Antistreptokinase antibodies and outcome of fibrinolytic therapy with streptokinase for left-sided prosthetic valve thrombosis.

BACKGROUND: Left-sided prosthetic valve thrombosis (PVT) is a serious complication of valve replacement. In developing countries, fibrinolysis with streptokinase (SK) is often used as the first line of treatment. Anti-streptokinase (anti-SK) antibodies are widely prevalent in the general population, but their effect on the efficacy and outcome of fibrinolysis with SK in patients with PVT is not known. METHODS: Patients with rheumatic heart disease and prosthetic valve replacement presenting with a first episode of left-sided PVT were enrolled. All patients underwent fibrinolysis with SK. An indirect enzyme-linked immunosorbent assay was used to detect anti-SK antibodies before fibrinolysis. Relationship of these antibodies to the outcome of fibrinolysis was evaluated. RESULTS: Forty-four patients treated for left-sided PVT were included. Thrombosis affected 33 mitral and 11 aortic prosthetic valves. On fibrinolysis with SK, 32 (73%) patients achieved complete success, whereas it was unsuccessful in the remaining 12 patients. There were 3 bleeding events, 1 stroke, and 3 deaths. Mean anti-SK antibody levels were not significantly different between patients who had complete success and those who did not (8.81 ± 2.43 vs 7.67 ± 1.26 Au/mL; P = .13) and did not correlate with the outcome after adjustment with other variables. Patients in New York Heart Association class III or IV had a greater chance of failed fibrinolytic therapy, even after adjustment for other prognostic variables (odds ratio 9.0; 95% CI 1.29-63.02; P = .027). CONCLUSION: Anti-SK antibody titers are not associated with success of fibrinolytic therapy using SK in patients with left-sided PVT.

Cor triatriatum: an unusual cause of elevated pulmonary capillary wedge pressure in a child with tetralogy of Fallot.

The coexistence of cor triatriatum and tetralogy of Fallot (TOF) is rare. Preoperative identification of cor triatriatum may be difficult owing to reduced pulmonary blood flow in patients with TOF. However, it is imperative to identify this rare combination as failure to identify obstruction to pulmonary venous egress may result in persistent pulmonary venous hypertension postoperatively. The authors discuss hemodynamic aspects of this rare coexistence in a 14-month-old child in whom pulmonary capillary wedge pressure was elevated despite right ventricular outflow obstruction.

A case of reversible dilated cardiomyopathy due to acromegaly with partial empty sella.

Acromegaly has several cardiovascular manifestations of which cardiomyopathy (CMP) and hypertension (HTN) are important and contribute to the increased mortality associated with the disease. Both these manifestations are reversible with treatment. However, very advanced CMP with severe systolic dysfunction has low likelihood of reversal. The reversibility is higher in young population and decreases as age advances. Also, the time required for these manifestations to resolve is about 1 year. Here, we describe a case in which HTN and advanced heart failure resolved in an aged patient within a very short span of 2 months from the time of presentation.

Incidence and predictors of de novo late-onset persistent atrial fibrillation in postoperative rheumatic heart disease patients (LOAF-RHD study).

PURPOSE: Late-onset atrial fibrillation (LOAF) after valve surgery for degenerative mitral valve disease often with underlying mitral valve prolapse is a known phenomenon. However, there is no similar data for postoperative rheumatic heart disease (RHD) patients. We sought to assess the incidence and predictors of LOAF during postoperative follow-up in RHD patients. METHODS: This single-center retrospective case-control study included a total of 384 RHD patients with normal sinus rhythm (NSR) who underwent rheumatic valve surgery between 1st July 2008 and 30th June 2013. Patients detected with de novo persistent atrial fibrillation (AF) after 2 months of valve surgery were diagnosed as having LOAF. Presurgical demographic and echocardiographic parameters were compared between the LOAF and NSR groups to identify risk factors for LOAF. RESULTS: The incidence of de novo LOAF after rheumatic valve surgery was 9.63% at an average of 2.67 ± 1.32 years follow-up. Age ≥ 32 years [OR 2.4 (95% CI 1.2-5.1); P = 0.01] and left atrial (LA) size ≥ 51 mm [OR 5.9 (95% CI 2.8-12.4); P < 0.0001] were the most significant and independent predictors of LOAF. Moreover, significant mitral valve disease was associated with a higher risk of LOAF than significant aortic valve disease (P = 0.037). LA size ≥ 51 mm at surgery showed a fair discriminative power [AUC = 0.75; sensitivity = 68%, specificity = 70%] to identify patients at high risk for LOAF. CONCLUSIONS: Late-onset AF develops in almost a tenth of the RHD patients postoperatively following corrective valve surgery. Preoperative LA size can be used to identify patients at high risk for LOAF.

An unusual cause of left ventricular outflow tract obstruction.

Left ventricular outflow tract obstruction (LVOTO) has been reported with bio-prosthetic and mechanical mitral valves (MV), though it is more common with the former. The obstruction can be dynamic or fixed. We hereby report a case of fixed LVOTO following bio-prosthetic MV replacement (MVR).

Invasive hemodynamics of constrictive pericarditis.

Cardiac catheterization and hemodynamic study is the gold standard for the diagnosis of pericardial constriction. Careful interpretation of the hemodynamic data is essential to differentiate it from other diseases with restrictive physiology. In this hemodynamic review we shall briefly discuss the physiologic basis of various hemodynamic changes seen in a patient with constrictive pericarditis.