Antithrombotic Strategy in the Three First Months following Bioprosthetic Heart Valve Implantation

Heart valve prosthesis unquestionably improve quality of life and survival of patients with severe valvular heart disease, but the need for antithrombotic therapy to prevent thromboembolic complications is a major challenge to clinicians and their patients. Of the articles analyzed, most were retrospective series of cases or historical cohorts obtained from the database. The few published randomized trials showed no statistical power to assess the primary outcome of death or thromboembolic event. In this article, we decided to perform a systematic literature review, in an attempt to answer the following question: what is the best antithrombotic strategy in the first three months after bioprosthetic heart valve implantation (mitral and aortic)?After two reviewers applying the extraction criteria, we found 1968 references, selecting 31 references (excluding papers truncated, which combined bioprosthesis with mechanical prosthesis, or without follow-up).Based on this literature review, there was a low level of evidence for any antithrombotic therapeutic strategy evaluated. It´s therefore interesting to use aspirin 75 to 100 mg / day as antithrombotic strategy after bioprosthesis replacement in the aortic position, regardless of etiology, for patients without other risk factors such as atrial fibrillation or previous thromboembolic event. In the mitral position, the risk of embolism, although low, is more relevant than in the aortic position, according to published series and retrospective cohorts comprised mostly of elderly non-rheumatic patients.The current evidence is limited to have a consistent and safe level of evidence regarding the best therapeutic strategy. Based on these studies, 75 to 100 mg/day of aspirin is interesting as antithrombotic strategy after implantation of aortic bioprosthesis, regardless of etiology, for patients with no other risk factors such as atrial fibrillation or previous thromboembolic event. As for mitral bioprosthesis, the risk of embolism, although low, is more relevant than in the aortic position, according to published series and retrospective cohorts - usually elderly non rheumatic patients.     

Tissue Doppler imaging and long axis left ventricular function: hypertrophic cardiomyopathy versus athlete's heart.

BACKGROUND: The different diagnosis between hypertrophic cardiomyopathy and athlete's heart has important clinical implications. The assessment of long axis left ventricular function with tissue Doppler imaging in hypertrophic cardiomyopathy (showing systolic and diastolic dysfunction with heterogeneity and asynchrony), may be useful in the differentiation of these situations. AIM: To study, with tissue Doppler imaging, long axis left ventricular function in a population of athletes (rowers) and to compare it with a population of non-obstructive hypertrophic cardiomyopathy patients. METHODS: In 24 patients with non-obstructive hypertrophic cardiomyopathy and in 20 competitive rowers with similar age, blood pressure and heart rate, we analyzed mitral annulus motion with pulsed tissue Doppler imaging in the 4 sides of the annulus (septal, lateral, inferior, anterior), in apical views. In each wave (systolic, rapid filling and atrial contraction) we measured velocities, time intervals and velocity-time integrals, and calculated heterogeneity and asynchrony indices. Data were compared between the groups, between the different sides in each group ("parallel analysis") and with conventional indices of global function. RESULTS: Hypertrophic cardiomyopathy patients showed: systolic function: lower velocities and integrals, shorter ejection time and shorter systolic time. These abnormalities occurred even in annular sites contiguous to walls without hypertrophy. DIASTOLIC FUNCTION: Much lower rapid filling velocities and integrals, lower atrial contraction velocities and integrals, lower e/a, longer isovolumic relaxation time and time to peak rapid filling wave. These abnormalities occurred even in annular sites adjacent to walls without hypertrophy. In the athletes group, the e/a ratio was never < 1, in any annular site. In hypertrophic cardiomyopathy patients this ratio was < 1 in 27% of the sites. CONCLUSIONS: 1--Systolic and diastolic long axis left ventricular function is different in hypertrophic cardiomyopathy and in athletes, in all mitral annulus sides. 2--The presence of these abnormalities in annular sites contiguous to walls without hypertrophy suggests that this technique may be useful in the differential diagnosis between these groups, particularly in the "gray zone" of Maron.     

Does hand involvement in systemic sclerosis limit completion of patient-reported outcome measures?

Clinical Rheumatology - The objective of this analysis is to examine whether the severity of systemic sclerosis (SSc)-hand involvement influences patient-reported outcome measure (PROM) completion...     

Anatomic relations of the Marshall vein: importance for catheterization of the coronary sinus in ablation procedures.

AIMS: Our objective was to study the anatomic relations of the human left atrial oblique vein (Marshall vein), particularly of its ostium opening into the coronary sinus, in order to guide ablation procedures related to that vein. METHODS AND RESULTS: The study was carried out in 23 heart-specimens (mean weight 446 +/- 204 g) of individuals whose mean ages were 43 +/- 21 years, 20 males. The coronary sinus was opened longitudinally, exposing the ostium of the tributary veins; the Vieussens valve was looked for, as well as its relationship to the left atrial oblique vein. The diameters of the left atrial oblique vein and the coronary sinus ostia were measured and the distance between them was determined. The left atrial oblique vein could be identified in 20 (87%) of the hearts, while the Vieussens valve was present in 17 (74%) of the specimens (in 16 of which the left atrial oblique vein was identified). In such condition, the vein was adjacent to the Vieussens valve and proximally positioned relative to the coronary sinus ostium in most of them (14/16 cases). The mean diameters of the left atrial oblique vein and of the coronary sinus ostia were, respectively, 1.23 +/- 0.38 and 8.22 +/- 1.88 mm. The mean distance between both ostia was 30.9 +/- 10.2 mm. CONCLUSION: When present, the left atrial oblique vein can be easily recognized, adjacent to the Vieussens valve. The mean distance between the coronary sinus opening and left atrial oblique vein ostium was around 30 mm, independently of the heart weight and the presence of cardiomegaly.