The Importance of International Normalized Ratio Monitoring in Patients With Mechanical Pulmonary Valve Prosthesis.

Background: The most challenging risk of mechanical valves is thromboembolic events; therefore, life-long anticoagulation therapy is necessary. Anticoagulation therapy should be adjusted for each patient with serial international normalized ratio (INR) monitoring. Due to the small number of patients with a mechanical valve in the pulmonary position, we are facing a lack of information about the therapeutic range of the INR in these patients. We aimed to evaluate patients with a history of pulmonary valve replacement (PVR) who faced malfunction and compare their INR and echocardiographic data at the time of malfunction and 3 months prior. Methods: In this cross-sectional study, 71 patients who had previously undergone PVR and presented to Shaheed Rajaie Cardiovascular Medical and Research Center with a diagnosis of pulmonary valve malfunction between 2014 and 2021 were included. Patients' INR and echocardiographic data at the time of the malfunction and 3 months before the malfunction diagnosis were gathered from the hospital's registry. IBM SPSS 20.0 was used for data analysis. Results: In this cross-sectional study, 71 patients with mechanical pulmonary valve malfunction were included. 49.3% (n = 35) were men, 50.7% (n=36) were women, and their mean age was 33.23 (±8.279). The mean INR of all patients 3 months before malfunction and at the time of malfunction was 2.29 (±0.753) and 2.20 (±0.704), respectively. Conclusion: In this study, most of our patients had an INR below the therapeutic range, both at the time of malfunction and 3 months prior. It emphasizes the importance of patient follow-up and keeping the INR in the therapeutic range.

Mechanical tricuspid valve thrombosis: A midterm follow-up study.

BACKGROUND: The incidence of prosthetic tricuspid valve (TV) thrombosis is the highest among heart valves. It can lead to high morbidity and mortality without proper treatment. In this study, we sought to report the management and clinical outcomes of patients with mechanical TV thrombosis. METHODS: The current study was conducted in Rajaei Heart Center on 42 patients with mechanical TV thrombosis from 2006 to 2017. The baseline characteristics and the rates of adverse events during the follow-up period were assessed. RESULTS: A total of 67 episodes of mechanical TV thrombosis in 42 patients were observed. The mean age of patients was 45.5 ± 14.3 years (19-77), and overall two-thirds were female. Thrombolytic therapy was used in 41 (61.1%), anticoagulant intensification in 16 (23.9%), and surgery as the first approach in 10 (14.9%) episodes; subsequently, surgery as the final approach was implemented in 20 (29.8%) episodes. In-hospital mortality occurred in two (2.98%) patients. The rates of freedom from recurrent thrombosis were 84%, 61%, and 21% at the end of 1, 4, and 10 years, respectively. Survival rates and freedom from chronic valve dysfunction were 93%, 82%, and 75% after 1, 4, and 10 years. CONCLUSIONS: The results of the present study showed that recurrent thrombosis requiring intervention is a major complication of mechanical TV, which underscores individual-approached therapy and close follow-up.

Evaluation of diastolic function in newly diagnosed hyperthyroid patients with preserved left ventricular systolic function.

BACKGROUND: Diastolic dysfunction has been reported as a cardiovascular effect of hyperthyroidism, and is also supposed to be a cause of heart failure manifestations in the patients with preserved ejection fraction (EF). METHODS: For evaluation of diastolic function in hyperthyroid patients and also diastolic function during performing exercise stress echocardiography, we conducted this study on 25 newly diagnosed hyperthyroid patients compared to 26 healthy subjects as control group. Diastolic function of the patients at rest was assessed using these parameters as follows: left atrium volume index, tricuspid regurgitation (TR) velocity, mitral inflow early diastolic flow (E wave), tissue Doppler of mitral annular velocity (e'), E/e' ratio, and isovolumic relaxation time (IVRT); and during exercise stress echocardiography, we judged diastolic response by measuring E/e' ratio and TR velocity at the peak of stress. RESULTS: The mean age of the patients was 39.64 ± 12.23 years old and 52% of them were female. History of exertional dyspnea was found in 64% of patients. All the patients had normal diastolic function at the time of resting and there was no significant difference in diastolic parameters between the two groups except for IVRT, which was lower in hyperthyroid patients. Interestingly, no patients developed diastolic dysfunction during exercise stress echocardiography. CONCLUSION: Our finding did not show diastolic dysfunction in hyperthyroid patients neither at rest nor during exercise echocardiography and did not support the hypothesis that diastolic dysfunction can be a cause of exertional intolerance and dyspnea in the patients with preserved EF.

The effect of colchicine on the echocardiographic constrictive physiology after coronary artery bypass graft surgery.

BACKGROUND: Constrictive physiology is a transitory condition that could lead to constrictive pericarditis, which is a rare complication after open-heart surgery. Anti-inflammatory drugs like colchicine are recommended for prevention of constrictive pericarditis; however, there is no evidence about the effect of colchicine on constrictive pericarditis. Thus, the aim of this study is to evaluate the preventive effect of colchicine on the incidence of echocardiographic constrictive physiology after open-heart surgery. METHODS: This was a parallel randomized, double-blind trial. Patients were randomly assigned to receive 1 mg colchicine once-daily from 48 hours before and 0.5 mg twice daily for 5 days after surgery. Primary outcome was the incidence of the constrictive physiology after primary endpoint (1 week after the surgery). The secondary outcome was the primary outcome after secondary endpoint (4 weeks after surgery) plus the new cases of constrictive physiology between the primary and secondary endpoints. RESULTS: Out of 160 participating patients, the primary outcome occurred in 19 patients (23%) in placebo and 11 (13%) in intervention groups. There was no significant difference between two groups (P = .106). After 4 weeks of follow-up, 19 patients (23%) in placebo and 9 (11%) in intervention groups had constrictive physiology whereas 2 out of 11 patients (18.2%) were recovered. The difference was significant (P = .038). No new case of constrictive physiology occurred between primary and secondary endpoints. CONCLUSION: Short-term use of colchicine has a preventive effect on reducing constrictive physiology after 1 month of open-heart surgery but not a week after that.

Rapid improvement in right ventricular free wall longitudinal strain measures after successful percutaneous mitral commissurotomy.

BACKGROUND: Percutaneous mitral commissurotomy (PMC) is currently the treatment of choice for patients with symptomatic mitral stenosis (MS) that have favorable valvular characteristics. We aimed to evaluate the effect of PMC on the longitudinal strain of the right ventricular (RV) free wall in patients with severe MS. METHODS: This prospective study recruited patients who underwent PMC. Transesophageal and transthoracic echocardiographic examinations were performed. The mitral valve area (MVA) was measured by three-dimensional evaluation. The RV longitudinal strain was measured via the speckle-tracking method. RESULTS: A total of 42 patients with a maximum MVA of 1.5 cm2 underwent PMC in our study. The MVA increased significantly after the procedure (pre-PMC MVA = 0.94 ± 0.20 cm2 vs post-PMC MVA = 1.45 ± 0.18 cm2 ; P < .01). Systolic pulmonary artery pressure decreased from 46.05 ± 14.08 mm Hg preprocedurally to 35.86 ± 7.53 mm Hg postprocedurally (P < .01). The mean RV free wall longitudinal strain was -19.00 ± 5.14%, which rose significantly after PMC to -20.97 ± 3.81 (P < .05). There were postprocedural increases, albeit nonsignificant, in the tricuspid annular peak systolic excursion, the peak systolic Doppler velocity of the RV free wall, and fractional area change. The improvement in the RV longitudinal strain was more prominent in the patients with an MVA of less than 1.0 cm2 . CONCLUSIONS: There was a significant post-PMC rise in the RV free wall longitudinal strain measures in our study population, demonstrating an immediate improvement in the RV systolic function of the patients.

Level of agreement in three-dimensional planimetric measurement of mitral valve area between transthoracic and transesophageal echocardiography.

BACKGROUND: Echocardiographic measurement of mitral valve area (MVA) is critical prior to percutaneous transmitral commissurotomy (PTMC). This study aimed to compare the agreement between transthoracic (TTE) and transesophageal echocardiography (TEE) in three-dimensional (3D) planimetric measurement of the MVA among patients with severe mitral stenosis. METHODS: MVA was measured with planimetry in 105 patients before undergoing PTMC. 3D reconstruction was applied to both TTE and TEE examinations. The MVA values from four different methods of 3D reconstruction were compared to the average values of 3D methods in TEE as the gold standard measurement method for the MVA in this study. The agreement levels between the two examinations were evaluated and analyzed for various reconstruction methods. RESULTS: The mean age was 49 ± 12 years for 28 men and 77 women who were enrolled. The image quality was graded as "excellent" in 57% of 3D images obtained by TTE, while it was graded as "excellent" in 81% of 3D images obtained by TEE. The ventricular zooming method in TTE with a bias of -0.006 ± 0.065 cm2 (P < 0.0001) had the highest agreement with the 3D-MVA in TEE. While 2D-TTE and 3D-TEE measurements of the MVA (R = 0.91; P < 0.0001) were significantly correlated, 2D-TTE overestimated the MVA by 0.19 cm2 . CONCLUSION: Although the quality of 3D images was significantly better in TEE than those in TTE, a good agreement existed between the measured 3D-TTE and 3D-TEE studies. We also demonstrated that 2D-TTE overestimated the MVA compare to 3D-TEE.