Nonoclusive thrombosis of mechanical mitral valve prosthesis caused by inadequate treatment of anticoagulant therapy resistance

Background. Oral anticoagulants have been used in the prevention of thromboembolic complications for over six decades. A rare, but possible problem in the application of these medications could be resistance to them. Case report. We presented a patient with nonocclusive thrombosis of the mechanical mitral prosthesis due to inadequately treated resistance to peroral anticoagulant therapy. Resistance to oral anticoagulant medications was proven by an increased dosage of warfarin up to 20 mg and, after that, acenokumarol to 15 mg over ten days which did not lead to an increase in the international normalized ratio (INR) value over 1.2. On the basis of information that she did not take food rich in vitamin K or medications which could reduce effects of oral anticoagulants, and that she did not have additional illnesses and conditions that could cause an inadequate response to anticoagulant therapy, it was circumstantially concluded that this was a hereditary form of resistance. Because of the existing mechanical prosthetics on the mitral position, low molecular heparin has been introduced into the therapy. The patient reduced it on her own initiative, leading to nonocclusive valvular thrombosis. Conclusion. When associated complications like absolute arrhithmia does not exist, the finding of resistance to oral anticoagulant agents is an indication for the replacement of a mechanical prosthetic with a biological one which has been done in this patients

Relationship between the type of atrial fibrillation and thromboembolic events

Background/Aim. Atrial fibrillation (AF) increases the risk for ischemic stroke and other thromboembolic (TE) events. Aim of the study was to examine the relationship between clinical types of atrial fibrillation (AF) and (TE) events. Methods. This longitudinal, observational study included patients with nonvalvular AF as main indication for in-hospital and/or outpatient treatment in the Cardiology Clinic, Clinical Center of Serbia during a period 1992-2007. The treatment of AF was based on the International Guidelines for diagnosis and treatment of AF, correspondent to given study period. Clinical types of AF were defined according to the latest ACC/AHA/ESC Guidelines for AF, from 2006. Diagnosis of central and systemic TE events during a follow-up was made exclusively by the neurologist and vascular surgeon. Results. During a follow-up of 9.9 ± 6 years, TE events were documented in 88/1 100 patients (8%). In the time of TE event 46/88 patients (52.3%) had permanent AF. The patients with permanent AF were at baseline significantly older and more frequently had underlying heart disease and diabetes mellitus. Cumulative TE risk during follow-up was similar for patients with paroxysmal and permanent AF, and significantly higher as compared to TE risk in patients with persistent AF. However, multivariate Cox proportional hazard regression analysis with independent variables clinical types of AF at baseline and in the time of TE event, clinical and echocardiographic characteristics and therapy for prevention of TE complications at baseline and at the time of TE event, did not reveal independent predictive value of clinical type of AF for the occurrence of TE events during a follow-up. Conclusion. TE risk in patients with AF does not depend on clinical type of AF. Treatment for prevention of TE events should be based on the presence of well recognized risk factors, and not on the clinical type of AF

Characteristics, outcome and predictors of one year mortality rate in patients with acute heart failure

Background/Aim. Acute heart failure (AHF) is one of the most common diseases in emergency medicine, associated with poor prognosis and high in-hospital and longterm mortality. The aim of this study was to investigate characteristics, outcomes and one year mortality of patients with AHF in the local population. Methods. This prospective study consisted of 64 consecutive unselected patients treated in the Coronary Care Unit of the Emergency Centre (Clinical Center of Serbia, Belgrade) and were followed for one year after the discharge. Results. Mean age of the patients was 63.6 ± 12.6 years and 59.4% were males. Acute congestion (43.8%) and pulmonary edema (39.1%) were the most common presentations of AHF. Mean left ventricular ejection fraction (LVEF) was 39.7% ± 9.25%, while 44.4% of the patients had LVEF ≥ 50%. At discharge, 55.9% of the patients received therapy with β-blockers, 94.9% diuretics, out of which 47.7% spironolactone, 94.9% patients were given ACE-inhibitors or angiotensin receptor blokcers (ARB). The 12-month all-cause mortality was 26.5%. Independent predictors of one year mortality were previous hospitalization due to heart disease, reduced LVEF, reduced fraction of shortening (FS) and a higher tricuspid velocity. Conclusion. One year mortality of our patients with AHF was high, similar to the known European studies. Independent predictors of one year mortality were previous hospitalization due to heart disease, reduced LVEF and LVFS and a higher tricuspid velocity

Ehokardiografija u ranoj detekciji poremećaja funkcije desne komore pri promjeni volumena krvi kod bolesnika na hemodijalizi

Uvod. Poremećaji funkcije desnog srca su prediktori loše prognoze kodpacijenata na programu hronične hemodijalize (HD). U ovoj studiji ispitivanaje validnost ehokardiografije u procjeni sistolne i dijastolne funkcije desnekomore kod pacijenata na HD.Metode. Istraživanjem je obuhvaćeno 30 pacijenata (55±11 godina) na hroničnojHD kojima su rađene standardna 2D ehokardiografija i tkivni Doppler, prijei nakon HD.Rezultati. Ispitivanje sistolne funkcije desne komore prije i poslije HD jepokazalo da su frakciona promjena površine – FAC (36%±11 vs. 34%±11,p=0,464) i amplituda sistolne pokretljivosti anulusa trikuspidne valuvle–TAPSE (25,2mm±4,8 vs. 24,2mm±5, p=0,207) bile u granicama normalnihvrijednosti, nezavisno od smanjenja ukupnog volumena krvi nakon HD, dokje frakciono skraćenje – Fs (43,8%±11,6 vs. 39,3%±13,2, p=0,014) bilo značajnomanje nakon HD, što pokazuje zavisnost ovog parametra od smanjenja cirkulatornogvolumena. Tei indeks desne komore pokazao je normalne vrijednosti,nezavisno od smanjenja punjenja desne komore nakon HD (0,59±0,44 vs.0,69±0,27, p=0,18). Evaluacija dijastolne funkcije desne komore preko brzinatranstrikuspidnog protoka (E talas, E/A) pokazala je značajno smanjenje brzinanakon smanjenja volumena poslije HD, dok je odnos brzina E/E’ (6,02±3,19vs. 5,66±1,83, p=0,599) ostao u granicama normalnih vrijednosti i nakon HD.Zaključak. Ehokardiografska procjena sistolne funkcije desne komore pomoćuFAC i TAPSE, kao i procjena globalne funkcije miokarda pomoću Tei indeksa,su pouzdane metode kod pacijenata na HD, pošto se njihove vrijednosti nisumijenjale u uslovima smanjenja cirkulatornog volumena nakon HD. Kaopouzdan parametar za procjenu dijastolne funkcije kod pacijenata na HD semože koristiti odnos brzina E/E’, koji se u ovom istraživanju nije značajnomijenjao usljed smanjenja volumena krvi nakon HD

Association between aortic stenosis severity and contractile reserve measured by two-dimensional strain under low-dose dobutamine testing

Background/Aim. Early detection of left ventricle (LV) systolic dysfunction could be a clue for surgical treatment in patients with significant aortic stenosis (AS). Therefore, we evaluated LV peak of global longitudinal strain (PGLS) using speckle tracking imaging at rest and during low-dose dobutamine infusion in asymptomatic patients with moderate and severe AS and preserved LV ejection fraction (EF). Methods. All the patients underwent coronary angiography and had no obstructive coronary disease (defined as having no stenosis greater than 50% in diameter). The patients were divided into two groups: above and below median of 0.785 cm2 aortic valve area (AVA). PGLS was measured from acquired apical 4-chamber and 2-chamber cine loops using a EchoPac PC-workstation at rest and during 5 μg/kg/min, 10 μg/kg/min, and 20 μg/kg/min dobutamine infusion, respectively. The global strain was the average of segment strains from the apical views. Results: A total of 62 patients with moderate and severe AS (AVA median reached the statistical significance (- 8.71 ± 2.68% vs -11.93 ± 3.74%, p = 0.002). In addition, PGLS increase was also significant in 4-chamber view in the patients with AVA above median, but only when comparing baseline to peak 20 μg/kg/min (-10.72 ± 3.07% vs -13.14 ± 4.79%; p = 0.034). Conversely, in both groups the increase of PGLS in 2-chamber view did not reach significance. Conclusion. Two-dimensional strain speckle tracking analysis of myocardial deformation with measurement of peak systolic strain during dobutamine infusion is a feasible and accurate method to determine myocardial longitudinal systolic function and contractile reserve and may contribute to clinical decision making in patients with significant AS

Echocardiographic evaluation of cardiac resynchronization therapy

Introduction: Cardiac resynchronization therapy (CRT) is relatively new tool in treatment of chronic heart failure (HF), especially in dilated cardiomyopathy (DCM) with the left bundle branch block (LBBB). Objective: The Objective of our study was to assess the success of CRT in treatment of severe HF and the role of echocardiography in the evaluation of Results of such therapy. Method: The group consisted of 19 patients, 13 males and 6 females, mean age 58.0±8.22 years (47-65 years) with CRT applied for DCM, severe HF (NYHA III-IV), LBBB and ejection fraction (EF) <35%. The mean follow up was 17 months (6.5-30). Standard color Doppler echocardiography examination was performed in all patients before and after CRT. The parameters of systolic and diastolic left ventricular function, mitral insufficiency and the right ventricular pressure were evaluated. Results: Following the CRT, statistically significant improvement of the end-systolic LV dimension, cardiac output, cardiac index, myocardial performance index (p<0.01) and stroke index (p<0.05) was recorded. The mean value of EFLV was increased by 10% and LV fractional shortening improved by 6% in 10/16 (62%) patients. CRT resulted in decreased MR (p<0.01), prolonged LV diastolic filling time (p<0.02) and reduced RV pressure (p<0.05). Interventricular mechanical delay was shortened by 28% (18 msec) Conclusion: CRT has an important role in improvement of LV function and correction of ventricular asynchrony. The echocardiography is a useful tool for evaluation of HF treatment with CRT

The impact of diabetes mellitus on restoring and maintaining of sinus rhythm in patients with persistent atrial fibrillation

We concluded that diabetes mellitus independently predicts the presence of recurrent atrial fibrillation but does not influence the possibility of sinus rhythm restoration. The relationship between atrial fibrillation and diabetes mellitus needs further investigation

Cardiac echinococcosis

Cardiac hydatid disease is rare. We report on an uncommon hydatid cyst localized in the right ventricular wall, right atrial wall tricuspid valve left atrium and pericard. A 33-year-old woman was treated for cough, fever and chest pain. Cardiac echocardiograpic examination revealed a round tumor (5.8 x 4 cm) in the right ventricular free wall and two smaller cysts behind that tumor. There were cysts in right atrial wall and tricuspidal valve as well. Serologic tests for hydatidosis were positive. Computed tomography finding was consistent with diagnosis of hydatid cyst in lungs and right hylar part. Surgical treatment was rejected due to great risk of cardiac perforation. Medical treatment with albendazole was unsuccessful and the patient died due to systemic hydatid involvement of the lungs, liver and central nervous system

Asymptomatic cardiovascular manifestations in diabetes mellitus: Left ventricular diastolic dysfunction and silent myocardial ischemia

Introduction. Several cardiovascular manifestations in patients with diabetes may be asymptomatic. Left ventricular diastolic dysfunction (LVDD) is considered to be the earliest metabolic myocardial lesion in these patients, and can be diagnosed with tissue Doppler echocardiography. Silent myocardial ischemia (SMI) is a characteristic and frequently described form of ischemic heart disease in patients with diabetes. Objective. The aim of the study was to assess the prevalence of LVDD and SMI in patients with type 2 diabetes, as well as to compare demographic, clinical, and metabolic data among defined groups (patients with LVDD, patients with SMI and patients with type 2 diabetes, without LVDD and SMI). Methods. We investigated 104 type 2 diabetic patients (mean age 55.4±9.1 years, 64.4% males) with normal blood pressure, prehypertension and arterial hypertension stage I. Study design included basic laboratory assessment and cardiological workup (transthoracic echocardiography and tissue Doppler, as well as the exercise stress echocardiography). Results. LVDD was diagnosed in twelve patients (11.5%), while SMI was revealed in six patients (5.8%). Less patients with LVDD were using metformin, in comparison to other two groups (χ2 =12.152; p=0.002). Values of HDL cholesterol (F=4.515; p=0.013) and apolipoprotein A1 (F=5.128; p= 0.008) were significantly higher in patients with LVDD. Conclusion. The study confirmed asymptomatic cardiovascular complications in 17.3% patients with type 2 diabetes