

Recurrent massive haemoperitoneum of ovarian origin during anticoagulant therapy in a patient with mitral valve prosthesis is described. The patient was treated conservatively on both occasions. The authors suggest that a trial of conservative approach may be considered in such patients.

Topics: Adult; Blood Transfusion; Corpus Luteum; Erythrocyte Transfusion; Female; Heart Valve Prosthesis; Hemoperitoneum; Humans; Mitral Valve; Rheumatic Heart Disease; Warfarin

Cerebral haemorrhage in anticoagulated patients with mechanical valvular prosthesis poses an uncommon but difficult management problem. Four such patients are presented: one patient had delayed haemorrhagic transformation of a preexisting cerebral infarct, one probably had de novo haemorrhage complicating hypertension and in two patients cerebral haemorrhage was associated with excessive anticoagulation. Conservative management including the use of fresh frozen plasma, delayed heparinisation and warfarinisation was used. Both patients with anticoagulant overdose died as a result of extensive haemorrhage despite the drainage of cerebellar haematoma in one patient. The remaining two patients survived with minimal neurological deficits. Diagnosis of the underlying cause of cerebral haemorrhage, and the timing of heparinisation and anticoagulation are discussed.

Topics: Adult; Aged; Cerebral Hemorrhage; Cerebral Infarction; Echocardiography, Doppler; Female; Heart Valve Prosthesis; Humans; Male; Middle Aged; Mitral Valve; Rheumatic Heart Disease; Tomography, X-Ray Computed; Warfarin

This article reports the methods and results of anticoagulant management in 653 patients with China-made Björk-Shiley mode Tilting Disc Cardiac Valve Prostheses. The total incidence of thromboembolic complications and valve thrombosis is 0.98 per 100 patient-years during the anticoagulation. The incidence of anticoagulant-related hemorrhage is 1.86 per 100 patient-years. In the anticoagulant period, 61 surgical operations were performed on 58 patients. The results showed that anticoagulant can be maintained in minor, superficial operations where blood ooze can be arrested by compression, temporarily discontinued in elective operations, and reversed abruptly by injecting Vitamin K1 in urgent operations. In addition we handled the contradictions between anticoagulant therapy and menses, contraceptive, pregnancy or delivery (29 patients) for 303 female patients favorably. We conclude that our methods gave excellent results, and were reasonable and practicable.

Topics: Adolescent; Adult; Female; Heart Valve Diseases; Heart Valve Prosthesis; Humans; Male; Middle Aged; Pregnancy; Pregnancy Complications, Cardiovascular; Rheumatic Heart Disease; Thrombosis; Warfarin

Topics: Aged; Aortic Valve; Female; Heart Valve Prosthesis; Hematoma, Epidural, Cranial; Humans; Magnetic Resonance Imaging; Mitral Valve; Neck; Rheumatic Heart Disease; Spinal Cord Compression; 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

The incidence of thromboembolic complications after St Jude Medical aortic valve replacement was evaluated in patients who received antiplatelet drugs alone (aspirin and dipyridamole). This report includes 107 consecutive patients undergoing aortic valve replacement with the St. Jude Medical prosthesis from February, 1980, until December, 1983. There were three perioperative deaths (2.8%). Thirty-seven of these patients received life-time warfarin anticoagulation and therefore were excluded from further analysis. The remaining 67 patients receiving antiplatelet drugs were followed up for 22 +/- 8 months (range 5 to 54 months) with a total observation period of 123 patient-years. Group 1 consisted of 52 patients having single St. Jude Medical aortic valve replacement (mean age 27 +/- 10 years). Group 2 included 15 patients having St. Jude Medical aortic valve replacement with additional mitral valve replacement (mean age 27 +/- 11 years). There were no postoperative embolic events in Group 1, but two St. Jude Medical aortic prostheses became thrombotic (2.1 per 100 patient-years) 19 and 32 months after the operation. Emergency aortic valve replacement was done in one of these patients and aortic thrombectomy in the other. Both patients are alive and doing well. In Group 2, three patients (10 per 100 patients-years) had thrombosis of the St. Jude Medical aortic valve 10, 12, and 30 months after the operation, and two of them required emergency aortic value replacement. One of these patients also had a massive left coronary embolus and could not be weaned from cardiopulmonary bypass. The third patient, who was asymptomatic, was prescribed warfarin anticoagulation and has been well. None of the seven patients in this group with St. Jude Medical aortic and mitral prostheses has had a thromboembolic event. These results indicate that antiplatelet drugs alone are associated with a very low risk of embolism but are insufficient to prevent thrombosis of St. Jude Medical aortic valves, even when the patients have sinus rhythm.

Topics: Adolescent; Adult; Aortic Valve; Aspirin; Blood Platelets; Dipyridamole; Female; Follow-Up Studies; Heart Valve Prosthesis; Humans; Male; Mitral Valve; Postoperative Complications; Prosthesis Design; Rheumatic Heart Disease; Risk; Thromboembolism; Time Factors; 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

Topics: Abnormalities, Drug-Induced; Abnormalities, Multiple; Female; Humans; Infant, Newborn; Pregnancy; Pregnancy Complications, Cardiovascular; Rheumatic Heart Disease; Warfarin

Massive subchorionic hematoma (Breus' mole) of the placenta occurred in a stillbirth. The mother was receiving oral warfarin sodium. The extravasated blood was mostly fetal in origin.

Topics: Adult; Chorion; Female; Fetal Blood; Fetal Death; Hematoma; Humans; Placenta Diseases; Pregnancy; Rheumatic Heart Disease; Warfarin

Topics: Aged; Drug Eruptions; Female; Foot Dermatoses; Humans; Rheumatic Heart Disease; Toes; Warfarin

A retrospective analysis of 40 patients with cardiac disease who received sodium warfarin (Coumadin) therapy during pregnancy has been performed. The fetal mortality was 12,5%, but no case of congenital epiphyseal stippling was detected. The incidence of maternal postpartum haemorrhage was high. Warfarin should whenever possible be withheld during the 1st trimester of pregnancy and replaced by heparin.

Topics: Abnormalities, Drug-Induced; Adult; Female; Fetal Death; Fetus; Heart Valve Diseases; Humans; Pregnancy; Pregnancy Complications; Pregnancy Complications, Cardiovascular; Retrospective Studies; Rheumatic Heart Disease; Warfarin

Seventy consecutive patients receiving warfarin as an anticoagulant were evaluated for the relationship between the response to the loading dose of warfarin and the response to the maintenance dose. No patients were excluded because of complicating diseases or the concurrent use of other drugs. There was a moderate correlation (r = 0.54, p less than 0.01) between response to the loading dose and response to the maintenance dose. Thus, a relatively weak response to a loading dose of warfarin can be used to predict a need for a relatively large maintenance dose in unselected patients requiring anticoagulant therapy. Age seems to be a relatively weak determinant of warfarin sensitivity. Other factors such as the genetic control mechanism, concurrent drug therapy, and complicating diseases apparently are more important determinants.

Topics: Adult; Aged; Cerebrovascular Disorders; Dose-Response Relationship, Drug; Female; Humans; Ischemic Attack, Transient; Male; Middle Aged; Prothrombin Time; Pulmonary Embolism; Rheumatic Heart Disease; Thrombophlebitis; Warfarin

Prenatal exposure to oral anticoagulants during pregnancy may result in defective fetal development or life-threatening hemorrhage. Fetal exposure during the first eight weeks of pregnancy may cause abnormal development of the facial structures, hypoplastic digits, strippled epiphyses, and mental retardation. Midtrimester exposure may result in optic atrophy, faulty brain growth, and developmental retardation. Third-trimester exposure may produce fetal anticoagulation, predisposing the infant to life-threatening hemorrhage in the perinatal period. Anticoagulation with heparin sodium does not provide a clearly safe alternative, since this therapy has been associated with excessive fetal loss.

Topics: Abnormalities, Drug-Induced; Abnormalities, Multiple; Administration, Oral; Adult; Anticoagulants; Body Weight; Chondrodysplasia Punctata; Female; Fetus; Gestational Age; Humans; Infant, Newborn; Maternal-Fetal Exchange; Optic Atrophy; Pregnancy; Pregnancy Complications, Cardiovascular; Rheumatic Heart Disease; Vitamin K; Warfarin

Topics: Atrial Fibrillation; Blood Coagulation; Blood Platelets; Cell Survival; Heart Valve Prosthesis; Humans; Male; Mitral Valve; Placebos; Rheumatic Heart Disease; Sulfinpyrazone; Thromboembolism; Uric Acid; Warfarin

The clinical course, through pregnancy and delivery, of a 30-year-old woman with rheumatic heart disease and a prosthetic mitral valve is presented. Despite maternal development of congestive cardiac failure and atrial fibrillation, the delivery of a healthy infant was achieved. The problems encountered during pregnancy and delivery in patients with rheumatic heart disease and prosthetic valves are discussed. These include the management of long-term anticoagulant therapy, prophylaxis against rheumatic fever and subacute bacterial endocarditis, impaired cardiac function, atrial fibrillation, breast feeding, and contraception as they relate both to the mother and the fetus and infant.

Topics: Adult; Atrial Fibrillation; Breast Feeding; Digoxin; Endocarditis, Subacute Bacterial; Female; Fetus; Heart Failure; Heart Valve Prosthesis; Heparin; Humans; Mitral Valve; Penicillin G Benzathine; Pregnancy; Pregnancy Complications, Cardiovascular; Prognosis; Rheumatic Fever; Rheumatic Heart Disease; Sulfadiazine; Warfarin

Topics: Abnormalities, Drug-Induced; Alcoholism; Cerebrovascular Disorders; Chondrodysplasia Punctata; Contraceptives, Oral; Diazepam; Female; Fetus; Furosemide; Humans; Hypertension; Infant, Newborn; Male; Pregnancy; Pregnancy Complications; Radiography; Rheumatic Heart Disease; Stress, Psychological; Warfarin

A successful cesarean section performed in a 24-year-old woman with rheumatic heart disease and a Starr-Edwards mitral valve prosthesis is reported. In the 33rd week of pregnancy, previous warfarin sodium therapy was discontinued and dipyridamole therapy instituted. Successful pregnancy and cesarean section in patients with mitral valve prostheses are possible with this regimen.

Topics: Adult; Cesarean Section; Dipyridamole; Female; Fetal Death; Heart Valve Prosthesis; Hemorrhage; Humans; Mitral Valve; Pregnancy; Pregnancy Complications, Cardiovascular; Rheumatic Heart Disease; Thromboembolism; Warfarin

Topics: Adult; Anticoagulants; Digoxin; Dipyridamole; Female; Heart Valve Prosthesis; Heparin; Humans; Mitral Valve; Pregnancy; Pregnancy Complications, Cardiovascular; Quinidine; Rheumatic Heart Disease; Warfarin

Topics: Anticoagulants; Atrial Fibrillation; Embolism; Female; Humans; Middle Aged; Renal Artery Obstruction; Rheumatic Heart Disease; Urography; Warfarin

Topics: Alcohols; Amobarbital; Animals; Antipyrine; Benzazepines; Blood Coagulation; Chloral Hydrate; Chlordiazepoxide; Enzyme Induction; Ethanol; Fluorometry; Half-Life; Humans; Hydrocortisone; Hypnotics and Sedatives; Ketones; Kinetics; Male; Metabolism; Microsomes, Liver; Morphinans; Nitro Compounds; Paralysis; Phenobarbital; Rats; Rheumatic Heart Disease; Secobarbital; Sleep; Time Factors; Warfarin

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

Topics: Anticoagulants; Embolism; Humans; Hypertension, Pulmonary; Myocardial Infarction; Phenindione; Renal Artery Obstruction; Rheumatic Heart Disease; Thrombosis; Warfarin

Topics: Atrial Fibrillation; Embolectomy; Embolism; Gastrointestinal Hemorrhage; Heparin; Humans; Mesenteric Artery, Superior; Mesenteric Vascular Occlusion; Postoperative Care; Postoperative Complications; Preoperative Care; Radiography; Rheumatic Heart Disease; Vascular Surgical Procedures; Warfarin

Topics: Arthritis; Coronary Disease; Geriatrics; Hemorrhage; Oxyphenbutazone; Phenylbutazone; Prothrombin Time; Rheumatic Heart Disease; Sodium; Toxicology; Warfarin

Topics: Angina Pectoris; Anticoagulants; Arteriosclerosis; Blood Coagulation Tests; Drug Therapy; Embolism; Family Practice; General Practice; Myocardial Infarction; Office Management; Prothrombin Time; Rheumatic Heart Disease; Thrombosis; Toxicology; Warfarin

Topics: Anticoagulants; Biomedical Research; Blood Coagulation Tests; Cerebrovascular Disorders; Coronary Disease; Drug Therapy; Factor VII; Hemorrhage; Humans; Phenindione; Prothrombin; Prothrombin Time; Rheumatic Heart Disease; Thromboembolism; Thrombophlebitis; Toxicology; Warfarin