Abstract: There is a 1% - 4% incidence of cardiac disease in pregnancy, and rheumatic heart disease is the most common diagnosis. On the condition that medical treatment is inefficacious, an open heart surgery should be performed. Because of the changes in physiological functions, there is a major difference between pregnant patients and the general population in perioperative management of valve replacement. Now , the pregnancy is not an absolute contraindication for cardiopulmonary bypass, though the incidence of mortality and birth defects remains high. It is helpful in decreasing complications and increasing survival rate by improving themethods of cardiopulmonary bypass, postoperative monitoring, anticoagulation etc. In this article, the progress in t reatments of perioperative period of cardiac valve replacement during pregnancy is reviewed.
Recent clinical trials showed that dabigatran was superior to warfarin for stroke prevention in patients with nonvalvular atrial fibrillation, however whether it is suitable for the lifelong anticoagulation in patients after heart valve replacement, remains controversial. Many animal experiments showed that dabigatran group was better than heparin and warfarin in the prevention of thrombosis and bleeding complications after valve replacement. Randomized, phaseⅡstudy to evaluate the safety and pharmacokinetics of oral dabigatran etexilate in patients after heart valve replacement (RE-ALIGN) clinical trial showed that dabigatran wasn't as effective as warfarin in preventing thrombosis, but increases the risk of bleeding. And there are some case reports about thrombosis and bleeding complications after taking dabigatran. At present, the efficacy and safety of dabigatran applying in patients after heart valve replacement still needs further study.
ObjectiveTo investigate the hotspots and frontiers and to reveal research trends of cirrhosis with portal vein thrombosis (PVT) by visual analysis.MethodsWe explored the distributions, key citations and research trends of articles on cirrhosis with PVT published from 1991 to 2020 by citation analysis, co-word analysis, and burst detection by information visual software CiteSpace.ResultsThe quantity of articles on cirrhosis with PVT had been increasing over time. The management of PVT remained the hotspots, while the efficacy and prognosis of anticoagulation of PVT as well as the risk factors and underlying mechanisms of PVT had been frontiers in recent years.ConclusionsAnticoagulation and risk factors have been hotspots and frontiers in recent years.
ObjectiveTo investigate the early diagnosis and proper treatment of acute mesenteric venous thrombosis (AMVT). MethodsThe clinical data of 105 cases of AMVT treated from January 2000 to December 2013 were analyzed retrospectively. ResultsThe diagnostic accuracy of ultrasonography and abdominal contrast-enhanced CT was 67.6% (71/105), 88.0% (81/92) respectively. The accuracy rate of abdominal cavity puncture or abdominal drainage in the diagnosis of intestinal necrosis was 100% (38/38). All cases received anticoagulation and thrombolysis as soon as the definite diagnosis of AMVT were made. Twenty-five cases underwent emergency operation due to the bowel necrosis at the visiting time, Anticoagulation and thrombolysis were performed in 80 patients, of which 7 patients received surgical treatment because of ineffective anticoagulation and thrombolytic therapy. Thrombectomy was performed in 15 cases simultaneously. Surgical treatment of 32 cases, 30 cases were cured and 2 patients died of multiple organ failure or short bowel syndrome within 1 month after operation. Seventy-three cases were treated with anticoagulation therapy alone, 72 patients were cured and discharged, the effective rate was 90.0%, another 1 case died due to cerebral hemorrhage within 1 month after operation. ConclusionsEarly diagnosis of AMVT and bowel necrosis, timely and accurate anticoagulation and thrombolysis, and proper surgical intervention can often achieve satisfactory results.
ObjectiveTo investigate the influence of high activity of CYP2C9 (Cytochrome P450 proteins 2C9)and VKORC (Vitamin K epoxide reductase C)on warfarin anticoagulation of patients after heart valve replacement (HVR). MethodsFrom February 2010 to May 2013, 40 patients with high activity of CYP2C9 and VKORC underwent HVR in the Department of Cardiac Surgery, the First Affiliated Hospital of Zhengzhou University. There were 18 male and 22 female patients with their age of 40-51 (45.18±2.93)years. There were18 patients receiving mitral valve replacement (MVR), 14 patients receiving MVR and tricuspid valvuloplasty (TVP), and 8 patients receiving double valve replacement (DVR). Depen-ding on whether they received preoperative genetic polymorphism detection of CYP2C9 and VKORC1, all the patients were divided into 2 groups with 20 patients in each group. Patients in group A didn't receive preoperative genetic polymorphism detection of CYP2C9 and VKORC1, while patients in group B received preoperative genetic polymorphism detection of CYP2C9 and VKORC1. Postoperatively, periodic examination of international normalized ratio (INR)was performed to adjust warfarin dosage. Time to reach expected INR value and morbidity were collected. All the patients were followed up for 3-12 months after discharge. Monthly telephone follow-up was performed to record INR values, morbidity and general recovery. ResultsPostoperatively, in group A, 2 patients had cerebral infarction, 2 patients had popliteal artery throm-bosis, 1 patient had pulmonary embolism, and 1 patient had thrombosis in the annulus. Expected INR was achieved 15-20 days after warfarin treatment among the other 14 patients without thromboembolism. Three months after surgery, CYP2C9 and VKORC1 gene polymorphism was examined to find 17 patients with positive CYP2C9*1/*1 (*2CC/*3AA)and positive VKORC1-1639 GA, and 3 patients with positive CYP2C9*1/*1 (*2CC/*3AA)and positive VKORC1-1639 GG. In Group B, patients received aspirin (100 mg/d)and low molecular heparin (0.4 ml/d)in addition to warfarin since the second posto-perative day. Expected INR was achieved 5-9 days after warfarin treatment, and then aspirin and low molecular heparin were discontinued. During the 6 months follow-up period, no obvious thromboembolism was found, and only 1 patient had epistaxis who was cured with nasal tamponade. ConclusionPreoperative detection of genetic polymorphisms of CYP2C9 and VKORC1 can provide important guidance for warfarin anticoagulation after HVR.
Objective To explorer the application value of the inferior vena cava filter (IVCF) implantation in the prevention of recurrent pulmonary embolism (PE). Methods Clinical data of 265 inpatients with PE admitted from November 2014 to November 2016 were retrospectively analyzed. The patients were divided into an IVCF treatment group (55 cases) and an anticoagulant therapy group (210 cases) according to treatment measure. All patients were followed up for 3 months to 2 years through regular review. The one-year PE and deep vein thrombosis (DVT) recurrence rates, one-year mortality and two-year mortality were compared between two groups. Results The PE and DVT recurrence rates were 9.1% and 21.8% in the IVCF treatment group, and were 18.6% and 11.0% in the anticoagulant therapy group, respectively. The PE recurrence rate was lower and the DVT recurrence rate was higher in the IVCF treatment group compared with the anticoagulant therapy group, the differences were statistically significant (P<0.05). The one-year mortality (29.1% vs. 12.9%) and two-year mortality (34.5% vs. 14.8%) were significantly higher in the IVCF treatment group than those in the anticoagulant therapy group (P<0.05). Conclusions IVCF without anticoagulation can reduce incidence of pulmonary embolism caused by the lower extremity DVT, but will increase DVT recurrence rate. It may be an alternative option for prevention of PE in patients with contraindications to anticoagulant therapy or recurrent PE patients after regular anticoagulant therapy.
ObjectiveTo explore optimal intensity of oral anticoagulation for patients with prosthetic heart valves in Northeast China. MethodsA total of 856 patients in Northeast China who underwent prosthetic heart valve replacement in the Department of Cardiovascular Surgery,Second Hospital of Jilin University from January 2005 to June 2013 were enrolled in this study. There were 406 male and 450 female patients with their age of 45.2±13.3 years. All the patients received low-intensity oral anticoagulation [international normalized ratio (INR) 1.5-2.2,aortic valve replacement (AVR):1.5-1.8,mitral valve replacement (MVR):1.8-2.2]. Patients were followed up after discharge,and the incidence of anticoagulation-related complications was summarized. ResultsThese patients were followed up for 1-78 (18.3±12.2) months,and the follow-up rate was 75.4%. Twelve patients (1.86%) had thromboembolic complications and 10 patients (1.55%) had hemorrhagic complications. Average warfarin dosage was 3.4±0.8 mg/day,and average INR was 1.94±0.54 during follow-up. ConclusionFor patients with prosthetic heart valves in Northeast China,low-intensity anticoagulation can produce satisfactory clinical outcomes to reduce the incidence of anticoagulation-related thromboembolic or hemorrhagic complications.
In recent years, the field of transcatheter heart valve interventional therapy has developed rapidly. Valvular thrombosis is a rare postoperative complication, which can affect valvular function early or lead to clinical embolic events, and is gradually being valued by surgeons. The clinical manifestations of thrombosis after different types of interventional valve replacement are different. Although anticoagulant therapy is believed to be effective for valve thrombosis, the selection of anticoagulant drugs and the duration of anticoagulation are still controversial. This article reviews the definition, clinical features, prevention and treatment of valve thrombosis after several types of transcatheter heart valve replacement, mainly related to transcatheter aortic valve replacement and transcatheter mitral valve replacement, and aims to provide a reference for the diagnosis and treatment of valve thrombosis after transcatheter heart valve replacement.
Objective To evaluate the safety and efficacy of simplified regional citrate anticoagulation in sustained low efficiency dialysis (SLED). Methods We prospectively analyzed the patients with acute kidney injury or end stage renal disease in Department of Nephrology, West China Hospital of Sichuan University from March 2017 to May 2018. All the patients received SLED treatment by Fresenius 4008s ARrTplus through either femoral or internal jugular venous catheter, with each session of SLED treatment lasting for 8 to 10 hours. We pumped in 4% tri-sodium citrate solution through the arterial line at 300 mL/h and citrate infusion was stopped 15 minutes before ending of treatment. The blood flow was 150 mL/min while the calcium-containing dialysate (Ca 1.25 mmol/L) was delivered at 200 mL/min. We recorded peripheral, post filter ionized calcium level, and systemic citrate concentration at 0, 2 and 6 hours, respectively. Results Sixty-two patients underwent 185 sessions of SLED. Three sessions of two patients were discontinued for filter clotting, while the rest 182 SLED sessions (98.4%) were all successfully completed. The systemic citrate concentrations at 2 and 6 hours after beginning were of no statistical difference [(0.82±0.31) vs. (0.86±0.31) mmol/L, P=0.21]. The 0-, 2-, 6-hour peripheral blood ionized calcium levels were (1.12±0.21), (1.09±0.12), and (1.11±0.09) mmol/L, respectively, with no significant difference (P>0.05), and post filter ionized calcium at 2 and 6 hours after beginning were recorded as (0.35±0.06) and (0.31±0.04) mmol/L. The trans-membrane pressure at 2 and 6 hours after beginning were (106.2±13.8) and (105.3±22.4) mm Hg (1 mm Hg=0.133 kPa), with no significant difference (P=0.42). At 6 hours after beginning, prothrombin time and activated partial thrombin time were identified to be similar to those before SLED. During SLED treatments, in 4 sessions (2.2%), patients suffered mild metabolic alkalosis, but all of them recovered 4 hours later by themselves. No bleeding complication, thrombocytopenia, cardiac arrhythmia, hypernatremia, metabolic alkalosis or hypotension was observed. Conclusion SLED under simplified citrate anticoagulation is safe and effective by using calcium containing dialysate, which achieves satisfying regional anticoagulation effect without interfering systemic clotting function, and provides a new option of anticoagulation for SLED.
Objective To explore the efficacy and safety of different Wafarin anticoagulation intensities in preventing thromboembolism in patients with paroxysmal non-valvular atrial fibrillation (PAF). Methods The patients with PAF were enrolled and divided into four groups. The patients were treated by different Wafarin anticoagulation intensities. The values of the control of international normalized ratio (INR) were 1.3-1.6 in Group 1, 1.7-2.0 in Group 2, 2.0-2.5 in Group 3, and 2.6-3.0 in Group 4. Main destination events, secondary destination events, main bleeding events, secondary bleeding events, main events (main destination events + main bleeding events), secondary events (secondary destination events + secondary bleeding events), and total events (main events + secondary events) were observed and compared in the four groups, respectively. Relevance between events of thromboembolism as well as bleeding and INR was analyzed. Results A total of 868 patients with moderate-high risk PAF were enrolled, and 826 patients (167 cases in Group 1, 220 cases in Group 2, 215 cases in Group 3, and 224 in Group 4) were included in final analysis. The follow-up results showed that the increase of INR led to a reduction in the destination events (there were significant differences between Group 1 and Group 2, 3, and 4 with Plt;0.05), but the bleeding events tended to rise. In terms of the incidence of main events, secondary events and total events, Group 1 was higher than Group 2, 3, and 4 with significant differences (Plt;0.05), except that the main event incidence of Group 1 was not significantly different from that of Group 4 (Pgt;0.05). Conclusion For Chinese patients with PAF, anticoagulation intensities of Wafarin with INR 1.7-2.5 can reduce the destination events with no rise in bleeding events. The anticoagulation intensities within this extent are safe and effective