Prognostic variables for clinical outcomes in valvular heart disease patients with moderate to severe secondary tricuspid regurgitation.

BACKGROUND AND AIM OF THE STUDY: Secondary tricuspid regurgitation (STR) is frequently seen in cardiology practice. Currently, few data are available on the prognostic variables associated with moderate or severe STR on death and progression to valve surgery. Hence, the study aim was to identify these prognostic variables. METHODS: In this retrospective study, patients with at least moderate STR were identified from an ongoing database and followed until death, any valvular heart surgery, or the end of the study. Clinical and echocardiographic variables including age, gender, coronary artery disease, device implantation (defibrillator or pacemaker), pulmonary disease, left ventricular ejection fraction, right ventricular size, right ventricular systolic pressure (RVSP), STR severity and concomitant valve disease were recorded. End-points were death and valve surgery. RESULTS: The average age of the 92 study participants was 68 +/- 16 years. During a mean follow up of 43 +/- 24 months, there were 13 deaths (14%) and 12 surgeries (13%). In multivariate analysis, both an elevated RVSP and device implantation were significant predictors of death (p = 0.0038 and 0.0487, respectively). Only an elevated RVSP was predictive of surgery (p = 0.05) and surgery-free survival (p = 0.0005). A RVSP > 48 mmHg had a hazard ratio of 3.93 (p = 0.0012) and a high diagnostic accuracy for predicting death, with an area under the receiver operating characteristic curve of 0.73. CONCLUSION: In patients with valvular heart disease and at least moderate STR, an elevated RVSP of at least 48 mmHg was associated with significantly increased mortality and decreased surgery-free survival.

Preventing stroke in atrial fibrillation patients - clinical utility of oral anticoagulants.

Atrial fibrillation is the most common of the cardiac arrhythmias and is associated with high risk of stroke and systemic thromboembolism. Prevention of these complications is therefore a major component of clinical management in patients with this rhythm disorder. The choice of antithrombotic therapy in any given patient depends on his or her risk profile and needs to be carefully balanced against the risk of bleeding. In this review we discuss the pathophysiology of thrombogenesis in atrial fibrillation, risk factors for systemic thromboembolism in atrial fibrillation, patient risk stratification modules both for systemic thromboembolism and the risk of bleeding, current antithrombotic therapy strategies, clinicoepidemiological evidence that led to their evolvement, the challenges that plague them, recent developments in the field and how they could possibly affect our future clinical decision making.

Left ventricular outflow tract and mid-cavity obstruction may cause false-positive dobutamine stress echocardiograms.

Left ventricular (LV) outflow tract obstruction (LVOTO) occurs in up to 20% of patients undergoing dobutamine stress echocardiography (DSE). Mid-cavity LV obstruction occurs less commonly during DSE. LV regional wall motion abnormalities during DSE may occur despite normal coronaries due to hypertensive blood pressure response and takotsubo stress cardiomyopathy. We describe herein two cases of LVOTO and one case of mid-cavity LV obstruction during DSE associated with transient apical hypokinesis.