scholarly journals Genetic Warfarin-Resistance Resulting in Surgery to Change a Prosthetic Valve

2020 ◽  
Author(s):  
Jahanzeb Malik ◽  
Uzma Ishaq ◽  
Nismat Javed ◽  
Mirza Adnan Baig ◽  
Muhammad Javaid
Keyword(s):  
Mitral Valve ◽  
Prosthetic Valve ◽  
Warfarin Dose ◽  
International Normalized Ratio ◽  
Drug Dosage ◽  
Heart Team ◽  
Clinical Scenarios ◽  
Genes Encoding ◽  
Prosthetic Mitral Valve ◽  
Warfarin Resistance

Warfarin is a readily available anticoagulant used worldwide in a variety of clinical scenarios. Patients who need more than 15 mg/day are considered to be warfarin resistant. Numerous genes have been implicated in warfarin pharmacogenetics, with genes encoding CYP2C9 and VKORC1 shown to be the most important determinants of drug dosage requirements. A 27-year-old woman was admitted as she had a sub-therapeutic international normalized ratio (INR) after prosthetic mitral valve replacement. Even after a warfarin dose of 50 mg/day, her INR was not in the therapeutic range, so the heart team decided to replace her metallic valve with a bioprosthetic valve, thus alleviating the need for anticoagulation.

scholarly journals Successful Fibrinolytic Therapy in a Challenging Obstructive Prosthetic Mitral Valve Thrombosis

2020 ◽  
Vol 8 ◽  
pp. 232470962092107
Author(s):  
Amr Essa ◽  
Toufik Haddad ◽  
Terrence Slattery
Keyword(s):  
Mitral Valve ◽  
Prosthetic Valve ◽  
Multimodality Imaging ◽  
Fibrinolytic Therapy ◽  
Mitral Valve Surgery ◽  
Prosthetic Valve Thrombosis ◽  
Valve Thrombosis ◽  
Mean Pressure ◽  
Normal Mean ◽  
Prosthetic Mitral Valve

Prosthetic valve thrombosis is a rare and severe complication of the mechanical prosthetic valve. Management can be challenging due to varying clinical presentation, overlapping features of differential diagnosis, and lack of randomized controlled trials on the therapeutic options. In this article, we report the case of a patient with a mechanical prosthetic mitral valve presented with symptoms of heart failure, and an echocardiography showing increased mean pressure gradient across the prosthesis along with a fixed posterior leaflet and a partially restricted anterior leaflet with no visible mass. That raised the concern for an obstructed prosthesis. After multimodality imaging and multidisciplinary team discussions, prosthetic valve thrombosis diagnosis was favored over other different diagnoses that included but not limited to pannus ingrowth. Fibrinolytic therapy was administrated, and the patient was discharged on optimal anticoagulation. Repeated echocardiography a month later showed normal mean gradient and normal functioning prosthetic mitral valve without the need for repeat mitral valve surgery.

scholarly journals Demonstration of a Rocking Prosthetic Mitral Valve Using 3-Dimentional Echocardiography and Live Surgical Imaging

2021 ◽  
Author(s):  
Sean Baskin ◽  
Rece Laney ◽  
Senthil Nathan ◽  
Feroze Mahmood ◽  
J. Michael Haering
Keyword(s):  
Mitral Valve ◽  
Transesophageal Echocardiography ◽  
Tissue Damage ◽  
Prosthetic Valve ◽  
Prosthetic Valve Endocarditis ◽  
Imaging Technology ◽  
Precise Identification ◽  
Prosthetic Mitral Valve ◽  
Surgical Manipulation

Prosthetic valve endocarditis is a complication of bacteremia which can cause damage to the prosthetic valve or the tissue to which it was sewn. Extensive tissue damage can result in a loss of anchoring and allow for abnormal valvular motion. Dehiscence can lead to excessive motion of the valve which is termed rocking. Through advances in imaging technology, live 3-dimentional (3-D) transesophageal echocardiography can allow for precise identification of the location of, and amount of dehiscence. We present a 37-year old male with a rocking prosthetic valve demonstrated on 3-D echocardiography and correlated to surgical manipulation.

scholarly journals Warfarin Dosing in a Patient withCYP2C9*3*3andVKORC1-1639 AAGenotypes

2014 ◽  
Vol 2014 ◽  
pp. 1-4
Author(s):  
Mark Johnson ◽  
Craig Richard ◽  
Renee Bogdan ◽  
Robert Kidd
Keyword(s):  
Vitamin K ◽  
Adverse Drug Events ◽  
Warfarin Dose ◽  
International Normalized Ratio ◽  
White Female ◽  
First Case ◽  
Increased Risk ◽  
Genes Encoding ◽  
Warfarin Dosing ◽  
Clinically Significant

Genetic factors most correlated with warfarin dose requirements are variations in the genes encoding the enzymes cytochrome P450 2C9 (CYP2C9) and vitamin K epoxide reductase (VKOR). Patients receiving warfarin who possess one or more genetic variations inCYP2C9andVKORC1are at increased risk of adverse drug events and require significant dose reductions to achieve a therapeutic international normalized ratio (INR). A 74-year-old white female with atrial fibrillation was initiated on a warfarin dose of 2 mg PO daily, which resulted in multiple elevated INR measurements and three clinically significant hemorrhagic events and four vitamin K antidote treatments over a period of less than two weeks. Genetic analysis later revealed that she had the homozygous variant genotypes ofCYP2C9*3*3andVKORC1-1639 AA. Warfarin dosing was subsequently restarted and stabilized at 0.5 mg PO daily with therapeutic INRs. This is the first case report of a white female with these genotypes stabilized on warfarin, and it highlights the value of pharmacogenetic testing prior to the initiation of warfarin therapy to maximize efficacy and minimize the risk of adverse drug events.

scholarly journals Prosthetic Heart Valves Thrombosis with Infectious Endocarditis - A Practical Review

2020 ◽  
Vol 17 (6) ◽  
pp. 55-64
Author(s):  
Silviu Stanciu ◽  
Alexandru Burcin ◽  
Diana Iancu ◽  
Maria Magdalena Gurzun ◽  
Alexandru Croitoru ◽  
...  
Keyword(s):  
Mitral Valve ◽  
Transesophageal Echocardiography ◽  
Clinical Judgment ◽  
Prosthetic Valve ◽  
Imaging Techniques ◽  
Clinical Status ◽  
Infectious Endocarditis ◽  
Prosthetic Heart Valves ◽  
Surgical Interventions ◽  
Clinical Scenarios

Abstract Simultaneous or sequential combination of prosthetic valve (PV) thrombosis and infectious endocarditis is a rare clinical finding. The management of these patients involves a complex multidisciplinary strategy using clinical judgment and imaging techniques. Transesophageal echocardiography (TEE) and especially 3D transesophageal echocardiography is essential. Moreover, positron emission tomography with fluorodeoxyglucose (F18-FDG PET/CT) can be a valuable tool to diagnose and manage these complicated clinical scenarios. We present the case of a 65-year-old patient who was admitted in our clinic for paroxysmal nocturnal dyspnea and chills for one week. He had multiple surgical interventions for rheumatic mitral valve disease (percutaneous mitral valvuloplasty in 2008, and mitral valve replacement and tricuspid annuloplasty in October 2019). At admission, the diagnosis of prosthetic valve thrombosis was established taking into account the clinical context (low INR values for the last two months), the patient symptoms and the echocardiographic findings. IV unfractionated heparin was administered. One week after admission the patient’s clinical status further deteriorated. TEE reevaluation showed partial thrombus regression with elements suggestive for concomitant infectious endocarditis. The diagnosis key is the clinical evolution and repeated TEE evaluations. In our case, they enabled the probable diagnosis of a sequential association of thrombosis and infectious endocarditis on mechanical PV. The therapeutic approach requires a high clinical suspicion and a prompt management, emergent surgery being the only lifesaving strategy in unstable patients with obstructive mechanical pathology.

Transcatheter mechanical manipulation of obstructed prosthetic mitral valve in an infant

2020 ◽  
Vol 30 (11) ◽  
pp. 1747-1749
Author(s):  
Yousef Arar ◽  
Jeff Hong ◽  
Surendranath Veeram Reddy
Keyword(s):  
Mitral Valve ◽  
Prosthetic Valve ◽  
Transoesophageal Echocardiography ◽  
Pulmonary Haemorrhage ◽  
Treatment Modalities ◽  
Prosthetic Heart Valves ◽  
Systemic Thrombolysis ◽  
Prosthetic Valve Thrombosis ◽  
Valve Thrombosis ◽  
Prosthetic Mitral Valve

AbstractProsthetic valve thrombosis is a serious complication of prosthetic heart valves that typically requires either surgical intervention or systemic thrombolysis. In patients with contraindications to both treatment modalities, options can be limited. We describe an alternative approach to managing prosthetic valve thrombosis in an infant presenting in extremis with pulmonary haemorrhage. Using transoesophageal echocardiography and fluoroscopic guidance, we restored function to the infant’s obstructed St. Jude prosthetic mitral valve through percutaneous transcatheter manipulation of the valve’s leaflets.

scholarly journals Fibrinolytic Treatment after Transient Ischaemic Attack Caused by Prosthetic Mitral Valve Thrombosis

2016 ◽  
Vol 2016 ◽  
pp. 1-4
Author(s):  
Cornel Koban ◽  
Michael Neuß ◽  
Grit Tambor ◽  
Frank Hölschermann ◽  
Christian Butter
Keyword(s):  
Mitral Valve ◽  
Complete Resolution ◽  
Prosthetic Valve ◽  
Prosthetic Valve Thrombosis ◽  
Echocardiographic Examination ◽  
Valve Thrombosis ◽  
Life Threatening ◽  
Ischaemic Attack ◽  
Prosthetic Mitral Valve ◽  
Surgical Valve Replacement

Prosthetic valve thrombosis is one of the most severe complications after surgical valve replacement. There are many possible presentations: from asymptomatic to life-threatening complications. We report on a 61-year-old female patient with prosthetic replacement of the aortic and mitral valve in the in-house department of cardiac surgery 3 months ago. The patient was suffering from aphasia during 5 minutes in domesticity. After her presentation in the emergency room, the echocardiographic examination revealed a thrombotic formation of the prosthetic mitral valve. At presentation, the anticoagulation was outside the effective range (INR: 1.7). A successful thrombolytic therapy with the plasminogen activator urokinase was begun with complete resolution of the thrombus.

scholarly journals 1646 Complicated aortic prosthetic valve endocarditis

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
M Do Lago Palacio Estrela ◽  
M G Paiva ◽  
R L Ferreira ◽  
A S L Gazola ◽  
P S C Pedreira ◽  
...  
Keyword(s):  
Mitral Valve ◽  
Prosthetic Valve ◽  
Prolonged Mechanical Ventilation ◽  
Prosthetic Valve Endocarditis ◽  
Blood Cultures ◽  
Oral Antibiotic ◽  
Heart Team ◽  
Mechanical Prosthesis ◽  
Aortic Prosthesis ◽  
18F Fdg

Abstract Introduction Prosthetic valve endocarditis (PVE) occurs in 1 to 3% of cases at 1 year and 3 to 9% at 5 years postoperative (PO) with 40% mortality. Clinical complications, uncontrolled infection and agents such as staphylococci and fungi indicate the need for surgery. Recent trial with stable patients (26.7% PVE), oral antibiotic therapy (ATB) proved to be as effect as intravenous antibiotic. However, in complicated cases, prolonged clinical treatment still an exception. Case Report ANFJ, male, 45 years old, aortic valve replacement by mechanical prosthesis in 2015, was hospitalized in Jun/18 with right front-temporal-parietal cerebral hemorrhage and sub febrile for 1 week. Transthoracic echocardiogram (TTE) showed pseudoaneurysm of the mitral valve anterior leaflet with 4+ regurgitation and aortic metallic prosthesis without dysfunction, but transesophageal echocardiogram (TEE) disclosed periprosthetic abscess. Empirical ATB was started until blood cultures yielded S. Agalactiae. After 3 weeks with ceftriaxone, patient persisted sub febrile, high CRP, pulmonary congestion and a new TEE showed mobile aortic prosthesis, fistula and periaortic regurgitation 4+. Urgent surgery was carried out at the same day for abscess drainage and replacement of prosthetic valve by biological aortic prosthesis but without mitral valve approach. Immediate PO underwent with hemodynamic instability, prolonged mechanical ventilation, pleural empyema, acute renal failure requiring dialysis and persistence of fever. Two weeks after surgery, TTE demonstrated new periprosthetic abscess with multiple collections along the ascending aorta. Reassessed by heart team and reoperation was contraindicated due to poor clinical conditions. Patient received parenteral broad-spectrum antibiotic evolving with clinical stabilization, normalization of inflammatory tests becoming afebrile. Aortic angiotomography in Aug/18 showed a periaortic collection of 3.0X2.0X1.9cm and contrast extravasation. New TEE in Aug/18 showed periprosthetic abscess and discrete aortic-right atrium fistula (2+). Maintained ATB until D42, persisting afebrile, negative blood cultures, normal leucogram and CRP. Considered inoperable, he was discharged on Sep/18. After 30 days, patient was stable, negative blood cultures however with worsening ESR (2 -> 99mm/h) and CRP (0.5 -> 15mg/dl). He performed ETT and 18F-FDG PET/CT on Nov/18 with persistence of abscess, fistula and high increase 18F-FDG uptake. Heart team again opted for prolonged oral ATB with amoxicillin 3.0gr/day. Re-evaluated on Dec/18 with laboratory normalization and good clinical evolution until last appointment on April/19 under oral antibiotic. Conclusion Reoperation of PVE improves prognosis, however in some cases where surgical risk is prohibitive, prolonged ATB may be the only option to control infecction or as a bridge for eventual heart transplantation. Abstract 1646 Figure.

scholarly journals Case report: Buddy wire technique to facilitate atrial septal crossing during transcatheter transseptal mitral valve implantation

2020 ◽  
Author(s):  
Ashvarya Mangla ◽  
Ameer Musa ◽  
Clifford J Kavinsky ◽  
Hussam S Suradi
Keyword(s):  
Heart Failure ◽  
Mitral Valve ◽  
Heart Valve ◽  
Interatrial Septum ◽  
Chronic Obstructive ◽  
Mitral Valve Stenosis ◽  
Heart Team ◽  
Transcatheter Heart Valve ◽  
Valve Implantation ◽  
Buddy Wire

Abstract Background Transcatheter mitral valve-in-valve implantation (MVIV) has emerged as a viable treatment option in patients at high risk for surgery. Occasionally, despite appropriate puncture location and adequate dilation, difficulty is encountered in advancing the transcatheter heart valve across interatrial septum. Case summary We describe a case of a 79-year-old woman with severe chronic obstructive pulmonary disease (COPD), prior surgical bioprosthetic aortic and mitral valve replacement implanted in 2007, atrial fibrillation, and Group II pulmonary hypertension who presented with progressively worsening heart failure symptoms secondary to severe bioprosthetic mitral valve stenosis and moderate-severe mitral regurgitation. Her symptoms had worsened over several months, with multiple admissions at other institutions with treatment for both COPD exacerbation and heart failure. Transoesophageal echocardiogram demonstrated preserved ejection fraction, normal functioning aortic valve, and dysfunctional mitral prosthesis with severe stenosis (mean gradient 13 mmHg) and moderate-severe regurgitation. After a multi-disciplinary heart team discussion, the patient underwent a transcatheter MVIV implantation. During the case, inability in advancing the transcatheter heart valve (THV) across interatrial septum despite adequate septal balloon pre-dilation was successfully managed with the support of a stiff ‘buddy wire’ anchored in the left upper pulmonary vein using the same septal puncture. The patient tolerated the procedure well and was discharged home. Discussion Operators should be aware of potential strategies to advance the THV when difficulty is encountered in crossing the atrial septum despite adequate septal preparation. One such strategy is the use of stiff ‘buddy wire’ for support which avoids the need for more aggressive septal dilatation.

scholarly journals Transcatheter mitral valve repair: an overview of current and future devices

Open Heart ◽  
2021 ◽  
Vol 8 (1) ◽  
pp. e001564
Author(s):  
Ole De Backer ◽  
Ivan Wong ◽  
Maurizio Taramasso ◽  
Francesco Maisano ◽  
Olaf Franzen ◽  
...  
Keyword(s):  
Clinical Trials ◽  
Mitral Valve ◽  
Mitral Valve Repair ◽  
Mitral Annulus ◽  
Therapeutic Strategies ◽  
Heart Team ◽  
Valve Repair ◽  
Careful Patient ◽  
Transcatheter Mitral Valve Repair ◽  
Tailored Approach

The field of transcatheter mitral valve repair (TMVr) for mitral regurgitation (MR) is rapidly evolving. Besides the well-established transcatheter mitral edge-to-edge repair approach, there is also growing evidence for therapeutic strategies targeting the mitral annulus and mitral valve chordae. A patient-tailored approach, careful patient selection and an experienced interventional team is crucial in order to optimise procedural and clinical outcomes. With further data from ongoing clinical trials to be expected, consensus in the Heart Team is needed to address these complexities and determine the most appropriate TMVr therapy, either single or combined, for patients with severe MR.

Sign in / Sign up

Export Citation Format

Share Document