Clinical safety and efficacy of thrombolytic therapy with low-dose prolonged infusion of tissue type plasminogen activator in patients with intermediate-high risk pulmonary embolism.

: The patients with intermediate-high risk pulmonary embolism who have acute right ventricular (RV) dysfunction and myocardial injury without overt hemodynamic compromise may be candidates for thrombolytic therapy. Alternative low-dose thrombolytic therapy strategies with prolonged infusion may further decrease the complication rates as its efficacy and safety have been previously proven in the management of prosthetic valve thrombosis. In this study, we aimed to investigate the clinical outcomes of low-dose prolonged thrombolytic therapy regimen in intermediate-high risk pulmonary embolism patients. This study enrolled 16 retrospectively evaluated patients (female 9, mean age: 70.9 ±â€Š13.5 years) with the diagnosis of acute pulmonary embolism who were treated with low-dose and slow-infusion of tissue-type plasminogen activator (t-PA). All patients underwent transthoracic echocardiography and computed tomography scan for assessment of thrombolytic therapy success. Low-dose prolonged thrombolytic therapy was successful in all patients. The mean t-PA dose used was 48.4 ±â€Š6.3 mg. There was residual segmental thrombus in nine (56.3%) patients after thrombolytic therapy. The arterial oxygen saturation and tricuspid annular plane systolic excursion increased after thrombolytic therapy whereas heart rate, RV to left ventricular (LV) ratio, systolic pulmonary artery pressure, and the frequencies of hypotension and tachypnea significantly decreased. There was no cerebrovascular accident or major bleeding requiring transfusion. There were two minor bleedings (12.5%) including hemoptysis and epistaxis. Thrombolytic therapy in these intermediate-high risk pulmonary embolism patients was associated with excellent clinical outcomes and survival to discharge (100%) without any 60-day mortality. Prolonged thrombolytic therapy regimen with low-dose and slow-infusion of t-PA may be associated with lower complication rates without comprimising effectiveness in patients with acute intermediate-high risk pulmonary embolism.

Real-world stroke prevention strategies in nonvalvular atrial fibrillation in patients with renal impairment.

BACKGROUND: The data regarding stroke prevention strategies in nonvalvular atrial fibrillation (NVAF) are limited especially in patients with renal impairment (RI). We sought to evaluate management dilemmas in patients with concurrent NVAF and RI in RAMSES (ReAl-life Multicenter Survey Evaluating Stroke Prevention Strategies inTurkey) study. METHODS: We conducted a prospective, multicenter, nation-wide registry in NVAF patients in outpatient cardiology clinics. All consecutive patients with NVAF were enrolled in RAMSES study (ClinicalTrials.gov identifier NCT02344901). The baseline data were collected. Glomerular filtration rate (GFR) was estimated by Cockcroft-Gault equation. RESULTS: A total number of 6273 patients from 29 provinces of Turkey with the contribution of 83 investigators were enrolled to the study. Of the study population, 1964(33%) patients had RI which was defined as GFR < 60 mL/min. Patients with RI had significantly higher CHA2 DS2 VASc and HAS-BLED scores compared to those without RI (3·9 ± 1·5 vs. 2·9 ± 1·5, and 2·0 ± 1 vs. 1·4 ± 1; P < 0·001). Prior history of major bleeding (6·9% vs. 4·1%, P < 0·001) and stroke (16·2% vs. 11·8%, P < 0·001) was significantly higher among individuals with concomitant RI and NVAF. Although RI patients had a higher risk for thromboembolism, number of the patients who did not receive any anticoagulant therapy was higher in patients with RI than without RI (30·1 vs. 26·4%, P = 0·003). CONCLUSION: RAMSES study showed that one-third of the patients with NVAF had RI in the real-world setting. Although it is mandatory in most of the patients with concomitant NVAF and RI, nearly one-third of these patients did not receive any anticoagulant therapy.

Low-Level Vitamin D Is Associated with Atrial Fibrillation in Patients with Chronic Heart Failure.

BACKGROUND: Atrial fibrillation (AF) frequently accompanies heart failure (HF), and causes exacerbation of symptoms and treatment failure in such patients. Vitamin D was recently suggested to be an important mediator of cardiovascular disease, including HF. OBJECTIVES: The aim of this study was to evaluate the relationship between vitamin D deficiency and AF in patients with chronic HF. MATERIAL AND METHODS: The study included 180 chronic HF patients that were divided into 2 groups based on having sinus rhythm [AF (-) group] or chronic AF [AF (+) group]. Vitamin D status was assessed via measurement of the serum 25-hydroxyvitamin D (25[OH]D) concentration. RESULTS: Mean age of the patients was 66 ± 8.7 years and 53.9% were male. There weren't any significant differences in age, gender, body mass index, etiology or chronic HF stage between the 2 groups. The vitamin D level in the AF (+) group was significantly lower than in the AF (-) group (11.05 ng/mL vs. 20 ng/mL, p < 0.001) and the parathyroid hormone level was significantly higher in the AF (+) group (76.7 vs. 55 pq mL, p < 0.001). The left atrium to body surface area ratio (LA/BSA) was significantly higher in the AF (+) group (45.03 mm/m2 vs. 42.05 mm/m2, p < 0.01). Independent predictors (based on multiple regression) of AF were vitamin D level (OR = 0.854, 95% CI: 0.805-0.907, p < 0.001) and LA/BSA ratio (OR = 1.077, 95% CI: 1.003-1.156, p < 0.05). The optimal vitamin D cut-off value for the prediction of AF was 16.50 ng/mL, with a sensitivity of 76.0% and specificity of 65.5% (AUC = 0.75, 95% CI: 0.67-0.82). CONCLUSIONS: A low plasma vitamin D concentration was strongly associated with AF in patients with chronic HF.

Successful radiofrequency ablation of atrial flutter causing hemodynamic instability in a patient with recent myocardial infarction.

Atrial flutter (AFL) is a common arrhythmia which may decrease cardiac output and may cause embolic events. Direct current (DC) cardioversion, medical cardioversion and radiofrequency (RF) ablation are therapeutic options, but over all RF ablation therapy has the longest event free period. Although development of AFL after myocardial infarction is quite common it may spontaneously recover or results in atrial fibrillation. Herein we report a patient with medical and electrical cardioversion resistant AFL which developed in the early post-myocardial infarction period causing hemodynamic instability, who was successfully treated with RF catheter ablation.

Value of serum fibrinogen levels in the assessment of mechanical prosthetic valve thrombosis.

BACKGROUND AND AIM OF THE STUDY: The evaluation of prosthetic valve thrombosis (PVT) is crucial due to higher mortality and morbidity rates. The study aim was to assess the value of fibrinogen in the diagnosis of PVT, an important and a common cause of prosthetic valve failure. METHODS: Between December 2007 and April 2012, 154 patients with PVT and 116 control subjects with a normally functioning prosthesis were enrolled in the study. PVT was diagnosed using transesophageal echocardiography, and fibrinogen levels were measured at presentation. The patients and controls had similar demographic features. RESULTS: NYHA functional class, ineffective anticoagulation, presence of symptoms and moderate to severe left atrial spontaneous echo contrast (LASEC) were significantly different between the groups. The fibrinogen level was significantly higher in patients with PVT compared to controls (393.46 +/- 127.87 versus 276.93 +/- 69.22 mg/dl, p < 0.001). Ineffective anticoagulation, the presence of symptoms, a poor NYHA functional class, the presence of moderate to severe LASEC and elevated fibrinogen levels were independent predictors of PVT on multivariate regression analysis (p < 0.001, odds ratio (OR) 38.811, 95% confidence interval (CI): 13.319-113.091; p < 0.001, OR 6.745, CI: 2.777-16.386; p = 0.031, OR 3.557, CI: 1.126-11.239; p = 0.026, OR 3.203, CI: 1.146-8.955, and p < 0.001, OR 1.011, CI: 1.007-1.016 respectively). CONCLUSION: Besides known indicators of PVT, including ineffective anticoagulation, the presence of LASEC and decreased NYHA functional capacity, elevated fibrinogen levels may be a valuable marker for the assessment of PVT.

The relationship between dipper/nondipper pattern and cardioankle vascular index in hypertensive diabetic patients.

OBJECTIVE: 24-h ambulatory blood pressure monitoring (24-h ABPM) is a better predictor of cardiovascular events (CVEs) than spot blood pressure (BP) measurements in hypertensive diabetic patients. In this patient group, the underlying mechanism of the relationship between a nondipper pattern determined with 24-h ABPM and increased incidence of CVE is unknown. Cardioankle vascular index (CAVI) is a new index of the overall arterial stiffness from the aorta to the ankle. The objective of the present study was to evaluate the relationship between a dipper/nondipper pattern and arterial stiffness in hypertensive diabetic patients using the CAVI method. METHODS: We enrolled 99 hypertensive patients with type-2 diabetes mellitus. 24-h ABPM and CAVI measurements were performed for all patients. The relationship between a dipper/nondipper pattern and CAVI measurements was analyzed. RESULTS: Sixty-three (63.6%) patients had a nondipper pattern. In univariate analysis, CAVI, mean arterial pressure (MAP)-asleep, overall diastolic BP, overall systolic BP, duration of hypertension, and statin use were significantly higher among patients with a nondipper pattern than that in dippers. Multivariate linear regression analyses showed that the difference between MAP-asleep and MAP-awake was associated independently with CAVI (ß coefficient=0.514, P<0.001). CAVI was correlated negatively with the nocturnal decrease in MAP (%) (r=-0.558 and P<0.001). CONCLUSION: The nondipper pattern determined with 24-h ABPM in hypertensive diabetic patients is associated with an increase in arterial stiffness. This patient group should be monitored closely for CVEs.

Complete atrioventricular block associated with non-penetrating cardiac trauma in a 40-year-old man.

BACKGROUND: Myocardial contusion is a rare complication of blunt chest trauma. Transient conduction and rhythm problems, right ventricular dysfunction, or pulmonary embolism may occur after chest trauma, but these complications almost always occur early in the post-operative period. OBJECTIVES: The objective is to describe a case illustrating that trauma may induce high-grade atrioventricular block. CASE REPORT: We report the case of a patient who developed delayed onset of complete atrioventricular block after transient complete atrioventricular block and alternating bundle branch block secondary to blunt chest trauma. CONCLUSION: Even with an injury that does not seem to be caused by direct penetrating trauma to the heart, maybe every trauma patient needs an electrocardiographic evaluation. It is important to note that myocardial healing is a continuous process after trauma, and additional pathology may be revealed later in the course of healing from myocardial contusion.

Acute anterior myocardial infarction in an 85-year-old male patient, complicated by the deadly duo: ventricular septal rupture and pseudoaneurysm.

Ventricular septal rupture and ventricular pseudoaneurysm formation are rare complications of acute myocardial infarction. Immediate intervention is mandatory in these circumstances. Our case is a unique presentation of an anterior myocardial infarction in an 85-year-old male, complicated by ventricular septal rupture and ventricular pseudoaneurysm formation.

Successful treatment of renal artery thromboembolism with low-dose prolonged infusion of tissue-typed plasminogen activator in a patient with mitral mechanical heart valve thrombosis under the guidance of multimodality imaging.

This case report describes the use of low-dose prolonged infusion of tissue-typed plasminogen activator in the treatment of renal artery thromboembolism secondary to prosthetic valve thrombosis, under the guidance of multimodality imaging. Thromboembolic occlusion of renal arteries is a rare disorder with serious consequences. It is generally associated with cardiac diseases and arrhytmias. Four consecutive doses of low-dose prolonged infusion of tissue-typed plasminogen activator [25 mg tissue-typed plasminogen activator (tpa) in 6 h] were administered to the patient. This case of renal artery thromboembolism secondary to mitral mechanical prosthetic valve thrombosis was successfully treated with low-dose prolonged infusion of tPA under the guidance of multimodality imaging with renal artery Doppler ultrasonography, multislice computerized tomographic angiography, renal angiography, two-dimensional and real-time three-dimensional transesophageal echocardiography. This case has demonstrated that low-dose prolonged infusion of tissue-typed plasminogen activator may be effective and well tolerated in the treatment of renal embolism.