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Detecting native and bioprosthetic aortic valve disease using 18F-sodium fluoride: Clinical implications.
Fletcher, AJ, Dweck, MR
Journal of nuclear cardiology : official publication of the American Society of Nuclear Cardiology. 2021;(2):481-491
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Abstract
Calcific aortic valve disease is the most common valvular disease and confers significant morbidity and mortality. There are currently no medical therapies that successfully halt or reverse the disease progression, making surgical replacement the only treatment currently available. The majority of patients will receive a bioprosthetic valve, which themselves are prone to degeneration and may also need replaced, adding to the already substantial healthcare burden of aortic stenosis. Echocardiography and computed tomography can identify late-stage manifestations of the disease process affecting native and bioprosthetic aortic valves but cannot detect or quantify early molecular changes. 18F-fluoride positron emission tomography, on the other hand, can non-invasively and sensitively assess disease activity in the valves. The current review outlines the pivotal role this novel molecular imaging technique has played in improving our understanding of native and bioprosthetic aortic valve disease, as well as providing insights into its feasibility as an important future research and clinical tool.
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Myocardial contrast echocardiography in the diagnosis of postoperative takotsubo myocardiopathy: case report and literature review.
Zeng, JH, Li, W, Yao, FJ, Liu, DH, Li, CL, Liu, YQ, Fan, R, Ye, M, Lin, H
BMC cardiovascular disorders. 2019;(1):9
Abstract
BACKGROUND Takotsubo cardiomyopathy (TCM) is a brief ventricular dysfunction that usually occurs after emotional or physical stress. Here, we report a patient who underwent cardiac surgery and then developed TCM during the postoperative period. CASE PRESENTATION A 51-year-old woman was admitted to our hospital complaining of chest tightness, palpitations and dyspnoea after activity. An echocardiogram performed by our hospital showed rheumatic heart disease (severe mitral stenosis and regurgitation) with normal cardiac function and wall motion. After mitral valve replacement, this patient developed heart failure with low blood pressure and tachycardia. Urgent bedside echocardiography demonstrated akinesis in the middle and apical segments of the left ventricle and a depressed ejection fraction (EF) of 36%. Myocardial contrast echocardiography (MCE) showed similar enhancement intensity in the basal, middle and apical segments. Quantitative analysis showed approximately equivalent maximum intensity in these regions. The diagnosis was considered TCM instead of myocardial infarction. Then, an intra-aortic balloon pump was inserted to maintain effective circulation and reduce the postcardiac load. Given ventilation therapy, postoperative anticoagulation therapy and anti-infection treatment, the patient recovered quickly. In the follow-up examination, the patient remained asymptomatic and showed normalization of ventricular wall motion in the apical segment. CONCLUSION This report presents a case of TCM in which MCE was used to demonstrate intact microvascular perfusion despite apical akinesis. This report might support the use of MCE as a substitute for invasive coronary angiography.
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3.
New Oral Anticoagulation after Heart Valve Replacement.
El-Battrawy, I, Baumann, S, Huseynov, A, Akin, I
Cardiovascular & hematological disorders drug targets. 2015;(2):106-9
Abstract
Antithrombotic treatment after heart valve surgery is of utmost importance depending on the type of used valve. Since in the early 1960s, oral anticoagulation with vitamin K antagonist are the gold-standard for prevention of thromboembolism at replaced heart valves. The introduction of new oral anticoagulation has dramatically changed treatment strategy in patients with atrial fibrillation and in patients with venous thromboembolism like deep vein thrombosis and pulmonary embolism. However, to date, the use of these newer drugs is contraindicated after implantation of mechanical heart valves for prevention of thromboembolism. Large trial revealed significantly higher rates of thromboembolism and bleeding events as compared to oral anticoagulation. Further studies are required to evaluate the several newer oral anticoagulations in patients with mechanical heart valve.
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4.
The optimal management of anti-thrombotic therapy after valve replacement: certainties and uncertainties.
Iung, B, Rodés-Cabau, J
European heart journal. 2014;(42):2942-9
Abstract
Anti-thrombotic therapy after valve replacement encompasses a number of different situations. Long-term anticoagulation of mechanical prostheses uses vitamin K antagonists with a target international normalized ratio adapted to the characteristics of the prosthesis and the patient. The association of low-dose aspirin is systematic in the American guidelines and more restrictive in the European guidelines. Early heparin therapy is frequently used early after mechanical valve replacement, although there are no precise recommendations regarding timing, type, and dose of drug. Direct oral anticoagulants are presently contraindicated in patients with mechanical prosthesis. The main advantage of bioprostheses is the absence of long-term anticoagulant therapy. Early anticoagulation is indicated after valve replacement for mitral bioprostheses, whereas aspirin is now favoured early after bioprosthetic valve replacement in the aortic position. Early dual antiplatelet therapy is indicated after transcatheter aortic valve implantation, followed by single antiplatelet therapy. However, this relies on low levels of evidence and optimization of anti-thrombotic therapy is warranted in these high-risk patients. Although guidelines are consistent in most instances, discrepancies and the low-level of evidence of certain recommendations highlight the need for further controlled trials, in particular with regard to the combination of antiplatelet therapy with oral anticoagulant and the early post-operative anti-thrombotic therapy following the procedure.
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5.
Aortic root rupture: implications of catheter-guided aortic valve replacement.
Berdajs, D
Current opinion in cardiology. 2013;(6):632-8
Abstract
PURPOSE OF REVIEW The safety and efficiency of trans catheter aortic valve implantation (TAVI) has been clearly demonstrated. In high-risk patients, the number of procedures is constantly increasing and in western European countries this procedure is employed in more than 30% of isolated aortic valve replacements. The literature, however, focusing on perioperative aortic root (AoR) rupture is rather limited to just a few reports. The aim of this review is to analyze the pathophysiology of AoR rupture during TAVI, stressing the implications of the morphology of the AoR for this devastating complication. RECENT FINDINGS Currently, perioperative AoR rupture ranges between 0.5 and 1.5% during TAVI, with almost 100% mortality. Recently, valve oversizing and balloon dilatation in a calcified and small AoR were considered as the most important predictive factors for this complication. SUMMARY The most fragile unit of the AoR is its anchoring substrate to the ostium of the left ventricle. This membranous structure is not involved in the degenerative process leading to aortic valve stenosis. Due to the TAVI and/or balloon dilatation of the calcium stationed on the three leaflets and their attachment, a lesion may result on this structure. And, as a consequence, there is rupture of the AoR.
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6.
Aortic stenosis and mitral regurgitation: implications for transcatheter valve treatment.
Barbanti, M, Dvir, D, Tan, J, Webb, JG
EuroIntervention : journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology. 2013;:S69-71
Abstract
Moderate or severe mitral regurgitation (MR) is a common finding in patients with severe aortic stenosis (AS). The combination may be a relative indication for double valve surgery, particularly when MR is severe, degenerative, associated with left atrial dilation, chronic atrial fibrillation, or mitral annular calcium. However, in patients for whom open surgery is not desirable, TAVI may provide a reasonable therapeutic strategy with an expectation in selected patients that MR may improve, be better tolerated, or be amenable to staged transcatheter mitral interventions. In this paper, we briefly review the surgical experience with concomitant AS and MR and discuss the potential implications of transcatheter-based heart valve techniques in this patient group.
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7.
[Stenosis of the aortic valve].
Helske, S, Kupari, M
Duodecim; laaketieteellinen aikakauskirja. 2011;(1):35-42
Abstract
The disease condition underlying the stenosis of the aortic valve resembles atherosclerosis and is dominated by activation of inflammatory cells, and accumulation of cholesterol and involves progressive fibrosis and calcification. Stenosis of the aortic valve may remain asymptomatic for long. Characteristic symptoms include exertional dyspnea and asthenia, angina pectoris type chest pain or loss of consciousness on exertion. The essential clinical finding on examination is a systolic murmur of the heart. Doppler ultrasonography of the heart is the diagnostic cornerstone. Stenosis of the aortic valve is treated with prosthetic valve surgery.
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8.
[Perioperative antocoagulation in patients with prosthetic heart valves: recommendations].
Wendt, D, Piotrowski, JA, Schönfelder, B, Marggraf, G, Thielmann, M, Jakob, H
Der Urologe. Ausg. A. 2010;(11):1368-71
Abstract
Lifelong anticoagulation, mainly with oral Vitamin K antagonists, represents the treatment of choice in patients with prosthetic heart valves to prevent thrombembolic complications. As a result, anticoagulant-related complications like excessive bleeding during interventions or surgical procedures will occur. Therefore, timely stopping of vitamin K antagonists prior to elective surgery is mandatory. However, based on the long half-life of all common vitamin K antagonists, interruption of oral anticoagulation will definitively lead to an increase of thrombembolic events. Hence, adequate bridging anticoagulation by temporary substitution of this therapy with heparin is necessary. This article gives a recommendation on the basis of the American College of Chest Physician and European Society of Cardiology current.
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9.
Anticoagulation for mechanical heart valves in patients with and without atrial fibrillation.
Baber, U, van der Zee, S, Fuster, V
Current cardiology reports. 2010;(2):133-9
Abstract
Surgical replacement of a native valve with a biological or mechanical prosthesis is the definitive treatment for many forms of advanced valvular heart disease. Mechanical heart valves are less prone to structural deterioration compared with bioprostheses, but require chronic oral anticoagulation to prevent thromboembolic events. Thromboembolic risk varies based on patient-related risk factors, including atrial fibrillation, advanced age, low ejection fraction, and hypercoagulability. Other important correlates of high thromboembolic risk include valve design, valve position, anticoagulation variability, and time from surgery. Clinical management is further complicated when antithrombotics may need to be interrupted or altered during surgery or pregnancy. At present, vitamin K antagonists are the only approved agents for thromboprophylaxis but are limited because of a narrow therapeutic window and requirement for frequent monitoring. Novel anticoagulants, including inhibitors of factor IIa and Xa, are currently being evaluated and may emerge as alternatives to vitamin K antagonists.
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10.
Oral anticoagulant therapy in patients with mechanical heart valve and intracranial haemorrhage. A systematic review.
Romualdi, E, Micieli, E, Ageno, W, Squizzato, A
Thrombosis and haemostasis. 2009;(2):290-7
Abstract
Optimal timing for restarting anticoagulant therapy after intracranial bleeding is a critical issue. The purpose of this systematic review is to summarize published studies on the management of oral anticoagulant therapy after intracranial bleeding secondary to the use of vitamin K antagonists in patients with a mechanical heart valve. A computer-assisted search of the MEDLINE and EMBASE electronic databases till January 2008 was performed. Two investigators independently performed study selection and completed a predefined quality assessment and data extraction form. Main inclusion criterion was the enrolment of patients with a mechanical heart valve and intracranial haemorrhage during oral anticoagulant treatment. Any randomised controlled trial, observational cohort study, case series and reports was included. No randomised controlled trials were identified. Six observational cohort studies were included in the final analysis. All studies were of low quality. A total of 120 patients were enrolled. Anticoagulation was restarted within a broad time range (2 days to 3 months). Four ischaemic strokes and two recurrent cerebral haemorrhages occurred after anticoagulation was restarted after a mean follow-up of 7.9 months. Eighteen patients were described in the selected case reports. Anticoagulant therapy was restarted within four days to eight weeks. Two patients had a recurrent haemorrhagic event, and no ischaemic events were reported. In conclusion, restarting oral anticoagulant therapy few days and, indirectly, stopping anticoagulant therapy for a few days (even for 7-14 days) after the occurrence of cerebral haemorrhage are both safe. However, well-designed studies are strongly recommended to provide better evidence.