Acute and chronic effects of mokuboito in a patient with heart failure due to severe aortic regurgitation.

Medical treatment for heart failure is still limited in patients with symptomatic aortic regurgitation (AR). Here we report the effects of mokuboito used in combination with standard medical therapy for heart failure in an inoperable patient with symptomatic severe AR. We observed acute effects of mokuboito in decreasing systemic vascular resistance and increasing cardiac output, as well as its chronic effects in improving New York Heart Association class, plasma brain natriuretic peptide levels, and left ventricular diastolic function. Given its efficacy, the use of mokuboito might be an additional treatment for patients with heart failure.

Native valve disease in patients with non-valvular atrial fibrillation on warfarin or rivaroxaban.

OBJECTIVE: To compare the characteristics and outcomes of patients with atrial fibrillation (AF) and aortic stenosis (AS) with patients with AF with mitral regurgitation (MR) or aortic regurgitation (AR) and patients without significant valve disease (no SVD). METHODS: Using Rivaroxaban Once-Daily, Oral, Direct Factor Xa Inhibition Compared With Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF) data, we analysed efficacy and safety outcomes, adjusting hazard ratios (HRs) for potential confounders using Cox regression analysis. RESULTS: Among 14 119 intention-to-treat ROCKET AF trial patients, a trial that excluded patients with mitral stenosis or artificial valve prosthesis, 214 had AS with or without other valve abnormalities, 1726 had MR or AR and 12 179 had no SVD. After adjusting for prognostic factors, the composite of stroke, systemic embolism or vascular death increased approximately twofold in patients with AS (AS 10.84, MR or AR 4.54 and no SVD 4.31 events per 100 patient-years, p=0.0001). All-cause death also significantly increased (AS 11.22, MR or AR 4.90 and no SVD 4.39 events per 100 patient-years, p=0.0003). Major bleeding occurred more frequently in AS (adjusted HR 1.61, confidence intervals (CI) 1.03 to 2.49, p<0.05) and MR or AR (HR 1.30, 1.07 to 1.57, p<0.01) than in no SVD, but there was no difference between AS and MR or AR (HR 1.24, 0.78 to 1.97). The relative efficacy of rivaroxaban versus warfarin was consistent among patients with and without valvular disease. Rivaroxaban was associated with higher rates of major bleeding than warfarin in patients with MR or AR (HR 1.63, 1.15 to 2.31). CONCLUSIONS: We found that patients with AF and AS on oral anticoagulants may have distinctly different efficacy and safety outcomes than patients with MR or AR or no SVD. TRIAL REGISTRATION NUMBER: NCT00403767; Post-results.

Clinical characteristics and outcomes with rivaroxaban vs. warfarin in patients with non-valvular atrial fibrillation but underlying native mitral and aortic valve disease participating in the ROCKET AF trial.

AIMS: We investigated clinical characteristics and outcomes of patients with significant valvular disease (SVD) in the Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF) trial. METHODS AND RESULTS: ROCKET AF excluded patients with mitral stenosis or artificial valve prostheses. We used Cox regression to adjust comparisons for potential confounders. Among 14 171 patients, 2003 (14.1%) had SVD; they were older and had more comorbidities than patients without SVD. The rate of stroke or systemic embolism with rivaroxaban vs. warfarin was consistent among patients with SVD [2.01 vs. 2.43%; hazard ratio (HR) 0.83, 95% confidence interval (CI) 0.55-1.27] and without SVD (1.96 vs. 2.22%; HR 0.89, 95% CI 0.75-1.07; interaction P = 0.76). However, rates of major and non-major clinically relevant bleeding with rivaroxaban vs. warfarin were higher in patients with SVD (19.8% rivaroxaban vs. 16.8% warfarin; HR 1.25, 95% CI 1.05-1.49) vs. those without (14.2% rivaroxaban vs. 14.1% warfarin; HR 1.01, 95% CI 0.94-1.10; interaction P = 0.034), even when controlling for risk factors and potential confounders. In intracranial haemorrhage, there was no interaction between patients with and without SVD where the overall rate was lower among those randomized to rivaroxaban. CONCLUSIONS: Many patients with 'non-valvular atrial fibrillation' have significant valve lesions. Their risk of stroke is similar to that of patients without SVD after controlling for stroke risk factors. Efficacy of rivaroxaban vs. warfarin was similar in patients with and without SVD; however, the observed risk of bleeding was higher with rivaroxaban in patients with SVD but was the same among those without SVD. Atrial fibrillation patients with and without SVD experience the same stroke-preventive benefit of oral anticoagulants.

Comparative study of vasodilators in an animal model of chronic volume overload caused by severe aortic regurgitation.

BACKGROUND: Aortic regurgitation (AR) is a disease of chronic left ventricular (LV) volume overload. Over time, AR will lead to LV dilatation, hypertrophy, and loss of function. There is currently no medical treatment proven effective to slow the evolution of this cardiomyopathy. Vasodilators were once thought to have protective effects, but recent publications have cast some doubts about their effectiveness. We hypothesized that drugs targeting the renin-angiotensin system should be more effective than those having no direct effect on the renin-angiotensin system. METHODS AND RESULTS: We designed a protocol comparing the effects of 3 vasodilators in a rat AR model (n=9 to 11 animals per group). The effects of a 6-month treatment of (1) nifedipine, (2) captopril, or (3) losartan were compared in male AR rats. Sham-operated and untreated AR animals were used as controls. Nifedipine-treated animals displayed hemodynamics, LV dilatation, hypertrophy, and loss of function similar to those of the untreated group. Both captopril and losartan were effective in improving hemodynamics, slow LV dilatation, hypertrophy, and dysfunction. Gene expression analysis confirmed the lack of effects of the nifedipine treatment at the molecular level. CONCLUSIONS: Using an animal model of severe AR, we found that vasodilators targeting the renin-angiotensin system were effective to slow the development of LV remodeling and to preserve LV function. As recently shown in the most recent human clinical trial, nifedipine was totally ineffective. Targeting the renin-angiotensin system seems a promising avenue in the treatment of this disease, and clinical trials should be carefully designed to re-evaluate the effectiveness of angiotensin I-converting enzyme inhibitors or angiotensin II receptor blockers in AR.

High prevalence of fenfluramine-related aortic regurgitation in women with end-stage renal disease secondary to Chinese herb nephropathy.

BACKGROUND: Non-controlled studies have noted a high prevalence of valvular regurgitation in patients with Chinese herb nephropathy; most of these patients had taken appetite suppressants. We aimed to determine the prevalence of valvular regurgitation and the role of appetite suppressants in patients with Chinese herb nephropathy. METHODS: This case-controlled echocardiographic study included 40 patients with end-stage renal failure due to Chinese herb nephropathy and 37 age-matched controls with end-stage renal disease due to nephropathy of other origin. Quantification of cumulative doses of appetite suppressants was performed. RESULTS: Aortic regurgitation was detected in 52.5% of patients with Chinese herb nephropathy, 72+/-1 months after stopping appetite suppressants, and in 21.6% of controls (P=0.009). No difference was found in the incidence of mitral or tricuspid regurgitation. A history of slimming medication was the only significant determinant for aortic regurgitation (P=0.009). Higher cumulative doses of Chinese herbs, (dex)fenfluramine and diethylpropion were observed in patients with Chinese herb nephropathy with, when compared to those without, aortic regurgitation. The dose-response relationship between the cumulative dose of drugs and the presence of aortic regurgitation was significant for fenfluramine only (chi-square=5.16, P=0.024). CONCLUSIONS: Six years after stopping appetite suppressants, aortic regurgitation remains highly prevalent among patients with end-stage Chinese herb nephropathy. The dose-related association with fenfluramine intake strongly confirms a determinant pathogenic role of anorectic drugs.

Beating-heart valvular surgery: a possible alternative for patients with severely compromised ventricular function.

Cardioplegic arrest of the severely compromised ventricle may make weaning from cardiopulmonary bypass problematic. We report a novel approach to myocardial protection in a patient requiring multi-valve surgery who had an ejection fraction of 15%. Warm oxygenated blood was infused continuously both antegrade and retrograde during aortic valve replacement and mitral and tricuspid valve repair. Adequacy of perfusion was confirmed by the absence of electrocardiographic changes. Clinical improvement suggests that this strategy of myocardial protection warrants further investigation.

Left ventricular outflow tract obstruction unmasked by nifedipine: a therapeutic pitfall in the management of chronic aortic regurgitation.

This case report illustrates the aggravation of a clinically silent left ventricular outflow tract obstruction by maintenance use of nifedipine in a patient with chronic severe aortic regurgitation, and demonstrates a potential limitation of vasodilator therapy in the management of this patient population. Recognition of this clinical scenario is imperative, as decision making in patients with chronic severe aortic regurgitation rests on the development of symptoms and/or left ventricular dysfunction in relation to the regurgitant volume. The importance of echocardiography in the detection of this valvular finding and in the follow up of these patients is emphasized.

Cardiac surgery using only autologous blood for a patient with hereditary spherocytosis: a case report.

A 50-year-old man was admitted to our hospital for possible surgery. Echocardiogram showed severe calcification of the aortic valve, and cardiac catheter examination recorded a gradient greater than 150 mmHg across the valve. These results determined aortic valve replacement (AVR) to relieve the pressure-overloaded ventricle. Preoperative evaluations however, demonstrated anemia derived from hereditary spherocytosis (HS), an inherited hemolytic disorder. In order to avoid homologous blood transfusion, the following strategies were tried; 1) an iron supplement and an injection of recombinant human erythropoietin (rHuEPO); 2) pre- and perioperative autologous blood transfusion; and 3) an aggressive iron supplement just after the surgery. These raised the blood hemoglobin concentration to the criterion where autologous blood donation was started, and maintained the hemoglobin level stable, up to his discharge. In conclusion, bloodless cardiac surgery is possible for cases with anemia, and some strategies should be tried to raise and maintain the blood hemoglobin concentration well.

[Erythropoietin for autologous transfusion. Use in a case of severe anemia with allo-immunization]. / Erythropoiétine pour transfusion autologue. Utilisation dans un cas d'anémie grave avec allo-immunisation.

In view of the transfusional risks of viral transmission (notably HIV), autologous transfusion is increasingly used; it is often the only possible type of transfusion. A 42-year-old woman with lupus erythematosus, chronic renal failure and triple cardiac valve disease demanding surgery was admitted for multifactorial severe anaemia. Treatment with erythropoietin (8000 units/day) iron replenishment, corticosteroids and polyvalent immunoglobulins was initiated. The patient was operated upon in April 1990. A preoperative cell-saver autotransfusion was performed during surgery. The postoperative period was uneventful. Homologous transfusion was not necessary. In this case where homologous transfusion was ruled out, erythropoiesis stimulated by erythropoietin enabled autotransfusion and cardiac surgery to be performed.

[Postoperative complications and treatments after Bentall operation].

Postoperative complications of Bentall operation for the annuloaortic ectasia have frequently occurred, although the mortality has been reduced. To reduce complications after Bentall operation we have taken three major treatments since 1987. The first was reimplantation technique of coronary ostia in replacing the ascending aorta and the aortic valve with a tube graft. The second was the infusion technique of cardioplegic solution such as retrograde cardioplegia infusion. The third method was to save blood and reduce the blood transfusion by preserving autoblood preoperatively and using cell saving machine. The purpose of this study was to analyse 20 patients who underwent the Bentall procedure and to investigate the effect of our treatments in Bentall operation on the operative results. We divided our patients into two groups. Fourteen patients in the group 1 were operated before 1987, when our principles were not performed. Six patients in group II were operated under the principles mentioned above. There were no differences in cardiopulmonary bypass time and ischemic time between group I and II. Transfused blood volume in group II was remarkably less than that of group I. Postoperative complications occurred in all patients in group I (100%), while three patients in group II (50%) had complications (p less than 0.05). We, hence, conclude that our method could be useful for reducing postoperative complication rate in Bentall operation.

Geometric and functional correlates of electrocardiographic repolarization and voltage abnormalities in aortic regurgitation.

Although electrocardiographic left ventricular hypertrophy is a recognized marker of disease severity in patients with chronic aortic regurgitation, the quantitative relations of repolarization abnormalities and QRS voltage to measurements of cardiac structure and function have not been established. The presence or absence of the "strain" pattern of repolarization and QRS voltage was compared with echocardiographic and radionuclide cineangiographic findings in 95 adults with sever, pure, chronic aortic regurgitation and no evidence of coronary artery disease. In contrast to 54 patients with normal repolarization, 41 patients with an abnormal repolarization pattern had greater left ventricular end-diastolic and end-systolic dimensions (7.2 +/- 1.1 versus 6.6 +/- 0.8 cm, p less than 0.002 and 5.2 +/- 1.2 versus 4.4 +/- 0.7, p less than 0.001, respectively), greater left ventricular mass (431 +/- 138 versus 303 +/- 89 g, p less than 0.001), higher end-systolic stress (128 +/- 46 versus 95 +/- 27 dynes-cm2 X 10(3), p less than 0.001), lower fractional shortening (28 +/- 8 versus 34 +/- 5%, p less than 0.001) and lower exercise ejection fraction (39 +/- 11 versus 51 +/- 8%, p less than 0.001). Multiple logistic regression analysis revealed that left ventricular mass and end-systolic stress were independently related to the presence of repolarization abnormalities (p less than 0.005). Among the 73 asymptomatic patients, those with normal repolarization had significantly lower prevalences of fractional shortening less than 25% (1 of 45 versus 5 of 27, p less than 0.05), left ventricular systolic dimension greater than 5.5 cm (1 of 45 versus 8 of 27, p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Beneficial effect of taurine in rabbits with chronic congestive heart failure.

To examine the effect of daily treatment with taurine on improving the status of congestive heart failure (CHF), we used rabbits with artificially induced aortic regurgitation. Ten rabbits were treated daily with taurine (100 mg/kg by mouth) and eight with guanidinoethyl sulfonate (GES) (100 mg/kg by mouth) immediately after induction of aortic regurgitation. The cumulative mortality rate at 8 weeks in the taurine-treated CHF group was 10% (1 of 10) compared with 53% (16 of 30) in the nontreated CHF group and 75% (6 of 8) in the GES-treated CHF group (p less than 0.05). Although cardiac function (max dP/dt) in CHF rabbits was significantly decreased (p less than 0.001), taurine-treated CHF rabbits maintained the same values as control rabbits. Taurine content of the left ventricular tissue of the CHF rabbits was significantly increased (p less than 0.01). Administration of taurine and GES to control rabbits for 8 weeks affected neither the hemodynamics nor the taurine content of the heart. It was concluded that taurine slowed the rapid progression of heart failure and consequently prolonged life expectancy.

Subacute bacterial endocarditis following ear acupuncture.

Ear acupuncture followed by sepsis caused subacute bacterial endocarditis in a patient with rheumatic valve disease.