Mechanical valve thrombosis: Current management and differences between guidelines.

All foreign bodies inserted in the circulatory system are thrombogenic and require temporary or lifelong antithrombotic therapies to prevent thrombosis. The adequate level of anticoagulation during the first few months determines the long-term durability, particularly for mechanical prostheses, and also for biological valves. Suboptimal anticoagulation is the most frequent source of mechanical valve thrombosis (MVT). The patient's clinical presentation decides how mechanical prosthetic valve obstruction is managed. If the mechanical valve thrombosis is obstructive and the patient is in a critical condition with hemodynamic instability, an immediate surgical intervention should be performed.  The thrombolytic treatment is an option for left mechanical valve thrombosis in patients who have high surgical risk and no contraindications and also for right heart valve thrombosis. In non-obstructive thrombosis on the mechanical valve, patients can be asymptomatic, requiring optimization of the anticoagulant treatment. Both obstructive and non-obstructive thrombus formed on the mechanical prosthesis can result in embolic events. If the thrombus persists following anticoagulant treatment, the recommended options include thrombolytic treatment or redo surgery. Pannus can also cause obstruction of the prosthesis for which surgical treatment is the only option. While these clinical scenarios may initially appear to have straightforward solutions in terms of surgery, thrombolysis, or effective anticoagulation, real-world clinical experience often proves more complex. For instance, a patient with some usual comorbidities and non-obstructive mechanical valve thrombosis, experiencing symptoms solely by repeated systemic embolizations, might undergo all three therapeutic options due to the unpredictable nature of MVT. Therefore, treatment indications can intersect both on the time axis and depending on the patient's clinical status and the expertise of the center where he is hospitalized. Moreover, the European and American guidelines show subtle but important differences. The aim of this review was to compare these differences, comment on recent studies and evidence gaps, propose a more pragmatic algorithm combining all current recommendations, and highlight important research directions for this disease that has dominated the cardiovascular landscape for more than five decades, but for which there have been no significant recent changes in management.

Diagnosis of Left-Sided Mechanical Prosthetic Valve Thrombosis: A Pictorial Review.

Although transcatheter valve therapy is rapidly evolving, surgical valve replacement is still required in many patients with severe left-side valve stenosis or regurgitation, the mechanical bi-leaflet heart valve being the standard prosthesis type in younger patients. Moreover, the prevalence of valvular heart disease is steadily increasing, especially in industrialized countries, and the problem of lifelong efficient anticoagulation of these patients remains fundamental, especially in the context where vitamin K antagonists continue to be the current standard of anticoagulation despite a level of oscillating anticoagulation. In this setting, avoiding prosthetic valve thrombosis after surgery is the number one objective for both the patient and the responsible physicians. Although rare, this complication is life threatening, with the sudden onset of acute cardiac failure such as acute pulmonary edema, cardiogenic shock, or sudden cardiac death and inadequate anticoagulation remaining the leading cause of prosthesis thrombosis, along with other risk factors. The availability of multimodal imaging techniques enables and encompasses to a full extent the diagnosis of mechanical valve thrombosis. The gold-standard diagnostic methods are transthoracic and transesophageal echocardiography. Moreover, 3D ultrasound has undoubted value in giving a more accurate description of the thrombus's extension. When transthoracic and transesophageal echocardiography are uncertain, the multidetector computer tomography examination is an important complementary imaging method. Fluoroscopy is also an excellent tool for evaluating the mobility of prosthetic discs. Each method complements the other to differentiate an acute mechanical valve thrombosis from other prosthetic valve pathologies such as pannus formation or infective endocarditis and aids the physician in accurately establishing the treatment method (surgical or pharmaceutical) and its optimal timing. The aim of this pictorial review was to discuss from an imagistic perspective the mechanical prosthetic aortic and mitral valve thrombosis and to provide an overview of the essential role of non-invasive exploration in the treatment of this severe complication.

Surgical Atrial Septal Patch Endocarditis in a Patient with a Complete Corrected Atrioventricular Canal Defect: A Case Report and Review of the Literature.

Infective endocarditis (IE) is common in patients with corrected congenital heart disease (CHD) with a residual lesion, but is rarely found on surgical patches used to close atrial septal defects (ASDs). This is also reflected in the current guidelines that do not recommend antibiotic therapy for patients with a repaired ASD with no residual shunt six months after closure (percutaneous or surgical). However, the situation could be different in the case of mitral valve endocarditis, which causes leaflet disruption with severe mitral insufficiency and could seed the surgical patch. We present herein a 40-year-old male patient with a past medical history of a complete surgically corrected atrioventricular canal defect performed in childhood who presented with fever, dyspnea and severe abdominal pain. Transthoracic and transesophageal echocardiography (TTE and TEE) revealed vegetation at the level of the mitral valve and the interatrial septum. The CT scan confirmed ASD patch endocarditis and multiple septic emboli, guiding the therapeutic management. An accurate evaluation of cardiac structures should be mandatory when a systemic infection is detected in CHD patients, even if the defects were surgically corrected, because the detection and eradication of such infectious foci as well as a surgical reintervention are particularly difficult to achieve in this subpopulation.

SUDOSCAN, an Innovative, Simple and Non-Invasive Medical Device for Assessing Sudomotor Function.

Diabetic autonomic neuropathy is probably the most undiagnosed but serious complication of diabetes. The main objectives were to assess the prevalence of peripheral and autonomic neuropathy in a population of diabetic patients, analyze it in a real-life outpatient unit scenario and determine the feasibility of performing SUDOSCAN tests together with widely used tests for neuropathy. A total of 33 patients were included in the study. Different scoring systems (the Toronto Clinical Neuropathy Score-TCNS; the Neuropathy Disability Score-NDS; and the Neuropathy Symptom Score-NSS) were applied to record diabetic neuropathy (DN), while the SUDOSCAN medical device was used to assess sudomotor function, detect diabetic autonomic neuropathy and screen for cardiac autonomic neuropathy (CAN). Fifteen (45.5%) patients had sudomotor dysfunction. The SUDOSCAN CAN risk score was positively correlated with the hands' electrochemical sweat conductance (ESC), diastolic blood pressure (DBP), the level of the glycated hemoglobin, as well as with the TCNS, NDS and NSS. Performing SUDOSCAN tests together with other tests for DN proved to be a feasible approach that could be used in daily clinical practice in order to screen for DN, as well as for the early screening of CAN, before more complex and time-consuming tests.