Combination anticoagulation strategy in pregnancy with mechanical valves: The KYBELE study.

BACKGROUND: Optimal first-trimester anticoagulation is still challenging in pregnant women with mechanical heart valves (MHVs) requiring high-dose warfarin. This multicenter prospective study aims to determine the optimal anticoagulation regimens for pregnant patients with MHVs. METHODS: All women were allocated to one of three treatment options during first trimester including lone low-molecular-weight heparin (LMWH), combination of LMWH + 2.5 mg warfarin, and LMWH+4 mg warfarin. Primary maternal outcome included a combination of death, thromboembolism, severe bleeding, and need for treatment of mechanical valve thrombosis (MVT). Any fetal loss was determined as primary fetal outcome. RESULTS: The study included 78 pregnancies in 65 women with MHVs. Primary maternal outcome rate was 44%, 12.5%, 3.5%, respectively. The rates of primary maternal outcome (44 vs 3.5%, P < .001), obstructive MVT (16 vs 0%, P = .04), MVT requiring treatment (28 vs 0%, P = .003), and cerebral embolism (24 vs 3.4%, P = .041) were found to be significantly higher in lone LMWH group compared to LMWH + 4 mg warfarin group. Moreover, the rates of primary maternal outcome (12.5 vs 44%, P = .015) and treatment for MHV thrombus (4.2 vs 28%, P = .049) were significantly lower in LMWH + 2.5 mg warfarin group compared to lone LMWH group. The incidences of fetal loss were 8 (32%) in the lone LMWH group, 8 (33.3%) in LMWH + 2.5 mg warfarin group, and 11 (37.9%) in LMWH + 4 mg warfarin group (P = .890 for 3-group).Warfarin related-embryopathy was not observed in any case. CONCLUSIONS: The combined anticoagulation strategy of LMWH plus low-dose warfarin during the first trimester of pregnancy may result in less maternal complications with comparable fetal outcomes in patients with MHVs. CONDENSED ABSTRACT: Low-molecular-weight heparin (LMWH) is thought to be safer for the fetus, however it is suspected to be less protective for the mother. To solve this dilemma, the authors suggested a novel anticoagulation strategy in pregnant women with prosthetic valves. Seventy-eight pregnancies of 65 women (median age 32 [27-35] years) were included in the study. A combination of LMWH and a reduced dose warfarin were associated with low rates of thrombus-related complications in pregnant patients with mechanical heart valves.

Double trouble during the left atrial appendage occlusion procedure.

Percutaneous structural interventions are being performed at increased numbers and rare findings or complications occur more frequently. Lipomatous hypertrophy of the interatrial septum (LHIS) is a relatively uncommon finding on transthoracic echocardiogram (TTE). The major challenge is the difficulty in performing transseptal puncture. We aimed to report the difficulties that were experienced during the left atrial appendage (LAA) closure in a case with an extreme form of LHIS.

3D TEE imaging in a patient with severe tricuspid regurgitation with dextrocardia and tricuspid commissural prolapse.

Although dextrocardia is a rare congenital anomaly, it may be accompanied by numerous pathologies. Tricuspid valve prolapse is an extremely uncommon cause of primary tricuspid valve disease, as is its association with dextrocardia. In this instance, we wished to share our knowledge of tricuspid commissural prolapse together with dextrocardia, which we augmented with 3D images.

A rare cause of pulmonary hypertension: Idiopathic fibrosing mediastinitis obstructing right pulmonary artery and pulmonary veins.

Fibrosing mediastinitis is caused by a proliferation of fibrous tissue in the mediastinum with encasement of mediastinal viscera and compression of mediastinal bronchovascular structures. Pulmonary hypertension (PH) may occur as a severe complication of the disease. Herein, we report a patient diagnosed with fibrosing mediastinitis and pulmonary hypertension, whose imaging tests showed obstruction of right pulmonary artery and veins.

A tricuspid mitral valve with severe regurgitation.

Tricuspid mitral valve is a rare entity, distinct from isolated clefts of the mitral leaflets. Echocardiographically, it manifests as the presence of three commissures, separate papillary muscles and concordant atrioventricular or ventriculoarterial connections. Three-dimensional transesophageal echocardiography helps distinguish the three cusps from clefts. Herein, we present a case of tricuspid mitral valve that led to severe mitral regurgitation.

A combination of severe complications in a case of infective endocarditis: Dehiscence of prosthetic aortic valve, aortic dissection, pseudoaneurysm, and hematoma causing right ventricular collapse.

Prosthetic valve endocarditis with mechanical complications causing pulmonary edema is fatal, therefore it needs to be diagnosed early and should be treated surgically in emergency setting. Transesophageal echocardiogram is crucial for recognizing the mechanical complications, which can be encountered on daily practice, but the coexistence of complications occurring on different mechanism is rather uncommon. Herein, we report a 21-year-old gentleman presenting with acute heart failure, whose imaging tests showed a combination of dehiscence of mechanical aortic valve prosthesis, aortic dissection, pseudoaneurysm, and hematoma causing right ventricular collapse.

Crochetage sign may predict late atrial arrhythmias in patients with secundum atrial septal defect undergoing transcatheter closure.

BACKGROUND: Atrial arrhythmias are well-known complications of atrial septal defect (ASD), and associated with substantial morbidity. After ASD closure, right atrial and ventricular enlargement regresses, however, the risk of atrial arrhythmia development continues. In this study, we aimed to investigate the relationship between the Crochetage sign, which is a possible reflection of heterogeneous ventricular depolarization due to long-term hemodynamic overload, and the development of late atrial arrhythmia after ASD closure. METHODS: This retrospective study included a total of 314 patients (mean age: 39.5 (30-50) years; male: 115) who underwent percutaneous device closure for secundum ASD. The study population was divided into two groups according to the presence or absence of the Crochetage sign. The Crochetage sign was defined as an M-shaped or bifid pattern notch on the R wave in one or more inferior limb leads. Cox-regression analysis was performed to determine independent predictors of late atrial arrhythmia development. RESULT: Fifty-seven patients (18.1%) presented with late atrial arrhythmia. Of these 57 patients, 30 developed new-onset atrial fibrillation/atrial flutter (AF/AFL), and 27 patients with pre-procedure paroxysmal AF/AFL had a recurrence of AF/AFL during follow-up. History of paroxysmal AF/AFL before the procedure (HR: 4.78; 95% CI 2,52-9.05; p < 0.001), the presence of Crochetage sign (HR: 3.90; 95% CI 2.05-7.76; p < 0.001), and older age at the time of ASD closure (HR: 1.03; 95% CI 1.01-1.06; p = 0.002) were found as independent predictors for late atrial arrhythmia. CONCLUSION: The presence of Crochetage sign may be used to predict the risk of late atrial arrhythmia development after transcatheter ASD closure.

Time interval between E and E' waves can predict complicated clinical course in patients with acute pulmonary embolism.

PURPOSE: Acute pulmonary embolism is a life-threatening cardiothoracic emergency leading to right ventricle systolic and diastolic dysfunction. In the present study, we investigated the right ventricle diastolic function and its predictive value in patients with acute pulmonary embolism. MATERIAL AND METHODS: Were prospectively recruited in this study 621 patients diagnosed with acute pulmonary embolism between December 2015 and June 2019. Among them, 173 were excluded, leaving 448 patients for follow-up. Transthoracic echocardiography was performed for the evaluation of the right ventricle systolic and diastolic indices. At 30-day follow-up, the patients were allocated either into the benign or in the complicated clinical course group. RESULTS: The group with complicated clinical course had higher value of pulmonary artery systolic pressure (PASP), right/left ventricle diameter ratio, E-wave velocity, E/A ratio, A' wave velocity, E/E' ratio, and time interval between E and E' waves (P < .05), but lower values of tricuspid annular plane systolic excursion, A-wave velocity, isovolumetric relaxation time, deceleration time, E', and E'/A' (P < .05). Complicated clinical course was associated with shorter isovolumetric relaxation time (r = .564, P < .001), E/E' (r = .495, P < .001), and TE-E' (r = .596, P < .001). Receiver operator characteristic curve analysis showed that TE-E' had the largest area under curve (TE-E' 0.82, IVRT 0.77, E/E' 0.72). A cut-off value of TE-E' = 70 milliseconds had an 81.1% sensitivity and 71.4% specificity for the prediction of the complicated clinical course. CONCLUSION: The assessment of the right ventricle diastolic function could predict the complicated clinical course in patients with acute pulmonary embolism.

Effects of atrial electromechanical delay and ventriculoatrial conduction over the atrial functions in patients with frequent extrasystole and preserved ejection fraction.

BACKGROUND: The deterioration of left atrial and ventricular functions was demonstrated in patients with frequent ventricular extrasystole (fVES). The exact pathophysiology of left atrial dysfunction in patients with fVES is unclear. Retrograde ventriculoatrial conduction (VAC) often accompanies fVES, which may contribute to atrial dysfunction. We investigated whether atrial electromechanical delay and VAC are related to these atrial functions in patients with frequent right ventricular outflow tract (RVOT) VES and preserved ejection fraction (pEF). METHODS: This study included 21 patients with pEF (eight males, 48 ± 11 years), who had experienced more than 10 000 RVOT-VES during 24-h Holter monitoring and had undergone electrophysiological study/ablation. The study also included 20 healthy age- and sex-matched control subjects. Transthoracic echocardiography was performed on all of the subjects. Atrial conduction time was obtained by using tissue Doppler imaging. Strain analysis was performed with two-dimensional speckle tracking echocardiography. RESULTS: The peak atrial longitudinal strain was significantly impaired in patients with fVES (P = 0.01). In addition, although the interatrial and left atrial conduction delay times were significantly different between each group (P < 0.001, P < 0.001), the right atrial conduction delay times were similar. When patients with fVES were divided into groups depending on the existence of retrograde VAC, atrial deformation parameters and conduction delay time did not significantly differ between either group. CONCLUSION: Frequent RVOT-VES causes left atrial dysfunction. This information is obtained through strain analyses and recordings of left atrial conduction times in patients with pEF. Regardless, retrograde VAC is not related to atrial dysfunction.

Acute myocardial infarction complicated with ventricular septal rupture and intracranial hemorrhage.

Ventricular septal rupture (VSR) is a rare but fatal complication of acute myocardial infarction (AMI) with an associated mortality that ranges from 41% to 80%. The treatment consists of supplemental oxygenation, afterload reduction, intraaortic balloon pump, and surgical repair. In selected patients, extracorporeal membrane oxygenation (ECMO) and/or percutaneous closure of the defect can be considered if anatomically appropriate. Echocardiography evaluates the morphology and location of the defect, anatomical concerns for percutaneous closure, and accompanying pathologies. We present a 48-year-old man with inferior myocardial infarction and basal VSR who was not a candidate for percutaneous closure. Surgery was planned, but he died from extensive subarachnoid and intracranial hemorrhage.

ST-segment elevation myocardial infarction possibly caused by thromboembolism from left atrial appendage thrombus after incomplete surgical ligation.

Coronary embolism (CE) is the underlying cause of 3% of acute coronary syndromes but is frequently overlooked in the differential diagnoses of acute coronary syndromes. The CE may be direct (left sided from the native or prosthetic heart valve, the left atrium, left atrial appendage or pulmonary venous bed), paradoxical (from the venous circulation through a patent foramen ovale, atrial septal defect, ventricular septal defects, cyanotic congenital heart defects or pulmonary arteriovenous malformations), or iatrogenic (following cardiac interventions. In patients with atrial fibrillation (AF), left atrial appendage (LAA) ligation during mitral valve surgery has long been recommended to decrease the future risk of embolic events such as myocardial infarction or ischemic stroke. Recently, Aryana et al reported that in patients with AF who underwent surgical ligation of LAA, the presence of incomplete ligation was associated with a significantly higher risk of stroke/systemic embolization than complete ligation (24% vs 2%).

Infarction of the septomarginal band and tricuspid papillary muscle rupture related to alcohol septal ablation for hypertrophic cardiomyopathy.

We presented a 77-year-old man with hypertrophic obstructive cardiomyopathy applied with flail tricuspid leaflet and severe tricuspid regurgitation leading to right heart failure 2 months after the failed septal ablation. The ruptured anterior tricuspid papillary muscle resulted from infarction of the base of anterior papillary muscle of the right ventricle (RV) confirmed by magnetic resonance imaging. As the septomarginal band is frequently lit up by intracoronary contrast that particular attention should be paid to the RV papillary muscles. And, if the papillary muscles or the RV free wall is brightened, then the use of that septal artery should be avoided.

Red Cell Distribution Width with CHADS2 and CHA2DS2-VASc score is associated with Post-operative Atrial Fibrillation after Coronary Artery Bypass Grafting.

BACKGROUND: The use of the CHA2DS2-VASc scoring system and red cell distribution width (RDW) as post-op Atrial Fibrillation (POAF) predictors may be promising for the identification of patients that are at a higher risk of POAF. METHODS: A total of 358 patients (57 patients with POAF, and 301 patients with non-POAF ) with sinus rhythm undergoing a coronary artery bypass graft (CABG) operation were included in the study retrospectively. Preoperative RDW levels and electrocardiograms with sinus rhythm were recorded. Patients with at least one 12-lead electrocardiogram with atrial fibrillation in the postoperative period, with or without medical or electrical cardioversion, were considered to have postoperative atrial fibrillation. A CHADS2 and CHA2DS2-VASc score was calculated for all of the patients. RESULTS: RDW levels were significantly higher in POAF group. RDW levels were significantly correlated with CHADS2 ( r = 0.15, P = .007) and CHA2DS2-VASc (r = 0.19 P = .0001) scores. CHA2DS2-VASc scores were significantly higher in patients with POAF, whereas CHADS2 scores did not differ between groups. In multivariate analysis, left atrial diameter (LAD) (OR:2.44 [95% CI 1.16 - 5.1], P = .018), age (OR:1.04 [95% CI 1.01 - 1.08], P = .01), and RDW (OR:1.16 [95% CI 1.0 - 1.36], P = .05) were found to be predictive for POAF. The area under the receiver-operating characteristic curve of RDW was 0.65 (0.57 - 0.72, P = .0001) with 68.4% sensitivity and 51.2 % specificity to predict POAF. CONCLUSION: Our study showed that age, LAD, and the reduced probability of RDW are predictors of POAF, and that RDW is strongly associated with the thromboembolic risk as determined by CHADS2 and CHA2DS2-VASc scores.

Is right atrioventricular valve always tricuspid?

A 71-year-old male with a medical history of hypertension was admitted to emergency department with hypertensive pulmonary edema. The patient appeared anxious and diaphoretic, and physical examination revealed tachypnea, crepitant rales in the both lungs and a systolic ejection murmur at the right sternal border, radiating to the both carotid arteries. The electrocardiography showed sinus tachycardia with indications of left ventricle hypertrophy Before the aortic valve surgery, transesophageal echocardiography (TEE) was performed for detailed evaluation of the aortic valve. Two-dimensional TEE showed mild tricuspid valve regurgitation and only two of three leaflets of the tricuspid valve at a time.

A rare complication of mechanical aortic valve replacement: Separation in the region of the mitral-aortic intervalvular fibrosa.

A 28-year-old man was admitted to our emergency service with a shortness of breath and palpitation. On admission, his blood pressure was high and he was in hypertensive pulmonary edema. His physical examination showed rales in both lungs and pansystolic murmur at mitral focus. His medical history included aortic valve replacement (AVR) because of native aortic valve infective endocarditis. Transthoracic echocardiography (TTE) showed normal functional aortic valve. Color flow imaging demonstrated severe mitral regurgitation with posterior eccentric jet. To examine in detail, transesophageal echocardiography (TEE) and three-dimensional (3D) echocardiography were performed. TEE disclosed a separation in the subaortic curtain leading to severe mitral regurgitation from the left ventricle to the left atrium. In addition to severe mitral regurgitation with posterior eccentric jet, 26-mm-long pouch was seen in mitral-aortic intervalvular fibrosa (MAIVF) at 120° TEE view. This pouch was separated from the mitral anterior leaflet junction releasing the mitral anterior leaflet and causing prolapse and chorda rupture in the A2 scallop of the mitral anterior leaflet. The MAIVF connects the anterior mitral leaflet to the posterior portion of the aortic annulus. The separation of the MAIVF represents a complication of the aortic valve replacement.

Spontaneous embolization of an atrial septal defect occluder device into the left ventricular outflow tract in a patient with pulmonary stenosis.

A 24-year-old man was admitted to our outpatient clinic for his routine checkup of consecutively percutaneously treated atrial septal defect (ASD) and pulmonary valvular stenosis 45 days ago. A 24 mm ASD occluder device was implanted under transthoracic echocardiographic guidance and 80 mm Hg peak-to-peak pulmonary valvular gradient decreased to 20 mm Hg gradient after pulmonary valve dilatation with 23 mm NUMED II transluminal valvuloplasty catheter balloon. Atrial septal defect (ASD) closure is now routinely performed using a percutaneous approach under echocardiographic guidance especially transthoracic echocardiography (TEE). Centrally located, ostium secundum type and less than 3.5 cm in size are considered ideal for device closure. Although there is considerable variation in size and location of the defects, TEE guidance is quite important for this proportion of ASDs. The selection of patients for percutaneous transcatheter closure of a secundum ASD requires accurate information regarding the anatomy of the defect such as its maximal diameter and the amount of circumferential tissue rims.

A new and simple method for clarifying the severity of tricuspid regurgitation.

BACKGROUND: No gold standard exists for grading tricuspid regurgitation (TR) severity. We developed a simple parameter, the right ventricular (RV) early inflow-outflow (RVEIO) index, using the early diastolic filling velocity and RV outflow velocity integrated over the systolic ejection period. We hypothesized that this index would help identify severe TR in clinical practice. METHODS: We obtained data from routine transthoracic echocardiograms. All records reporting moderate (n=395) or severe (n=395) TR were reanalyzed to measure vena contracta (VC) width, TR jet area, effective regurgitant orifice (EROA) derived with the proximal isovelocity surface area method, RVEIO index, and right-sided chamber volumes. RESULTS: Significant linear trends were demonstrated for right atrial volume index, end-diastolic volume index, E-wave velocity, RV velocity time integral, TR jet area, VC width, and EROA with increasing TR severity. Independent predictors of severe RT included RVEIO index ≥ 10, VC width ≥ 0.7 cm, TR jet area>10 cm2 , and EROA ≥ 0.4 cm2 . CONCLUSION: RVEIO index is a useful, simple, accurate, and independent predictor of severe TR that adds incrementally to traditional methods of quantifying TR severity. Accurate quantification and classification of TR severity is critical for clinical decision-making and management; therefore, the incorporation of RVEIO index into the integrative approach to grading TR severity should be considered.

Left atrial remodeling in patients undergoing percutaneous mitral valve repair with the MitraClip system: an advanced echocardiography study.

BACKGROUND: The goal of this study was to determine changes in left atrial (LA) function with two-dimensional speckle tracking echocardiography (2DSTE) and real-time full-volume three-dimensional echocardiography (RT3DE) after percutaneous mitral valve repair with the MitraClip system. Furthermore, we investigated whether baseline and/or changes in LA function after MitraClip repair had any impact on prognosis. METHODS: A total of 25 consecutive patients (age: 57±12 years, 76% male) with moderate-to-severe or severe mitral regurgitation (MR) were included. Patients underwent 2DSTE and RT3DE before the clip implantation and after the 12-month follow-up. Prognostic data were also recorded via the use of telephone calls and follow-up visits for 12 months after the procedure. RESULTS: Compared with the baseline, the LA reservoir strain (LA-Res) (7.66±4.3% vs 11.15±7.5%, P<.001) and LA contraction strain (LA-Pump) (4.64±4.3% vs 7.63±5.8%, P=.001) improved significantly after MitraClip repair; significant improvements were also seen in three-dimensional (3D) minimum LA volume index (LAV min) and maximum LA volume index (LAV max). On the other hand, conventional LA indices did not change. In total, eleven major adverse cardiac events (MACE) were observed at the 1-year follow-up. In univariate analyses, the preprocedural echocardiographic parameters that were associated with the MACE within 1 year after MitraClip repair were 3D-LAV min and LA-Res. Furthermore, these indices significantly correlated with improved functional parameters and MR reduction. CONCLUSION: In conclusion, a successful MitraClip procedure can reverse the process of LA remodeling within 12 months, and this can be detected by 2DSTE and RT3DE. Also, patients with preprocedural lower LA-Res and higher 3D-LAV min had the worst prognoses at the 1-year follow-up.

[Pericardial effusion predicts mortality in patients with chronic obstructive pulmonary disease]. / Kronik obstrüktif akciger hastaliginda perikart sivi birikimi mortalite öngördürücüsüdür.

OBJECTIVES: Chronic obstructive pulmonary disease (COPD) is an increasingly important cause of morbidity and mortality worldwide. Pericardial effusion (PE) is a current issue proven to be a mortality predictor, especially in pulmonary arterial hypertension. In this study, we aimed to evaluate the prognostic value of PE in COPD. STUDY DESIGN: The study cohort consisted of 488 COPD patients and a control group of 50 healthy patients. At the start of the study, 37 patients (7.5%) had PE. Mean follow-up time was 12 months (range; 1-16 months). Clinical spirometric and echocardiographic data were compared between patients with PE(+) group (n=37), patients without PE(-) group (n=451) and the healthy control group. RESULTS: Right ventricular functions were more depressed and pulmonary arterial pressure was more elevated in the PE(+) group. Also, Kaplan-Meier survival curve analysis showed that at one-year follow- up, mortality was higher in the PE(+) group: PE(-) group 139 (30.8%), PE(+) group 21 (56.8%) log-Rank p value: 0.009). Age, presence of PE, and oxygen usage were independent predictors of mortality in Cox regression analysis. CONCLUSION: Presence of PE predicts mortality in COPD patients at one-year follow-up.

The value of plasma D-dimer level on admission in predicting no-reflow after primary percutaneous coronary intervention and long-term prognosis in patients with acute ST segment elevation myocardial infarction.

D-dimer is a final product of fibrin degradation and gives an indirect estimation of the thrombotic burden. We aimed to investigate the value of plasma D-dimer levels on admission in predicting no-reflow after primary percutaneous coronary intervention (p-PCI) and long-term prognosis in patients with ST segment elevation myocardial infarction (STEMI). We retrospectively involved 569 patients treated with p-PCI for acute STEMIs. We prospectively followed up the patients for a median duration of 38 months. Angiographic no-reflow was defined as postprocedural thrombolysis in myocardial infarction (TIMI) flow grade <3 or TIMI 3 with a myocardial blush grade <2. Electrocardiographic no-reflow was defined as ST-segment resolution <70%. The primary clinical end points were mortality and major adverse cardiovascular events (MACE). The incidences of angiographic and electrocardiographic no-reflow were 31 and 39% respectively. At multivariable analysis, D-dimer was found to be an independent predictor of both angiographic (p < 0.001), and electrocardiographic (p < 0.001) no-reflow. Both mortality (from Q1 to Q4, 5.7, 6.4, 11.3 and 34.1%, respectively, p < 0.001) and MACE (from Q1 to Q4, 17.9, 29.3, 36.9 and 52.2%, respectively, p < 0.001) rates at long-term follow-up were highest in patients with admission D-dimer levels in the highest quartile (Q4), compared to the rates in other quartiles. However, Cox proportional hazard model revealed that high D-dimer on admission (Q4) was not an independent predictor of mortality or MACE. In contrast, electrocardiographic no-reflow was independently predictive of both mortality [Hazard ratio (HR) 2.88, 95% confidence interval (CI) 1.04-8.58, p = 0.041] and MACE [HR 1.90, 95% CI 1.32-4.71, p = 0.042]. In conclusion, plasma D-dimer level on admission independently predicts no-reflow after p-PCI. However, D-dimer has no independent prognostic value in patients with STEMI.