Non-vitamin K antagonist oral anticoagulants (NOACs) for thromboembolic prevention, are they safe in congenital heart disease? Results of a worldwide study.

BACKGROUND: Current guidelines consider vitamin K antagonists (VKA) the oral anticoagulant agents of choice in adults with atrial arrhythmias (AA) and moderate or complex forms of congenital heart disease, significant valvular lesions, or bioprosthetic valves, pending safety data on non-VKA oral anticoagulants (NOACs). Therefore, the international NOTE registry was initiated to assess safety, change in adherence and quality of life (QoL) associated with NOACs in adults with congenital heart disease (ACHD). METHODS: An international multicenter prospective study of NOACs in ACHD was established. Follow-up occurred at 6 months and yearly thereafter. Primary endpoints were thromboembolism and major bleeding. Secondary endpoints included minor bleeding, change in therapy adherence (≥80% medication refill rate, ≥6 out of 8 on Morisky-8 questionnaire) and QoL (SF-36 questionnaire). RESULTS: In total, 530 ACHD patients (mean age 47 SD 15 years; 55% male) with predominantly moderate or complex defects (85%), significant valvular lesions (46%) and/or bioprosthetic valves (11%) using NOACs (rivaroxaban 43%; apixaban 39%; dabigatran 12%; edoxaban 7%) were enrolled. The most common indication was AA (91%). Over a median follow-up of 1.0 [IQR 0.0-2.0] year, thromboembolic event rate was 1.0% [95%CI 0.4-2.0] (n = 6) per year, with 1.1% [95%CI 0.5-2.2] (n = 7) annualized rate of major bleeding and 6.3% [95%CI 4.5-8.5] (n = 37) annualized rate of minor bleeding. Adherence was sufficient during 2 years follow-up in 80-93% of patients. At 1-year follow-up, among the subset of previous VKA-users who completed the survey (n = 33), QoL improved in 6 out of 8 domains (p ≪ 0.05). CONCLUSIONS: Initial results from our worldwide prospective study suggest that NOACs are safe and may be effective for thromboembolic prevention in adults with heterogeneous forms of congenital heart disease.

[Management of atrial fibrillation in 2011]. / Prise en charge de la fibrillation auriculaire en 2011.

Some new guidelines have been published by European (2010) and American (2011) Societies of Cardiology regarding to the management of atrial fibrillation, the most frequent arrhythmia affecting from 1 to 2% of the global population. In this article we summarize and analyse the new aspects of these guidelines in which the different types of atrial fibrillation are redefined, as well as new criterias for the indication of oral anticoagulation and bleeding risk. New antiarrhythmic and anticoagulant molecules also appear in these guidelines, and there is growing evidence for the use of catheter ablation.

[Cor triatriatum in the adult]. / Coeur triatrial chez l'adulte.

A 18-year old girl suffering from effort dyspnea presented to our hospital. She had no previous medical history. The first investigations revealed a linear structure traversing the left atrium. A transoesophageal echocardiogram demonstrated a thin mobile membrane in the atrium. Many investigations were realized to describe better this structure and its contribution to the symptoms. Cor triatrium is a rare congenital disease and its discovery is rare in adulthood. So, there are no guidelines for the optimal management.

Doxycycline and hepatotoxicity.

The hepatotoxicity of tetracyclines is well known. If microvesicular steatosis due to a high dose of tetracycline has virtually disappeared, it can also be observed with other drugs belonging to the tetracycline family. To our knowledge, hepatotoxicity induced by doxycycline has never been reported. In our patient, the abrupt onset of hepatic failure, five days after the start of doxycycline and the rapid normalization after the drug was stopped, leads to suspect a causal relationship between doxycycline and liver insufficiency. We must however be careful before concluding, because our patient received also acetylsalicylic acid and paracetamol, two other potential hepatotoxic drugs.