Spontaneous Coronary Artery Dissection and Papillary Muscle Rupture in Patient With Undiagnosed Vascular Ehler-Danlos Syndrome.

We present the case of a woman with acute coronary syndrome on the basis of spontaneous coronary artery dissection causing a papillary muscle rupture with severe mitral regurgitation and acute heart failure. The patient subsequently underwent successful emergent surgery of both the mitral and tricuspid valves. Postoperatively, the patient was diagnosed with vascular Ehlers-Danlos syndrome. (Level of Difficulty: Advanced.).

[Papillary muscle rupture in acute coronary syndromes - a clinical chameleon with high mortality]. / Papillarmuskelruptur ­ en klinisk kameleont med hög mortalitet.

A paradigm shift in the treatment of acute coronary syndromes has led to a lower incidence of papillary muscle ruptures and other mechanical complications, with a risk of decreased vigilance for these serious complications. Sudden clinical deterioration with pulmonary edema and circulatory instability in the post infarction period should raise suspicion of papillary muscle rupture. Silent mitral regurgitation without an audible systolic murmur is not uncommon in the acute setting. Most cases of papillary muscle rupture develop high levels of CRP which should not be misinterpreted as signs of an infection. Studies from the modern reperfusion era shows a bimodal time course with the majority of cases presenting within 24 hours of the infarction and the rest primarily within the first week of the post infarction period. Early detection and diagnosis with cardiac ultrasound and prompt surgical treatment are important factors for prognosis.

Quadruple Bioprosthetic Valve Replacement in a Patient With Severe Carcinoid Heart Disease.

Carcinoid heart disease typically affects the tricuspid and pulmonary valves, causing severe regurgitation and/or stenosis. Valve surgery has been shown to reduce right heart failure and improve long-term prognosis in these patients. We report a severe case of a patient with all 4 heart valves involved who underwent successful quadruple bioprosthetic valve replacement. (Level of Difficulty: Intermediate.).

Bleeding complications related to warfarin treatment: a descriptive register study from the anticoagulation clinic at Helsingborg Hospital.

The most common indication for treatment with warfarin is the prevention of ischemic stroke in patients with atrial fibrillation. Time in therapeutic range (TTR) is an important tool to evaluate the quality of anticoagulation treatment. The aim of this study was to investigate the quality of treatment and the incidence of bleeding complications in patients on warfarin treatment treated by the anticoagulation clinic in Helsingborg. This is the first study that has specifically focused on the spontaneous reporting of bleeding complications in a real-world population. A total of 4,400 patients with a total of 8,394 patient years were registered, in the database Journalia AVK, during the time period November 1, 2007 to November 1, 2010. The mean age was 72 years. TTR was 73.3 % for the whole population. 421 patients suffered from haemorrhagic events. The frequency of major and fatal bleedings and intracranial haemorrhage (ICH) were 1.6, 0.2 and 0.5% per patient-year, respectively. A correlation between age and severe bleeding (major, fatal and ICH) (p = 0.003) was seen, but no correlation between gender and severe bleeding (p = 0.27). In 60 out of 455 bleeding events the complication had been reported to the anticoagulation clinic. At the anticoagulation clinic in Helsingborg the quality of warfarin treatment is good compared to previous results described in the literature, with regards to bleeding complications and efficacy. However, in our study, we confirm that the spontaneous reporting of bleeding complications related to warfarin is inadequate, and that review of patient records is needed to assure proper follow-up.