Thromboembolism – ABC CARDIOL

ABC

Original Article

Incidence and Predictors of Clinical Outcomes in Patients with Valvular and Nonvalvular Atrial Fibrillation Using Vitamin K Antagonists

Idelzuita Leandro Liporace et al. Gustavo Bernardes F. Oliveira Lucas Bassolli de Oliveira Alves Nadia Marchiori Galassi … Andreia Dias Jeronimo Fernanda Maria Lopes Gregory Y. H. Lip Álvaro Avezum

Abstract

Background

Vitamin K antagonists (VKA) represent an important therapeutic strategy offered by the Brazilian Unified Public Health System to patients with atrial fibrillation (AF). However, predictors of relevant clinical outcomes are understudied in the real world.

Objective

To determine the incidence and independent predictors of clinical outcomes in patients with valvular and nonvalvular AF treated with VKA.

Methods

This prospective cohort included patients with valvular and nonvalvular AF receiving VKA for ≥ 1 year. The primary outcomes were cardiovascular death, thromboembolic events, and major and clinically relevant non-major bleeding, separately and as a composite outcome. The outcomes were independently adjudicated. P values < 0.05 were considered statistically significant.

Results

The study included 1,350 patients, with a mean age of 69.2 (± 11.8) years, 53.6% female, followed up for 17 (15 – 19) months. The annual incidence of thromboembolic events and cardiovascular death was 4.4%, and predictors were prior thromboembolism (hazard ratio [HR] 2.12; 95% confidence interval [CI] 1.22 – 3.67), time in therapeutic range (TTR) < 50% (HR 1.98; 95% CI 1.16 – 3.37), and glomerular filtration rate (GFR) < 45 mL/min/1.73 m² (HR 2.76; 95% CI 4.82 – 1.58). The rate of major and clinically relevant non-major bleeding was 3.24% per year (95% CI 2.47 – 4.14), and predictors were prior bleeding (HR 2.60; 95% CI 1.47 – 4.61) and mechanical prosthesis (HR 1.91; 95% CI 1.15 – 3.15). The composite outcome was 8.7% per year, and predictors were prior bleeding (HR 1.70; 95% CI 1.07 – 2.70), TTR 44 mm (HR 1.97; 95% CI 3.26 – 1.19).

Conclusions

Prior thromboembolism or bleeding, reduced GFR and TTR levels, and enlarged left atrium were predictors of clinical outcomes in patients with AF treated with VKA.

Read Full Article

ABC

Original Article

Lack of Anticoagulant Use in Patients with Atrial Fibrillation and Increased Risk of Thromboembolic Events According to Sex: Insights from a Multicentric Brazilian Study

Emiliano Medei et al. Renata Moll-Bernardes Martha V. T. Pinheiro Andréa S. Sousa … Barbara Abufaiad Andre Feldman Guilherme D’andrea Saba Arruda Thiago Libano Csernik Monteiro Fabio Augusto De Luca Benhur Davi Henz Denilson C. Albuquerque Antonio Aurelio P. Fagundes Junior Marcia M. Noya-Rabelo Angelina Silva Camiletti Rose Mary Frajtag Ronir R. Luiz Olga F. Souza

Abstract

Background

Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia, and its presentation differs according to age and sex. Recent studies have revealed differences in AF among various demographic groups, including the Latin American population.

Objectives

To better understand potential disparities in AF prevalence and treatment strategies in the Brazilian population through data from a large multicentric prospective registry.

Methods

The Rede D’Or AF registry is a multicenter prospective observational study including patients aged ≥ 18 years with AF who were seen in the emergency department of 32 tertiary hospitals in Brazil. Patients were characterized according to sex and other baseline characteristics and were classified according to previous anticoagulant use. The lack of anticoagulant use in patients with previous indications was analyzed. Statistical significance was set at 5%.

Results

The study data were from a total of 1955 patients enrolled. Male sex was more prevalent, and men were younger than the women. Due to an increased prevalence of previous AF episode and a higher CHA₂DS₂-VASc score, more women had indications for anticoagulant therapy; however, a significant proportion was not receiving this treatment. From 29 in-hospital deaths, 15 patients had previous indication for anticoagulation, but only 3 were using anticoagulants.

Conclusion

This study revealed sex-related differences in the Brazilian population of patients with AF that are consistent with trends in high-income countries. The promotion of better implementation of anticoagulant and antithrombotic therapies to reduce the risk of death and thromboembolic events among women with AF in Brazil is crucial.

Read Full Article

IJCS

Editorial

Can D-dimer be Used as a Marker for Thromboembolic Events in Pediatric Patients With COVID-19?

Thais Rocha Salim et al. Gabriel Porto Soares

D-dimer is a protein resulting from fibrin degradation. It is released into the circulation when clot degradation occurs and is therefore used as a marker for thromboembolic events and fibrinolysis. The main role of D-dimer lies in its negative predictive value for the exclusion of thromboembolic events, when its level is below 500 ng/mL. Because D-dimer functions as an inflammatory marker, various non-thromboembolic situations can contribute to an increase in its level, such as advanced age, pregnancy, postpartum period, neoplasms, renal insufficiency, and sepsis. Age is a crucial factor when considering D-dimer a thromboembolic marker. Healthy populations over 70 years of age have shown a 50% increase in D-dimer levels without correlation with thrombotic or inflammatory events.

During the COVID-19 pandemic, several studies have demonstrated a positive correlation of elevated D-dimer levels, prolonged coagulation time, and low platelet count with mortality from COVID-19.^,,,Although D-dimers lack high specificity as a diagnostic tool, they have been widely used as predictors of severity and complications in this setting, given that D-dimer tests are rapid, simple, and low-cost.^– However, hyperinflammation caused by SARS-CoV-2 infection can lead to an increase in D-dimer unrelated to thrombosis, which implies its correlation with other tests and caution in interpreting the results.

[…]

Read Full Article

IJCS

Original Article

Elevated D-Dimer as a Marker For Thromboembolic Events in Pediatric Patients With Covid-19: A Systematic Review

Jade Zarichta Costa et al. Pietro Preis Casagrande Franciely Vanessa Costa Maíra Cola Roberta de Paula Martins

Abstract

Background:

The 2019 Coronavirus disease is known to cause thromboembolic events. There is little information on the severe COVID-19 consequences in children.

Objectives:

To determine whether elevated D-dimer levels in the pediatric population with COVID-19 are a risk marker for the development of thromboembolic events. If so, D-dimer levels could be used to determine prophylactic anticoagulation measures if needed.

Methods:

This is a systematic review, performed according to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and registered in the International Prospective Register of Systematic Reviews (PROSPERO) database. The last database search update was on December 14, 2021, resulting in 79 documents for analysis. Data were taken from various databases and queried by topic, keyword, or abstract.

Results:

Of the 79 articles found, only seven were selected for this analysis. Of these articles, only one had thromboembolic events. In the other articles, D-dimer levels were elevated but were considered controversial in terms of predicting events, with no clear association between the magnitude of D-dimer change and the magnitude of thrombosis risk.

Conclusions:

Although used for adults, D-dimer was not a good parameter for assessing the risk of thromboembolic events in individuals younger than 21 years. The main shortcomings are the fact that D-dimer increases with any type of inflammation and is, therefore, not a specific marker, and that it is elevated in many patients even without the occurrence of thromboembolic events.

Read Full Article

ABC

Editorial

Health-related Quality of Life and Long-term Outcomes after Mildly Symptomatic COVID-19: Exploring the Protocol

Lucas Borges Pereira et al. João Paulo Vilela Rodrigues Fabiana Rossi Varallo Leonardo Régis Leira Pereira

The post-COVID-19 condition has been defined by the World Health Organization as a “condition that occurs in individuals with a history of probable or confirmed SARS-CoV-2 infection, typically after three months from the onset of COVID-19, with symptoms lasting at least two months and that an alternative diagnosis can not explain.” The primary symptoms associated with this condition include fatigue, muscle and joint pain, shortness of breath, sleep difficulties, mental and neurological symptoms such as depression and anxiety, loss of smell and taste, headache, and difficulty in thinking and concentrating. ^, The cytopathic effect of the virus on the endothelium, along with endothelial damage as a consequence of systemic inflammation, has been associated with cardiovascular events such as myocarditis, myocardial infarction, arrhythmias, and thromboembolic events.

Various studies conducted worldwide have also found evidence of other signs and symptoms. ^– However, the incidence of these symptoms has shown significant variation due to the heterogeneity of the studies. This variation may be associated with factors such as the post-COVID study period, the region where the study was conducted, and the severity of the disease.

[…]

Read Full Article

ABC

Original Article

F Wave Amplitude as a Predictor of Thromboembolism and Success of Electrical Cardioversion in Patients with Persistent Atrial Fibrillation

Renan Teixeira Campelo et al. Luciana Armaganijan Dalmo A. R. Moreira Matheus Kiszka Scheffer … Guilherme Dagostin de Carvalho João Italo Dias França

Abstract

Background

Atrial fibrillation (AF) is classified according to the amplitude of fibrillatory waves (f) into fine waves (fAF) and coarse waves (cAF).

Objectives

To correlate the amplitude of f waves with clinical, laboratory, electrocardiographic, and echocardiographic variables that indicate a high risk of thromboembolism and to assess their impact on the success of electrical cardioversion (ECV).

Methods

Retrospective, observational study that included 57 patients with persistent non-valvular AF who underwent ECV. The maximum amplitude of f waves was measured in lead V1. cAF was defined when f ≥ 1.0mm and fAF when f < 1.0mm. The findings were correlated with the indicated variables. Values of p < 0.05 were considered statistically significant.

Results

cAF (n = 35) was associated with greater success in ECV (94.3% vs. 72.7%, p = 0.036) even after adjusting for variables such as age and BMI (p = 0.026, OR = 11.8). Patients with fAF (n = 22) required more shocks and more energy to revert to sinus rhythm (p = 0.019 and p = 0.027, respectively). There was no significant association between f-wave amplitude and clinical, echocardiographic, and laboratory parameters.

Conclusions

The amplitude of f wave was not associated with echocardiographic, clinical and laboratory parameters that indicate a high risk of thromboembolism. cAF was associated with a higher chance of success reverting to sinus rhythm employing ECV. A greater number of shocks and energy were required for reversion to sinus rhythm in patients with fAF.

Read Full Article

ABC

Editorial

Anticoagulation Therapy with Warfarin: A Reality of Brazilian Public Health that Lacks Structure for Better Control

Martino Martinelli Filho

The increase in longevity in recent decades has led to a progressive increase in the prevalence of atrial fibrillation (AF) worldwide.^,

As a result, anticoagulation therapy has become increasingly indicated in preventing thromboembolic events. The need for continuous use drove the preference for oral anticoagulants, historically represented by antivitamin K (VKA) drugs and, more recently, by new anticoagulants (anti-factor X). Among these, a VKA, warfarin, is the most prominent for its low cost.

[…]

Read Full Article

ABCIC

Viewpoint

Non-compaction cardiomyopathy: How Can Imaging Contribute?

José de Arimateia Batista Araújo Filho et al. Antonildes Nascimento Assunção-Jr José Rodrigues Parga

[…]

Read Full Article

ABC

Research Letter

Aortic and Renal Artery Thrombosis as the First Clinical Manifestation of COVID-19 in a Heart Transplant Recipient

Deborah de Sá Pereira Belfort et al. Fabiana G. Marcondes-Braga Sandrigo Mangini Caio Rebouças Fonseca Cafezeiro … Diógenes Amauri Gonçalves Furlan Fernando Bacal

Introduction

The novel coronavirus infection emerged in Wuhan, China, in the end of 2019 and is now a pandemic. The relation between COVID-19 and thrombotic events is well established, even for patients under prophylactic anticoagulation. Although venous and arterial thromboembolic events have been described, usually stroke and acute myocardial infarction (AMI),^, there are few reports of arterial thrombosis in unusual sites. Almost all reports of thrombotic events are of intensive care unit (ICU) patients, and the incidence of thromboembolism in mild cases of COVID-19 is still not clear.

We report a case of a male heart transplant recipient admitted to emergency department with thrombosis of right renal artery and thoracic descending aorta associated with COVID-19.

[…]

Read Full Article

ABC

Original Article

Determinants of Functional Capacity in Patients with Chagas Disease

Whesley Tanor Silva et al. Henrique Silveira Costa Pedro Henrique Scheidt Figueiredo Márcia Maria Oliveira Lima … Vanessa Pereira Lima Fábio Silva Martins da Costa Matheus Ribeiro Ávila Vanessa Amaral Mendonça Ana Cristina Rodrigues Lacerda Maria Carmo Pereira Nunes Manoel Otávio Costa Rocha

Abstract

Background:

Chagas disease leads to reduced functional capacity. However, the stage at which functional impairment is detectable remains unclear.

Objectives:

The present study was addressed to compare the functional capacity of patients at different stages of Chagas disease and healthy individuals and to verify the determinants of peak oxygen uptake (VO2peak).

Methods:

In a cross-sectional study, 160 individuals were selected, 35 healthy and 125 with Chagas disease. In the Chagasic group, 61 (49%) were in the indeterminate form of the disease, 45 (36%) with Chagas cardiomyopathy (ChC) and preserved cardiac function and 19 (15%) with cardiac dysfunction and dilated ChC. The data were analyzed using univariate and multivariate regression analysis. Statistical significance was set at 5%.

Results:

Patients in the indeterminate form of disease showed similar functional capacity to healthy individuals (p>0.05). Patients with ChC and preserved cardiac function had lower VO2peak than patients in the indeterminate form (p<0.05), but showed similar VO2peak values than dilated ChC (p=0.46). The age, male sex, NYHA functional class, diastolic blood pressure, ratio of the early diastolic transmitral flow velocity to early diastolic mitral annular velocity, left ventricular ejection fraction (LVEF) and left ventricular end-diastolic diameter were associated with functional capacity. However, only age, male sex, LVEF and NYHA functional class, remained associated with VO2peak in the final model (adjusted R2=0.60).

Conclusion:

Patients with ChC had lower functional capacity than patients in the indeterminate form. LVEF, age, male sex and NYHA functional class were determinants with VO2peak in patients with Chagas disease.

Read Full Article

ABC

Editorial

Atrial Fibrillation and Cryptogenic Thromboembolic Events

Benhur Davi Henz et al. Luiz Roberto Leite

Detection of subclinical atrial fibrillation in cryptogenic and embolic stroke of undetermined source

The use of long-term monitoring dramatically improved the ability to detect short, rare, and asymptomatic AF periods in stroke patients. The EMBRACE study evaluated 572 patients with ischemic stroke in the last 6 months, with no AF diagnosis, with randomization for 30-day continuous monitoring (287 patients) vs. 24-hour Holter (285 patients).

The AF detection rates (> 30 seconds) were 16.1% in the long-term monitoring group vs. 3.2% in the Holter group. Similarly, when Implantable Monitors (IM) were used, as in the CRYSTAL-AF (Cryptogenic Stroke and underlying Atrial Fibrillation) study, AF detection rates using IM were higher than the standard detection rates during a long-term follow-up: 8.9%, 12.4% and 30% vs. 1.4%, 2.0% and 3% in the period of 6, 12 and 36 months.

[…]

Read Full Article

ABC

Original Article

Uninterrupted Use of Oral Anticoagulants for the Ablation of Atrial Flutter: A Single Center Cohort of 154 Patients

Tiago Luiz Luz Leiria et al. Alexandre Kreling Medeiros Eduardo Dytz Almeida Antonio Lessa Gaudie Ley … Catarine Benta Lopes dos Santos Roberto Toffani Sant'Anna Marcelo Lapa Kruse Leonardo Martins Pires Gustavo Glotz de Lima

Abstract

Background:

The uninterrupted use of oral anticoagulation (OAC) with vitamin K antagonists (VKAs) for electrophysiology procedures has been more and more recommended. The clinical practice in our service recommends the continuous use of these drugs for atrial flutter ablation. There is little evidence as to the uninterrupted use of non-vitamin K antagonist oral anticoagulants (NOACs) in this scenario.

Objective:

To compare the rates of complications related with the uninterrupted use of different types of oral anticoagulants in patients referred to atrial flutter (AFL) ablation.

Methods:

Historical, single-center cohort of ablation procedures by AFL conducted from November 2012 to April 2016. The primary outcome was the occurrence of hemorrhagic or embolic complication during the procedure. The secondary outcome was the occurrence of stroke or transient ischemic attack (TIA) in follow-up. The statistical significance level was 5%.

Results:

There were 288 ablations per AFL; 154 were carried out with the uninterrupted use of OAC (57.8% with VKA and 42.2% with NOAC). Mean age was 57 ± 13 years. The rate of hemorrhagic complication during the procedure was 3% in each group (p = NS). The rate of stroke/TIA was, respectively, of 56/1,000 people-year in the VKA group against zero/1,000 people-year in the NOAC group (p = 0.02).

Conclusion:

In our population there were no hemorrhagic complications regarding the procedure of OAC use uninterruptedly, including NOACs. There was higher occurrence of stroke/TIA in the follow-up of the group of patients undergoing VKAs; however, this difference may not only be a result of the type of OAC used.

Read Full Article

ABC

Anatomopathological Session

Case 3/2017 – A 47-Year-Old Female with Refractory Heart Failure and Embolic Acute Myocardial Infarction

João Gabriel Batista Lage et al. Paulo Sampaio Gutierrez

Clinical aspects

This case can be approached in two ways: chronic disease and acute decompensation. Taking the chronic disease way, some possible etiologies of heart failure can be considered. With the negative Chagas serology and her known comorbidities, the major hypotheses to be considered for this patient are hypertensive heart disease (dilated phase), microcirculation disease due to diabetes mellitus, and idiopathic dilated cardiomyopathy.^– The patient attended to only two medical consultations, being her complementary investigation unfinished. Now, taking the acute decompensation way, it was relatively clear at the beginning that the infectious hypothesis was the most plausible, being the elevation in the levels of myocardial necrosis markers probably related to sepsis and hemodynamic instability (type 2 acute myocardial infarction). However, after the results of the other complementary tests (echocardiography and coronary angiography), the hypothesis of acute myocardial infarction of embolic cause gained strength, mainly due to the finding of an intracavitary thrombus on the first exam. Therefore, we hypothesize that the significant left ventricular dysfunction determined the formation of the thrombus, whose fragment embolized to the coronary circulation, causing an acute myocardial infarction, culminating with dysfunction worsening, thus triggering the cascade that led to the patient’s death.

Some of the causes of coronary emboli are heart valvular disease, cardiomyopathy, coronary atherosclerosis and atrial fibrillation. In a postmortem study by Prizel et al., an intracavitary thrombus was present in 33% of the cases. Nevertheless, a superimposed infectious cause for decompensation cannot be ruled out. (João Gabriel Batista Lage, MD)

[…]

Read Full Article

IJCS

Case Report

Use of Thrombolysis in PE Said to be of no High-Risk, which Presents Acute Cor Pulmonale

Nicolle Lopes Guenther et al. Nágela Simão Vinhosa Nunes Valdênia Pereira de Souza Ronaldo Vegni e Souza

Introduction

PE is a condition that is often difficult to recognize due to its varied clinical presentation, ranging from unclear symptoms to severe conditions that quickly leading the patient to shock and death. It is the third most common cardiovascular disease worldwide, of high mortality and morbidity, with an estimated incidence of 100-200 per 100,000 inhabitants, according to the Guidelines of the European Society of Cardiology.

There is a variety of related risk factors, including major orthopedic surgeries, traumas, prolonged immobilization, malignant neoplasia, spastic and flaccid paralysis, hormonal contraception, congestive heart failure, thrombophilia, obesity and pregnancy.^, However, PE can occur even in the absence of known risk factors.

[…]

Read Full Article

ABC

Review Article

Antithrombotic strategy in the three first months following bioprosthetic heart valve implantation

André R. Durães et al. Milena A. O. Durães Luis C. L. Correia Roque Aras

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.

Read Full Article

ABC

Artigo Original

Percutaneous occlusion of left atrial appendage with the Amplatzer Cardiac PlugTM in atrial fibrillation

Márcio José Montenegro et al. Edgard Freitas Quintella Aníbal Damonte Hugo de Castro Sabino … Ricardo Zajdenverg Gustavo Pinaud Laufer Bernardo Amorim André Pereira Duque Estrada Cristian Paul Yugcha Armas Aline Sterque

Background: Atrial fibrillation is associated with embolic strokes that often result in death or disability. Effective in reducing these events, anticoagulation has several limitations and has been widely underutilized. Over 90% of thrombi identified in patients with atrial fibrillation without valvular disease originate in the left atrial appendage, whose occlusion is investigated as an alternative to anticoagulation. Objective: To determine the feasibility of percutaneous occlusion of the left atrial appendage in patients at high risk of embolic events and limitations to the use of anticoagulation. Methods: We report our initial experience with Amplatzer Cardiac PlugTM (St. Jude Medical Inc., Saint Paul, Estados Unidos) in patients with nonvalvular atrial fibrillation. We selected patients at high risk of thromboembolism, major bleeding, contraindications to the use or major instability in response to the anticoagulant. The procedures were performed percutaneously under general anesthesia and transesophageal echocardiography. The primary outcome was the presence of periprocedural complications and follow-up program included clinical and echocardiographic review within 30 days and by telephone contact after nine months. Results: In five selected patients it was possible to occlude the left atrial appendage without periprocedural complications. There were no clinical events in follow-up. Conclusion: Controlled clinical trials are needed before percutaneous closure of the left atrial appendage should be considered an alternative to anticoagulation in nonvalvular atrial fibrillation. But the device has shown to be promissory in patients at high risk of embolism and restrictions on the use of anticoagulants.

Read Full Article

ABC

Artigo Original

Medial hypertrophy in patients with pulmonary embolism: anatomopathological study

Renato Tambellini Arnoni et al. Fábio Biscegli Jatene Wanderley Marques Bernardo Vera Demarchi Aiello … Tanas Jatene Rosângela Monteiro Lea Maria Macruz Demarchi

OBJECTIVE: To compare the arterial response of cases of acute and chronic embolism, seeking to associate ischemic pulmonary remodeling with progression to chronicity. METHODS: Retrospective analysis of 61 necropsies of patients who died in the Instituto do Coração (31 cases of pulmonary embolism and 30 cases of acute myocardial infarction). Slides of pulmonary tissue were obtained from all cases and analyzed qualitative and quantitatively (medial thickness measurement). RESULTS: Qualitative analysis enabled the differentiation between cases of embolism and the control group, thus characterizing the two groups and defining the adequate choice of the control group. The alterations predominated in patients with embolism (alveolar inflammation and edema, infarction, vasoconstriction, concentric intimal proliferation, presence of thrombus). Quantitative analysis demonstrated higher percent medial thickness in the cases of embolism than in the control group; among the cases of embolism, no differences in intra (acute – 19.74 and chronic – 20.04) and pre-acinar (acute – 18.85 and chronic – 18.68) arteries were observed. CONCLUSION: The lack of difference among the groups with embolism and the higher values of percent medial thickness in the peripheral arteries allow the conclusion that the vascular response is more intense and starts in these arteries.

Read Full Article

ABC

Original Article

Assessment of Thromboembolism After the Cox-Maze Procedure for Chronic Atrial Fibrillation Secondary to Mitral Valve Lesion

Renato A. K. Kalil et al. Paula L. M. Nesralla Gustavo G. Lima Tiago L. Leiria … Rogério Abrahão Paulo Moreno Paulo R. Prates João R. M. Sant'Anna Ivo A. Nesralla

OBJECTIVE: To assess the occurrence of late thromboembolism after surgical repair of chronic atrial fibrillation (AF) simultaneously with repair of mitral valve using the Cox-Maze procedure. METHODS: 69 patients underwent Cox 3 procedure, with no cryoablation simultaneously with mitral valvuloplasty or prosthesis. Mean age was 49.9±13.2 years. Mean follow-up was of 31.7±19 months. Types of lesion were as follows: 33 (48%) stenoses, 23 (33%) insufficiencies, and 13 (19%) double lesions. Procedures were: 64 (93%) valvuloplasties, 3 (4%) biological and 2 (3%) mechanical prosthesis placement. There were 9 (13%) patients with previous systemic embolism and 2 (3%) had left atrial thrombi. RESULTS: Early mortality was 7% and late 1%. 2 patients (3%) were reoperated for mitral placement. At last evaluation, 10 patients (15%), were in AF. The remaining 59 (85%) were either in sinus / atrial rythm (74%) or under pacing (12%). There were no occurrence of early or late, systemic or pulmonary embolism. Permanent anticoagulation was employed in 16 cases, 10 in regular rythm and 6 in AF. The remaining 47 (75%), 2 in AF and 45 in regular rythm, did not receive anticoagulants. CONCLUSIONS: These results are in accordance with others series, where the occurrence of embolism was rare after maze procedure. Permanent systemic anticoagulation seems to be unnecessary in those cases.

Read Full Article

ABC

Artigo Original

Valve replacement with the Omnicarbon valve prosthesis: a 10-year follow-up

Santiago Florez et al. Salvatore Di Stefano Yolanda Carrascal Juan Bustamante … Enrique Fulquet José Ramón Echevarria Casquero Elena Javier Gualis Luis Fiz

OBJECTIVE: We retrospectively examined the outcomes of 264 patients who underwent consecutive Omnicarbon valve implantation surgery between April 1985 and May 1995. METHODS: At the time of surgery, patients who received this mechanical prosthesis averaged 57±11 years of age. Omnicarbon valves were placed in the aortic position in 36% of the cases, in the mitral position in 44%, and in both positions in 20%. Follow-up was carefully performed, with most patients undergoing physical examination at our clinic. While taking the case history, cardiac physicians specifically questioned the patient about valve-related complications. RESULTS: Accumulated total patient-years is 1291, with a mean follow-up time of 5.4 years. Survival at 10 years is 79.4±3.9%, including all causes of death and early mortality. Complications recorded during the 11-year study include: thromboembolism (0.1%), hemorrhage (0.4%), endocarditis (0.2%), and nonstructural failure (1.2%). No hemolytic anemia, valve thrombosis, or structural failure was detected during this long-term experience. Functional capability of these patients was subjectively assessed by the NYHA classification system. With follow-up time averaging over 5 years, 97% of our Omnicarbon valve patients are in NYHA I or II. CONCLUSION: The Omnicarbon mechanical prosthesis provides a good clinical performance for up to 10 years in both the aortic and mitral positions. Results indicated a low incidence of thromboembolism and of hemorrhagic complications.

Read Full Article

ABC

Artigo Original

Incidence of intracardiac thrombus and thromboembolism in the first three months after bioprosthetic valve implantation

Auristela Isabel de Oliveira Ramos et al. Helio Maximiano de Magalhães Mercedes Maldonado Dorival Júlio Della Togna … Zilda Machado Meneghelo Antoninho Sanfins Arnoni Lucia Machado Nisia Lyra Gomes Paulo Paredes Paulista

OBJECTIVE: To assess the incidence of intracardiac thrombus and thromboembolism in the first 3 months after bioprosthetic valve replacement and to identify the risk factors for thrombus formation. METHODS: The study comprised 184 patients, aged between 15 and 75 years, who underwent bioprosthetic valve implantation. Transthoracic and transesophageal (TEE) echocardiographies were performed in the in-hospital phase (mean, 8.4±3 days) and after 3 months (mean, 97.4±21.7 days). RESULTS: The incidence of thrombus was significantly greater in patients with a prosthesis in the mitral or mitroaortic position (21.0%) than in those with a prosthesis in the aortic position (2.8%), P<0.001. The multiple logistic regression identified the prosthesis in the mitral or mitroaortic position as the only independent variable for thrombus formation. On the 3-month follow-up, TEE showed a thrombus in 35 (20.7%) of the 169 patients on echocardiographic assessment, 31.7% in mitral patients and 3.1% in aortic patients, P<0.001. In the third month, the multiple logistic regression also identified the prosthesis in the mitral or mitroaortic position as the only independent variable for thrombus formation. During the 3-month follow-up, 3 (1.6%) patients died and 8 (4.3%) experienced embolic phenomena, all in the cerebral territory. CONCLUSION: The incidence of thrombi in the first 3 months after bioprosthetic valve implantation was 14.1% in the first 10 days and 20.7% in 3 months. A prosthesis in the mitral or mitroaortic position was identified as a risk factor for thrombus formation. The incidence of embolic phenomena clinically diagnosed was lower than the proportion of atrial thrombi documented on echocardiography.

Read Full Article