Invasive hemodynamics of constrictive pericarditis

Cardiac catheterization and hemodynamic study is the gold standard for the diagnosis of pericardial constriction. Careful interpretation of the hemodynamic data is essential to differentiate it from other diseases with restrictive physiology. In this hemodynamic review we shall briefly discuss the physiologic basis of various hemodynamic changes seen in a patient with constrictive pericarditis

An unusual cause of left ventricular outflow tract obstruction

Left ventricular outflow tract obstruction (LVOTO) has been reported with bio-prosthetic and mechanical mitral valves (MV), though it is more common with the former. The obstruction can be dynamic or fixed. We hereby report a case of fixed LVOTO following bio-prosthetic MV replacement (MVR)

Streptokinase versus recombinant tissue-type plasminogen activator for thrombolysis of mechanical prosthetic heart valve thrombosis

Aims and Objectives: This study was designed to compare streptokinase (STK) versus recombinant tissue-type plasminogen activator (rt-PA) for thrombolysis in patients with prosthetic heart valve thrombosis (PHVT). Background: Optimal management of PHVT remains controversial. Thrombolytic therapy is a reasonable alternative to surgery. Numerous thrombolytic protocols with STK, urokinase, and rt-PA have been used over the past 40 years. So far there is a lack of consensus on the ideal thrombolytic agent for PHVT. There are no major studies comparing efficacy of STK versus rt-PA. Methods and Results: Sixty patients who underwent thrombolysis for PHVT over 1 year were studied. Forty-eight patients were thrombolysed with STK, whereas 12 patients received rt-PA. Overall 68.33% (41/60) patients showed complete response (CR), whereas 85% (51/60) showed some improvement in hemodynamics, with no significant difference in efficacy according to age, sex, duration from surgery, New York Heart Association Class III–IV, presence of atrial fibrillation, type of valve, or history of stroke. Overall 10% patients developed major complications with mortality of 5%. CR to thrombolytic therapy was numerically better with STK (72.9% vs. 50%; P = 0.12) and mortality was significantly higher in rt-PA (16.6% vs. 2%, P = 0.038). Mean duration of successful thrombolysis was significantly longer with STK as compared to rt-PA (22.96 ± 19.2 vs. 3 h). Conclusion: STK use as compared to rt-PA was associated with numerically more successful thrombolysis and significant lower mortality, hence may be optimal for elective thrombolysis

Prevalence of thiamine deficiency in heart failure patients on long-term diuretic therapy

Background: Loop diuretics are an integral part of heart failure management. It has been shown that loop diuretics cause thiamine deficiency (TD) by increasing its urinary loss. The aim of this study was to determine the prevalence of TD in heart failure patients on long-term oral loop diuretics. Methods: Heart failure patients (cases) on oral loop diuretics (furosemide ≥40 mg/day or torsemide ≥20 mg/day), irrespective of the cause of heart failure, were compared to non-heart failure patients (controls) not on loop diuretics in a 1:1 ratio. Whole blood free thiamine level was determined by liquid chromatography-tandem mass spectrometry method. Results: A total of 100 subjects were enrolled in a 1:1 ratio (50 cases and 50 controls). 67% of the total study population had TD, (defined as whole blood free thiamine level <0.7 ng/ml). There was no difference in mean thiamine level between cases and controls. On comparing patients with TD in both groups, patients on diuretics had significantly lower thiamine level compared to the patients, not on diuretics (P < 0.0001). Conclusions: There was no difference in the thiamine level when patients on loop diuretics were compared to controls. However, very low thiamine levels (<0.1 ng/ml) was significantly more common in patients on loop diuretics

Antistreptokinase antibodies and outcome of fibrinolytic therapy with streptokinase for left-sided prosthetic valve thrombosis

Background: Left-sided prosthetic valve thrombosis (PVT) is a serious complication of valve replacement. In developing countries, fibrinolysis with streptokinase (SK) is often used as the first line of treatment. Anti-streptokinase (anti-SK) antibodies are widely prevalent in the general population, but their effect on the efficacy and outcome of fibrinolysis with SK in patients with PVT is not known. Methods: Patients with rheumatic heart disease and prosthetic valve replacement presenting with a first episode of left-sided PVT were enrolled. All patients underwent fibrinolysis with SK. An indirect enzyme-linked immunosorbent assay was used to detect anti-SK antibodies before fibrinolysis. Relationship of these antibodies to the outcome of fibrinolysis was evaluated. Results: Forty-four patients treated for left-sided PVT were included. Thrombosis affected 33 mitral and 11 aortic prosthetic valves. On fibrinolysis with SK, 32 (73%) patients achieved complete success, whereas it was unsuccessful in the remaining 12 patients. There were 3 bleeding events, 1 stroke, and 3 deaths. Mean anti-SK antibody levels were not significantly different between patients who had complete success and those who did not (8.81 ± 2.43 vs 7.67 ± 1.26 Au/mL; P = .13) and did not correlate with the outcome after adjustment with other variables. Patients in New York Heart Association class III or IV had a greater chance of failed fibrinolytic therapy, even after adjustment for other prognostic variables (odds ratio 9.0; 95% CI 1.29-63.02; P = .027). Conclusion: Anti-SK antibody titers are not associated with success of fibrinolytic therapy using SK in patients with left-sided PVT