Traumatic fatal cerebral hemorrhage in an old patient with a history of multiple sclerosis under dabigatran: a case report and review of the literature

One disadvantage of direct anticoagulant drug is the lack of an antidote, which may become relevant in patients with traumatic brain injury. A 77-years old man with atrial fibrillation and syncope received dabigatran despite recurrent falls. Due to a ground-level-fall, he suffered from subarachnoidal and intraparenchymal hemorrhages, subdural hematoma and brain edema with a midline shift. Despite osteoclastic trepanation and hematoma-evacuation he remained comatose and died seven days later without regaining consciousness. Most probably, decreased dabigatran clearance due to increased age might have contributed to the fatal course. We suggest withholding anticoagulant therapy in patients with unexplained falls. If anticoagulant therapy is deemed necessary, vitamin-K-antagonists with their potential for laboratory monitoring and reversal of anticoagulant activity should be preferred.     

RVOT mural and mitral valve endocarditis: A case report

Mural endocarditis is a very rare condition. This entity involves bacterial growth on cardiac walls. In addition, concomitant valvular endocarditis, along with mural endocarditis, is an extremely rare combination. The diagnosis of mural endocarditis is difficult and requires more advanced cardiac imaging, such as a transesophageal echocardiogram. The differential diagnoses of mural masses include vegetations, thrombi, metastasis, and benign and malignant tumors. We present a rare and unusual case of Methicillin-Resistant Staphylococcus aureus bacteremia with findings of both right ventricular outflow tract mural endocarditis and valvular endocarditis involving the mitral valve.     

Acute limb ischemia due to Candida lusitaniae aortic valve endocarditis

We present a case of a 35-year-old male with history of intravenous heroin use, who presented with acute limb ischemia and was found to have Candida lusitaniae endocarditis. After an urgent intervention to salvage the right lower extremity, successful outcome of his infection was achieved by a combined surgical and antifungal treatment.     

Mid-term results of mitral valve repair for complicated active bacterial endocarditis in high-risk patients

Mitral valve repair in endocarditis achieves a competent valve and prevents septic embolization and acute left ventricular failure, in which operative mortality could be increased. Early and mid-term results were examined to establish whether emergency mitral valve repair offers an advantage in complicated active endocarditis. Ten patients with complicated active native valve endocarditis underwent mitral valve repair. The mean age was 45.8 ± 18.5 years; two patients were female (20%). All patients had severe mitral regurgitation, which combined in one patient with mitral valve stenosis. New York Heart Association (NYHA) functional class was IV in all patients. The macroscopically infected tissue with vegetation in all patients was excised. Multiple techniques were required to achieve valve competence. There was one (10%) hospital death in a patient with persistent congestive heart failure, and a reoperation in another (10%) after 2 years. Mean follow-up was 32.1 ± 12.7 months (range 1–45 months) and was complete. There were no late deaths, recurrent endocarditis, or thromboembolic events. Seven patients (77.7%) were in NYHA functional class I, and two (22.2%) were in class II. Mitral valve repair in complicated active bacterial endocarditis limited to leaflet tissues has a low operative mortality and valve-related morbidity, with promising mid-term survival in high-risk patients.     

Pre-operative atrial fibrillation as the key determinant of outcome of mitral valve repair for degenerative mitral regurgitation.

AIMS: To examine the impact of pre-operative atrial fibrillation (AF) on the outcome of mitral valve repair (MVR) for degenerative mitral regurgitation (MR). METHODS AND RESULTS: Among 392 patients with moderate to severe MR who underwent MVR between 1991 and 2002, 283 patients with isolated degenerative MR were followed for 4.7+/-3.3 years. Of 27 deaths, nine were due to cardioembolic events and four were due to left ventricular (LV) dysfunction. When compared with patients with pre-operative AF, those with sinus rhythm (SR) had better survival (96+/-2.1 vs. 87+/-3.2% at 5 years, P=0.002) and higher cardiac event-free rates (96+/-2.0 vs. 75+/-4.4% at 5 years, P<0.001). In patients with pre-operative SR, observed and expected survival were similar (P=0.811). Cox multivariable regression analysis confirmed AF [P=0.027, adjusted hazard ratio (AHR) 2.9] and age as independently predictive of survival, and AF (P=0.002, AHR 3.1), New York Heart Association Class, and LV fractional shortening as independently predictive of cardiac event. CONCLUSION: Death due to LV dysfunction was not frequent and cardioembolic events due to AF were the leading cause for cardiac death. Pre-operative AF became a strong independent predictor of survival and morbidity. Patients with pre-operative SR had excellent prognosis. The benefits of preventing cardioembolic events due to AF validate the indication of MVR for patients with high risk for AF.     

Pharmacology,benefits, unaddressed questions,and pragmatic issues of the newer oral anticoagulants for stroke prophylaxis in non-valvular atrial fibrillation and proposal of a management algorithm

This systematic review aims to provide an update on pharmacology, efficacy and safety of the newer oral direct thrombin and factor Xa inhibitors, which have emerged for the first time in ~ 60 years as cogent alternatives to warfarin for stroke prophylaxis in non-valvular atrial fibrillation. We also discuss on four of the most common clinical scenarios with several unsolved questions and areas of uncertainty that may play a role in physicians' reluctance to prescribe the newer oral anticoagulants such as 1) patients with renal failure; 2) the elderly; 3) patients presenting with atrial fibrillation and acute coronary syndromes and/or undergoing coronary stenting; and 4) patients planning to receive AF ablation with the use of pulmonary vein isolation. New aspects presented in current guidelines are covered and we also propose an evidence-based anticoagulation management algorithm.     

二尖瓣置换时采用盐水冲洗的射频改良迷宫手术治疗心房颤动

目的报告二尖瓣置换时采用盐水冲洗的射频改良迷宫手术治疗心房颤动。方法2003年5月至2006年4月83例二尖瓣置换手术患者接受了术中盐水冲洗的射频改良迷宫手术,本组患者中男性23例、女性60例,年龄23～65(46±12)岁,二尖瓣狭窄49例、二尖瓣反流6例、二尖瓣双病变28例,心功能(NYHA分级)Ⅳ级7例、Ⅲ级76例,心房颤动持续时间0．5-18．0(5．4±4．0)年。手术采用Cardioblate系统,射频能量25～30 W,盐水冲洗速度180～240 ml／h。在完成右心房主要的切口及消融后阻断主动脉,经房间隔后左心房切口或房间隔切口施行左心房消融、二尖瓣置换及其他所需的手术,复跳后再完成右心房余下的消融及切口。术后常规使用胺碘酮,定期随访。结果术后围术期死亡2例(机械瓣故障1例,多器官衰竭1例)。体外循环时间70～160(101±26)min,主动脉阻断时间32～106(61±22)min,射频消融时间4～23(11±6)min。随访过程中猝死2例,失访2例。62例患者术后随访1年以上,其中53例恢复窦性心律(85％,53／62)。结论二尖瓣置换时采用盐水冲洗的射频改良迷宫手术治疗持续心房颤动是合理及有效的。     

Percutaneous devices for stroke prevention

The most important approaches to prevent cerebral ischemia by catheter technique are patent foramen ovale (PFO) closure in patients with a history of cryptogenic stroke and left atrial appendage (LAA) occlusion in atrial fibrillation (AF) patients. Over the past years, several new devices have been developed for these procedures. Results of randomized trials comparing device therapy, antiplatelet, or anticoagulation therapy are still not available. However, several nonrandomized studies have shown promising results. This article gives a review on the current results and techniques of the most commonly used devices as well as on new developments and approaches to catheter-based stroke prevention.     

口服抗凝药物预防心房颤动患者脑卒中的研究进展

<正>心房颤动是临床常见的心律失常,我国拥有心房颤动患者超过800万。脑卒中是心房颤动的严重并发症,与年龄和血压匹配的对照人群相比,无潜在瓣膜性心脏病的心房颤动患者发生脑卒中可能性是对照人群的5倍以上,有瓣膜性心     

缺血性卒中防治中的抗凝治疗

凝血系统的激活在缺血性卒中,尤其是心源性脑栓塞的发生和发展过程中起着重要作用.作为缺血性卒中的主要预防措施之一,抗凝治疗愈来愈受到广泛关注.同时,针对凝血途径中的不同环节进行干预的抗凝药研究也取得了重大进展.     

Noninvasive support for and characterization of multiple intranodal pathways in patients with mitral valve disease and atrial fibrillation

Twenty-four-hour ambulatory ECG recordings were made in 22 patientswith mitral valve disease and sustained atrial fibrillation.Computer analysis was used to stratify 64-beat periods accordingto the average ventricular rate levels. The distribution ofpooled RR-intervals from heart-rate levels 50–60, 60–70... 160–170 were then presented as histograms, using a20 ms width. This heart-rate stratified analysis revealed abi- or trimodal RR-distribution in 16 of the 22 patients. Thisfinding was interpreted as indicating the presence of two separateatrionodal pathways and in some cases nodal escape activityin addition. A limited heart-rate range may have obscured thisphenomenon in 5 of the 6 cases without signs of bimodality.At high heart rates, AV-nodal conduction occurred via a ‘fastpathway’ whilst at successively lower heart rates, thisconduction was blocked and a ‘slower pathway’ wasused instead. In addition, at successively slower rates, thedominant cycle of conduction via either pathway tended to lengthenaccording to a linear relationship. The change of dominancefrom the fast to the slow pathway occurred between 90 and 120beats per minute in almost all cases. The further electrophysiologicalcharacterization of patients with 2 pathways was done by calculationof differences and ratios between lengths of dominant cyclesof different pathways at the rate of change of dominance. Thefindings may serve as reference data for further studies ofAV-nodal conduction using the same method. Furthermore, thestudy strongly indicates that dual A V-nodal pathways are anubiquitous phenomenon and supports the hypothesis that evenin man, AV-nodal input follows two main routes: (a) along thecrista terminals between the coronary sinus and the tricuspidvalve and (b) from the interatrial septum.     

The effect of surgical access for mitral valve surgery on incidence of atrial fibrillation and atrioventricular block

Atrial fibrillation and conduction disorders are very common and severe postoperative complications in heart surgery.Retrograde analysis of patients (n = 103) who had undergone mitral valve surgery or concomitant mitral and tricuspid valve surgery was performed (from January 2006 to December 2016). Patients from each group were divided into two groups: a subgroup with surgery access through the right atrium and interatrial septum (transseptal access) and a subgroup with surgery access through the left atrium (left atrial access). The following data were recorded for all patients: age, sex, extracorporeal circulation time, aortic clamping time, blood loss after surgery, count of blood transfusions administered, the need for surgical revision because of higher blood loss and postoperative atrial and atrioventricular conduction defect (atrial fibrillation and atrioventricular block with pacemaker implantation).A statistically significant difference in extracorporeal circulation time (p < 0.05) and aortic clamping time (p < 0.01) was recorded between transseptal access and left atrial and right atrial access separately, if combined surgery of both atrioventricular valves was performed. No other statistically significant differences were recorded between the groups.In general, the choice of surgical access for mitral valve on incidence of postoperative atrial and atrioventricular conduction disorders showed no effect. Both access through the right atrium and interatrial septum and access through the left atrium have a similar incidence of postoperative atrial fibrillation and atrioventricular block.     

微波消融治疗心房颤动在风湿性心脏病二尖瓣置换术中的应用

目的研究风湿性心脏病二尖瓣手术同期行心内膜微波消融术治疗持续性心房颤动(简称房颤)的效果。方法66例患者随机分为两组,33例在二尖瓣手术中行心内膜微波消融治疗,另外33例设为对照组,单独行瓣膜手术。结果微波组主动脉阻断时间、体外循环时间长于对照组(63.818±17.738 min vs 47.545±18.018 min;108.879±32.191 min vs 85.333±22.885 min。P均<0.05)。术后两组均未出现严重并发症。随访2.3±1.4年,微波组中24例(72.7%)维持窦性心律,对照组中5例(15.2%)为窦性心律,两组比较,P<0.05。术后6个月、2年,微波组左房内径明显小于对照组(P<0.05);术后2年,微波组三尖瓣返流量明显低于对照组(P<0.05)。结论微波消融治疗房颤安全、效果确切,可延缓术后左房内径变大及三尖瓣返流的进展。     

LAA occluder device for stroke prevention: Data on WATCHMAN and other LAA occluders

NOAC therapy has become the standard for stroke prevention in patients with atrial fibrillation. Yet some patients suffer extracranial bleeding events or have other reasons to seek non-pharmacologic stroke protection. LAA occlusion with the WATCHMAN device has been proven safe and effective for such patients and is now recommended in current guidelines for this patient group; other devices also seek approval.     

Appropriate dosing of nonvitamin K antagonist oral anticoagulants for stroke prevention in atrial fibrillation

The development of nonvitamin K antagonist oral anticoagulants (NOACs) has been a major advance in therapy for patients requiring oral anticoagulation, particularly for long-term indications such as stroke prevention in atrial fibrillation (AF). The NOACs are generally easier to dose and manage due to less heterogeneity of effect across individuals and fewer drug and food interactions, compared with warfarin. However, the treatment effect of NOACs may vary based on important patient characteristics, particularly renal function. Therefore, the package inserts for these drugs have dosing recommendations for patients with impaired kidney function, which are frequently but not always based on evidence from large-scale, randomized, clinical trials. Furthermore, there is evidence that NOAC dosing inconsistent with the regulatory labeling may be associated with adverse clinical outcomes. This review discusses the evidence supporting the current NOAC dosing, current dosing practices, associated outcomes, and gaps in knowledge regarding use of NOACs in patients with AF.