Stroke Related to Transcatheter Heart Valve Thrombosis.

Non-obstructive transcatheter heart valve (THV) thrombosis as a potential mechanism after stroke after transapical transcatheter aortic valve replacement (TAVR) is demonstrated by the present case report. By performing cardiac computed tomography (CT) in addition to standard transthoracic echocardiography (TTE) follow up after TAVR, it has been shown recently that non-obstructive THV thrombosis may be more common than previously anticipated. However, the clinical implications of non-obstructive THV thrombosis remain unclear. In the present patient, post-TAVR TTE and transeophageal echocardiography demonstrated normal THV function, and showed no evidence of THV thrombosis. In contrast, cardiac CT revealed findings consistent with THV thrombosis. The patient subsequently developed acute ischemic stroke that was treated with thrombolysis. Follow up cardiac CT and echocardiography demonstrated complete THV thrombus resolution.

Individual, expected diameters of the ascending aorta and prevalence of dilations in a study-population aged 60-74 years: a DANCAVAS substudy.

To determine individual, expected normal diameters of the ascending aorta (AAo) and prevalence of dilations based upon an absolute cut-off point (≥ 40 mm) and individual cut-off point (≥ 25% than expected normal). Non-contrast computed tomography (CT) scans were obtained in 14,993 individuals (95.0% male, mean age 67.8 ± 3.8). A sub-group (n = 291) had AAo diameter measured by transthoracic echocardiography. A prediction formula for AAo diameters was created from multivariate linear regression analysis based upon gender, age, and body surface area. An index was made by dividing observed diameters with predicted diameters. A size-index ≥ 1.25 was defined as dilated. Prevalence of AAo dilations among males and females using 40 mm as cut-off point were 10.6% and 2.1% (p < 0.001), respectively, while 3.3% and 2.6% (p = 0.305) using the size-index ≥ 1.25, respectively. Proportion of agreement between cases of AAo dilations from the size-index and 40 mm was 93.0%. Using the size-index as 'golden standard' for dilation, the sensitivity and specificity using 40 mm as cut-off point for males were 100.0% and 92.4%, respectively, while 75.0% and 99.9%, respectively, for females. For males and females, the positive predicted values were 31.3% and 93.8%, respectively; the negative predicted values were 100.0% and 99.3%, respectively. An absolute echocardiographic size-criterion of 40 mm entails a significant number of females with missed AAo dilation, and a large number of males are mistaken to have dilated AAo. Thus, AAo diameters should be evaluated in relation to gender, age and BSA. This study provides a formula for potential clinical implementation.

Are there long-term benefits in following stable heart failure patients in a heart failure clinic?

OBJECTIVES AND DESIGN: This study describes the long-term outcome of 163 patients with stable mild to moderate heart failure (NYHA II-III), who already were enrolled in a heart failure clinic and now were randomized to continued follow-up in the heart failure (HF) clinic or else to usual care (UC). The primary outcome was unplanned hospitalisations and death, the secondary endpoints were pharmacological therapy, NYHA class, six-minute-walking distances and NT-pro BNP level. RESULTS: At the end of follow-up we found no significant differences in total number of hospitalisation (p = 0.2) or mortality (16% vs. 16%) between the two groups. Patients in the HF clinic cohort achieved a significantly better NYHA score (p < 0.01), significantly longer walking-distances (p = 0.04) and received a significantly higher dose of angiotensin-converting enzyme inhibitors (p < 0.001) and beta-blockers (p < 0.001). No significant difference was found on the level of NT-pro BNP (p = 0.4). CONCLUSIONS: Patients with mild to moderate HF may benefit from long-term follow-up in a HF clinic in terms of pharmacological therapy and functional status, but we found no significant impact on unplanned hospitalisations or death.

Transcatheter Aortic Valve Thrombosis: Incidence, Predisposing Factors, and Clinical Implications.

BACKGROUND: There are limited data on the incidence, clinical implications, and predisposing factors of transcatheter heart valve (THV) thrombosis following transcatheter aortic valve replacement (TAVR). OBJECTIVES: The authors assessed the incidence, potential predictors, and clinical implications of THV thrombosis as determined by contrast-enhanced multidetector computed tomography (MDCT) after TAVR. METHODS: Among 460 consecutive patients who underwent TAVR with the Edwards Sapien XT or Sapien 3 (Edwards Lifesciences, Irvine, California) THV, 405 (88%) underwent MDCT in addition to transthoracic and transesophageal echocardiography 1 to 3 months post-TAVR. MDCT scans were evaluated for hypoattenuated leaflet thickening that indicated THV thrombosis. RESULTS: MDCT verified THV thrombosis in 28 of 405 (7%) patients. A total of 23 patients had subclinical THV thrombosis, whereas 5 (18%) patients experienced clinically overt obstructive THV thrombosis. THV thrombosis risk did not differ among different generations of THVs (8% vs. 6%; p = 0.42). The risk of THV thrombosis in patients who did not receive warfarin was higher compared with patients who received warfarin (10.7% vs. 1.8%; risk ratio [RR]: 6.09; 95% confidence interval [CI]: 1.86 to 19.84). A larger THV was associated with an increased risk of THV thrombosis (p = 0.03). In multivariable analysis, a 29-mm THV (RR: 2.89; 95% CI: 1.44 to 5.80) and no post-TAVR warfarin treatment (RR: 5.46; 95% CI: 1.68 to 17.7) independently predicted THV thrombosis. Treatment with warfarin effectively reverted THV thrombosis and normalized THV function in 85% of patients as documented by follow-up transesophageal echocardiography and MDCT. CONCLUSIONS: Incidence of THV thrombosis in this large study was 7%. A larger THV size may predispose to THV thrombosis, whereas treatment with warfarin appears to have a protective effect. Although often subclinical, THV thrombosis may have important clinical implications.

Early aortic transcatheter heart valve thrombosis: diagnostic value of contrast-enhanced multidetector computed tomography.

BACKGROUND: Early stent valve thrombosis after transcatheter aortic valve implantation (TAVI) is a rare complication, which is diagnosed based on the appearance of clinical symptoms of heart failure and echocardiographic findings. After TAVI, transthoracic echocardiography is performed to assess transcatheter heart valve (THV) function. However, preliminary reports indicate the potential additive clinical value of multidetector computed tomography (MDCT) for the diagnosis of THV thrombosis. We sought to determine the value of MDCT for the diagnosis of THV thrombosis and the frequency of this complication after balloon-expandable TAVI. METHODS AND RESULTS: MDCT was performed in 140 patients within 1 to 3 months after TAVI with the Edwards Sapien XT THV to assess the presence of THV thrombosis and THV stent geometry. Post-TAVI MDCT identified THV thrombosis in 5 patients (4%). Of note, 4 of these patients were asymptomatic and had a normal transthoracic echocardiographic examination without signs of thrombus formation or flow obstruction. In patients with THV thrombosis, a left ventricular ejection fraction of <35% was present in 3 (60%), whereas 2 (40%) did not receive standard post-TAVI dual-antiplatelet therapy. Neither THV underexpansion nor THV noncircularity was detected in patients with THV thrombosis. CONCLUSIONS: Post-TAVI MDCT is a valuable tool for the diagnosis of THV thrombosis, and this complication seems to be more common than previously anticipated. Larger studies are required to identify specific risk factors of THV thrombosis.

Severe aortic coarctation in an adult patient with normal brachial blood pressure.

The present case shows that a normal brachial blood pressure (BP) does not exclude severe coarctation and should be considered in normotensive patients presenting with a systolic murmur and/or unexplained severe left ventricular hypertrophy. Congenital coarctation of the aorta is a narrowing of the descending aorta, usually located distal to the origin of the subclavian artery, causing hypertension in the upper part of the body. This condition may be undiagnosed until adult life where the clinical presentation most often is high BP in the upper extremities. A 57-year-old patient with severe aortic coarctation and left ventricular hypertrophy presented with normal brachial BP. However, standard suprasternal view by echocardiography indicated coarctation. Multislice computed tomographic (CT) angiography revealed an uncommon location of the aortic narrowing with the right and left subclavian arteries originating below the area of coarctation, explaining the equally low BP in both upper extremities.

[Radiofrequency ablation of ventricular tachycardia after acute myocardial infarction]. / Radiofrekvensablation af ventrikulaer takykardi efter et akut myokardieinfarkt.

A 66 year-old man presented drug-refractory, repetitive ventricular tachyarrhythmias after acute myocardial infarction. Despite successful revascularization, the patient suffered recurrent episodes of rapid ventricular tachycardia which could only be managed by radiofrequency ablation.

[Dilated cardiomyopathy as a side effect of treatment with infliximab]. / Dilateret kardiomyopati som bivirkning af infliximabbehandling.

We report a case of heart failure after infusion of Remicade (infliximab) in a patient without heart insufficiency. The patient, a 25-year-old woman with inflammatory bowel disease, developed new-onset heart failure after receiving TNF antagonist therapy. After the treatment was discontinued and heart failure therapy was started, the patient improved significantly. The U.S. Food and Drug Administration has published 47 case reports of heart failure after therapy with a tumor necrosis factor antagonist, where 38 patients developed new-onset heart failure and 9 patients experienced heart failure exacerbation. There are no published reports of heart failure after TNF antagonist therapy in the Danish literature.