Complication Of Heart Valve Replacement Research Articles

Diagnostic Value of D-Dimer and INR in Patients Suspected to Have Prosthetic Valve Dysfunction.

Prosthetic valve dysfunction is a potentially critical complication of heart valve replacement. An easy and quickly applicable diagnostic procedure is required for recognizing the prosthetic valve dysfunction. The purpose of this study was to prospectively define the diagnostic value of D-dimer and INR level in predicting prosthetic valve dysfunction. This cross-sectional study was performed in 70 patients suspected to have prosthetic valve dysfunction admitted to Imam Ali Hospital, affiliated with Kermanshah University of Medical Sciences (KUMS), Kermanshah Province, Iran. Cinefluoroscopy, as the gold standard diagnostic test, was used for the diagnosis of prosthetic valve dysfunction in enrolled patients. Two milliliters of blood from each patient were taken into a tube containing sodium citrate anticoagulant. To evaluate D-dimer, the cutoff value was set at 500 ng/ml. Also, to evaluate international normalized ratio (INR), the cutoff value was set at 2. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (PLR), and negative likelihood ratio (NLR) of the serum markers were used to describe predictive properties. Of 70 patients, 27 (38.6%) were male and 43 (61.4%) were female, and the mean age was 54.67±15.11 years (range, 18 to 80 years). Of 70 patients, 27 (38.6%) had prosthetic heart valve malfunction demonstrable by fluoroscopy, and 19 patients (27.1%) had D-dimer levels >500 ng/ml. Elevated D-dimer levels (>500 ng/ml) have been indicated to have sensitivity of 70.4%, and hence an NPV of 84.3%, specificity of 100%, PPV of 100%, NLR of 0.3, and the infinity value of PLR for predicting prosthetic valve dysfunction. There was a significant relationship between fluoroscopy and D-dimer test (P=0.001). A kappa coefficient value of 0.745 indicated a substantial agreement between D-dimer and fluoroscopy testing. Mixing test (combination of D-dimer and INR) showed to have 100% sensitivity, and hence a NPV of 69.8%, specificity of 69.8%, PPV of 51.8%, NLR of 1.41, and PLR of 1.44 for predicting prosthetic valve dysfunction. D-dimer with moderate sensitivity and high specificity is an ideal marker for the diagnosis of prosthetic valve dysfunction in suspected patients. Enhanced plasma D-dimer level is not by itself diagnostic of a prosthetic valve dysfunction but may alert physicians to refer the patient for more detailed examination, preferably by fluoroscopy. Mixing test with 100% sensitivity can apply as a rule-out test.

Transcatheter paravalvular leak closure is an effective alternative to surgical repair with respect to 5-year outcomes

Abstract Introduction Paravalvular leakage (PVL) is a relatively common complication of heart valve replacement, associated with heart failure and increased mortality. Transcatheter PVL closure may be a promising alternative to surgical repair, especially in high-risk patients. Purpose Assessment of safety and efficacy of transcatheter PVL closure compared to surgical repair. Methods This is a retrospective single-centre study including all consecutive patients who underwent either transcatheter PVL closure between January 2013 and December 2020, or surgical repair between March 2015 and December 2020. Primary endpoints were 5-year all-cause mortality and the composite of 5-year cardiovascular mortality and rehospitalization for the underlying condition. Secondary endpoints were technical success and individual patient success at one year according to the PVL Academic Research Consortium. Results Of the 129 patients included, 85 went for transcatheter repair and 44 went for surgical repair. As compared to surgical repair, patients undergoing transcatheter PVL closure were older (71 years vs. 64,5 years; p≤0,01) and more symptomatic (NYHA class III & IV; 76,5% vs. 59,1%; p=0,04). At 5 years, transcatheter PVL closure was comparable to surgery in terms of the primary composite endpoint (HR: 1,20; 95% CI: 0,68–2,13; p=0,54), all-cause mortality (HR: 1,70; 95% CI: 0,82–3,50; p=0,15) and rehospitalization for the underlying condition (HR: 1,12; 95% CI: 0,54–2,89; p=0,780). Rates of technical success (92,9% vs. 95,5%; p=0,58) and individual patient success at one year (70,6% vs. 77,3%; p=0,87) were similar between transcatheter PVL closure and surgery respectively. Transcatheter PVL closure was associated with shorter in-hospital stay (7 days vs. 14 days; p≤0,01). Conclusion These findings support the use of transcatheter closure of PVL, especially in high-risk patients. Long term survival remains temperate in these challenging patients. Funding Acknowledgement Type of funding sources: None.

Safety of thrombolytic therapy in patients with prosthetic heart valve thrombosis who have high international normalized ratio levels.

Prosthetic valve thrombosis (PVT) is a rare but life-threatening complication of heart valve replacement. Based on the current guidelines, the treatment of a large number of these patients could be performed through the administration of thrombolytic agents. In the present study, we aim to assess the safety of thrombolytic therapy in patients with PVT who have high international normalized ratio (INR) levels. In this study, we retrospectively analyzed outcomes of thrombolytic therapy in 65 PVT patients with different levels of INR at the time of fibrinolysis at a tertiary cardiac center. Mean age of patients was 51.6 ± 12.47 years. The tricuspid valve was the most common site of prosthetic valve thrombosis (64.6%). The Median (range) of INR was 2.1 (0.9-4.9). The majority of patients (50.8%) achieved a complete response following thrombolytic treatment. There were no cases of intracranial hemorrhage. Other major and minor bleedings occurred in 3 (4.6%) and 10 (15.4%) patients, respectively. No embolic stroke and systemic embolism were observed. We found no significant difference in the frequency of major (P-value = .809) and minor (P-value = .483) bleeding as well as response to thrombolytic therapy (P-value = .658) between patients with different levels of INR. Total administered dose of Streptokinase was also similar in PVT patients with or without major (P-value = .467) and minor (P-value = .221) bleeding complications. We concluded that there was no significant difference between PVT patients presenting with subtherapeutic and high INR levels who received thrombolytic treatments regarding both minor and major bleeding complications as well as response to thrombolysis.

Early Onset Prosthetic Valve Endocarditis: Experience at a Cardiothoracic Surgical Hospital, 2006-2016.

Early onset prosthetic valve endocarditis (EO-PVE) is an serious complication associated with heart valve replacement surgery. To describe the epidemiologic, clinical, and laboratory profile of patients with EO-PVE in a cardiac surgical hospital. A retrospective analysis of an endocarditis database, implemented prospectively, with a post hoc study driven by analysis of cases of adults with definite endocarditis occurring up to 12 months after heart valve surgery. We identified 26 cases in 2,496 surgeries in the period 2006-2016. The average annual incidence was 1.04%. The median time between valve replacement and the diagnosis of EO-PVE was 33 days (interquartile range [IQR] 19.25-118.75). Biologic and mechanical prostheses were affected in 53.8% and 46.2%, respectively. Rheumatic disease was present in 57.7% of patients. The most common causative pathogens were Staphylococcus epidermidis (23.1%). No Staphylococcus aureus infection was reported. Complications were present in 73.1% of cases, including embolism (65.4%), acute renal failure (38.5%), and heart failure (23.1%). The mortality rate at 30 days and 12 months was 3.8% and 34.6%, respectively. In our cohort EO-PVE was an serious complication of heart valve replacement with a high morbidity and mortality, despite its low frequency.

The current status of fluoroscopy and echocardiography in the diagnosis of prosthetic valve thrombosis-a review article.

Prosthetic valve thrombosis (PVT) is a potentially life-threatening complication of heart valve replacement. Early diagnosis is crucial for the prevention of significantly morbid and lethal complications. Cinefluoroscopy (CF) and echocardiography have been widely used for diagnosing PVT. In recent years, the role of CF has declined since the introduction of transesophageal echocardiography and the great improvements in ultrasound technology including real time three-dimensional imaging. Nevertheless, both echocardiography and CF provide different kinds of information on prosthesis function, and therefore they are considered as complementary and not alternative. In this review, we aimed to summarize the current status of CF and echocardiography in the diagnosis of PVT.

Formulation of Dipyridamole Sustained Release Tablet Using Floating System

Dipyridamole is a drug for prevention of postoperative thromboembolic complication of heart valve replacement and long term therapy of angina pectoris will be well absorbed in stomach. To maintain therapeutic plasma concentration in long time and to increase bioavalaibility is needed a sustained release dosage form having the long residence time in the stomach. The objective of this research was to make floating sustained release tablet of dipyridamole conforming to the requirement that was set up by dipyridamol therapeutic concentration. Tablets were made by wet granulation method using aquadest as a liquid binder, HPMC K4M, Ac-di-sol, Avicel PH 102, talk, and Mg stearat. Dissolution assay was carried out using type 2 release tester at rotation speed of 50 rpm in medium 900 mL HCl 0.1 N at 37 ± 0.5 °C for 8 hours. The formulation containing of 50 mg dipirydamole, HPMC K4M (30%), Ac-di-sol (20%), Avicel PH 102 (37%), talk (2%), and Mg stearat (1%) released 59.61 ± 6.73% and 89.34 ± 5.87% of dipyridamole respectively after 4 and 8 hours that conformed to the requirement.

Surgery for prosthetic valve obstruction. A single center study of 136 patients.

Prosthetic heart valve obstruction (PHVO) is a potentially fatal complication of heart valve replacement with mechanical substitute mainly due to thrombosis. The purpose of this report is to present a single-center experience of 136 consecutive patients operated on between 1978 and 2001. The diagnosis of PHVO was mainly assessed by fluoroscopy and/or echocardiography. Thrombosed valves were bileaflet (82), tilting disc (47) and ball cage (7) valves; of these, 90 were in mitral, 38 in aortic, six in aortic and mitral position, and two in tricuspid position. The mean interval between the first implantation and valve thrombosis was 7.4+/-6.6 years (range 1 day to 28 years); in 37 patients preoperative medical therapy (fibrinolysis in 21, and heparin alone in 16) was unsuccessful. Operative procedures included valve re-replacement in 104 cases and declotting-pannus excision in 32 cases. Early hospital mortality was 10.3% (14 patients), all in NYHA class III or IV, and one patient suffered a perioperative cerebral embolic event. Surgery was then successful in 121 of 136 patients (89%), but during a 3.15-year follow-up, prosthetic heart valve thrombosis recurred in ten out of 122 survivors (8.1%). From this experience, it can be concluded that for most PHVO, early operation is currently effective and safe, especially in patients in stable hemodynamic condition preoperatively.

Role of cine-fluoroscopy, transthoracic, and transesophageal echocardiography in patients with suspected prosthetic heart valve thrombosis

Prosthetic heart valve thrombosis (PVT) is a rare but potentially life-threatening complication of heart valve replacement. An effective, quick, and easy diagnostic method is highly desirable. We evaluated the diagnostic efficacy of cine-fluoroscopy (CF), transthoracic (TTE), and transesophageal (TEE) echocardiography in 82 consecutive patients with mechanical valves and suspected PVT. Criteria for PVT were: leaflet(s) motion restriction at CF, increased Doppler gradients at TTE, and evidence of thrombi at TEE. Patients were divided in 4 groups (A, B, C, and D) according to results of CF and TTE. Group A was composed of 24 patients with positive CF and TTE. Thrombi were detected by TEE in all cases, suggesting that when both are positive, CF and TTE correctly identified PVT in all patients so that TEE may be deferred. Group B was composed of 12 patients with positive CF and negative TTE; TEE showed PVT in 4 patients (33%). These patients had very slight leaflet motion restriction as in the case of initial PVT. This suggests that CF compared with Doppler may identify patients with “hemodynamically significant” PVT. The remaining 8 patients in this group had monocuspid prostheses with negative TEE, suggesting that abnormal leaflet motion at CF may be due to functional changes. Therefore, TEE should always be performed in case of monocuspid prostheses with isolated CF abnormalities. Group C was composed of 18 asymptomatic patients with small-sized aortic prostheses and very high Doppler gradients on routine TTE. CF showed normal leaflet motion and TEE ruled out PVT in all cases outlining the diagnostic role of CF in this particular subset. Finally, group D was composed of 28 patients with negative CF and TTE. TEE did not show thrombi in 24 of 28 patients (86%), confirming that, when both yield negative results, CF and TTE are reliable methods to rule out valve thrombosis in most cases. However, in 4 of 28 patients (14%) TEE showed “nonobstructive” prosthetic thrombosis: these patients had mitral prostheses, chronic atrial fibrillation, and 3 of 4 had systemic embolisms. Thus, TEE should be performed in selected patients despite negative CF and TTE results. Sensitivity, specificity, and positive and negative predictive values were 87%, 78%, 80%, and 91% for CF and 75%, 64%, 57%, and 78% for TTE, respectively. CF and TTE correctly identified PVT in 70 of 82 patients (85%). TEE was actually required in 15% of the cases. Thus, CF and TTE are quick, effective, and complementary diagnostic tools to diagnose PVT in most patients. TEE still remains the gold standard technique in selected cases.

Role of transesophageal echocardiography in the diagnosis and management of prosthetic valve thrombosis

Thrombosis is a serious complication of heart valve replacement. Diagnosis is often difficult with previously reported techniques, including precordial two-dimensional echocardiography, suffering from low sensitivity and specificity. Management is similarly difficult, with a 40% to 50% reported mortality rate in early surgical series. Three cases are presented in which thrombosis of a left-sided prosthetic valve (one aortic, three mitral) was diagnosed by means of transesophageal echocardiography. All three patients were treated with streptokinase and had clinical and echocardiographic resolution. In one patient, who had recurrent thrombosis and received a second course of streptokinase, the course was complicated by a massive embolic stroke and death. Another patient with a recurrence underwent successful valve replacement.Transesophageal echocardiography is ideal for the diagnosis and follow-up of patients with prosthetic vaive thrombosis. Although effective, thrombolysis in this setting is associated with a high risk of thromboembolic phenomena and significant risk of death. Thrombolytic therapy may be considered in highly selected patients who have an unacceptable risk for reoperation.

Cholelithiasis: A frequent complication of artificial heart valve replacement

The results of this investigation reveal that 39 per cent of patients in a study group of 46 patients with heart valve prostheses had gallstones if they survived 18 months or longer following valve replacement. In contrast, the prevalence of gallstones in a general population of autopsied rheumatic heart disease patients, including those who had been operated for severe valvular heart disease and had not survived for more than one month, was only 12 per cent. These findings suggest that gallstones are a frequent late complication of heart valve replacement.

A Complication of Heart-Valve Replacement

ABSTRACT To the Editor:— Lamkin et al (194: 1019, 1965) have done a service in calling attention to the commonest late complication of heart-valve replacement, namely, thromboembolism. In discussing the genesis of the thromboemboli in their patient, the authors did not consider the loud apical holosystolic murmur. Such a finding in the presence of a Starr-Edwards mitral prosthesis usually means regurgitation through a break in the suture line about the valve. After angiographic confirmation, closure of the defect is indicated, because this will probably reduce the likelihood of thromboembolism.