Recommendations for the management of prosthetic valve thrombosis

Prosthetic valve thrombosis (PVT) is a life-threatening disease, for which treatment strategies have been controversial. Herein, existing data on management options are reviewed, and conclusions drawn as to the choice and use of treatment strategies for PVT. The use of transesophageal echocardiography (TEE) allows distinction to be made between obstructive and non-obstructive PVT by the presence or absence of occluder motion limitation. The differentiation of PVT from pannus and vegetation is, however, still limited by TEE. The incidence of PVT has been underestimated by not taking into account a large percentage of non-obstructive PVT. Although the standard treatment for PVT has been surgery, thrombolysis has lower mortality rates, particularly in patients in NYHA functional classes III-IV. The lowest complication rates with thrombolysis have been achieved in patients with non-obstructive PVT. Pregnancy, left atrial appendage thrombi and large PVT are not contraindications to thrombolysis. The third therapeutic option is anticoagulant therapy. The detrimental effect of anticoagulant treatment in obstructive PVT was shown in a prospective study. Non-obstructive thrombi of > 5 mm length have been treated with higher success rates and lower complication rates by thrombolysis than by anticoagulant treatment. In conclusion, all patients with suspected PVT should undergo multiplane TEE. Thrombolysis is the first-line treatment for obstructive PVT, independent of NYHA class and thrombus size if there are no contraindications. Serial TEE studies must be conducted during thrombolysis. Surgery should be reserved for those patients in whom thrombolysis is contraindicated, or has failed. Initial anticoagulant therapy is recommended only for small, non-obstructive PVT if anticoagulation had been subtherapeutic; otherwise, thrombolysis is the treatment of choice if there are no contraindications.     

全军心律失常介入治疗资料总汇

目的汇总分析全军心律失常介入治疗资料,了解此领域工作的现状与不足。方法由全军心血管内科专业委员会组织对2005年1月1日至2006年12月31日期间全军医疗单位心律失常介入治疗资料进行注册登记和统计分析。结果①此次注册共收到全军40家医院共9 934例注册资料。开展射频消融(RFCA)工作的医院共33家,注册病例数6 242例,其中开展三维标测技术治疗快速心律失常的医院有9家,病例数达180例;开展心脏器械置入治疗工作的医院共39家,病例数3 656例。②6 242例RFCA注册资料总成功率97.45%,复发率2.12%,并发症发生率0.54%。各类心律失常中,房室折返性心动过速(AVRT)最多,房室结折返性心动过速(AVNRT)次之,AVRT和AVNRT成功率始终保持在较高的水平,而心房颤动(AF)的复发率最高。34例并发症中血管并发症和完全性房室传导阻滞占绝大部分。③多家单位开展了新型三维标测系统治疗复杂快速性心律失常。180例注册病例中,AF最多、共110例(61.11%),成功率99.09%,复发率24.55%;非特发性室性心动过速(non-IVT)次之、共26例(14.44%),成功率88.46%,复发率8.33%;其余类型心律失常完成例数较少。④3 656例心脏器械置入病例总成功率99.92%(3 653/3 656),并发症发生率1.94%(71/3 653)。在各种器械置入适应证中,病窦综合征占最大比例,其次为房室传导阻滞。双腔起搏比例远超过心室单腔起搏。三腔双心室起搏器及埋藏式心脏转复除颤器的临床应用尚较少。结论全军心律失常介入治疗发展迅速。     

Recommendations for reporting morbid events after heart valve surgery

Major reasons for the considerable heterogeneity among published results of heart valve surgery are inconsistency in follow up techniques, reporting systems and classification of adverse events. The present recommendations are intended to harmonize the presentation of clinical material in order to improve comparison of data from different sources for the analysis of pooled data. The quality of an observational study is largely, if not entirely, due to the follow up technique, which may be graded according to six categories: Self-reporting of adverse events/well-being by the patients may be classified 'excellent'; if the information is gathered and re-checked at short-term intervals. Data obtained from in-hospital or outpatient examinations by qualified examiners at least twice a year or other personal contact through qualified examiners may be regarded as 'sufficient', if the results are re-checked by contacting the treating home physician. All other follow up techniques may be regarded as inappropriate. Consequences of complications are entirely dependent on severity and possible sequelae. It is therefore recommended to grade any reported complication according to its severity by utilizing a score system. Embolisms are best categorized by utilizing the performance status scale. Bleeding events may be categorized according to severity as fatal, major (requiring hospital transmission with transfusion, surgery or with permanently increased disability) or minor (not requiring hospital admission, surgery or transfusion). In some cases it will remain unclear whether an event was primarily embolic or hemorrhagic. These complications should be summarized as 'not categorized'. The reporting of morbid events due to thrombosis, embolism and bleeding should go along with information regarding the quality of antithrombotic management.     

An overview of regular dialysis treatment in Japan as of 31 December 2003

A statistical survey of 3750 nationwide dialysis facilities was carried out by the Japanese Society for Dialysis Therapy (JSDT) at the end of 2003, with answers to the questionnaires received from 3717 facilities (99.12%). The population of dialysis patients in Japan at the end of 2003 was 237,710, and the number of dialysis patients per million people was 1862.7. The crude death rate during a 1-year period from the end of 2002 to the end of 2003 was 9.3%. The mean age of patients newly introduced to dialysis was 65.4 years, and the mean age of the entire dialysis population was 62.3 years. The primary diseases in the patients newly introduced to dialysis in 2003 included diabetic nephropathy (41.0% of patients) and chronic glomerulonephritis (29.1% of patients). The mean serum neutral fat concentration for all the dialysis patients was 113.9 +/- 71.7 mg/dL (+/- SD). The mean serum low density lipoprotein (LDL)-cholesterol concentration was 90.8 +/- 30.9 mg/dL. Dialysate calcium concentrations ranging from 3.0 mEq/L to less than 3.5 mEq/L were used for majority of the dialysis patients (55.4%). Among anticoagulants given to the dialysis patients, heparins were the most commonly used in 79.3% of the dialysis patients. The relationship between blood pressure during dialysis and life expectancy for 1 year was analyzed for 43,465 patients who had undergone dialysis three times per week at the end of 2001. Results showed a significantly high mortality risk for patients who had systolic blood pressure of less than 100 mm Hg at the start of dialysis, systolic blood pressure of less than 100 mm Hg at the end of dialysis, and the greatest decrease (lowest) in systolic blood pressure of less than 120 mm Hg during dialysis. Patients who received vasopressor therapy during dialysis had a higher mortality risk than those who received no vasopressor therapy.     

Purpura chez une jeune femme hyperthyroïdienne

IntroductionPropylthiouracil (PTU) is a synthetic antithyroid drug that can induce ANCA-associated vasculitis.ObservationA 27-year-old woman diagnosed with Graves’ disease was on PTU for the past 10 years. She developed purpuric lesions of the legs and on the tip of the nose diagnosed as vasculitis. ANCAs were positive, with anti-MPO and anti-PR3 on blood ELISA. After discontinuation of PTU, she was able to fully recover.ConclusionAll synthetic antithyroid drugs can induce ANCA-associated vasculitis, more often PTU. In most cases, antibodies are directed against MPO. Dual anti-MPO and anti-PR3 positivity is possible, but rare. The mechanism could be through an accumulation of PTU in neutrophils, altering the structure of MPO and making it immunogenic. PTU can also induce ANCA-free or lupus vasculitis, maculopapular rashes or urticaria. Many other drugs can induce ANCA-associated vasculitis.