Mitral Valvular Heart Disease Research Articles

Real-world insights on anticoagulation therapies in non-valvular atrial fibrillation: a comprehensive electronic health record-based study using natural language processing and machine learning

Abstract Background Limited evidence exists regarding real-world practices and outcomes of oral anticoagulation in patients with Non-Valvular Atrial Fibrillation (NVAF). Purpose To conduct a retrospective real-world data (RWD) study using Natural Language Processing (NLP) and Machine Learning (ML) on Electronic Health Records (EHRs) to evaluate the efficacy and safety of Direct Oral Anticoagulants (DOACs) and vitamin K antagonists (VKAs) in NVAF patients. Methods Retrospective study in 15 Spanish hospitals between 2014-2020 including adult NVAF patients treated with oral anticoagulants without anticoagulation history, recent thrombotic events, rheumatic mitral valvular heart disease, mitral valve stenosis, venous thromboembolism, nor pregnancy. We employed EHRead®, a free text analysis engine utilizing NLP and ML to extract RWD from EHRs based in SNOMED CT (standardized coding system). Free-text information was extracted and organized in an anonymized database for population-based descriptive and comparative analysis. After matching patients using propensity-score matching (PSM), we used Kaplan-Meier curves to compare VKA vs DOAC efficacy on thrombotic prevention, safety, and mortality. Results After evaluating 138,773,332 EHRs from 4.6 million patients, 44,292 NVAF patients were included; 35,267 (79.6%) treated with VKA and 9,025 (20.4%) with DOAC. Half of them were men (53.0%) with a mean (SD) age of 76.3 (12.7) years. VKA-treated patients tended to be older, with more cardiovascular comorbidities and higher CHA2DS2-VASc scores than DOACs-treated patients (Table 1). Using PSM, 8,930 patients were matched per subgroup with standardized mean differences below 10% for all confounders. The comparative analysis showed that DOAC-treated patients had a significant lower risk of thrombotic, minor bleeding events, and mortality than VKA-treated ones, with no significant differences in major bleeding (Figure 1). Conclusion The application of NLP and ML allowed us to create an extensive, plausible, and detailed database of Spanish NVAF patients from RWD in EHRs. In our cohort, we found a higher efficacy and lower mortality and minor bleeding events with DOACs over VKAs, without differences in major bleeding events. This study was sponsored by Pfizer and Bristol Myers Squibb. JCS, MA & CS were paid consultants to Pfizer and Bristol Myers Squibb in connection with the development of this abstract. CAC & LMS are employes of the SAVANA who were paid consultants to Pfizer and Bristol Myers Squibb in connection with the development of this abstract. DA & SFC are employees of Pfizer.Table 1Figure 1

Tricuspid regurgitation: Frequency, clinical presentation, management and outcome among patients with severe left-sided valvular heart disease in Europe. Insights from the ESC-EORP Valvular Heart Disease II survey.

Tricuspid regurgitation (TR) is commonly observed in patients with severe left-sided valvular heart disease (VHD). This study sought to assess TR frequency, management and outcome in this population. Among 6883 patients with severe native left-sided VHD or previous left-sided valvular intervention enrolled in the EURObservational Research Programme prospective VHD II survey, moderate or severe TR was very frequent in patients with severe mitral VHD (30% when mitral stenosis, 36% when mitral regurgitation [MR]), especially in patients with secondary MR (46%), and rare in patients with severe aortic VHD (4% when aortic stenosis, 3% when aortic regurgitation). An increase in TR grade was associated with a more severe clinical presentation and a poorer 6-month survival (p < 0.0001). Rates of concomitant tricuspid valve (TV) intervention at the time of left-sided heart valve surgery were high at the time of mitral valve surgery (50% when mitral stenosis, 41% when MR). Concordance between class I indications (patients with severe TR) for concomitant TV surgery at the time of left-sided valvular heart surgery according to guidelines and real-practice decision-making was very good (88% overall, 95% in patients operated on for MR). In this large international prospective survey among patients with severe left-sided VHD, moderate/severe TR was frequent in patients with mitral valve disease and was associated with a poorer outcome as TR grade increased. In patients with severe TR, compliance to guidelines for class I indications for concomitant TV surgery at the time of left-sided heart valve surgery was very good.

Female Gender in Cardiac Surgery: Is it Still a Significant Risk? A Retrospective Study in Saudi Arabia.

Female sex is considered an independent predictor for mortality and morbidity following cardiac surgery. This study is to review the outcomes of adult cardiac surgery between males and females in a Saudi tertiary referral hospital. This was a retrospective study for 925 adult patients operated on for ischemic coronary artery disease and acquired aortic and mitral valvular heart disease from 2015 to August 2023. We analyzed patient characteristics, intraoperative data, and postoperative results to compare outcomes between males and females. Preoperative risk factors were not significantly different in both groups. Postoperative outcomes showed gender-based differences. In univariable analysis, females, compared to males, had significantly greater odds of prolonged postoperative ventilation (>24 hours), 32.8% of females compared to 20.7% of males (p < 0.001). Also, sternal wound infection was notably higher among females (13.3%) (p < 0.001). Mortality also exhibited a significant association, with 14.2% of females experiencing mortality compared to 9.4% of males (p = 0.049). In the multivariable analysis for elevated postoperative troponin, the use of pre-operative intra-aortic balloon pump, urgent/emergent surgery, elevated pre-operative troponin and combined bypass grafting with valve surgery, were also predictive of higher post-operative troponin concentrations (beta = 0.43, 95% CI: 0.25 to 0.62, p < 0.001). Females in Saudi Arabia have an increased risk of short-term morbidity and mortality after cardiac surgery compared to males. Vague and delayed presentation and then the late diagnosis and referral are likely the main contributing factors. This highlights the need to implement preoperative measures to improve early diagnosis and referral to eliminate gender bias.

Auricle Myxoma, Evidence from the Clinic to Cardiovascular Emergency Surgery, Triad: Cardiac, Systemic, Embolic

Cardiac tumors are infrequent, primary tumors, such as atrial myxoma, are estimated at 000017 to 0.13% of all cardiac neoplasms, postmortem records, n relation to its frequency, it is more than the other primary ones, in 67% the left atrial myxoma, 23% in the right atrium and less frequent the biaurals left. age group from 30 to 60 years, more in the female sex, in the childhood is more related to alterations in skin lentiginosis, nevi as Carney.autosomica dominant síndrome. In genetic studies, alterations in the PRKAR1A gene on chromosome 17 are found. We present the case of a patient with a request for pre-surgical evaluation, urological prolapse of the bladder, with systemic manifestations, weight loss, chronic anemic syndrome treated with vitamins and trace elements, by a private physician, without remission. It is worth mentioning that the physical and cardiovascular examination revealed semiotic onygomatic seizures of Duroziez in the mitral area, with auscultatory changes in the left lateral decubitus position, for which reason I propose the diagnosis of mitral valvular heart disease vs atrial myxoma, with 2 elements of clinical judgment of the classic triad of myxoma, in the performance of the transcutaneous echocardiogram, a cardiac mass was observed, at the level of the left atrium, spherical, of 5.5 cmt diameter, hyperechogenic. Great mobility in cycles cardiac, prolapse of the mitral valve in diastole with stenosis, the emergency consultation was made to cardiovascular surgery in a hospital of greater complexity, a procedure with complete excision of the tumor of approx 12 cmt by 5.5 cmt diameter, with satisfactory evolution of the patient

Abstract 15233: Risk of Venous Thromboembolism and Nonrheumatic Valvular Heart Disease in Patients With Elevated Lipoprotein(a): A Retrospective Cohort Study

Introduction: Higher Lipoprotein(a) (Lp(a)) levels are known to be associated with increased risk of ASCVD. However, the effect of elevated Lp(a) on other cardiovascular (CV) diseases is largely unknown. We sought to identify whether Lp(a) level might be a risk factor for non-atherosclerotic CV conditions. Methods: Using data from the Healthy Nevada Project (HNP), a population genetic study based in Northern Nevada with &gt;52,000 participants, we conducted a retrospective analysis of all participants with recorded Lp(a) levels. An exploratory analysis was performed examining associations between elevated Lp(a) levels and various CV conditions based on ICD 10 codes. Elevated Lp(a) was defined as &gt;50 mg/dl or &gt;125 nmol/L. We examined ICD 10 codes related to venous thromboembolic (VTE) disease and non-rheumatic valvular heart disease (VHD). A Fisher’s Exact Test was performed to assess the significance of these associations. Results: Out of 4,010 HNP participants (age: 62±30; 42.7% female) with an Lp(a) result, 881 had elevated Lp(a), with incidence ~7% higher (~30% vs. ~23%) in Black, Pacific, and Native American groups. Of those with elevated Lp(a) levels, 96 (10.9%) had diagnoses (dxs) of VTE vs. 270 of 3129 (8.6%) participants with normal Lp(a) (p=0.046). Specifically, 9.76% of elevated Lp(a) participants vs. 7.51% of normal Lp(a) participants had dxs of DVT (p=0.035). No significant difference was found between elevated Lp(a) and PE. Additionally, 227 (25.8%) participants with elevated Lp(a) had VHD dxs compared to 593 (18.9%) participants from the normal Lp(a) cohort (p=0.0001). Specifically, 14.98% of elevated Lp(a) participants vs. 10.48% of normal Lp(a) participants had Aortic VHD (p=0.0003), and 14.87% of elevated Lp(a) participants vs. 10.35% normal Lp(a) participants had Mitral VHD (p=0.0003). No significant association was found between elevated Lp(a) and pulmonic or tricuspid VHD. Less novel but significant associations between elevated Lp(a) and Stroke (p=0.046) and CAD (p=0.0001) were also observed. Conclusions: In our study, elevated Lp(a) levels were significantly associated with increased risk of VTE and nonrheumatic VHD. An examination of these risks in association with germline genetic studies of ASCVD in the HNP is ongoing.

Valvular disease burden in the modern era of percutaneous and surgical interventions: the UK Biobank

BackgroundThe burden of valvular heart disease (VHD) has increased significantly among ageing populations, yet remains poorly understood in the present-day context of percutaneous and surgical interventions.ObjectiveTo define the incidence, clinical...

Preclosure of large bore venous access sites in patients undergoing transcatheter mitral replacement and repair.

We aim to report on the efficacy and safety of large bore venous access (LBVA) preclosure with Perclose™ (Abbott Vascular Devices) suture-mediated device use following transcatheter edge-to-edge (TEER) and replacement (TMVR). Patients requiring TEER and TMVR require LBVA. Clinical outcome data on the use of suture-mediated devices for LBVA site closure are limited. Between 2012 and 2019, 354 consecutive high-risk patients with mitral valvular heart disease underwent TEER (n = 287) with MitraClip and TMVR (n = 67) with Edwards Sapien Valves. Patients had LBVA with 24 or 16 French sheaths. All patients underwent preclosure of LBVA except for one that underwent manual hemostasis. There were no closure device failures. None of the cases required surgical repair of the access site following venous preclosure. Two cases had large hematomas (>6 cm) following Perclose in each group. Six cases had small hematomas (<6 cm and >2 cm) with three in each group. There was one major bleeding using Mitral Valve Academic Research Consortium 2 definition (retroperitoneal bleed from arterial puncture) unrelated to the venous closure. Transfusion related to vascular access complication was required in five cases. There were two immediate acute deep venous thromboses postprocedure; one of which occurred after preclosure. There were no arteriovenous malformations, pseudoaneurysms, or access site infections reported following Perclose. In this large sample size analysis, Proglide preclosure technique is a feasible and safe alternative approach to achieving hemostasis after removal of LBVA sheaths in patients undergoing TEER and TMVR. Randomized trials are needed to compare the different modalities of hemostasis.

Intractable/ Persistent Hiccups Due to Acute Subdural Haemorrhage as a Result of Prolonged Inr in a 55 Year Old Man with Rheumatic Mitral Valvular Heart Disease and Atrial Fibrillation: A Case Report

A 58 year old man was brought to hospital in state of deep coma following severe headache for one day. His GCS was 3/15 and had flaccid all 4 limbs with equivocal planter response on both sides on arrival. NECT head showed acute subdural haemorrhage with surrounding cerebral oedema, mid-line shift and corning of brain stem. After giving mannitol and dexamethasone, four hours later, he became fully conscious and orientated; his motor power returned to normal. He was on warfarin 3mg daily for rheumatic mitral valvular heart disease with atrial fibrillation and his INR on arrival was 3.5. He had intractable hiccups once he regained consciousness. Both pharmacological and non-pharmacological measures were tried for distressing hiccups; there was no therapeutic success. His hiccups disappeared completely only after removing the haematoma by burr hole surgery.

Abstract 11984: Impact of Underlying Pulmonary Hypertension on In-Hospital Outcomes Among Patients With Septic Shock

Background: Pulmonary Hypertension (PHTN) patients typically have chronic multiple comorbidities and are more vulnerable to acute clinical conditions leading to decreased survival. The impact of pulmonary hypertension on outcomes in patients with septic shock remains unknown. Methods: Adult patients with a diagnosis of septic shock were identified in the National Readmissions Database (NRD) between the years 2016-2017. Propensity matched retrospective cross sectional clinical outcomes were compared between patients with and without non-cardiac PHTN using appropriate statistical methods after nearest matching on a 2:1 ratio for several demographic, social and clinical variables. Patients with cardiogenic shock, aortic and mitral valvular heart disease, underlying systolic and combined heart failure (HF), and PHTN due to left heart disease were excluded from the primary analysis. Appropriate ICD-10 codes were used. Results: A total of 13,676 patients diagnosed with non-cardiac PHTN and septic shock were identified with a mean age of 68 years and 58.6% identified as females. Patients with PHTN had higher comorbidities, including hypertension, chronic pulmonary disease, renal failure, diabetes, CAD, and obesity. After matching, patients with septic shock and non-cardiac PHTN were noted to have a higher mortality (33.2% vs 31.3%, p &lt; 0.001), greater vasopressor use (7.9% vs 6.6%, p &lt; 0.001), higher rates of acute heart failure (1.1% vs 0.6%, p &lt; 0.001), longer hospital stay (14.0 days vs 12.7 days, p &lt; 0.001), and higher hospital costs ($196,411 vs $171,537), when compared to patients with septic shock and without PHTN. Rates of AKI were noted to be lower in patients with PHTN. Amongst stroke outcomes, minimal differences in ischemic strokes were noted. There were no MI outcomes observed. Discussion: PHTN is associated with worse mortality, morbidity, and resource utilization outcomes in patients admitted with septic shock, except AKI. These findings should be interpreted carefully given the administrative nature of the database, and the population cohort restricted to readmissions.

Burden of Valvular Heart Disease in Patients with Fabry Disease

Fabry disease (FD) is an X-linked lysosomal storage disorder in which glycosphingolipids accumulate in tissues, causing multisystem disease. FD is associated with mild tricuspid, aortic, and mitral valvular heart disease (VHD).1-3 The burden of VHD in the aging FD population treated with modern medical therapy, including enzyme replacement therapy (ERT), substrate reduction therapy, and aggressive control of cardiovascular comorbidities, is unknown. We describe the burden of VHD in a multicenter cohort of patients with FD with access to contemporary FD therapy.

Non-infectious thrombotic endocarditis associated with chronic rheumatic heart disease and disseminated tuberculosis.

ABSTRACTRheumatic heart disease is still common in developing countries and requires prompt intervention to prevent chronic complications. Vegetations in rheumatic heart disease might be due to acute episodes of rheumatic fever itself or due to either infective endocarditis (IE) or Non-infectious thrombotic endocarditis (NITE). Each form of vegetations has specific pathological characteristics on gross and microscopic examination. However, clinically IE and NITE may have overlapping signs and symptoms. A chance of misdiagnosis of NITE as culture-negative infective endocarditis is higher if the former present with infective symptoms like fever. NITE of valves can be due to underlying associated malignant neoplasm, particularly mucinous adenocarcinoma, pneumonia, cirrhosis, autoimmune disorders, and hypercoagulable state. The coexistence of tuberculosis, non-infectious thrombotic endocarditis and rheumatic valvular heart disease was rarely documented in medical literature. We describe a case of chronic rheumatic heart disease with vegetations in the posterior mitral valve leaflet, treated as culture-negative infective endocarditis, which, at autopsy, reveals the presence of Nonbacterial thrombotic endocarditis vegetation over calcified, fibrosed mitral valve leaflets and associated disseminated tuberculosis along with classic pathological sequela findings of chronic rheumatic mitral valvular heart disease in lungs and liver.

Thromboembolism and bleeding complications in anticoagulated patients with atrial fibrillation and native aortic or mitral valvular heart disease: a descriptive nationwide cohort study.

To describe the risks of thromboembolism and major bleeding complications in anticoagulated patients with atrial fibrillation (AF) and native aortic or mitral valvular heart disease using data reflecting clinical practice. Descriptive cohort study of anticoagulated patients with incident AF and native aortic or mitral valvular heart disease, identified in nationwide Danish registries from 2000 to 2018. A total of 10043 patients were included, of which 5190 (51.7%) patients had aortic stenosis, 1788 (17.8%) patients had aortic regurgitation, 327 (3.3%) patients had mitral stenosis, and 2738 (27.3%) patients had mitral regurgitation. At 1 year after AF diagnosis, the risk of thromboembolism was 4.6% in patients with mitral stenosis taking a vitamin K antagonist (VKA), and 2.6% in patients with aortic stenosis taking a VKA or non-vitamin K antagonist oral anticoagulant (NOAC). For patients with aortic or mitral regurgitation, the risks of thromboembolism ranged between 1.5%-1.8% in both treatment groups. For the endpoint of major bleeding, the risk was ∼5.5% in patients with aortic stenosis or mitral stenosis treated with a VKA, and 3.3-4.0% in patients with aortic or mitral regurgitation. For patients treated with a NOAC, the risk of major bleeding was 3.7% in patients with aortic stenosis and ∼2.5% in patients with aortic or mitral regurgitation. When using data reflecting contemporary clinical practice, our observations suggested that 1 year after a diagnosis of AF, anticoagulated patients with aortic or mitral valvular heart disease had dissimilar risk of thromboembolism and major bleeding complications. Specifically, patients with aortic stenosis or mitral stenosis were high-risk subgroups. This observation may guide clinicians regarding intensity of clinical follow-up.

Effectiveness of sildenafil in pulmonary hypertension secondary to mitral valve disease

Background and Aim: Pulmonary arterial hypertension almost always accompanies long-standing mitral valvular heart disease. The objective of this study is to study the effectiveness of sildenafil in reducing pulmonary hypertension in the peroperative and perioperative period. Materials and Methods: Fourteen patients were randomized into two groups test and control. Patients with mitral valvular disease with Pulmonary Artery Systolic Pressure (PASP) >50 were selected from the outpatient department and echo was done before the admission. Patients in the test group and control group were administered oral sildenafil 25 mg and placebo, respectively, three times a day in the preoperative period in the same fashion for 2 weeks. Preoperative echo was repeated thereafter. After induction of anesthesia and with all aseptic and antiseptic precautions, pulmonary artery catheter was inserted in the right internal jugular vein. PASP was calculated ½ hour after the induction of anesthesia. After operation, patients were monitored by transthoracic echo after 1 week. After discharge, patients were monitored by transthoracic echo at 1 month and at 3 months. Patients' data were analyzed using the statistical tools such as mean, Chi-square test for independence, and paired t-test. Results: There was a statistically significant reduction in PASP in the sildenafil group in the preoperative period (P

P2750Why should cardiopulmonary exercise testing be routinely used for assessing patients with valvular heart disease?

Abstract Introduction The role of cardiopulmonary exercise testing (CPET) is unquestionable to assess prognosis in heart failure. In patients with valvular heart disease (VHD), the functional capacity (FC) is crucial to aid in the right timing of surgery. The aim of this study was to compare the assessment of the FC by CPET and NYHA and the correlation between ventilatory efficiency parameters and resting systolic pulmonary artery pressure (SPAP). Methods We studied 100 VHD patients (57% female) who underwent a CPET. We calculated the real METS (RM) as indexed peak VO2/3.5 (1 MET=3.5 ml O2/kg/min) and compared to estimated METS (EM) derived by the time of exercise. An agreement analysis between RM, EM and NYHA was calculated. The correlation among VE/Vslope CO2, EqCO2at anaerobic threshold (AT), PETCO2, partial pressure end-tidal CO2 at AT and SPAP was analyzed. Results The results are shown in Table and Figure. The RM and the EM were 4.7±1.7 and 5.5±3, respectively (p&lt;0.01) with a low agreement (ICC=0.6, p&lt;0.01). The agreement between NYHA and the classification obtained from peak % of predicted peak VO2 was very low (weighted kappa =0.06, p=0.28). In patients with severe mitral VHD, the ventilatory efficiency parameters were correlated with SPAP (PETCO2 (AT), r=−0.7, p=0.002; EqCO2 (AT), r=0.5, p=0.04:VE/Vslope CO2, r=0.3, p 0.2), whereas in those with severe aortic VHD, these correlations were much lower (PETCO2 (AT), r=−0.3, p=0.13; EqCO2 (AT), r=0.2, p=0.15; VE/Vslope CO2, r=0.18, p 0.31). Total (n=100) Mitral regurgitation (n=35) Aortic regurgitation (n=23) Age 65 (29–86) 66 (30–84) 65 (11–87) LVEF (%) 62±6 63±6 61±7 SPAP (mmHg) 40±11 39±11 36±8 NYHA I (60%), II (33%), III (7%) I (63%), II (29%), III (9%) I (63%), II (33%), III (4%) Indexed peak VO2 (ml/min/kg) 16±6 17±6 19±8 Peak % predicted VO2 73±18 74±17 79±18 Predicted VO2 AT (%) 58±19 54±19 61±22 Eq CO2 AT 33±6 32±7 32±5 VE/VSlope CO2 33±6 32±7 33±8 PetCO2 AT 34±4 36±4 36±5 Type and degree of VHD Conclusions NYHA scale and estimation of METS derived from the time of exercise clearly overestimated the FC of our population. In our series, the ventilatory inefficiency in patients with mitral VHD could be a surrogate marker of advanced disease and could lead to an earlier intervention.

Abstract 17253: Gender Disparities Across the Spectrum of Valvular Heart Disease in Elderly Chinese Patients

Introduction: Evidence for the gender gap in valvular heart disease (VHD) has been mixed. This study aimed to investigate the potential gender differences concerning distribution patterns, clinical characteristics, management and in-hospital outcomes of noteworthy VHD in the elderly Chinese population. Hypothesis: Gender disparities exist across the spectrum and management of valvular heart disease in elderly Chinese patients. Methods: The China Degenerative Valve Disease (China DVD) Cohort Study was conducted from October 2016 to December 2017 in 72 centers from China. It included prospectively 8923 patients aged ≥60 years with moderate to severe native VHD, infective endocarditis, or previous valve intervention. In-hospital outcomes after invasive treatments were evaluated by composite endpoint consisting of death, major bleeding and nonfatal stroke. Results: Of all the 8923 VHD patients, men accounted for 52.48%, with aortic regurgitation (AR; 13.2% vs. 6.5%) and aortic stenosis (AS; 5.8% vs. 3.8%) contributing more of the VHD diagnosis than women. By contrast, the proportion of women with mitral stenosis (MS; 4.8% vs. 1.8%) was much higher than men. While the rheumatic causes stayed significant in MS, a growing predominance of degenerative causes was detected regardless of gender in patients with aortic VHD and MR. Body mass index, history of smoking, hypertension, CHD, cardiomyopathy, aortic diseases and previous intervention were significantly higher in men whereas women were more frequently complicated with atrial fibrillation or atrial flutter. Concerning medical intervention, coronary angiography was used in 51.5% of male patients compared to 47.3% of female patients (p=0.01). Among the 2188 patients received invasive treatments, the prosthetic replacement was performed in 61% of women with AS in comparison to 47.2% of men with AS (p=0.006). Conversely, men with AR were more likely to receive prosthetic replacement than women (29.8% vs. 21.3%, p=0.008). No significant differences were found in patients with mitral VHD. Operative mortality was &lt; 5% for single VHD. Multivariate regression analysis revealed an association between in-hospital outcomes and higher BMI as well as concomitant aortic disease regardless of gender. Conclusions: This study provides sex-specific data on characteristics and management of elderly Chinese patients with VHD. Pronounced sex-specific patterns were observed for aortic VHD and MS.

Non-Vitamin K Antagonist Oral Anticoagulants for Mechanical Heart Valves: Is the Door Still Open?

The estimated prevalence of mitral or aortic valvular heart disease is ≈2.5% in the general population of Western countries, and is expected to rise with population aging. A substantial proportion of patients with valvular heart disease undergoes surgical valve replacement. Mechanical heart valves are much more durable than bioprostheses, and are thus preferentially implanted in patients with a longer life expectancy, but have the major drawback of requiring lifelong anticoagulation to prevent valve thrombosis because of their higher thrombogenicity. The non-vitamin K antagonist oral anticoagulants (NOACs) are replacing vitamin K antagonists in many settings, including bioprostheses, because of their favorable safety and efficacy profiles. However, mechanical heart valves currently pose an absolute contraindication to NOACs based on the results of a single phase II study comparing dabigatran and warfarin (RE-ALIGN [Randomized, Phase II Study to Evaluate the Safety and Pharmacokinetics of Oral Dabigatran Etexilate in Patients after Heart Valve Replacement]). That trial was stopped prematurely because of an excess of both stroke and bleeding with the dabigatran doses tested. Because of such negative findings, research in this area has been halted. We believe that several aspects of both the preclinical studies and the RE-ALIGN trial should be critically reevaluated. In our opinion, 1 single trial with a single NOAC does not represent sufficient evidence for dismissing a therapeutic strategy, anticoagulation with NOACs, that has shown better safety and at least similar efficacy as warfarin in the setting of atrial fibrillation and venous thromboembolism,. Herein, we reevaluate this topic to identify the patient profile that has the greatest likelihood of benefit from some of the NOACs, with a focus on factor Xa inhibitors, thus providing some perspectives for basic and translational research.

Treatment and discharge patterns among patients hospitalized with non-valvular atrial fibrillation transitioning from the inpatient to outpatient setting

Objective: To evaluate inpatient oral anticoagulant (OAC) treatment, discharge location, and post-discharge OAC treatment for patients hospitalized with non-valvular atrial fibrillation (NVAF).Research design and methods: Retrospective study using claims data linked to hospital electronic health records (EHR). Patients (n = 2,484) were hospitalized with a primary (38%) or secondary (62%) diagnosis of AF without evidence of mitral valvular heart disease or valve replacement between January 2009 and September 2013. Inpatient OAC treatment was identified from EHR data.Main outcome measures: Inpatient and post-discharge OAC treatment [direct OAC (DOAC; apixaban, rivaroxaban, dabigatran), warfarin, no OAC] and discharge location (long-term care, home health-care, home self-care).Results: Mean age was 72.6 years, 61.2% were male, and 89.5% had a CHA2DS2-VASc score ≥2. Overall, 6.4% received a DOAC, 38.0% warfarin, and 55.6% no OAC during hospitalization. Compared to other treatment groups, patients receiving DOAC were younger and more likely to be male. The majority (72.2%) were discharged to home health-care, 13.2% home self-care, and 6.0% long-term care. Among patients who were treated with warfarin during hospitalization, 40.3% filled a warfarin prescription within 30 days post-discharge, whereas among patients who were treated with a DOAC, 52.4% filled a DOAC prescription within 30 days post-discharge. Some NVAF patients not treated with an OAC during hospitalization filled a prescription for warfarin (18.0%) or DOAC (1.9%) within 30 days post-discharge. Results were similar among patients with CHA2DS2-VASc score ≥2.Conclusions: Most patients hospitalized for NVAF were discharged to home support, and the majority did not have OAC treatment during hospitalization or the 30 days post-discharge. Additional investigation should be conducted on trends beyond 30 days post-hospitalization, and the reasons for not receiving anticoagulation therapy in patients at moderate-to-severe risk of stroke or systemic embolism. Helping to avoid preventable strokes is an important goal for public health.

A Lady with Systemic Lupus Erythematosus and Mitral Stenosis

Mitral stenosisis a valvular heart disease caused by a number of diseases. Chronic rheumatic fever is the most important cause. Among rare causes, some rheumatoid diseases like SLE may involve cardiovascular system causing libman- sacks endocarditis,pericardial diseases and other valvular lesions mostly associated with positive antiphospholipid and anticardiolipin antibody.Here, we presented a case of rheumatic mitral valvular heart disease having systemic lupus erythromatosus but negative antiphospholipid and anticardiolipin antibody.Bangladesh Heart Journal 2016; 31(2) : 109-112

Drug-induced aortic valve stenosis: An under recognized entity

BackgroundWe have been intrigued by the observation that aortic stenosis (AS) may be associated with characteristic features of mitral drug-induced valvular heart disease (DI-VHD) in patients exposed to valvulopathic drugs, thus suggesting that beyond restrictive heart valve regurgitation, valvulopathic drugs may be involved in the pathogenesis of AS. MethodsHerein are reported echocardiographic features, and pathological findings encountered in a series of patients suffering from both AS (mean gradient >15mmHg) and mitral DI-VHD after valvulopathic drugs exposure. History of rheumatic fever, chest radiation therapy, systemic disease or bicuspid aortic valve disease were exclusion criteria. ResultsTwenty-five (19 females, mean age 62years) patients having both AS and typical features of mitral DI-VHD were identified. Mean transaortic pressure gradient was 32+/−13mmHg. Aortic regurgitation was ≥ mild in 24 (96%) but trivial in one. Known history of aortic valve regurgitation following drug initiation prior the development of AS was previously diagnosed in 17 patients (68%). Six patients underwent aortic valve replacement and 3 both aortic and mitral valve replacement. In the 9 patients with pathology analysis, aortic valvular endocardium was markedly thickened by dense non-inflammatory fibrosis, a characteristic feature of DI-VHD. ConclusionThe association between AS and typical mitral DI-VHD after valvulopathic drug exposure may not be fortuitous. Aortic regurgitation was usually associated to AS and preceded AS in most cases but may be lacking. Pathology demonstrated the potential role of valvulopathic drugs in the development of AS.

Routine Troponin Measurements Are Unnecessary to Exclude Asymptomatic Coronary Events in Acute Ischemic Stroke Patients

Obtaining serum troponin levels in every patient with acute stroke is recommended in recent stroke guidelines, but there is no evidence that these contribute positively to clinical care. We sought to determine the clinical significance of measuring troponin levels in acute ischemic stroke patients. We reviewed 398 consecutive patients with acute ischemic stroke at a large academic institution from 2010 to 2012. Troponin levels were measured as a result of protocol in place during part of the study period. The mean age was 70 years (standard deviation ±16 years) and 197 (49.5%) were men. Chronic kidney disease was present in 78 (19.6%), coronary artery disease in 107 (26.9%), and atrial fibrillation in 107 (26.9%). Serum troponin T was measured in 246 of 398 patients (61.8%). Troponin was elevated (>.01 ng/mL) at any point in 38 of 246 patients (15.5%) and was elevated in 28 patients at all 3 measurements (11.3% of those with troponin measured). Only 4 of 246 patients (1.6%) had a significant uptrend. Two were iatrogenic in the setting of hemodynamic augmentation using vasopressors to maintain cerebral perfusion. One case was attributed to stroke and chronic kidney disease and another case to heart failure from inflammatory fibrocalcific mitral valvular heart disease. Serum troponin elevation in patients with ischemic stroke is not usually caused by clinically significant acute myocardial ischemia unless iatrogenic in the setting of vasopressor administration. Serum troponin levels should be measured judicially, based on clinical context, rather than routinely in all stroke patients.