Non-vitamin K antagonist oral anticoagulants in atrial fibrillation accompanying mitral stenosis: the concept for a trial.

Patients at thromboembolic risk with non-valvular atrial fibrillation (AF) can now be managed either with a vitamin K antagonist (VKA) or with a fixed dose of a non-VKA oral anticoagulant (NOAC), while patients with valvular AF have been restricted to VKAs on the basis of a potentially higher risk and different mechanism of thrombosis, and the lack of sufficient data on the efficacy of NOACs. The terms 'non-valvular AF' and 'valvular AF' have not been however consistently defined. 'Valvular' AF has included any valvular disorder, including valve replacement and repair. In AF with rheumatic mitral disease, observational studies strongly suggest that VKA treatment is valuable. These patients have not been included in NOAC trials, but there is also no stringent argument to have excluded them. This is at sharp variance from patients with mechanical valves, also excluded from the pivotal Phase III trial comparing warfarin with NOACs, but in whom a single Phase II trial of dabigatran etexilate against VKA treatment was stopped prematurely because of increased rates of thromboembolism as well as increased bleeding associated with dabigatran. Until more data are available, such patients should be therefore managed with VKAs. We here propose an open-label randomized trial of one of the NOACs against the best of treatment available in regions of the world in which rheumatic heart disease is still highly prevalent, aiming at showing the superiority of the NOAC used against current standard treatment

Uneventful Disappearance of a Large Left Atrial Ball Thrombus with Enoxaparin in a Patient with Mitral Stenosis Associated with Pregnancy

An atrial thrombus is a relatively common echocardiographic finding in patients with mitral valve stenosis (MVS) and atrial fibrillation (AF). However, a “ball thrombus” or floating thrombus in the left atrium is a rare and specific entity associated with MVS. A 24-year-old woman with rheumatic MVS presented with complaints of progressive dyspnea and inferior limbs edema that began 23 days earlier after a caesarean operation for stillbirth carried out at 8 months of pregnancy. At the time of hospitalization, she was in New York Heart Association functional class III and the ECG showed sinus rhythm. Transthoracic color-flow Doppler echocardiography revealed a thick, stenotic mitral valve with a valvular area of 0.9 cm2, and an echogenic large left-atrial mass diagnosed as a free-floating left-atrial thrombus that was corroborated by transesophageal echocardiography. She refused surgery and was treated medically, and low molecular weight heparin (LMWH) (enoxaparin 80 mg/12 h) was given for 14 days and was discharged uneventfully on coumarin. Two days before discharge, a transthoracic and transesophageal ecocardiography showed disappearance of the ball thrombus uneventfully leaving spontaneous echo contrast inside the left atrium. To the best of our knowledge, this is the first case showing disappearance of a giant left atrial ball thrombus with LMWH treatment in a patient with severe MVS during sinus rhythm associated with pregnancy

Case Report: Tetris Ball In The Left Atrium

A free-floating ball thrombus in the left atrium is a rare and serious medical problem that can cause fatal systemic emboli or block the flow of blood into the left ventricle, which usually ends in sudden death.This report discusses a case of a significant left atrial thrombus that was found to be free-floating in an enlarged left atrium. A 73-year-old male, who had experienced a cerebrovascular infarction and hemorrhage five days earlier, along with a history of chronic atrial fibrillation, was referred to the cardiology department to investigate the embolic cause. A transthoracic echocardiogram identified a free-floating ball thrombus. Thrombolytic therapy was not recommended because there were areas of bleeding within the cerebrovascular infarction and the patient had a high risk profile The individual, with several comorbid conditions, a Glasgow Coma Scale score of 8, and right-sided hemiplegia, was classified as high-risk by the cardiovascular surgery team. In spite of the potential for bleeding complications, treatment with warfarin and unfractionated heparin was started. Subsequent evaluations indicated that the thrombus did not diminish in size. We lost our patient due to progressive heart failure and cardiogenic shock while anticoagulant treatment was continuing. As a result, in such cases, it is important to determine the treatment according to the patient's general condition, glaskow coma score, embolization and the risk of fatal bleeding

Thrombus flottant de l’oreillette gauche révélé par des embolies multiples

Introduction: Le thrombus flottant de l’oreillette gauche  est rare. Il se produit habituellement au niveau d’une oreillette gauche très dilatée  avec une stagnation du flux sanguin, résultat d’une sténose mitrale rhumatismale sévère  avec fibrillation atriale.Observation clinique : Nous rapportant l’observation clinique d’une patiente de 58 ans, qui s’est présentée aux urgences pour un œdème pulmonaire associé à un syndrome oedémato-ascétique et une oligurie. L’exploration initiale a retrouvé une insuffisance rénale pré-terminale . La patiente a bénéficié en urgence d’une séance d’hémodialyse, au terme de cette séance, elle a présentée une obnubilation sans trouble de focalisation et une ischémie aigue du membre inférieur droit.L’ECG a révélé une arythmie complète par fibrillation auriculaire. L’échocardiographie transthoracique a retrouvé un rétrécissement  mitral rhumatismal, associé à un énorme thrombus flottant de l’OG L’échographie doppler rénale et l’angioscanner abdominal ont mis en évidence un infarctus rénal gauche secondaire à une embolie de l’artère rénale gauche. Le scanner cérébral était normal.La patiente a été opérée  en urgence.Les suites opératoires étaient marquées par la récupération d’une fonction rénale et une revascularisation du membre inferieur droit. Cependant la patiente a présenté à J+2 une hémiplégie gauche suite à un infarcissement hémorragique cérébral conduisant au décès de la patiente à J+8.Conclusion : Le thrombus de l’OG est une complication classique du rétrécissement mitral. Il est associé à des complications graves. Le traitement médical seul par anticoagulants ou thrombolytiques est réservé aux cas très graves contre-indiquant une chirurgie ou chez les patients refusant l’intervention.

Some Observations on Mitral Stenosis: A Survey of 100 Cases Surviving Mitral Valvotomy

The clinical features of mitral stenosis are discussed with particular reference to age, the incidence of rheumatic fever and the method of grading in 100 cases surviving valvotomy. The cardinal features of the examination of these cases are discussed. The pre-operative preparation is mentioned and the various important aspects of anaesthesia, blood transfusion and the technique of the operation are explained. Some of the operative difficulties are underlined, and suggestions are made in preventing or dealing with them. The recognition and the treatment of the various post-operative complications is important. The operative mortality figures are given, and the causes of death are discussed. The alterations in the clinical examination following the operation are detailed. The results predicted at the time of operation are compared with the results obtained. The result at six months is assessed in relation to the valve split. The assessment at six months is compared with the "final" assessment. A special analysis is made of the cases operated on for three or more years, with particular reference to those cases showing deterioration. Positive auricular biopsies are correlated with the results and the value of lingular biopsies discussed. Various conclusions are drawn from these different aspects of mitral stenosis and its treatment

Intra‑cardiac masses in adults: A review of echocardiogram records at two echocardiographic laboratories in Enugu, South‑East Nigeria

Background: Transthoracic echocardiography (TTE) is an excellent initial diagnostic technique used to evaluate and diagnose cardiac masses, even though transoesophageal echocardiography (TEE) provides superior image resolution and better visualization of cardiac masses, especially in patients with suboptimal transthoracic echocardiographic studies. TTE is the clinical procedure of choice for identification of left ventricular thrombi. TTE has greater than 90% sensitivity and greater than 85% specificity for detection of left ventricular thrombi and is probably superior to the sensitivity and specificity of TEE, especially for apical thrombi.Aims: The study aimed to identify the common types of cardiac masses and their commonest locations in the heart.Materials and Methods: We did a retrospective review of our echocardiogram reports from May 2003 to July 2012 to identify the frequency of intra‑cardiac masses in adults, as well as the gender distribution and commonest location of these masses.Results: There were 2,814 echo examinations in adults over this period, comprising 1,661 males (59.1%) and 1,153 females (40.9%). Intra‑cardiac masses were found in 20 of these patients representing 0.7% of the study population. Thrombi were the commonest masses noted in our study, and there were more masses in the atria than in the ventricles. The left heart chambers also had more masses than the right heart chambers. There was no sex difference in the frequency of cardiac masses.Conclusion: Intra‑cardiac masses are rare, and transthoracic echocardiography is still valuable in the diagnosis and initial characterization of cardiac masses.Keywords: Adults, echocardiography, intra‑cardiac masses, NigeriaNigerian Journal of Clinical Practice • Oct-Dec 2013 • Vol 16 • Issue

Anaesthesia for transvenous transcatheter tricuspid valve-in-valve implantation

The authors report and discuss the anaesthetic management of a transvenous transcatheter tricuspid valve replacement. The conduct of anaesthesia, the challenges encountered and the specific risks associated with the procedure will be discussed. Percutaneous tricuspid valve replacement may be safely performed under general anaesthesia, provided that the procedure is understood and all possible eventualities considered. As the quality of percutaneous prostheses improves, and if longterm follow-up confirms this as a safe option, anaesthesiologists will be expected to provide perioperative care for a growing number of these cases.Keywords: transvenous, transcatheter, tricuspid prosthesis, valve-in-valve implantatio

Estenosis mitral complicada con trombos intracavitarios y fibrilación auricular: Reporte de un caso

Introduction: Mitral stenosis impedes blood flow from the left atrium to the left ventricle. Rheumatic fever is the main etiology, and 60% evolve into rheumatic heart disease (RHD). Among the most frequent complications we have: Acute pulmonary edema, atrial fibrillation, systemic embolisms and chest pain. The diagnosis of valvular heart disease is made through physical examination and complementary methods such as electrocardiogram and echocardiography. Case presentation: A 56-year-old female patient was referred for cardiology consultation due to two episodes of acute pulmonary edema associated with rapid palpitations. The electrocardiogram (ECG) reported atrial fibrillation with preserved ventricular response. Transthoracic echocardiogram showed a severe mitral stenosis, with left atrial enlargement, thrombi in the roof of the left atrium and moderate tricuspid insufficiency.  Diagnosis of mitral valve disease of rheumatic etiology was established. Treatment was started with bisoprolol, furosemide, digoxin, rivaroxaban or warfarin. After several months of follow-up, the patient died. Discussion and Conclusion: It is important to highlight the clinical presentation of the disease, endemic areas of rheumatic fever, and the probability that a patient with signs and symptoms of heart failure could have rheumatic valve disease. Similarly, the  therapeutic management of the patient, highlighting the use of vitamin K antagonists and not new oral anticoagulants, maintaining an INR of 2 and 3, in patients with new onset or paroxysmal atrial fibrillation, and patients in sinus rhythm with a history of systemic embolic events, thrombi in the left atrium, and left atrial enlargement.La estenosis mitral es una valvulopatía que impide el flujo de sangre desde la aurícula izquierda hacia el ventrículo izquierdo. La fiebre reumática es la principal etiología en países en vías de desarrollo, otras causas pueden ser de carácter degenerativo o congénito. Los síntomas más frecuentes son disnea de esfuerzo, que en ocasiones puede progresar a edema agudo de pulmón, además de la presencia de palpitaciones.Otra sintomatología que se presenta en función de la gravedad es la presencia de hemoptisis, dolor torácico embolia sistémica, signos y síntomas de falla cardiaca derecha. El diagnóstico se realiza mediante anamnesis, examen físico y métodos complementarios como electrocardiograma y ecocardiograma. El objetivo fue presentar un caso de una paciente femenina de 56 años de edad, con diagnóstico de estenosis mitral complicada con trombos intracavitarios y fibrilación auricular.La paciente presentó disnea y fibrilación auricular, con historial de hipertensión e insuficiencia cardiaca. El ecocardiograma reveló estenosis mitral severa con trombosintracavitarios, hipertrofia auricular izquierda y disfunción ventricular derecha. Se manejó con anticoagulantes, betabloqueantes, diuréticos y digoxina, pero suspendió los anticoagulantes, persistiendo los trombos. Sufrió síncope, paro cardiorrespiratorio, y se diagnosticó un gran trombo flotante en la aurícula izquierda. Paciente fallece por sospecha de tromboembolismo pulmonar. Se concluye que la falta de adherencia al tratamiento llevó a un desenlace fatal con sospecha de tromboembolismo pulmonar no confirmado, resaltando la importancia del manejo individualizado en estos casos