Self-managed anticoagulation: results from a two-year prospective randomized trial with heart valve patients.

BACKGROUND: This study was conducted to assess the ability of patients receiving heart valve replacements to practice self-managed anticoagulation using a portable coagulometer. METHODS: We carried out a prospective, randomized trial, comparing self-managed anticoagulation with conventional management. Patients practicing self-managed anticoagulation (51 patients) did so at home, measuring their international normalized ratio and then deciding on their dosage of warfarin, while conventionally controlled patients (n = 49) attended hospital clinics or were managed by their family physicians. RESULTS: We successfully trained 41 of 44 patients who agreed to self-manage their anticoagulant therapy; 34 of the 41 managed their own anticoagulation at home for 2 years. Their control, assessed by a number of tests in range (67.6% versus 58.0%) and time in therapeutic range (76.5% versus 63.8%), was significantly better than that for the group managed conventionally (p < 0.0001). There was no significant difference in mortality or morbidity between the two groups. CONCLUSIONS: Self-managed anticoagulation is a reliable, easily learned method of controlling anticoagulation, and it is suitable for approximately two thirds of patients, with excellent results.

Coronary artery surgery and myxoedema.

A patient with a preoperative diagnosis of myxoedema had triple vessel coronary artery bypass surgery. The perioperative and postoperative course was essentially uneventful. The most appropriate management of a patient with coronary artery disease who has concomitant myxoedema is first to improve myocardial blood flow by relieving coronary obstruction and then to treat the thyroid deficiency.

Cardiogenic shock due to papillary muscle rupture in acute myocardial infarction.

We report a case of papillary muscle rupture complicating acute myocardial infarction which resulted in acute cardiogenic shock. The patient underwent urgent replacement of the mitral valve and made an uncomplicated recovery.

Origin of the left coronary artery from the right pulmonary artery: a report of successful surgery in a 3-month-old child.

Successful reimplantation into the aorta of an anomalous left coronary artery arising from the right pulmonary artery is described in a 3-month-old child. Preoperative and postoperative angiograms are included, and serial echocardiography demonstrates the marked improvement in left ventricular function.

Heart failure associated with infective endocarditis. A review of 40 cases.

Thirty one (78%) of 40 consecutive patients (aged 13-79, mean 44 years) with infective endocarditis had congestive heart failure at presentation. Twenty six (65%) had had rheumatic heart disease and 17 (43%) patients had prosthetic valves. Eight (20%) patients had undergone dental procedures within three months of presentation. Blood cultures were positive in only 22 (55%) of the patients. In nine (41%) of them streptococci of the viridans group were isolated and in seven (32%) patients endocarditis was due to Staphylococcus aureus. Eight patients had Q fever endocarditis. Sixteen patients required operation because of haemodynamic deterioration while they were in hospital; 11 patients had native valves and five had prosthetic valves. Seven had emergency operations and were pyrexial at that time. Four of the seven died in hospital. Of the 12 who were alive and well after surgery only two required further surgery two and three years after the initial operation. Twelve (30%) of the 40 patients died in hospital; in 10 death was mainly due to left ventricular failure or congestive heart failure. All patients died who had renal failure (four cases), myocardial infarction (two cases), complete heart block (one case), or ventricular fibrillation (two cases) before operation. Six (33%) of the 18 patients with culture negative endocarditis died. Two of the four patients seen and treated more than 12 weeks after the onset of symptoms died, as did three of the five patients with prosthetic valves who required surgery while in hospital. Three patients with neurological complications survived and only two (29%) of the seven patients with blood cultures that were positive for Staphylococcus aureus died. Of these 40 high risk patients optimal antibiotic treatment and early surgery for haemodynamic difficulty ensured that 28 (70%) were discharged from hospital alive and well.

Discrete subaortic stenosis.

Data concerning 17 consecutive patients with discrete subaortic stenosis are recorded. Twelve patients underwent operative resection of the obstructing lesion. Of these all except one were symptomatic and all had electrocardiographic evidence of left ventricular hypertrophy or left ventricular hypertrophy with strain. They had a peak resting systolic left ventricular outflow tract gradient of greater than 50 mmHg as predicted from the combined cuff measurement of systolic blood pressure and the echocardiographically estimated left ventricular systolic pressure and/or as determined by cardiac catheterisation. The outflow tract gradient as predicted from M-mode echocardiography and peak systolic pressure showed close correlation with that measured at cardiac catheterisation or operation. During the postoperative follow-up from one month to 11 years, of 11 patients, one patient required a further operation for recurrence of the obstruction four years after the initial operation. All patients are now asymptomatic. Five patients have not had an operation. The left ventricular outflow tract gradient as assessed at the time of cardiac catheterisation was greater than 50 mmHg. One patient has been lost to follow-up. The remaining four have been followed from four to eight years and have remained asymptomatic and the electrocardiograms have remained unchanged. Careful follow-up of all patients is essential with continuing clinical assessment, electrocardiograms, M-mode and two-dimensional echocardiograms, and if necessary cardiac catheterisation. Prophylaxis against bacterial endocarditis is also essential.

Management of ventricular septal rupture in acute myocardial infarction.

Four patients with rupture of the interventricular septum after myocardial infarction are described. This condition carries a grave prognosis. Surgical repair of the septum is almost always urgently required if the left-to-right shunt is large (QP/WS > 3). Results are better if surgery can be deferred for six weeks to allow the infarcted area to heal and the tissues to be come firmer. This delay may be achieved by using a combination of agents to reduce afterload and to exert a positive inotropic effect. The timing of surgical intervention was an important factor in the survival of three of the four patients.