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CASE DESCRIPTION: A 67-year-old man was admitted with progressive heart failure due to blood culture-negative endocarditis of the aortic valve. Urgent aortic valve replacement was needed. Polymerase chain reaction (PCR) testing of samples of the explanted aortic valve revealed Tropheryma whipplei. The patient received ceftriaxone, followed by long-term co-trimoxazole. Recent arthralgia may have been a diagnostic clue. CONCLUSION: Whipple's endocarditis should be considered in patients with arthralgia and blood culture-negative endocarditis (BCNIE). LEARNING POINTS: Whipple's endocarditis should be considered in patients with symptoms of arthralgia and blood culture-negative endocarditis (BCNIE).Serum polymerase chain reaction is the main diagnostic test.Both physician awareness and multidisciplinary management by regional endocarditis teams are recommended strategies to provide optimal patient care.
RESUMEN
BACKGROUND: Clinicians lack substantiated guidance on when vitamin K antagonist (VKA) treatment should be interrupted preoperatively, especially with regard to phenprocoumon, with its long half-life of 5.5 days. OBJECTIVE: To evaluate the efficacy of discontinuing phenprocoumon 5 days preoperatively and determine whether a safe international normalized ratio (INR) was reached. METHODS: This was a retrospective review of 118 patients using phenprocoumon prior to elective surgery. Preoperative INRs and factors that could potentially influence these values were identified and described. A safe preoperative INR was defined as <1.8. RESULTS: Of the 118 included patients, 42 patients (35.6%) had an off-target INR. The male sex was significantly and independently associated with an off-target INR (odds ratio [OR] 2.4, 95% confidence interval [CI] 1.022-5.445). A high American Society of Anesthesiologists (ASA) classification was also significantly and independently associated with an off-target INR (OR 2.3, 95% CI: 1.029-5.173). CONCLUSION: Discontinuation of phenprocoumon 5 days preoperatively resulted in an INR < 1.8 in more than one-third of patients. Individualizing or extending the period of phenprocoumon discontinuation may be a necessary treatment option.