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Echocardiographic image of a patient with primary, myxomatous mitral valve disease. Note the large jet of mitral regurgitation (arrowhead) attributed to a flail leaflet (asterisk). LA indicates left atrium; LV, left ventricle.
Context in source publication
Context 1
... 2014 AHA/ACC valve guidelines stressed the impor- tance of identifying the mechanism of MR given that management and outcomes differ between chronic primary and secondary MR (Figures 1 and 2). Additionally, in recognition of the increased risk of adverse outcomes with smaller effective regurgitant orifice 29 in secondary MR, the 2014 guidelines defined severe MR using a lower quantifi- cation threshold for secondary MR. ...
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Cardiogenic strokes comprised 11% of all strokes and 25% of ischemic strokes. An accurate identification of the cause of stroke is necessary in order to prepare an adequate preventive strategy. In this review the confirmed and potential causes of embolic strokes are presented, which can be detected in echocardiography in the context of present trea...
Citations
... The incidence of degenerative valve disease is on the rise as the general population ages, leading to an increase in the need for surgical interventions to repair or replace these valves. The incidence of valvular diseases in the general population is 11.9 %, with mitral regurgitation being the most common, followed by aortic regurgitation (Matiasz and Rigolin, 2018). Surgery remains the mainstay of treatment for symptomatic patients with severe disease, with excellent long-term outcomes (Reddy and Punjabi, 2007). ...
Valve surgery is common in cardiac procedures, with fasteners like COR-KNOT® and hand-tied knots used for knot securing. This study compares their efficacy in valve surgery patients. We searched PubMed, SCOPUS, and Cochrane Central until August 2023. Outcomes assessed included aortic cross-clamp time (AXT), cardiopulmonary bypass (CPB) time, valvular regurgitation, mortality, prolonged ventilatory support, atrial fibrillation, post-operative left ventricular ejection fraction (LVEF), and renal failure. Subgroup analysis was performed for minimally invasive and open cardiac surgery. We used a random effects model for analysis. We included eight observational studies and two randomized controlled trials (RCTs) with a total of 1.411 participants. COR-KNOT significantly reduced AXT [MD-15.14, 95 % CI (-18.57,-11.70), P<0.00001] and CPB time [MD-12.38, 95 % CI (-14.99,-9.77), P<0.00001]. Valvular regurgitation [RR 0.40, 95 % CI (0.26, 0.61), P<0.0001] and need for prolonged ventilatory support [RR 0.29, 95 % CI (0.13, 0.65), P=0.003] were significantly lower with COR-KNOT. There were no significant differences in mortality [RR 0.39, 95 % CI (0.09, 1.69), P=0.44], atrial fibrillation [RR 1.03, 95 % CI (0.83, 1.27), P=0.81], LVEF changes [MD 0.05, 95 % CI (−1.37, 1.47), P = 0.95], or renal failure [RR 0.87, 95 % CI (0.16, 4.80), P = 0.87]. COR-KNOT devices reduce operative time and valvular regurgitation without increasing mortality or adverse outcomes. This supports their use in enhancing surgical efficiency and patient outcomes. However, ongoing discussions about suturing techniques, especially in minimally invasive procedures, highlight the need for further research and consensus among practitioners.
... About high-risk cardiac conditions for IE, almost 90% of the total sample correctly identified more than 50% of heart diseases that would justify the prophylactic use of antibiotics, as recommended by the AHA. 21 However, only 5% of cardiologists and 2% of dentists identified all of them. In addition, moderate-risk heart diseases were often mentioned when the question was about high-risk IE heart diseases. ...
... Warfarin and other VKAs require routine laboratory monitoring and dose adjustment to maintain the International Normalized Ratio (INR) in the target range, and thereby minimize the risks of thromboembolism and bleeding [2,3]. Guidelines recommend different target ranges for MHV patients depending on the type of prosthesis, the position of the prosthesis as well as the presence additional risk factors for thromboembolism such as atrial fibrillation, but high quality evidence on the optimal target range is lacking [4][5][6][7]. Anticoagulation practices also varies by region, with Western compared with East Asian countries often using higher INR targets [8]. INR targets of 2.5, 3.0 or higher are often used in Western, whereas lower targets are frequently used East Asian countries [4][5][6][7][8]. ...
... Anticoagulation practices also varies by region, with Western compared with East Asian countries often using higher INR targets [8]. INR targets of 2.5, 3.0 or higher are often used in Western, whereas lower targets are frequently used East Asian countries [4][5][6][7][8]. ...
The optimal INR target in patients with mechanical heart valves is unclear. Higher INR targets are often used in Western compared with East Asian countries. The objective of this systematic review and meta-analysis was to summarize the evidence for the efficacy and safety of lower versus higher INR targets in Western and East Asian left-sided mechanical heart valve patients. We searched Western databases including Cochrane CENTRAL, Medline, and Embase as well as Chinese databases including SinoMed, CNKI, and Wanfang Data in addition to grey literature for Randomized Controlled Trials (RCTs) and observational studies. We pooled risk ratios (RRs) using random-effects model. Low and high INR targets were defined by the individual studies. We identified nine RCTs, including six Western (n = 5496) and three East Asian (n = 209) trials, and 17 observational studies, including two Western (n = 3199) and 15 East Asian (n = 5485) studies. In the RCTs, lower compared with higher targets were associated with similar rates of thromboembolism (2.4 vs. 2.3%; RR: 1.14, 95% CI 0.82, 1.60, I2 = 0%) and lower rates of both total bleeding (21.9 vs. 40.9%, RR: 0.46, 95% CI 0.28, 0.78, I2 = 88%) and major bleeding. RCT data showed no statistical heterogeneity by region. These effects were consistent in the observational data. We downgraded the quality of evidence due to serious risk of bias and imprecision. In patients with left-sided contemporary mechanical heart valves, low quality evidence suggests lower INR targets are associated with similar rates of thromboembolism and moderate quality evidence suggests lower rates of bleeding.
... Despite an overall low mortality rate, there is a significant risk of complications with surgical AVR, especially in older and frail patients [2]. Transcatheter aortic valve replacement (TAVR) has gained wide acceptance as a safe alternative to surgery in those with symptomatic, severe AS [3]. A variety of vascular access sites are feasible for valve delivery during TAVR [4]. ...
Introduction:
There is a paucity of data regarding the outcomes of transcatheter aortic valve replacement (TAVR) among patients with thoracic or abdominal aortic aneurysms (AA). Using the Nationwide Inpatient Sample (NIS) database, we explored the safety of TAVR among patients with a diagnosis of AA.
Methods:
We queried the National Inpatient Sample database (2012-2017) for hospitalized patients undergoing TAVR, using ICD-9 and ICD-10 codes for endovascular TAVR. Reports show that > 95% of endovascular TAVR in the US is via transfemoral access, so our population are mostly patients undergoing transfemoral TAVR. Using propensity score matching, we compared the trends and outcomes of TAVR procedures among patients with versus without AA.
Results:
From a total sample of 29,517 individuals who had TAVR procedures between January 2012 and December 2017, 910 had a diagnosis of AA. In 774 matched-pair analysis, all-cause in-hospital mortality was similar in patients with and without AA OR 0.63 [(95% CI 0.28-1.43), p = 0.20]. The median length of stay was higher in patients with AA: 4 days (IQR 2.0-7.0) versus 3 days (IQR 2.0-6.0) p = 0.01. Risk of AKI [OR 1.01 (0.73-1.39), p = 0.87], heart block requiring pacemaker placement [OR 1.17 (0.81-1.69), p = 0.40], aortic dissection [OR 2.38 (0.41-13.75), p = 0.25], acute limb ischemia [OR 0.46 (0.18-1.16), p = 0.09], vascular complications [OR 0.80 (0.34-1.89), p = 0.53], post-op bleeding [OR 1.12 (0.81-1.57), p = 0.42], blood transfusion [OR 1.20 (0.84-1.70), p = 0.26], and stroke [OR 0.58 (0.24-1.39), p = 0.25] were similar in those with and without AA.
Conclusions:
Data from a large nationwide database demonstrated that patients with AA undergoing TAVR are associated with similar in-hospital outcomes compared with patients without AA.
... Based on the AHA/ACC 2017 Guidelines for IE prophylaxis, a sheet for data collection was constructed by the researcher. It comprised the four parts below [13] : ...
Background:
Infective endocarditis (IE) is a disease endangering human lives. Therefore, several prophylactic measures are required to improve the protection of endocarditis-prone patients from bacteremia resulting from various dental actions. These measures range from developing the dental hygiene to trials of different antimicrobial agents.
Objectives:
To examine the knowledge and practices of dentists in Aseer Region, Saudi Arabia, regarding antibiotic prophylaxis against IE.
Design:
Cross-sectional study.
Setting:
Aseer Region, Saudi Arabia.
Patients and methods:
The participants were interviewed at their workplaces and the data collection sheet was constructed based on the guidelines of the American Heart Association/American College of Cardiology (AHA/ACC, 2017).
Main outcome measures:
The examination of the data gathered was calculated using Statistical Package for Social Sciences (SPSS, version 25) such as to test the significance of variation in dentists' mean knowledge scores as per their personal characteristics. An output with P values <0.05 was statistically significant.
Sample size:
182 Dentists.
Results:
Dentists' mean knowledge score was 17.5 ± 3.7 (out of 24). The least correct responses regarding dental procedures that require prophylactic antibiotics were "root canal treatment" (30.8%). Regarding cardiac conditions that require prophylactic antibiotics, dentists' least correct responses were "heart failure" (50%). Dentists' mean knowledge scores differed significantly according to their age groups (P = 0.032), nationality (P = 0.002), education/qualification (P = 0.002). Mean knowledge scores differed significantly according to dentists' years of experience (P = 0.018) and sources of information (P < 0.001). Amoxicillin was the most regularly recommended antibiotic (90.7%), while 86.8% correctly stated 30--60 min. before the procedure as the time for prophylactic antibiotic administration.
Conclusions:
The knowledge of dentists in Aseer Region regarding the use of preventive drugs for the control and prevention of IE is suboptimal. The inclusion of the latest AHA guidelines into the dentistry curricula is highly recommended.
Limitations:
Outcome are simultaneously assessed.
... Therefore, patients with mechanical heart valves require lifelong anticoagulation with an international normalized ratio (INR) target range of 2.0 to 3.5, depending on the valve insertion position; the target INR for such patients is higher than that for patients with atrial fibrillation because of a substantially high risk of thrombosis and systemic embolism. [1,5,6] Anticoagulant therapy is associated with bleeding and thromboembolic risks. Maintaining accurate control and therapeutic levels of INR is important. ...
Available classification tools and risk factors predicting bleeding events in elderly patients after mechanical valve replacement may not be suitable in Asian populations. Thus, we aimed to identify an accurate model for predicting bleeding in elderly patients receiving warfarin after mechanical valve replacement in a Korean population. In this retrospective cohort study, a random forest model was used to determine factors predicting bleeding events among 598 participants. Twenty-two descriptors were selected as predictors for bleeding. Steroid use was the most important predictor of bleeding events, followed by labile international normalized ratio, history of stroke, history of myocardial infarction, and cancer. The random forest model was sensitive (80.77%), specific (87.67%), and accurate (85.86%), with an area under the curve of 0.87, suggesting fair prediction. In the elderly, drug interactions with steroids and overall physical condition had a significant effect on bleeding. Elderly patients taking warfarin for life require lifelong management.
... However, continued management could cause stress due to the risk of bleeding and blood clots, which can lead to valve failure, heart failure, reoperation, increased medical expenses, poor quality of life, and death. Therefore, having a plan for correct medication use is essential [5,6]. For life-long management, taking warfarin to maintain valve function is crucial, and individual counselling and management on anticoagulation control is required to maintain therapeutic INR for older patients with various underlying diseases [7]. ...
... Its validity and reliability were verified. It comprises 10 questions: necessity of medication (5) and medication concerns (5). Responses for each question are marked on a 5-point Likert scale ranging from 1 = 'not at all' to 5 = 'very much', and the range of the summation score for each sub-area is 5-25 points. ...
... Self-efficacy was measured using the Chronic Disease Self-Efficacy Scale-Korean version (CDSES-K), a tool standardized in Korean by Kim et al. [26], which is based on the Chronic Disease Self-Efficacy Scale (CDSES) developed by Lorig et al. [27]. It comprises 32 questions covering 8 areas, including the following items: controlling symptom management (7) and controlling depression (5). We included the following questions: regular exercise (3); illness-related information (1); help received through family, friends, or community (4); communicating with medical staff (3); general disease management (5); and housework (4). ...
Non-adherence is highlighted as one of the main contributors to the occurrence of adverse events and negative clinical outcomes in patients treated with warfarin. The aim was to examine knowledge on warfarin, medication belief, depression, and self-efficacy as factors influencing medication adherence for anticoagulation control. This was a cross-sectional study. The participants in this study were patients who visited an outpatient clinic of cardiovascular surgery to administer anticoagulants after mechanical valve replacement surgery at a tertiary hospital in Seoul. Responses of 154 participants on questionnaires were analyzed from 10 September to 26 December 2020. Multiple regression analyses were performed to assess the factors influencing medication adherence among the patients with anticoagulation control. Factors influencing medication adherence were consuming warfarin for 3 to 5 years, awareness of target prothrombin time international normalized ratio, knowledge of warfarin, and depression. Medication beliefs and self-efficacy had no significant influence on medication adherence. The most important factors associated with medication adherence in patients with mechanical heart valves were knowledge about warfarin and depression. In the control of oral anticoagulants that require continuous management, education and providing accurate guidance is more important than personal preferences. Clinical nurses should facilitate educational programs tailored to the characteristics of the patient, including their purpose and method of taking warfarin, specific diets, their knowledge on warfarin’s interaction with other drugs, symptoms of adverse events, and self-management. In addition, healthcare providers should check whether warfarin therapy is being controlled by evaluating medication adherence and depression levels among patients.
... A pesar de lo anterior, las características de este tipo de pacientes, como ya se mencionó, cada vez más añosos y con mayor número de comorbilidades, han determinado que surjan otras técnicas menos invasivas, con el fin de disminuir el elevado riesgo que la cirugía, que incluye circulación extracorpórea y todas las complicaciones relacionadas a un procedimiento abierto mayor, podría tener sobre estos pacientes. Es por lo anterior que, desde el año 2002, año en el cual se realizó el primer reemplazo valvular aórtico transcatéter (RVAT) [3], el manejo de esta patología ha sufrido cambios considerables, con muchos estudios actuales y guías clínicas apuntando a que esta sería una alternativa adecuada en pacientes de riesgo prohibitivo o elevado (recomendación clase I, evidencia nivel A) y de riesgo intermedio (recomendación clase IIa) [4]. Incluso, estudios más recientes aprueban su uso en pacientes de riesgo bajo [5]. ...
... A modo de ejemplo, en las guías de la AHA/ACC de manejo de valvulopatías del año 2014, se reconocía al RVAT como la alternativa de preferencia en pacientes con riesgo quirúrgico prohibitivo (clase 1, nivel de evidencia B) y como alternativa a la cirugía en pacientes con riesgo quirúrgico alto (clase IIa, nivel de evidencia B). En las guías actualizadas del año 2017, se recomienda RVAT en pacientes de riesgo prohibitivo y alto, como recomendación clase 1, nivel de evidencia A [4]. Lo anterior, se basa principalmente en el estudio PARTNER 1 [6], un ensayo clínico randomizado, multicéntrico, que incluyó a 699 pacientes con estenosis aórtica severa sintomática y con riesgo quirúrgico prohibitivo o alto (definido como un riesgo de muerte operatorio mayor o igual al 15%), comparando los resultados ...
... 13 Recently, as the first-line treatment plan for class 1-B indications, the 2017 American Heart Association (AHA)/ American College of Cardiology (ACC), based update of the 2014 AHA / ACC instruction for the treatment of patients with valvular heart disease advised using slow-infusion low-dose TT or immediate surgery for obstructive PVT. 14 Complications of thrombolysis in PVT include major bleeding intracerebral, systemic embolism, recurrent PVT, and death. 15,16 Surgery is recommended for vital surgery for obstructive thrombosis (thrombus more than one cm 2 ) or fibrinolytic therapy for non-obstructive PVT (approximately 10 mm). ...
... Bleeding during fibrinolysis is rare in the absence of bleeding conditions like pregnancy, postoperative, or pericarditis. 14 Maintenance of anticoagulation therapy with INR monitoring is the corner stone for prevention of thrombus formation among patients with prosthetic valve replacement. 21 More efforts are need for patient education and drug adherence of anticoagulation therapy. ...
Prosthetic cardiac valve thrombosis is a rare but dangerous complication; 1,2 particularly in patients with low conformity on anticoagulant therapy. Thromboembolic problems happen after mechanical valve substitution in 0.5 - 8 percent. 3-5 Fibrinolytic therapy to treat the thrombosis is widely used nowadays with high efficacy and no severe side effects as compared to emergency surgical treatment, which is associated with high mortality.6 Surgical valve repair in patients with rheumatic heart disease remains the gold standard for the treatment. Thrombosis of the prosthetic heart valve in patients undergoing valve replacement, is the most severe and deadly complication. Currently, the treatments available for symptomatic prosthetic valve thrombosis are immediate surgery or thrombolytic therapy (TT). In rural hospital settings patients are poor and there is a lack of surgical expertise. These factors make TT the perfect treatment for prosthetic valve thrombosis. But one should be aware of embolic complications.
... The current joint guidelines of the American College of Cardiology and American Heart Association and the current European Society of Cardiology guidelines for the management of aortic valve disease state that surgical AVR is recommended for symptomatic patients with severe aortic stenosis and asymptomatic patients with severe aortic stenosis who meet an indication for AVR when surgical risk is low or intermediate. 1 In the UK, the National Adult Cardiac Surgery Audit published by National Institute for Cardiac Outcome Reporting reported 13 027 procedures for aortic valve disease in the UK from April 2018 to March 2019. 2 Outcomes are generally excellent with in-hospital observed mortality in the UK of 1.5% for first-time elective procedures. 3 In low-risk patients with a EuroSCORE 2 of less than 4, a mortality of less than 0.7% was observed in over 15 000 patients undergoing AVR surgery in the UK between 2016 and 2019. 2 Strengths and limitations of this study ► Large proportion of eligible patients recruited, and all patient randomised contributed to the primary outcome. ...
Objective
To compare clinical and health economic outcomes after manubrium-limited mini-sternotomy (intervention) and conventional median sternotomy (usual care).
Design
A single-blind, randomised controlled trial.
Setting
Single centre UK National Health Service tertiary hospital.
Participants
Adult patients undergoing aortic valve replacement (AVR) surgery.
Interventions
Intervention was manubrium-limited mini-sternotomy performed using a 5–7 cm midline incision. Usual care was median sternotomy performed using a midline incision from the sternal notch to the xiphisternum.
Primary and secondary outcome measures
The primary outcome was the proportion of patients who received a red cell transfusion postoperatively and within 7 days of index surgery. Secondary outcomes included proportion of patients receiving a non-red cell blood component transfusion and number of units transfused within 7 days and during index hospital stay, quality of life and cost-effectiveness analyses.
Results
270 patients were randomised, received surgery and contributed to the intention to treat analysis. No difference between mini and conventional sternotomy in red-cell transfusion within 7 days was found; 23/135 patients in each arm received a transfusion, OR 1.0 (95% CI 0.5 to 2.0) and risk difference 0.0 (95% CI −0.1 to 0.1). Mini-sternotomy reduced chest drain losses (mean 181.6 mL (SD 138.7) vs conventional, mean 306·9 mL (SD 348.6)); this did not reduce red-cell transfusions. Mean valve size and postoperative valve function were comparable between mini-sternotomy and conventional groups; 23 mm vs 24 mm and 6/134 moderate or severe aortic regurgitation vs 3/130, respectively. Mini-sternotomy resulted in longer bypass (82.7 min (SD 23.5) vs 59.6 min (SD 15.1)) and cross-clamp times (64.1 min (SD 17.1) vs 46·3 min (SD 10.7)). Conventional sternotomy was more cost-effective with only a 5.8% probability of mini-sternotomy being cost-effective at a willingness to pay of £20 000/QALY (Quality Adjusted Life Years).
Conclusions
AVR via mini-sternotomy did not reduce red blood cell transfusion within 7 days following surgery when compared with conventional sternotomy.
Trial registration number
ISRCTN29567910 ; Results.
