Value of serum fibrinogen levels in the assessment of mechanical prosthetic valve thrombosis.

BACKGROUND AND AIM OF THE STUDY: The evaluation of prosthetic valve thrombosis (PVT) is crucial due to higher mortality and morbidity rates. The study aim was to assess the value of fibrinogen in the diagnosis of PVT, an important and a common cause of prosthetic valve failure. METHODS: Between December 2007 and April 2012, 154 patients with PVT and 116 control subjects with a normally functioning prosthesis were enrolled in the study. PVT was diagnosed using transesophageal echocardiography, and fibrinogen levels were measured at presentation. The patients and controls had similar demographic features. RESULTS: NYHA functional class, ineffective anticoagulation, presence of symptoms and moderate to severe left atrial spontaneous echo contrast (LASEC) were significantly different between the groups. The fibrinogen level was significantly higher in patients with PVT compared to controls (393.46 +/- 127.87 versus 276.93 +/- 69.22 mg/dl, p < 0.001). Ineffective anticoagulation, the presence of symptoms, a poor NYHA functional class, the presence of moderate to severe LASEC and elevated fibrinogen levels were independent predictors of PVT on multivariate regression analysis (p < 0.001, odds ratio (OR) 38.811, 95% confidence interval (CI): 13.319-113.091; p < 0.001, OR 6.745, CI: 2.777-16.386; p = 0.031, OR 3.557, CI: 1.126-11.239; p = 0.026, OR 3.203, CI: 1.146-8.955, and p < 0.001, OR 1.011, CI: 1.007-1.016 respectively). CONCLUSION: Besides known indicators of PVT, including ineffective anticoagulation, the presence of LASEC and decreased NYHA functional capacity, elevated fibrinogen levels may be a valuable marker for the assessment of PVT.

Complete atrioventricular block associated with non-penetrating cardiac trauma in a 40-year-old man.

BACKGROUND: Myocardial contusion is a rare complication of blunt chest trauma. Transient conduction and rhythm problems, right ventricular dysfunction, or pulmonary embolism may occur after chest trauma, but these complications almost always occur early in the post-operative period. OBJECTIVES: The objective is to describe a case illustrating that trauma may induce high-grade atrioventricular block. CASE REPORT: We report the case of a patient who developed delayed onset of complete atrioventricular block after transient complete atrioventricular block and alternating bundle branch block secondary to blunt chest trauma. CONCLUSION: Even with an injury that does not seem to be caused by direct penetrating trauma to the heart, maybe every trauma patient needs an electrocardiographic evaluation. It is important to note that myocardial healing is a continuous process after trauma, and additional pathology may be revealed later in the course of healing from myocardial contusion.

Management of heparin-induced thrombocytopenia during thrombolytic therapy for prosthetic valve thrombosis.

BACKGROUND AND AIM OF THE STUDY: Heparin-induced thrombocytopenia (HIT) is a serious complication of heparin administration. As HIT may occur during the thrombolysis of prosthetic heart valve thrombosis (PVHT) due to the administration of heparin, this entity should be considered during and after sessions of this regimen. The study aim was to investigate the development, diagnosis, and management of HIT during thrombolytic therapy (TT) of PHVT. METHODS: A diagnosis of HIT was made on a clinical basis and laboratory confirmation based on a particle immunofiltration assay. Serial transthoracic echocardiography and two-dimensional transesophageal echocardiography were used to detect thrombus morphology and hemodynamic changes before and after TT sessions in 214 patients. RESULTS: Four patients (1.9%) who underwent TT for PHVT were diagnosed with HIT. The mean period of onset of HIT after heparin exposure was 8.7 +/- 3.9 days, while mean platelet levels before and after heparin infusion were 308,000/mm3 and 77,250/mm3, respectively. Fondaparinux was employed as bridging therapy in three patients. TT resulted in a successful outcome in two patients, while two other patients underwent surgery for increased valve gradients (due to progression of obstructive PHVT during TT in one case, and obstructive PHVT resulting in a cerebrovascular accident in the other case). CONCLUSION: Details are presented of the development of HIT during TT for PHVT, which resulted in an increased thrombus size immediately after successful TT. Fondaparinux may be considered as an effective bridging treatment in this regimen.