Anticoagulant bridging in left-sided mechanical heart valve patients.

BACKGROUND: In preparation for an invasive procedure with a high bleeding risk, patients with a mechanical heart valve temporarily have to discontinue their anticoagulant therapy and are usually bridged with either intravenous unfractionated heparin (UFH) or subcutaneous low-molecular-weight heparin (LMWH). In this study we retrospectively analyzed the safety of UFH versus LMWH as bridging strategy in left-sided mechanical heart valve patients. METHODS: We performed a retrospective multicenter study in four surgical centers in The Netherlands. Patients with a mechanical heart valve implantation bridged from January 2010 until January 2015 were included. The cumulative incidence of adverse events in the 30days following the procedure was recorded. Main outcomes were major bleeding according to International Society on Thrombosis and Haemostasis (ISTH) criteria, symptomatic thromboembolism, and mortality. RESULTS: In total, 238 (174 aortic, 42 mitral, 22 aortic+mitral) bridging episodes were included. The incidence of major bleeding was 16 (19%) events in the UFH group versus 29 (19%) events in the LMWH group (p=0.97). Incidences of thromboembolism were 2 (2.4%) versus 1 (0.6%). The incidence of death was 1 (1.2%) patient in the UFH group versus 3 (1.9%) patients in the LMWH group. More than 50% of all bleeding complications were categorized as a major bleeding. CONCLUSIONS: Bridging anticoagulation in patients with aortic and mitral mechanical valves is associated with considerable risk, but no difference was apparent between UFH and LMWH strategy. The rate of thromboembolism and death was low with either strategy and the vast majority of adverse events were bleedings.

[Trachea compression due to a Kommerell diverticulum in a patient with a right-sided aorta]. / Tracheacompressie door divertikel van Kommerell bij een rechtszijdige aorta.

A 64-year-old man who was evaluated for a long history of a discontinuous barking cough with difficulty in coughing up sputum was found to have 90% stenosis of the trachea. Further imaging studies revealed a right-sided descending aorta with an aberrant left subclavian artery arising from a Kommerell diverticulum. This caused the compression of the trachea. The compression was relieved by transposition of the aberrant left subclavian artery to the ascending aorta and replacement of the aneurysmatic part of the aorta by an endoprosthesis.

Multiple Lambl's excrescences with subvalvular extension, a rare cause of cryptogenic stroke: treated by port-access cardiac surgery.

A young male patient was evaluated for a cardiac cause of ischaemic stroke. In the work-up, a tumour was detected on the subvalvular apparatus of the mitral valve for which operative removal was scheduled. A port-access procedure was applied as a novel way of treatment. On thoracoscopic intracardiac inspection, however, multiple tumours were seen attached to the chordae tendineae and to the anterior leaflet of the mitral valve. It was decided to not to perform a plasty but to remove the valve in toto and insert a mechanical valve prosthesis. The tumours were diagnosed as multiple giant Lambl's excrescences.