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1.
Rev. bras. cir. cardiovasc ; 35(5): 789-796, Sept.-Oct. 2020. tab, graf
Article in English | SES-SP, LILACS, SES-SP | ID: biblio-1137325

ABSTRACT

Abstract Introduction: Although it is the most common agent among the fungal causes of endocarditis, Candida albicans endocarditis is rare. Objective: To evaluate the efficacy of amphotericin B in the treatment of C. albicans endocarditis beyond a systematic review. Data search: Articles in English, Spanish and Portuguese, conducted in the following databases: MEDLINE, LILACS, IBECS and SciELO, in humans and published in the last 25 years. Study selection: Observational studies, clinical trials, and case series providing data on the amphotericin B use in patients with a C. albicans endocarditis diagnosis without age limitations. Data synthesis: From the initial search (n=79), 25 articles were fully evaluated, of which 19 were excluded for meeting one or more exclusion criteria, remaining five articles (two observational studies and three case series). Patients using amphotericin B demonstrated improvement in survival rates, and its main use was in association with the surgical method as well as with caspofungin association. Conclusion: Literature lacks evidence to conclude about efficacy and safety of amphotericin B in the treatment of fungal endocarditis. Randomized clinical trials are necessary to provide better evidence on the subject.


Subject(s)
Humans , Infant, Newborn , Child , Candida albicans , Amphotericin B/therapeutic use , Endocarditis/microbiology , Endocarditis/drug therapy , Antifungal Agents/therapeutic use , Cross-Sectional Studies
2.
Rev. habanera cienc. méd ; 19(1): 125-142, ene.-feb. 2020. tab, graf
Article in Spanish | LILACS, CUMED | ID: biblio-1099151

ABSTRACT

Introducción: La endocarditis infecciosa es una condición severa que puede presentarse luego de procedimientos odontológicos invasivos, principalmente en pacientes portadores de válvulas cardiacas protésicas y enfermedad cardiaca reumática y congénita. Es importante identificar el nivel de conocimientos de los estudiantes de Odontología para establecer reformas en el plan de estudios de la carrera. Objetivo: Determinar el nivel de conocimiento sobre profilaxis antibiótica de endocarditis infecciosa previa a procedimientos odontológicos en estudiantes de último año de Odontología de Lima. Material y métodos: Estudio analítico y transversal, cuya muestra estuvo constituida por 117 estudiantes del último año de la carrera de Odontología de la Universidad Nacional Mayor de San Marcos (UNMSM), la Universidad Nacional Federico Villareal (UNFV) y la Universidad Peruana Cayetano Heredia (UPCH), de Lima, Perú, durante el año 2014. El instrumento de evaluación fue una encuesta de 20 preguntas cerradas sobre epidemiología y etiopatogenia de endocarditis infecciosa e indicación y farmacología de la profilaxis antibiótica previa a procedimientos odontológicos. Los resultados fueron catalogados en 3 niveles: bajo, regular y alto. Resultados: El 53,84 por ciento de los internos presentó un nivel de conocimiento bajo, mientras el 32,47 por ciento un nivel regular y el 13,69 por ciento un nivel alto. El nivel de respuesta promedio fue 10,1 ± 2,95 [IC95 por ciento(9,57-10,65)]. Por universidad, los internos de la UNMSM tuvieron un nivel de conocimiento promedio de 11 ± 2,60 [IC95 por ciento (9,84-12,15)], los de UNFV tuvieron 8,8 ± 3,36 [IC95 por ciento (7,74 - 9,86)] y los de UPCH tuvieron 10,7 ± 2,41 [IC95 por ciento (10,08-11,39)]; p=0,002. Conclusiones: El nivel de conocimiento sobre profilaxis antibiótica de endocarditis infecciosa en estudiantes de último año de Odontología de Lima es predominantemente bajo(AU)


Introduction: Infective endocarditis is a severe condition that can occur after invasive dental procedures, mainly in patients with prosthetic heart valves and rheumatic and congenital heart disease. It is important to identify the level of knowledge of dental students to establish reforms in the curriculum of the career. Objective: To determine the level of knowledge about antibiotic prophylaxis of infective endocarditis prior to dental procedures in last-year dental students of Lima. Material and methods: Analytical and cross-sectional study whose sample was made up of 117 last-year dental students of the National University of San Marcos (UNMSM), the National University Federico Villareal (UNFV) and the Peruvian University Cayetano Heredia (UPCH) from Lima, Peru, during the year 2014. The evaluation instrument was a survey of 20 closed questions on epidemiology and etiopathogenesis of infective endocarditis and indication and pharmacology of antibiotic prophylaxis prior to dental procedures. The results were cataloged in 3 levels: low, regular and high. Results: The results show that 53,84 percent of the interns presented a low level of knowledge, while 32,47 percent had a regular level and 13,69 percent a high level. The average response level was 10,1 ± 2,95 [95 percent CI (9,57-10,65)]. By university, UNMSM interns had an average level of knowledge of 11 ± 2,60 [95 percent CI (9,84-12,15)], UNFV had 8,8 ± 3,36 [95 percent CI (7,74-9,86)] and those of UPCH had 10,7 ± 2,41 [95 percent CI (10,08-11,39)]; p=0.002. Conclusions: The level of knowledge about antibiotic prophylaxis of infective endocarditis in last- year dental students in Lima is predominantly low(AU)


Subject(s)
Humans , Adult , Students, Dental , Health Knowledge, Attitudes, Practice/ethnology , Antibiotic Prophylaxis/methods , Education, Dental/methods , Endocarditis/drug therapy , Peru/epidemiology
3.
Arch. argent. pediatr ; 115(5): 307-310, oct. 2017. ilus
Article in English, Spanish | LILACS, BINACIS | ID: biblio-887383

ABSTRACT

Las nuevas opciones de tratamiento prolongan la hospitalización y aumentan las infecciones intrahospitalarias bacterianas y fúngicas, pero también mejoran la sobrevida de los recién nacidos hospitalizados en la unidad de cuidados intensivos neonatales. Las infecciones fúngicas invasivas en neonatos están asociadas con una morbimortalidad significativa. También pueden diseminarse a órganos específicos y causar endocarditis, endoftalmitis, artritis séptica, nefropatía obstructiva y meningitis. En el caso de la endocarditis, se recomiendan tratamientos antimicóticos sistémicos agresivos y, en algunos casos, la intervención quirúrgica del neonato. Informamos el caso de un lactante prematuro, de bajo peso al nacer, con vegetación intracardíaca. Esta es una complicación rara y potencialmente mortal de infecciones fúngicas invasivas. El paciente recibió tratamiento con caspofungina y un activador tisular del plasminógeno recombinante, en vez de una intervención quirúrgica.


Developing treatment options have resulted in prolonged admission and increased bacterial and fungal nosocomial infections as well as improved survival in neonatal intensive care unit. Invasive fungal infections in newborns are associated with significant morbidity and mortality and can cause endorgan dissemination such as endocarditis, endophthalmitis, septic arthritis, obstructive nephropathy and meningitis. Endocarditis requires aggressive systemic antifungal therapy and sometimes surgical intervention in neonates. We report a low birth weight premature infant with intracardiac vegetation that is rare and a life-threatening complication of invasive fungal infections. He was treated with caspofungin and recombinant tissue plasminogen activator in stead of surgical intervention.


Subject(s)
Humans , Male , Infant, Newborn , Candidiasis/drug therapy , Tissue Plasminogen Activator , Endocarditis/microbiology , Endocarditis/drug therapy , Echinocandins/therapeutic use , Lipopeptides/therapeutic use , Candida parapsilosis , Antifungal Agents/therapeutic use , Recombinant Proteins/therapeutic use , Infant, Very Low Birth Weight
4.
Indian J Med Sci ; 2011 Feb; 65(2) 69-72
Article in English | IMSEAR | ID: sea-145593

ABSTRACT

Ochrobactrum anthropi is an emerging pathogen increasingly affecting the immunocompromised host. Only four cases of infective endocarditis have been documented in literature. Therapeutic approach is a rising challenge as it is resistant to most of the currently available beta lactam antibiotics with the exception of carbapenems. We report a case of prosthetic valve endocarditis secondary to Ochrobactrum anthropi infection; the host was temporarily immunocompromised due to disseminated herpes zoster after surgery.


Subject(s)
Aged , Aortic Valve/surgery , Aortic Valve/transplantation , Endocarditis/drug therapy , Endocarditis/etiology , Heart Valve Prosthesis , Herpes Zoster/complications , Humans , Male , Ochrobactrum anthropi/pathogenicity , Surgical Wound Infection , beta-Lactams/therapeutic use , beta-Lactam Resistance/drug effects
5.
Heart Views. 2010; 11 (1): 2-9
in English | IMEMR | ID: emr-99038

ABSTRACT

Infective endocarditis is a common disease in Yemen. Although the incidence of rheumatic valvular disease and uncorrected congenital heart disease in adults is high in Yemen, there are few data regarding the pattern, characteristic features and outcome of infective endocarditis in Yemen. The aim was to study the characteristic, clinical features and diagnostic criteria of infective endocarditis in Yemeni patients and the outcome in patients treated with medical therapy. Seventy-two consecutive patients admitted to Kuwait teaching hospital in Sana'a with suspected infective endocarditis between June 1, 2005 and June 1, 2007 were included in this study. A questionnaire including history, clinical findings, and result of requested investigations, treatment, complications and outcome was used. The diagnosis was based on Dukes criteria, which proposed two major or five minor criteria. In our study, we included raised erythrocyte sedimentation rate [ESR] as a minor criteria. The patients were classified as definite, possible and rejected cases. All patients received empirical antibiotic therapy. The mean age was 28.56 +/- 14.5 years. Men were 30 [42.2%] while women were 42 [57.7%]. 59 [81.9%] of the patients had been admitted due to fever. Past history of rheumatic heart disease was positive in 38 [53.3%] of the patients. Mitral regurgitation was the commonest form of valvular affection 54 [82.1%] of patients followed by aortic regurgitation in 45 [63%]. Anemia was present in 53 [74%] while raised erythrocyte sedimentation rate was high in all patients. Vegetations were detected by transthorasic echocardiography in 51 [70.83%] of the patients while blood culture was positive in only 7 [9.6%]. After adding high ESR to the criteria, definite infective endocarditis were found in 34 [47.2%]; possible in 38 [52.7%] and no rejected patients. Sixty-two [87.5%] of the patients improved and were discharged in good general condition. Nine patients died, an In hospital mortality of 12.5%. Patients with IE in Yemen were younger than those patients in western countries, RHD is the commonest predisposing factor. Duke's criteria in addition to high ESR as minor criteria improved the diagnostic possibilities and using empirical antibiotic therapy improves the outcome


Subject(s)
Humans , Male , Female , Adult , Endocarditis/drug therapy , Surveys and Questionnaires , Treatment Outcome , Blood Sedimentation , Echocardiography
8.
Indian Heart J ; 2007 Mar-Apr; 59(2): 118-23
Article in English | IMSEAR | ID: sea-4979

ABSTRACT

Significant advances have been made in the management of infective endocarditis with the advent of antimicrobial therapy, surgery and transesophageal echocardiography, bringing hope to patients suffering from this once uniformly fatal illness. However, recent studies show that the mortality from infective endocarditis is still in the order of 20-30%. The prognostic determinants for adverse outcomes and the indications for surgical therapy in patients with infective endocarditis have recently received renewed attention. Our current understanding of these controversial issues will be reviewed in this paper.


Subject(s)
Endocarditis/drug therapy , Endocarditis, Bacterial/drug therapy , Heart Valve Prosthesis , Heart Valve Prosthesis Implantation , Humans , Prognosis , Risk Assessment , Risk Factors
9.
LJM-Libyan Journal of Medicine. 2007; 2 (1): 43-45
in English | IMEMR | ID: emr-84063

ABSTRACT

A 35-year-old man with pre-existing rheumatic heart disease and aortic regurgitation [AR] presented with intermittent fever, ankle swelling and clinical evidence of endocarditis. Transoesophageal echocardiogram [TEE] revealed vegetations and destruction of the aortic valve [AV]. Blood cultures grew a gram positive coccobacillus which was phenotypically identified as Abiotrophia defectvia [A.defectiva]. A diagnosis of infective endocarditis [IE] due to A.defectiva was made. Treatment, with penicillin and gentamicin, was administered for 4 weeks. Mechanical valve replacement was required few days after starting the antibiotic therapy. The patient had a favorable outcome on follow up. Although A.defectiva is an uncommon cause of endocarditis, early and correct identification of this pathogen is important to improve the outcome and the prognosis of patients with IE due to this organism


Subject(s)
Humans , Male , Adhesins, Bacterial , Rheumatic Heart Disease , Aortic Valve Insufficiency , Endocarditis/drug therapy
10.
Indian J Med Microbiol ; 2005 Apr; 23(2): 139-40
Article in English | IMSEAR | ID: sea-54106

ABSTRACT

The incidence of endocarditis produced by the so-called "opportunists" as a complication of prosthetic valve surgery is progressively increasing in frequency and gradually transforming the clinical picture habitually associated with this disease. Candida endocarditis is an unusual but severe complication caused by Candida albicans or other fungal species. This case and a review of the literature indicate that Candida endocarditis treated with amphotericin B and prosthetic valve replacement may recur months after treatment, and that late recurrent Candida endocarditis, which is difficult to diagnose and treat, may be best prevented by lifelong antifungal suppressive therapy.


Subject(s)
Adult , Amphotericin B/therapeutic use , Antifungal Agents/therapeutic use , Bioprosthesis/adverse effects , Candida tropicalis/isolation & purification , Candidiasis/drug therapy , Endocarditis/drug therapy , Female , Heart Valve Prosthesis/adverse effects , Humans , Mitral Valve/surgery , Review Literature as Topic
11.
Article in English | IMSEAR | ID: sea-46560

ABSTRACT

Tricuspid valve endocarditis is more common in injection drug users. Pulmonary valve and Eustachian valve endocarditis have been reported but are very rare. Earlier reports of endocarditis in injection drug users emphasized the dominance of right sided involvement. In a series of 105 patients 86 % were right sided and 14 % had left sided involvement. We report a case of isolated tricuspid valve endocarditis in an injection drug user affecting a structurally normal heart and review of the literature on this subject. Key Words: injection drug use, tricuspid valve endocarditis.


Subject(s)
Adult , Echocardiography, Doppler , Endocarditis/drug therapy , Fatal Outcome , Humans , Male , Substance Abuse, Intravenous/complications , Tricuspid Valve
12.
Arq. bras. cardiol ; 82(4): 378-383, abr. 2004. ilus
Article in English, Portuguese | LILACS | ID: lil-358598

ABSTRACT

Paciente de 34 anos, com lúpus eritematoso sistêmico e síndrome de anticorpo antifosfolípide secundária, evoluiu com crises convulsivas, parcialmente controladas com anticonvulsivante, e ausculta de sopro cardíaco, cuja propedêutica mostrou a presença de vegetação em valva mitral. Diante do diagnóstico de endocardite de Libman-Sacks foi iniciada terapia com warfarina sódica, e após seis meses de anticoagulação oral, a paciente apresentava controle total das crises convulsivas e desaparecimento da vegetação valvar ao ecocardiograma. São discutidas a ocorrência da endocardite de Libman-Sacks no lúpus eritematoso sistêmico, sua associação com a síndrome de anticorpo antifosfolípide e a terapêutica anticoagulante, e feita uma revisão da literatura.


Subject(s)
Humans , Female , Adult , Anticoagulants/therapeutic use , Endocarditis/drug therapy , Lupus Erythematosus, Systemic/drug therapy , Warfarin/therapeutic use , Administration, Oral , Antiphospholipid Syndrome/complications , Echocardiography, Transesophageal , Endocarditis/complications , Lupus Erythematosus, Systemic/complications , Mitral Valve
13.
Medicina (B.Aires) ; 64(2): 152-154, 2004.
Article in Spanish | LILACS | ID: lil-444338

ABSTRACT

Fungal endocarditis, in particular due to Candida species, requires medical and surgical treatment and amphotericin B is the drug of choice. Caspofungin is an echinocandin very effective against Candida and Aspergillus. We present a patient with Candida tropicalis endocarditis, fluconazol resistant, treated with caspofungin, on a compassional basis as a result of adverse effects with amphotericin B. The patient had a microbiological response.


Las endocarditis causadas por hongos, (Candida en particular), requieren tratamiento médico-quirúrgico,siendo la anfotericina B la droga de elección. Caspofungina es una equinocandina con gran actividadsobre Candida y Aspergillus. Se presenta un paciente con una endocarditis por Candida tropicalis resistente a fluconazol tratado con caspofungina bajo un esquema de salvataje, luego de haber presentado efectos adversos por anfotericina B. El paciente tuvo respuesta microbiológica.


Subject(s)
Aged , Humans , Male , Antifungal Agents/therapeutic use , Candida tropicalis/drug effects , Candidiasis/drug therapy , Endocarditis/drug therapy , Fluconazole/therapeutic use , Peptides, Cyclic/therapeutic use , Candidiasis/complications , Endocarditis/microbiology , Fatal Outcome , Drug Resistance, Fungal
14.
Rev. chil. infectol ; 17(2): 158-60, 2000.
Article in Spanish | LILACS | ID: lil-269409

ABSTRACT

La gonorrea continúa siendo una enfermedad frecuente. En Chile 70 porciento de las cepas de neisseria gonorrhoeae son resistentes a penicilina y mantienen 100 porciento de sensibilidad a cefalosporinas de tercera generación y ciprofloxacina. Se revisan los esquemas terapéuticos propuestos para las infecciones gonocóccicas uretrales, cervicales, rectales, faríngeas, conjuntivales, forma diseminada, endocarditis y meningitis. Además se comentan las exigencias del tratamiento en la mujer embarazada, en pacientes infectados por virus de inmunodeficiencia humana, en casos de coexistencia con chlamydia trachomatis y en pacientes alérgicos a b lactámicos


Subject(s)
Humans , Male , Female , Adolescent , Adult , Cephalosporins/adverse effects , Gonorrhea/complications , Gonorrhea/drug therapy , Penicillin Resistance , Quinolones/adverse effects , Azithromycin/therapeutic use , Cefotaxime/therapeutic use , Ceftriaxone/therapeutic use , Cephalosporins/therapeutic use , Ciprofloxacin/therapeutic use , Conjunctivitis/drug therapy , Endocarditis/drug therapy , Meningitis/drug therapy , Pregnancy/drug effects , Acquired Immunodeficiency Syndrome/drug therapy
15.
SQUMJ-Sultan Qaboos University Medical Journal. 2000; 2: 25-31
in English | IMEMR | ID: emr-55823

ABSTRACT

Objective - The increase in resistance to gram positive organisms and seriousness of infective endocarditis, makes it necessary to look for an alternate treatment. Method- In-vitro activity of synercid was compared with penicillin, amoxycillin, teicoplanin, vancomycin, clindamycin and erythromycin. Result - Synercid showed minimum inhibitory concentrations [MIC] within the narrow range of 0.06-0.5 mg/I. MIC50 and mode values were both 0.25 mg/I. There was just two-fold difference between the MIC50 [0.25 mg/I] and the MIC90, [0.5 mg/I]. Although the MICs of synercid for S. oralis were relatively high compared to penicillin, clindamycin, erythromycin and teicoplanin, the in-vitro bactericidal activity of synercid was much greater. Synercid MBC values were < 4 mg/I for most of the isolates, except for one of 16 mg/I and the other >64 mg/I. Killing curve was performed on six isolates of S. oralis from infective endocarditis, two from septicaemia patients and two from the oral flora of normal individuals. Conclusion - Synercid showed superior bactericidal activity when compared to penicillin and vancomycin against all ten isolates of S. oralis tested. Synercid was bactericidal [99.9% kill] against all ten isolates of S. oralis within six hours of contact


Subject(s)
Humans , Sepsis/drug therapy , Endocarditis/drug therapy , Streptococcal Infections/drug therapy , Microbial Sensitivity Tests , Teicoplanin , Anti-Bacterial Agents , Penicillins , Amoxicillin , Erythromycin , Vancomycin
17.
Medicina (B.Aires) ; 58(3): 301-2, 1998. ilus
Article in Spanish | LILACS | ID: lil-213408

ABSTRACT

La curación sin cirugía de la endocarditis micótica en válvula protésica es raramente descripta. Comunicamos un caso de endocarditis por Candida tropicalis sobre una prótese biológica en posición tricuspídea, en la que se consideró que la cirurgía estaba contraindicada. Se había identificado una gran vegetación sobre la prótesis biológica. Se inició tratamiento antimicótico, observándose mejoría progressiva del cuadro y desaparición de la vegetación a lo largo de 15 meses de seguimiento. El tratamiento completó 2 gr de anfotericina B para continuar luego con fluconazol. Nuestra paciente representa el primer caso de endocarditis en válvula protésica por Candida tropicalis que sobrevive sin cirugía.


Subject(s)
Humans , Female , Middle Aged , Amphotericin B/therapeutic use , Antifungal Agents/therapeutic use , Candidiasis/drug therapy , Endocarditis/drug therapy , Fluconazole/therapeutic use , Heart Valve Prosthesis/microbiology , Prosthesis-Related Infections/drug therapy , Candidiasis/microbiology , Endocarditis/microbiology , Heart Valve Prosthesis/microbiology , Prosthesis-Related Infections/microbiology
18.
Medicina (B.Aires) ; 56(3): 284-6, 1996.
Article in Spanish | LILACS | ID: lil-181486

ABSTRACT

La endocarditis producida por Lactobacillus spp. es una infección infrecuente. Se han descrito 42 casos desde 1938 hasta la fecha y sólo 17 de ellos evolucionaron favorablemente con tratamiento médico, sin necesidad de reemplazo valvular. Si bien se han publicado unos pocos casos de infecciones producidas por Lactobacillus spp. en nuestro país, ninguno de ellos correspondió a endocarditis infecciosa. Se presenta un caso de endocarditis producida por Lactobacíllus casei sub. rhamnosus vancomicinaresistente en un varón de 29 años con antecedentes de prolapso de válvula mitral, que requirió reemplazo valvular para su curación, debido al fracaso del tratamiento con penicilina y gentamicina. El enfermo presentó una evolución favorable en el post-operatorio inmediato y fue dado de alta a los 7 días en buen estado general, no presentando signos ni síntomas de recurrencia en los controles realizados durantes los 2 años siguientes. Enfatizamos la necesidad de identificar rapidamente el género Lactobacíllus ante un aislamiento de hemocultivos de enfermos con endocarditis, puesto que dicho género puede confundirse con otras especies que se asocian más frecuentemente con esta patologia y que generalmente presentan respuesta clínica favorable frente a los tratamientos con antimicrobianos. Sugerimos que se considere la posibilidad de un reemplazo valvular precoz ante la presencia de endocarditis producida por Lactobacillus spp.


Subject(s)
Humans , Male , Adult , Endocarditis/surgery , Lactobacillus casei/isolation & purification , Mitral Valve/transplantation , Anti-Bacterial Agents/therapeutic use , Communicable Diseases , Endocarditis/drug therapy , Endocarditis/etiology , Drug Resistance, Microbial
19.
Arq. bras. med ; 68(4): 221-4, jul.-ago. 1994.
Article in Portuguese | LILACS | ID: lil-142914

ABSTRACT

A estenose mitral é geralmente reumática e é considerada grave quando a área é menor do que 1cm². A fibrilaçäo atrial e a embolia säo as complicaçöes mais temidas. O grande avanço na conduçäo destes casos acha-se representado pela ecocardiografia doppler. O tratamento clínico inclui a prevençäo da febre reumática e da endocardite, bem como o uso judicioso de diuréticos, digitálicos e antiarrítmicos. O tratamento invasivo tem condiçöes próprias, incluindo a comissurotomia cirúrgica e fechada, a valvuloplastia e a troca valvar. Infelismente a reestenose ainda é relativamente freqüente


Subject(s)
Humans , Male , Female , Digitalis , Echocardiography, Doppler , Embolism/complications , Endocarditis/drug therapy , Rheumatic Fever/drug therapy , Atrial Fibrillation/complications , Mitral Valve Stenosis , Dyspnea , Mitral Valve Stenosis/diagnosis , Mitral Valve Stenosis/surgery , Mitral Valve/physiology
20.
J Postgrad Med ; 1992 Oct-Dec; 38(4): 199-200
Article in English | IMSEAR | ID: sea-117487

ABSTRACT

A case of rheumatic heart disease (RHD) with prosthetic mitral valve endocarditis receiving anticoagulation with heparin, underwent medical termination of pregnancy in a second trimester. The following report entails the use of aminocaproic acid (ACA) in preventing excessive bleeding during and after the procedure, while the patient continued to receive anticoagulant therapy.


Subject(s)
Abortion, Therapeutic/methods , Adult , Aminocaproates/administration & dosage , Cerebrovascular Disorders/drug therapy , Endocarditis/drug therapy , Female , Heart Valve Prosthesis , Heparin/adverse effects , Humans , Mitral Valve Insufficiency/complications , Pregnancy , Pregnancy Complications, Cardiovascular/drug therapy , Rheumatic Heart Disease/complications
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