Obstructive Prosthetic Mitral Valve Thrombosis Successfully Thrombolysed with Low-Dose Ultra-Slow Infusion of Tissue Plasminogen Activator

Prosthetic valve thrombosis (PVT) is one of the major causes of posthetic heart valve failure. Treatment modalities for this rare but life threatening complication include anticoagulation with heparin, thrombolytic therapy (TT) and re-do valve surgery. Guidelines lack definitive class I recommendations due to lack of randomised controlled trials, and usually leave the choice of treatment to the clinician’s experience. Surgery is suggested as a first line strategy in most situations of left sided PVT; however, TT has been recently used with successful outcomes1-3. This report describes a patient with giant thrombus located on the prosthetic mitral valve, which was succesfully treated with ultraslow infusion (25 hours) of low dose (25 mg) tissue plasminogen activator (tPA) under the guidance of two-dimensional (2D) and real-time three-dimensional (RT -3D) transesophageal echocardiography (TEE) and fluoroscopy

P-wave dispersion and its relationship to aortic stiffness in patients with acute myocardial infarction after cardiac rehabilitation

BACKGROUND: The aim of our study was to investigate the P-wave dispersion from standard electrocardiograms (ECGs) in patients with acute myocardial infarction (AMI) after cardiac rehabilitation (CR) and determine its relation to arterial stiffness. METHODS: This is a prospective study included 33 patients with AMI and successfully re-vascularized by percutaneous coronary intervention (PCI) underwent CR. Left ventricular ejection fraction (LVEF) was measured by biplane Simpson&rsquo;s method. Left atrium (LA) volume was calculated. The maximum and minimum durations of P-waves (Pmax and Pmin, respectively) were detected, and the difference between Pmax and Pmin was defined as P-wave dispersion (Pd = Pmax&ndash;Pmin). Aortic elasticity parameters were measured. RESULTS: LVEF was better after CR. The systolic and diastolic blood pressures decreased after CR, these differences were statistically significant. With exercise training, LA volume decreased significantly. Pmax and Pd values were significantly shorter after the CR program. The maximum and minimum P-waves and P-wave dispersion after CR were 97 &plusmn; 6 ms, 53 &plusmn; 5 ms, and 44 &plusmn; 5 ms, respectively. Aortic strain and distensibility increased and aortic stiffness index was decreased significantly. Aortic stiffness index was 0.4 &plusmn; 0.2 versus 0.3 &plusmn; 0.2, P = 0.001. Aortic stiffness and left atrial volume showed a moderate positive correlation with P-wave dispersion (r = 0.52, P = 0.005; r = 0.64, P = 0.000, respectively). CONCLUSION: This study showed decreased arterial stiffness indexes in AMI patient&rsquo;s participated CR, with a significant relationship between the electromechanical properties of the LA that may raise a question of the preventive effect of CR from atrial fibrillation and stroke in patients with acute myocardial infarction. &nbsp; Keywords: Cardiac Rehabilitation, P-Wave Dispersion, Aortic Stiffness, Acute Myocardial Infarction&nbsp;</p

Protez kalp kapak trombozu olan hastalarda trombolitik tedavininhemen sonrasında endotel fonksiyonlarında gözlenen iyileşme

Objective: Prosthetic valve thrombosis (PVT) is a serious complication among patients with prosthetic heart valves. Thrombolytic therapy (TT) is now widely used as first-line treatment for PVT. Endothelial dysfunction has previously been reported in patients with PVT. The aim of this study was to investigate the changes in endothelial function soon after TT in PVT patients.Methods: The study group included 85 patients with PVT [female: 53 (62.3%); age: 48.7 +/- 13.9 years] who were evaluated prospectively before and shortly after TT. All of the patients were evaluated using transthoracic and transesophageal echocardiography. TT was administered in all cases with a low-dose, ultra-slow infusion regimen. Endothelial function was evaluated using a noninvasive measurement of flow-mediated dilatation (FMD) of the brachial artery during reactive hyperemia.Results: The study population included 38 (44.7%) obstructive and 47 (55.3%) non-obstructive PVT patients. The obstructive PVT patients had lower baseline FMD values than the non-obstructive PVT group (5.31 +/- 0.76% vs. 5.87 +/- 0.84%; p=0.003). TT was successful in 79 patients (92.9%). FMD was significantly increased in the successfully thrombolyzed patients after TT (5.65 +/- 0.86% vs. 7.13 +/- 1.26%; p<0.001). There was no significant difference in the FMD values after TT in patients who were unresponsive to TT (5.07 +/- 0.61% vs. 5.38 +/- 0.95%; p=0.371). There was a significant increase in FMD values after TT in patients with obstructive PVT (5.31 +/- 0.76% vs. 8.22 +/- 1.15%; p<0.001). However, this difference was not statistically significant for patients with non-obstructive PVT (5.87 +/- 0.84% vs. 6.11 +/- 0.95%; p=0.276).Conclusion: This study demonstrated that successful TT may contribute to improvement of impaired endothelial function in patients with obstructive PVT.Amaç: Protez kapak trombozu (PKT) gelişimi protez kalpkapaklı hastalarda ciddi bir komplikasyondur. Son zamanlarda trombolitik tedavi (TT) PKT tedavisinde ilk tercih olarakyaygın olarak kullanılmaktadır. Daha önceki çalışmalarda PKThastalarında endotel disfonksiyonunun varlığı bildirilmiştir.Bu çalışmada, PKT hastalarında TT sonrasında endotelfonksiyonlarında olan değişiklikleri araştırmayı amaçladık.Yöntemler: Bu çalışmaya TT öncesi ve sonrası prospektifolarak takip edilen 85 PKT hastası [kadın: 53 (%62,3), ortalama yaş: 48,7±13,9 yıl] dahil edildi. Tüm hastalar transtorasik ve transözofajiyal ekokardiyografi ile değerlendirildi. Tümhastalarda düşük doz ultra yavaş infüzyon rejimine göre TTuygulandı. Endotel fonksiyonları reaktif hipereminin nedenolduğu akım aracılı genişleme (Flow Mediated Dilation, FMD)ölçülmesi ile değerlendirildi.Bulgular: Çalışmaya 38 (%44,7) tıkayıcı ve 47 (%55,3)tıkayıcı olmayan PKT hastası alındı. Tıkayıcı PKT hastalarıtıkayıcı olmayan PKT hastalarına göre daha düşük bazal FMDdeğerlerine sahiplerdi (%5,31±0,76 ve %5,87±0,84; p=0,003).TT 79 (%92,9) PKT hastasında başarılı idi. Ortama FMDdeğerleri başarılı TT grubunda TT sonrasında anlamlı olarakyükseldi (%5,65±0,86 ve %7,13±1,26; p<0,001). BaşarısızTT grubunda TT sonrası FMD değerlerinde anlamlı değişiklikizlenmedi (%5,07±0,61 ve %5,38±0,95; p=0,371). TıkayıcıPKT olan hastalarda TT sonrasında FMD değerleri anlamlıolarak yükseldi (%5,31±0,76 ve %8,22±1,15; p<0,001).Fakat, tıkayıcı olmayan PKT hastalarında TT sonrası FMDdeğerlerinde anlamlı değişiklik izlenmedi (%5,87±0,84 ve%6,11±0,95; p=0,276).Sonuç: Bu çalışmada, tıkayıcı PKT hastalarında başarılıTT’nin bozulan endotel fonksiyonlarının düzelmesine katkısunabildiği gösterilmiştir