Assessment of plasma lactate and core-peripheral temperature gradient in association with stages of naturally occurring myxomatous mitral valve disease in dogs.

OBJECTIVE: To evaluate plasma lactate concentrations and core-peripheral temperature gradients as perfusion parameters in dogs with heart failure caused by myxomatous mitral valve disease (MMVD) and to determine whether the above perfusion parameters are correlated with disease stages. DESIGN: Prospective observational study. SETTING: University teaching hospital. ANIMALS: After excluding 129 dogs because of exclusion criteria, 7 dogs with heart failure classified as stage B2 and 10 dogs classified as stage C according to the American Heart Association (AHA)/American College of Cardiology (ACC) were included in the study. Six dogs without MMVD were evaluated as the control group. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Among the evaluated parameters, the plasma lactate concentrations were increased in stage C (median 3.70 mmol/L [33.3 mg/dL], interquartile range (IQR) 0.72 mmol/L [6.5 mg/dL]) compared with those in the control (median 2.80 mmol/L [25.2 mg/dL], IQR 0.8 mmol/L [7.2 mg/dL]; P = 0.024) and stage B2 groups (median 2.70 mmol/L [24.3 mg/dL], IQR 1.8 mmol/L [16.2 mg/dL]; P = 0.045). Significant differences were not observed in the core-peripheral temperature gradients among the control, stage B2, and stage C dogs. CONCLUSIONS: Dogs with structural heart disease as a result of MMVD may have occult tissue hypoperfusion in stage C that is demonstrated by hyperlactatemia.

An Effective Treatment for Heart Failure Caused by Valvular Heart Diseases: Thoracic Sympathetic Block.

BACKGROUND: The pilot study is designed to investigate the effect of continuous thoracic sympathetic block (TSB) on cardiac function, reconstruction, and hemodynamic parameters in patients with heart failure resulting from valvular heart disease. METHOD: The cardiac function parameters, including left ventricle ejection fraction (LVEF), left ventricle end-diastole diameter (LVEDD), fractional shortening (FS), and N-terminal prohormone of brain natriuretic peptide (NT-proBNP), were measured in 19 patients before and after TSB treatment. The patients were also classified on the basis of NYHA classification system. RESULTS: 4 weeks of TSB administration improved cardiac function in 18 of 19 patients (94.74%). The patients' LVEF, LVEDD, and NT-proBNP were all improved significantly after treatment. CONCLUSIONS: The favorable clinical outcome of TSB administration suggests an alternative treatment for the patients with heart failure caused by valvular dysfunctions.

ASSESSMENT OF WARFARIN TREATMENT EFFICACY BY MEANS; OF USING COAGULATION TEST RESULTS WITHIN THE THERAPEUTIC RANGE.

Time in Therapeutic Range (TTR) is a value used to assess the efficacy of Warfarin treatment. The aim of our study is to determine the effective INR levels and the rate of TTR in patients on Warfarin regimen due to Atrial Fibrillation (AF) or Mechanical Prosthetic Valve (MPV). A total of 94 patients (58 female, and 36 male, mean age: 64.9±11years) on Warfarin treatment due to AF or MPV with at least 10 INR levels measurements in the last 6 months were included in this retrospective study. The patients were divided into 2 groups. Group 1 consisted of the patients with Valvular AF (n=47); Group 2 included the patients with Non-Valvular AF (n=47); TTR and INR levels were compared. The average of INR values were found as 2,4 (min: 1,3, max: 4,3) in all patients; 2,3 (min: 1,3, max: 4,2) in Group 1; 2,6 (min: 1,3, max: 4,3) in Group 2. The average of TTR values was found 40.3% (min: 10%, max: 80%) in all patients; 43.8% (min: 10%, max: 80%) in Group 1; 36,8% (min: 10%, max: 80%) in Group 2. INR and TTR values are needed to assess the effectiveness of the Warfarin treatment. The patients in treatment with Warfarin should be well trained and frequently monitored. On the other hand, the underlying factors of the TTR values being determined as lower in the Turkish patient population might be due to the lower socio-economic and socio-cultural status, inadequate education levels, and the insufficient information on use of the medication provided by the doctors to the patients.

Clinical Applications of Natriuretic Peptides in Assessment of Valvular Heart Disease.

Biomarkers such as natriuretic peptides (NPs) have evolving clinical utility beyond the scope of heart failure. The role of NPs in the management of valvular heart disease is a growing area of investigation. NPs have much potential in the assessment of asymptomatic patients with hemodynamically significant valvular lesions who have traditionally been excluded from consideration of surgical intervention. NPs also have a role in the risk stratification of these patients as well as in routine surveillance and monitoring. Together with echocardiographic data and functional status, NPs are being incorporated into the management of valvular heart disease. In this review we examine the evidence for the role of natriuretic peptides in assessment of VHD.

Postdischarge international normalized ratio testing and long-term clinical outcomes of patients with heart failure receiving warfarin: findings from the ADHERE registry linked to Medicare claims.

BACKGROUND: Effective warfarin thromboprophylaxis requires maintaining anticoagulation within the recommended international normalized ratio (INR) range. INR testing rates and associations between testing and outcomes are not well understood. HYPOTHESIS: INR testing rates after hospitalization for acute decompensated heart failure are suboptimal, and testing is associated with lower risks of mortality and adverse clinical events. METHODS: We conducted a retrospective cohort study of patients who were long-term warfarin users and were hospitalized for heart failure, had a medical history of atrial fibrillation or valvular heart disease, and were enrolled in fee-for-service Medicare. INR testing was defined as ≥1 outpatient INR test within 45 days after discharge. Using Cox proportional hazards models, we examined associations between testing and all-cause mortality, all-cause readmission, and adverse clinical events at 1 year. RESULTS: Among 8558 patients, 7722 (90.2%) were tested. After 1 year, tested patients had lower all-cause mortality (23.5% vs 32.6%; P < 0.001) and fewer myocardial infarctions (2.0% vs 3.3%; P = 0.02). These differences remained significant after multivariable adjustment with hazard ratios of 0.72 (95% confidence interval [CI]: 0.63-0.84; P < 0.001) and 0.58 (95% CI: 0.41-0.83; P = 0.003), respectively. Differences in all-cause readmission, thromboembolic events, ischemic stroke, and bleeding events were not statistically significant. CONCLUSIONS: Postdischarge outpatient INR testing in patients with heart failure complicated by atrial fibrillation or valvular heart disease was high. INR testing was associated with improved survival and fewer myocardial infarctions at 1 year but was not independently associated with other adverse clinical events.

Assessment of changes in hemostatic markers in Cavalier King Charles Spaniels with myxomatous mitral valve disease.

OBJECTIVE: To evaluate markers of hemostasis and their relationship to the degree of mitral regurgitation (MR) and platelet function in Cavalier King Charles Spaniels (CKCSs) with myxomatous mitral valve disease. ANIMALS: 76 clinically healthy CKCSs and 24 control dogs. PROCEDURE: All dogs underwent echocardiographic examination; various hemostatic, hematologic, and biochemical variables were evaluated in blood. The CKCSs were allocated to 1 of 3 groups on the basis of MR severity. In 8 control dogs and 8 CKCSs, plasma von Willebrand factor (vWF) multimer analysis was performed. RESULTS: Compared with control dogs, plasma fibrinogen concentration was higher in all CKCSs and related to left ventricular end diastolic diameter and left atrial-to-aortic root ratio among all CKCSs. The activated partial thromboplastin times and plasma D-dimer concentration were similar among the 4 groups. Plasma vWF concentration was lower in CKCSs with moderate to severe MR, compared with that of CKCSs with no MR and control dogs. There was a relationship between plasma vWF concentration and platelet function in CKCSs but not in control dogs. In 4 CKCSs with moderate to severe MR and low plasma vWF concentration, amounts of vWF high-molecular-weight multimers (HMWMs) were low. CONCLUSIONS AND CLINICAL RELEVANCE: In CKCSs, MR appeared to be associated with a low plasma vWF concentration and likely a loss of vWF HMWMs (possibly through their destruction via shear stress to the blood). The importance of the changes in plasma fibrinogen concentration and the thromboembolic risk in dogs with MR remain to be investigated.

[Comparison of interleukin-6 and C-reactive protein serum concentrations assessment in diagnosis of infective endocarditis]. / Porównanie przydatnosci oznaczania stezenia interleukiny-6 i bialka C-reaktywnego w diagnostyce infekcyjnego zapalenia wsierdzia.

UNLABELLED: Serum interleukin-6 (IL-6) level might be used to aid in diagnosis of infective endocarditis (IE), especially when blood cultures are negative. One of typical acute phase proteins is C-reactive protein (CRP), often served as an additional inflammation maker. The aim of the study was to compare serum IL-6 and CRP concentrations assessment in diagnosis and monitoring of IE. The study group consisted of 40 patients with ongoing IE and valvular heart diseases. Two control groups consisted of patients with valvular heart diseases: 15 without infection and another 15 with urinary tract infection. The diagnosis of IE was established according to the Duke University criteria; in 34 patients positive blood cultures were found. Serum IL-6 and CRP were measured on three occasions after diagnosis of IE was established and during antimicrobial treatment (mean period 14 +/- 7 days) by ELISA. Usefulness of both parameters for IE diagnosis were described. Reference values were defined as 0-12.5 pg/ml for IL-6, and 0-10 mg/l for CRP. Mean concentrations of IL-6 and CRP in patients with IE (37 +/- 44.3 pg/ml and 27.1 +/- 23.9 mg/l) were significantly higher than in controls: with urinary tract infection (9.1 +/- 4.42 pg/ml and 6.95 +/- 4.39 mg/l) and without infection (3.95 +/- 1.4 pg/ml and 2.21 +/- 0.96 mg/l). CRP concentration was not significantly correlated with IL-6 (r = 0.51, p = 0.07). The significant tendency of consecutive IL-6 concentrations to decrease (from 37 +/- 44.3 to 8.7 +/- 5.7 pg/ml), without decrease of CRP (from 27.1 +/- 23.9 mg/l to 22 +/- 18.3 mg/l) was found. CONCLUSIONS: 1. Elevated serum IL-6 and CRP levels may suggest ongoing IE. 2. Sensitivity, specificity, positive and negative predictive value are nonsignificantly higher for IL-6 than CRP. 3. Combined assessment of serum IL-6 and CRP concentration has no higher value in diagnosis of IE. 4, IL-6 level decrease is faster than CRP during antimicrobial treatment, and it helps better and faster monitoring of treatment.

The efficacy and safety of aprotinin use in cardiac surgery.

BACKGROUND: The serine protease inhibitor aprotinin has received much attention in cardiac surgical practice as a pharmacologic intervention to improve the hemostatic derangement associated with cardiopulmonary bypass. This review highlights the major studies undertaken to investigate the efficacy and safety of aprotinin use in both primary and repeat coronary artery bypass graft surgical procedures. METHODS: There have been at least 45 controlled studies in more than 7,000 patients in a variety of patient populations. These have ranged from primary coronary artery bypass graft and valve operations to complex reoperation procedures, including aortic arch reconstructions and thoracic organ transplantation. The recently completed International Multicenter Graft Patency Experience trial, the largest study to date, involved 870 patients at 13 international sites. The study examined the effects of aprotinin on graft patency, incidence of myocardial infarction, and blood loss in patients undergoing primary coronary artery bypass graft operations with cardiopulmonary bypass. RESULTS: Twenty-one studies in approximately 5,000 patients undergoing primary coronary artery bypass graft or valve operations reported 33% to 66% reduction in blood loss with full-dose aprotinin therapy; 15 of the same studies reported significant reductions in transfusion requirements, ranging from 31% to 85%. The recently completed International Multicenter Graft Patency Experience study observed a significant reduction in thoracic-drainage volume of 43% (p < 0.0001) and a 49% (p < 0.001) reduction in the requirement for allogeneic blood transfusions. Aprotinin did not affect the occurrence of definite myocardial infarction (aprotinin, 2.9% versus placebo, 3.8%) or mortality (aprotinin, 1.4% versus placebo, 1.6%). There was no observed difference in the patency of internal mammary artery bypass grafts from all study sites in aprotinin- versus placebo-treated patients (aprotinin, 98.2% versus placebo, 98.0%). CONCLUSIONS: Given the risks and costs associated with excessive bleeding and transfusions and the limited supply of banked blood, aprotinin represents an important and safe approach to blood conservation.

Platelet responses to cardiopulmonary bypass. Assessment by a shear stress activation technique.

Platelet responses before and during cardiopulmonary bypass were studied using a shear stress activation technique. Whole blood was passed through a 10 microns micro-porous filter and the percentage of platelets retained was determined. Retention in control subjects (n = 20, age 62 +/- 11 years) was 65.2 +/- 15.1%. Patients with ischaemic heart disease (n = 20, age 61 +/- 9 years) had significantly higher retention at 82.6 +/- 13.2%, p less than 0.001. In valvular heart disease (n = 15, age 57 +/- 14 years) the retention rate was 43.5 +/- 15.4%, lower than both controls and ischaemic heart disease patients (p less than 0.001). In vitro haemodilution had no significant effect on platelet retention. High retention rates were maintained in patients undergoing coronary artery surgery. During valve surgery retention increased before aortic cross-clamp removal (83.5 +/- 13.4%) compared with baseline values (p less than 0.001) and remained high 24 hours postoperatively (79.6 +/- 9.4%). Platelet retention also increased within 20 minutes of thoracotomy without cardiopulmonary bypass (n = 10, age 57 +/- 8 years, 79.3 +/- 11.6% versus 61.6 +/- 10.9% baseline, p less than 0.01) and remained high 24 hours postoperatively. Significant differences in platelet responses, assessed by shear stress activation, were demonstrated between healthy controls and patients with ischaemic and valvular heart disease. Surgery, with or without extracorporeal circulation, caused a significant increase in platelet retention.