Infective endocarditis in pregnancy: A case report / 北京大学学报(医学版)

Infective endocarditis in pregnancy is extremely rare in clinical practice. Guidelines addressing prophylaxis and management of infective endocarditis do not extensively deal with concomitant pregnancy, and case reports on infective endocarditis are scarce. Due to increased blood volume and hemodynamic changes in late pregnancy, endocardial neoplasms are easy to fall off and cause systemic or pulmonary embolism, respiratory, cardiac arrest and sudden death may occur in pregnant women, the fetus can suffer from intrauterine distress and stillbirth at any time, leading to adverse outcomes for pregnant women and fetuses. The disease is dangerous and difficult to treat, which seriously threatens the lives of mothers and babies. Early diagnosis and reasonable treatment can effectively improve the prognosis of patients. The most important method for the treatment of infective endocarditis requires early, adequate, long-term and combined antibiotic therapy. Moreover, surgical controversies regarding indication and timing of treatment exist, especially in pregnancy. In terms of the timing of termination of pregnancy, the timing of cardiac surgery, and the method of surgery, individualized programs must be adopted. A pregnant woman with 30+5 weeks of gestation is reported. She was admitted to hospital due to intermittent chest tightness, suffocation and fever, with grade Ⅲ cardiac insufficiency. Imaging revealed large mitral valve vegetation, 22.0 mm×4.1 mm and 22.0 mm×5.1 mm, respectively, and severe valve regurgitation. Mitral valve perforation was more likely, blood culture suggested Staphylococcus epidermidis infection, after antibiotic conservative treatment, the effect was poor. After the joint consultation including cardiology, neonatology, interventional vascular surgery, anesthesiology, and obstetrics, the combined operation of obstetrics and cardiac surgery was performed in time. The heart was blocked for 60 minutes, the bleeding was 1 200 mL, the newborn was mildly asphyxiated after birth, and the birth weight was 1 890 g. Nine days after the operation, the patient was discharged from the hospital, and the newborn was discharged with the weight of 2 020 g. Critical cases like this require a thorough weighing of risks and benefits followed by swift action to protect the mother and her unborn child. An optimal outcome in a challenging case like this greatly depends on effective interdisciplinary communication, informed consent of the patient, and concerted action among the specialists involved.

Endocardite aórtica e tricúspide em pacientes de hemodiálise com embolia sistêmica e pulmonar / Aortic and tricuspid endocarditis in hemodialysis patient with systemic and pulmonary embolism

RESUMO Este artigo relata o caso de um homem caucasiano de 43 anos de idade com nefropatia terminal em tratamento com hemodiálise e apresentando endocardite infecciosa das válvulas aórtica e tricúspide. O quadro clínico foi dominado pelo comprometimento neurológico, devido à embolia cerebral e a componentes hemorrágicos. Uma tomografia computadorizada tóraco-abdominal revelou um êmbolo séptico pulmonar. O paciente foi submetido à antibioticoterapia empírica utilizando ceftriaxona, gentamicina e vancomicina, sendo o tratamento modificado para flucloxacilina e gentamicina após o isolamento de S. aureus nas hemoculturas. A equipe multidisciplinar determinou que o paciente deveria ser submetido à substituição de válvulas após estabilização da hemorragia intracraniana; contudo, no oitavo dia após a hospitalização, o paciente entrou em parada cardíaca causada por embolia séptica pulmonar maciça, vindo a falecer. Apesar do risco de agravamento da lesão hemorrágica cerebral, em pacientes de alto risco deveria ser considerado realizar precocemente uma intervenção cirúrgica.

ABSTRACT This is a case report of a 43-year-old Caucasian male with end-stage renal disease being treated with hemodialysis and infective endocarditis in the aortic and tricuspid valves. The clinical presentation was dominated by neurologic impairment with cerebral embolism and hemorrhagic components. A thoracoabdominal computerized tomography scan revealed septic pulmonary embolus. The patient underwent empirical antibiotherapy with ceftriaxone, gentamicin and vancomycin, and the therapy was changed to flucloxacilin and gentamicin after the isolation of S. aureus in blood cultures. The multidisciplinary team determined that the patient should undergo valve replacement after the stabilization of the intracranial hemorrhage; however, on the 8th day of hospitalization, the patient entered cardiac arrest due to a massive septic pulmonary embolism and died. Despite the risk of aggravation of the hemorrhagic cerebral lesion, early surgical intervention should be considered in high-risk patients.

Anticoagulação na insuficiência cardíaca e valvopatias / Anticoagulation in heart failure and valvulopathies

A insuficiência cardíaca e as valvopatias são entidades patológicas representativas de expressiva parte do universo das cardiopatia sem nosso meio. No curso de sua evolução, têm como denominador comum o risco de desenvolvimento de eventos tromboembólicos,responsáveis muitas vezes por graves sequelas neurológicas. Os mecanismos descritos por Virchov (hipercoagulabilidade, estase, e alteração da função do endotélio - parede vascular) estão presentes nestes pacientes e explicam a maior incidência desses eventos. Embora a compreensão do risco seja algo claro na literatura atual, menos claro é o real benefício da anticoagulação e ou antiagregação plaquetária para prevenção dos eventos tromboembólicos nessa população. Particularmente na presença de fibrilação atrial, ambas as entidades expõem os pacientes ao risco de fenômenos embólicos. Na eventual presença de próteses valvares, este risco pode ser ainda superior. A opção por uma terapia anticoagulante para a prevenção de um evento trombótico ou embólico deve ser baseada na avaliação particular do risco de um paciente e nos possíveis benefícios que a anticoagulação pode oferecer. Portanto, a prevenção do tromboembolismo deve fazer parte do manejo dos pacientes portadores de insuficiência cardíaca e doença valvar. Nesse artigo, procuramos revisar sumariamente aspectos epidemiológicos e os mecanismos envolvidos na gênese do risco trombótico desses pacientes e buscamos com base em estudos clínicos relevantes, meta-análises, revisões de literatura e diretrizes vigentes, identificar as situações de benefício da terapia antitrombóticanos pacientes com IC e valvopatias.

Heart failure (HF) and cardiac valvular disease are majorrepresentatives of the pathological cardiovascular diseases. In thenatural course of these diseases, they share a major denominator,the risk of thromboembolism, which in turn are responsible forsevere neurological damage. The mechanisms described by Virchov(hypercoagulability, stasis and alteration of the endotheliumfunction - the vascular wall) are present in these patients and explainthe higher incidence of these events. Although the understandingof the risk of thromboembolism is clear in the literature, it is notwell known the real benefit of anticoagulation and/or antiplatelettherapy for the prevention of thromboembolic events in patients atrisk. Particularly, in the presence of atrial fibrillation, both entitiesexpose these individuals to the risk of severe thromboembolism.When valvular prosthesis are present, this risk can be increasedseveral times. The choice of the best regimen of the anticoagulantand antiplatelet therapies to the prevention of thromboembolismshould be based in the individual risk of patients and in the possiblebenefits offered by the anticoagulation. As both heart failure andcardiac valvular diseases share the necessity of anticoagulation,this article reviews the epidemiology and mechanisms involved inthe genesis of thrombotic risk in these patients. Relevant clinicaltrials, meta-analysis, literature reviews and current guidelines arethe foundation to identify the benefits of antithrombotic therapy inthis population.

Uso crônico de anticoagulante oral: implicações para o controle de níveis adequados / Constant use of oral anticoagulants: implications in the control of their adequate levels / Uso crónico de anticoagulante oral implicaciones para el control de niveles adecuados

FUNDAMENTO: Dosagens inapropriadas e subterapêuticas anticoagulantes podem resultar em sérias complicações tromboembólicas. O uso dessa terapêutica requer especial atenção e precisa de um acompanhamento clínico e laboratorial rigoroso. OBJETIVO: Identificar fatores associados ao controle adequado dos níveis de anticoagulação oral, verificando o conhecimento e a percepção dos pacientes relacionados à terapêutica empregada. MÉTODOS: Estudo transversal que incluiu 140 pacientes acompanhados no ambulatório de anticoagulação oral, de novembro de 2005 a junho de 2006. Um questionário estruturado foi elaborado e aplicado para obtenção de características clínicas, conhecimento sobre a terapêutica, adesão ao tratamento (teste de Morisky) e percepção do paciente. RESULTADOS: As principais indicações para uso do anticoagulação oral foram fibrilação atrial (61,4 por cento) e prótese metálica (55 por cento). O tempo de uso variou entre 24 e 72 meses, e o femprocumona (58 por cento) foi o mais empregado. Em relaçãoà percepção da terapêutica, 95 por cento dos pacientes mencionaram preocupação com o uso diário dessa medicação. A realização periódica de exames de sangue (21,4 por cento) e a tomada rigorosa de anticoagulação oral (12,8 por cento) foram compreendidas como limitantes. Observou-se conhecimento adequado entre os pacientes com international normalized ratio (INR) fora da faixa (64 por cento) e na aderência entre os pacientes com INR dentro da faixa terapêutica (54 por cento), porém sem significância estatística. CONCLUSÃO: Os resultados deste estudo demonstraram uma prevalência de pacientes em uso de anticoagulação oral com o INR dentro dos valores ideais, embora tenha sido grande a porcentagem de pacientes não-aderentes à terapêutica. O conhecimento insatisfatório quanto à terapêutica empregada e ao autocuidado torna-se evidente nessa população.

BACKGROUND: Inappropriate and subtherapeutic anticoagulants dosages may result in severe thromboembolic and bleeding complications. The use of this treatment requires special attention and strict clinical and laboratory follow-up. OBJECTIVE: To identify factors associated with appropriate control of the oral anticoagulant use, assessing the patients' knowledge and perception of the treatment. METHODS: A cross-sectional study which included 140 patients followed in the oral anticoagulation outpatient clinic from November 2005 to June 2006. A structured questionnaire was drafted and applied to obtain the clinical characteristics of the patients and their knowledge about the treatment, their compliance with the treatment (Morisky´s test) and their perception of the treatment. RESULTS: The main indications for the use of oral anticoagulation therapy were atrial fibrillation (61.4 percent) and a prosthetic heart valve (55 percent). The duration of anticoagulation ranged from 24 to 72 months, and phenprocoumon (58 percent) was the most commonly used anticoagulant. As to the perception of the treatment, 95 percent of the patients mentioned concern about daily use of this medication. Periodic blood tests (21.4 percent) and the strict intake of oral anticoagulant (12.8 percent) were considered limiting factors. Adequate knowledge was outstanding in patients with an international normalized ratio (INR) outside the therapeutic range (64 percent), compared to patients with an INR within the therapeutic range (62 percent), as well as compliance with treatment in patients with an INR within the therapeutic range (54 percent), but with no statistical significance. CONCLUSION: The results of this study show a prevalence of patients using oral anticoagulant with an INR within optimal values, although a high percentage of patients do not comply with the treatment. In this population it is clearly seen that they do not fully understand the treatment.

FUNDAMENTO: Dosis inapropiadas y subterapéuticas anticoagulantes pueden resultar en serias complicaciones tromboembólicas. El uso de esta terapéutica requiere especial atención y precisa un seguimiento clínico y analítico riguroso. OBJETIVO: Identificar factores asociados al control adecuado de los niveles de anticoagulación oral, verificando el conocimiento y la percepción de los pacientes relacionados a la terapéutica empleada. MÉTODOS: Estudio transversal que incluyó a 140 pacientes seguidos en el ambulatorio de anticoagulación oral, desde noviembre de 2005 a junio de 2006. Se elaboró y se aplicó un cuestionario estructurado para la obtención de características clínicas, conocimiento sobre la terapéutica, adhesión al tratamiento (test de Morisky) y percepción del paciente. RESULTADOS: Las principales indicaciones para uso de anticoagulación oral fueron fibrilación atrial (61,4 por ciento) y prótesis metálica (55 por ciento). El tiempo de uso varió entre 24 y 72 meses, y el fenprocumona (58 por ciento) fue el más empleado. Con relación a la percepción de la terapéutica, el 95 por ciento de los pacientes mencionaron preocupación con el uso diario de esta medicación. La realización periódica de análisis de sangre (21,4 por ciento) y el tomar anticoagulación oral rigurosamente (12,8 por ciento) fueron comprendidos como limitantes. Se observó conocimiento adecuado entre los pacientes con international normalized ratio (INR) fuera del intervalo (64 por ciento) y en la adhesión entre los pacientes con INR dentro del intervalo terapéutico (54 por ciento), aunque sin significancia estadística. CONCLUSIÓN: Los resultados de este estudio mostraron una prevalencia de pacientes en uso de anticoagulación oral con el INR dentro de los valores ideales, aunque haya sido grande el porcentaje de pacientes no adheridos a la terapéutica. El conocimiento insatisfactorio con relación a la terapéutica empleada y al autocuidado se vuelve evidente en esa población.

Late prosthetic valve endocarditis due to Cardiobacterium hominis, an unusual complication.

We report a case of prosthetic valve endocarditis caused by Cardiobacterium hominis in a patient who had undergone atrial septal defect closure and mitral valve replacement of the heart in 1978. He presented with pyrexia of unknown origin and congestive cardiac failure. Investigations revealed infective endocarditis of prosthetic valve in mitral portion. Blood culture samples grew C. hominis. The patient was empirically started on vancomycin and gentamicin intravenously and ceftriaxone was added after isolation of the organism. Though subsequent blood cultures were negative, patient remained in congestive cardiac failure and died due to complications.

Nitroglycerine improves cardiac functions during gynaecological laparoscopic surgery in patients with valvular heart disease, transesophageal echocardiographic study

Gynaecological laparoscopic surgery is being increasingly applied to a variety of operations. In patients with valvular heart disease, there may be a dangerous haemodynamic effects of both Trendelenburg position and abdominal gas insufflation in the form of increased regurgant flow with subsequent decrease in the ejection fraction. With the use of vasodilators [Nitroglycerine] this effect was improved to a great extent with the possibility that we can use the laparoscopic technique in valvular cardiac patients provided that the heart is compensated. We used transesophageal echocardiography [TEE] to monitor cardiac performance, gas embolism, and hemodynamic effects of positioning and pneumoperitoneum in 20 females complaining of regurgant valvular heart disease [mild to moderate mitral, tricusped, or aortic valve regurge], undergoing laparoscopic gynaecological surgical procedures.A four-chamber view was used continuously, except at predetermined intervals, when a complete TEE examination for cardiac function was performed. Other clinical variables recorded include systolic, diastolic, and mean arterial blood pressure; heart rate [HR], pulse oximetric saturations; and end-tidal CO2. Baseline valvular incompetence was seen in 13 of the 16 patients when supine and asleep. After positioning for surgery and induction of pneumoperitoneum, TEE revealed valvular incompetence with regurgitation more pronounced from baseline in 15 of 16 patients. In one patient, gas entered the right atrium from the inferior vena cava, worsening tricuspid regurgitation. Nitroglycerine infusion 1-2 micro g/kg/min was started after abdominal insufflation to evaluate its effects on valvular dysfunction during pneumoperitoneum and Trendelenburg position. Hemodynamic variables and ejection fraction were tested by using repeated-measures analysis of variance for significance [P<0.05]. Trendelenburg position resulted in insignificant increase in heart rate and decrease in mean arterial pressure. Pneumoperitoneum with Trendelenburg position resulted in significant increase in systolic and mean arterial pressure, with significant reduction in ejection fraction. The regurgant flow was significantly increased in all patients as detected by TEE. With the use of nitroglycerine infusion, significant improvement EF, with significant increase in heart rate. Using TEE, the regurgant flow was significantly decreased in all patients after nitroglycerine infusion. Laparoscopic gynaecologic surgical procedures can be performed in patients with mild to moderate valvular regurgitations. Nitroglycerine infusion can be of great help to decrease the regurgant flow which is increased due to both the Trendelenburg position and pneumoperitoneum

Manejo médico-quirúrgico en la disfunción de prótesis valvular mecánica cardica izquierda por obstrucción. Once años de experiencia / Medical and surgical treatment of left sided mechanic prosthesis valve dysfunction due to obstruction. Eleven years experience

Reportamos la experiencia médico-quirúrgica en disfunción de protesis valvulares mecánicas cardiacas izquierdas. De enero de 1986 a junio de 1997, se incluyeron a 108 pacientes consecutivos: 24 hombres y 84 mujeres, con edad promedio de 45 años, sometidos a 114 procedimientos quirúrgicos, 104 en posición mitral y 10 aórticos. El intervalo entre el reemplazo valvular y la disfunción fue de uno a 247 meses, media de 53.8 ñ 56.7 meses; 75 por ciento de los casos tenían anticoagulación inadecuada INR de 2.06 ñ 0.79. En 76 por ciento de los casos, la clase funcional (CF) fue III ó IV NYHA, el diagnóstico se realizó por clínica y ecocardiografía en 96 por ciento de los enfermos. Encontramos obstrucción por disco fijo en 107 casos y disfunción intermitente en siete. Los procedimientos quirúrgicos incluyeron 103 reemplazos protésicos y limpieza en 11 casos. Los hallazgos patológicos fueron: trombosis en 92 casos, pannus en nueve y ambos en 13 casos. El tiempo de circulación extracorpórea en los pacientes que fallecieron vs. los sobrevivientes fue (159.90 ñ 108.95 vs 87.32 ñ 27.53 min) y pinzamiento aórtico (64.8 ñ 20.69 vs 48.28 ñ 23.71 min) (p < 0.001), respectivamente. Hubo 12 muertos (10.5 por ciento), todos en CF III ó IV NYHA (p< 0.05); cinco fallecieron durante el procedimiento quirúrgico. En conclusión, el diagnóstico debe establecerse clínicamente apoyado en estudios de gabinetes. Los factores de riesgo asociados a la mortalidad fueron edema pulmonar, estado de choque, retraso en la cirugía tiempos quirúrgicos prolongados y clase funcional III ó IV de la NYHA

Effects of thrombolytic therapy on evolution of mitral regurgitation in patients with inferior wall myocardial infarction

Forty patients with first inferior wall MI were prospectively studied. Thrombolytic therapy [i.v. Streptokinase] was administered to 20 patients [SK group]. The other 20 patients [control group] received the conventional treatment for acute MI, but not streptokinase as they were not candidates for reperfusion therapy due to either late arrival or contraindications. Doppler echocardiography was performed one week after acute MI and repeated one month later aiming at studying MR and left ventricular function [LV]. Significant MR was defined as moderate or severe. Only p value < 0.05 was considered significant. It was concluded that thrombolytic therapy in inferior MI has beneficial effects, it reduces the incidence and severity of MR, preserves LV function and improves survival. In view of the present findings, the study supported the use of thrombolytic therapy in patients with inferior wall myocardial infarction

Anticoagulación en cardiología: segunda parte / Anticoagulation in cardiology: second part

En esta actualización se intenta mediante un conocimiento patogenético de los procesos tromboembólicos en varias enfermedades cardiovascular y la estratificación del riesgo en alto, mediano y bajo en las diferentes situaciones clínicas, establecer una terapéutica anticoagulante racional. En la circulación arterial, la injuria de la pared del baso produce activación plaquetaria y formación de fibrina, lo cual sugiere combinación de terapeutica antiagregante y anticoagulante. Los pacientes con alto riesgo con angina inestable o IAM deben ser tratados agresivamente con una combinación de inhibidores plaquetarios, anticoagulante y trombolíttaicos de acuerdo al caso clínico. Los pacientes tras angioplastia o bypass con puente venoso deben recibir antiagregantes y adecuada anticoagulación durante el procedimiento. Los pacientes con riesgo más moderado son los que se hallan en fase crónica estable de angina o con antecedentes de IAM, angioplastia o bypass y deben ser preferentemente tratados con inhibidores plaquetarios. En pacientes con bajo riesgo la aspirina debería ser reindicada a los que presentan factores de riesgo coronario como diabetes, tabaquismo, antecedentes familiares o hiercolesterolemia. Dentro de las cámaras cardíacas la activación del sistema de cascada de la coagulación predomina sobre la activación plaquetaria que la terapia anticoagulante sola es la más apropiada. En alto riesgo se encuentran aquellos con F.A. y embolismo previo asi como los que tienen F.A. con estenosis mitral o tirotoxicosis. Pacientes con mediano riesgo son los que cursan infarto anterior reciente o miocardiopatia dilatada descompensada. Algunos pacientes con F.A. sin valvulopatía entran dentro de este grupo, pero los subgrupos en esta población aún tienen que ser mejor definidos. Los más bajo riesgo son los pacientes con F.A. sin evidencia de cardiopatía y aquellos con aneurismas crónicos de ventrículo izquierdo. En las válvulas protésicas inteviene tanto la activación de la cascada de la coagulación, como en menor grado, la activación plaquetaria sobre todo en válvulas mecánicas. Los pacientes con alto riesgo aquellos con prótesis viejas o embolismo previo, deben ser tratados con anticoagulantes y antiagregantes. En mmediano riesgo se encuentran aquellos con modernas prótesis o con bioprótesis en presencia de F.A. que pueden ser matenidos con anticoagulación sola...

Intervençöes odontológicas na vigência de medicaçäo anticoagulante / Dental procedures during anticoagulant administration

Foram estudados 36 doentes sob tratamento com drogas anticoagulantes administradas por via oral e submetidos a intervençöes odontológicas. As idades variarm de 20 a 68 (média de 43,5) anos, Vinte (55,6%) enfermos eram do sexo feminino e 16 (44,4%) do masculino. Os medicamentos utilizados foram a fenindiona em 33 (91,7%) pacientes, o warfarin em um (2,7%) e a hidroxicumarina em dois (5,6%). Os doentes eram portadores de prótese valvar cardíaca metálica (23 casos, 64%), de bioprótese (dois casos, 5,5%), de outras valvopatias (nove casos, 25) de estenose prévia da valva mitral submetida à comissurotomia (dois casos, 5,5%). Foram realizadas: a) 83 intervençöes em caráter eletivo, nas quais as drogas foram suspensas por um período de 2 a 7 dias, até o tempo de protrombina atingir valores em torno de 60%. Foram observados dois hematomas gengivais sem repercussäo clínica expressiva; b) 16 intervençöes em caráter de urgência, sem interromper o uso de medicaçäo anticoagulante. Foi observado sangramento excessivo controlado sem dificuldade com medidas locais em um doente. Conclui-se que a intervençäo odontológica com baixo risco de sangramento pode ser realizada na vigência de medicaçäo anticoagulante