Süleyman Karakoyun

Comparison of Different TEE-Guided Thrombolytic Regimens for Prosthetic Valve Thrombosis: The TROIA Trial

OBJECTIVES The aim of this prospective study was to identify the most effective and safest regimen among different thrombolytic treatment strategies. BACKGROUND The best treatment strategies for prosthetic valve thrombosis have been controversial. METHODS Transesophageal echocardiography-guided thrombolytic treatment was administered to 182 consecutive patients with prosthetic valve thrombosis in 220 different episodes (156 women; mean age, 43.2 ± 13.06 years) between 1993 and 2009 at a single center. These regimens chronologically included rapid (Group I), slow (Group II) streptokinase, high-dose (100 mg) tissue plasminogen activator (t-PA) (Group III), a half-dose (50 mg) and slow infusion (6 h) of t-PA without bolus (Group IV), and a low dose (25 mg) and slow infusion (6 h) of t-PA without bolus (Group V). The endpoints were thrombolytic success, in-hospital mortality, and nonfatal complication rates. RESULTS The overall success rate in the whole series was 83.2%; it did not differ significantly among Groups I through V (68.8%, 85.4%, 75%, 81.5%, and 85.5%, respectively; p = 0.46). The overall complication rate in the whole series was 18.6%. Although the overall complication rate was similar among Groups I through IV (37.5%, 24.4 %, 33.3%, and 29.6%, respectively; p > 0.05 for each comparison), it was significantly lower in Group V (10.5%, p < 0.05 for each). The combined rates of mortality and nonfatal major complications were also lower in Group V than in the other groups, with all differences significant except for comparison of Groups IV and V. By multivariate analysis, the predictors of combined mortality plus nonfatal major complications were any thrombolytic therapy regimen other than Group V (odds ratios for Groups I through IV: 8.2, 3.8, 8.1, and 4.1, respectively; p < 0.05 for each) and a history of stroke/transient ischemic attack (odds ratio: 3.5, p = 0.011). In addition, there was no mortality in Group V. CONCLUSIONS Low-dose slow infusion of t-PA repeated as needed without a bolus provides effective and safe thrombolysis in patients with prosthetic valve thrombosis. (Comparison of Different TRansesophageal Echocardiography Guided thrOmbolytic Regimens for prosthetIc vAlve Thrombosis; NCT01451320).

Thrombolytic Therapy for the Treatment of Prosthetic Heart Valve Thrombosis in Pregnancy With Low-Dose, Slow Infusion of Tissue-Type Plasminogen Activator

Background— Prosthetic valve thrombosis during pregnancy is life-threatening for mother and fetus, and the treatment of this complication is unclear. Cardiac surgery in pregnancy is associated with very high maternal and fetal mortality and morbidity. Thrombolytic therapy has rarely been used in these patients. The aim of this study is to evaluate the safety and efficacy of low-dose (25 mg), slow infusion (6 hours) of tissue-type plasminogen activator for the treatment of prosthetic valve thrombosis in pregnant women. Methods and Results— Between 2004 and 2012, tissue-type plasminogen activator was administered to 24 consecutive women in 25 pregnancies with 28 prosthetic valve thrombosis episodes (obstructive, n=15; nonobstructive, n=13). Mean age of the patients was 29±6 years. Thrombolytic therapy sessions were performed under transesophageal echocardiography guidance. The mean dose of tissue-type plasminogen activator used was 48.7±29.5 mg (range, 25–100mg). All episodes resulted in complete thrombus lysis after thrombolytic therapy. One patient had placental hemorrhage with preterm live birth at the 30th week, and 1 patient had minor bleeding. Conclusions— Low-dose, slow infusion of tissue-type plasminogen activator with repeated doses as needed is an effective therapy with an excellent thrombolytic success rate for the treatment of prosthetic valve thrombosis in pregnant women. This protocol also seems to be safer than cardiac surgery or any alternative medical strategies published to date. Thrombolytic therapy should be considered first-line therapy in pregnant patients with prosthetic valve thrombosis.

Thrombolytic Therapy for the Treatment of Prosthetic Heart Valve Thrombosis in Pregnancy with Low Dose, Slow Infusion of t-PA

Background— Prosthetic valve thrombosis during pregnancy is life-threatening for mother and fetus, and the treatment of this complication is unclear. Cardiac surgery in pregnancy is associated with very high maternal and fetal mortality and morbidity. Thrombolytic therapy has rarely been used in these patients. The aim of this study is to evaluate the safety and efficacy of low-dose (25 mg), slow infusion (6 hours) of tissue-type plasminogen activator for the treatment of prosthetic valve thrombosis in pregnant women. Methods and Results— Between 2004 and 2012, tissue-type plasminogen activator was administered to 24 consecutive women in 25 pregnancies with 28 prosthetic valve thrombosis episodes (obstructive, n=15; nonobstructive, n=13). Mean age of the patients was 29±6 years. Thrombolytic therapy sessions were performed under transesophageal echocardiography guidance. The mean dose of tissue-type plasminogen activator used was 48.7±29.5 mg (range, 25–100mg). All episodes resulted in complete thrombus lysis after thrombolytic therapy. One patient had placental hemorrhage with preterm live birth at the 30th week, and 1 patient had minor bleeding. Conclusions— Low-dose, slow infusion of tissue-type plasminogen activator with repeated doses as needed is an effective therapy with an excellent thrombolytic success rate for the treatment of prosthetic valve thrombosis in pregnant women. This protocol also seems to be safer than cardiac surgery or any alternative medical strategies published to date. Thrombolytic therapy should be considered first-line therapy in pregnant patients with prosthetic valve thrombosis.

Ultraslow thrombolytic therapy: A novel strategy in the management of PROsthetic MEchanical valve Thrombosis and the prEdictors of outcomE: The Ultra-slow PROMETEE trial

BACKGROUND Low-dose (25mg), slow infusion (6hours) of tissue-type plasminogen activator (t-PA) with repetition as needed has been shown to provide effective and safer thrombolysis in patients with prosthetic valve thrombosis (PVT). Further prolonging the infusion time may be rational with regard to reducing complication rates without reducing success rates. We aimed to investigate the efficacy and safety of ultraslow (25hours) infusion of low-dose (25mg) alteplase (t-PA) for PVT. METHODS AND RESULTS Transesophageal echocardiography-guided thrombolytic therapy (TT) was administered to 114 patients with PVT in 120 different episodes between 2009 and 2013 in a single center. Prosthetic valve thrombosis was obstructive in 77 (64.2%) and nonobstructive in 43 (35.8%) episodes. Ultraslow infusion (25hours) of low-dose (25mg) t-PA, as the TT regimen, was used in all patients admitted with PVT. The end points were thrombolytic success, mortality, and complication rates. The overall success rate of TT was 90% (95% CI 0.85-0.95). The univariate predictors of an unsuccessful result were higher New York Heart Association (NYHA) class, thrombus cross-sectional area, duration of suboptimal anticoagulation, lower baseline valve area, and presence of atrial fibrillation. The NYHA class was the only independent predictor of TT failure by multiple variable analysis. The overall complication rate was 6.7% (3.3% nonfatal major, 2.5% minor, and 0.8% death). The predictors of complications were presence of atrial fibrillation, higher NYHA class, and thrombus area. CONCLUSION Ultraslow (25hours) infusion of low-dose (25mg) t-PA without bolus appears to be associated with quite low nonfatal complications and mortality for PVT patients without loss of effectiveness, except for those with NYHA class IV.

Sixty-Four–Section Cardiac Computed Tomography in Mechanical Prosthetic Heart Valve Dysfunction Thrombus or Pannus

Background—Distinguishing pannus and thrombus in patients with prosthetic valve dysfunction is essential for the selection of proper treatment. We have investigated the utility of 64-slice multidetector computed tomography (MDCT) in distinguishing between pannus and thrombus, the latter amenable to thrombolysis. Methods and Results—Sixty-two (23 men, mean age 44±14 years) patients with suspected mechanical prosthetic valve dysfunction assessed by transesophageal echocardiography were included in this prospective observational trial. Subsequently, MDCT was performed before any treatment was started. Periprosthetic masses were detected by MDCT in 46 patients, and their attenuation values were measured as Hounsfield Units (HU). Patients underwent thrombolysis unless contraindicated, and those with a contraindication or failed thrombolysis underwent surgery. A mass which was completely lysed or surgically detected as a clot was classified as thrombus, whereas a mass which was surgically detected as tissue overgrowth was classified as pannus. A definitive diagnosis could be achieved in 37 patients with 39 MDCT masses (22 thrombus and 17 pannus). The mean attenuation value of 22 thrombotic masses was significantly lower than that in 17 pannus (87±59 versus 322±122; P<0.001). Area under the receiver operating characteristic curve was 0.96 (95% confidence interval: 0.91–0.99; P<0.001), and a cutoff point of HU≥145 provided high sensitivity (87.5%) and specificity (95.5%) in discriminating pannus from thrombus. Complete lysis was more common for masses with HU<90 compared with those with HU 90 to 145 (100% versus 42.1%; P=0.007). Conclusions—Sixty-four slice MDCT is helpful in identifying masses amenable to thrombolysis in patients with prosthetic valve dysfunction. A high (HU≥145) attenuation suggests pannus overgrowth, whereas a lower value is associated with thrombus formation. A higher attenuation (HU>90) is associated with reduced lysis rates.

Time-to-reperfusion in STEMI undergoing interhospital transfer using smartphone and WhatsApp messenger

OBJECTIVE The objective of this study is to assess the efficacy of WhatsApp application as a communication method among the emergency physician (EP) in a rural hospital without percutaneous coronary intervention (PCI) capability and the interventional cardiologist at a tertiary PCI center. BACKGROUND Current guidelines recommend that patients with ST-segment elevation myocardial infarction (STEMI) receive primary PCI within 90 minutes. This door-to-balloon (D2B) time has been difficult to achieve in rural STEMI. METHODS AND RESULTS We evaluated 108 patients with STEMI in a rural hospital with emergency department but without PCI capability to determine the impact of WhatsApp triage and activation of the cardiac catheterization laboratory on D2B time. The images were obtained from cases of suspected STEMI using the smartphones by the EP and were sent to the interventional cardiologist via the WhatsApp application (group 1, n=53). The control group included concurrently treated patients with STEMI during the same period but not receiving triage (group 2, n=55). The D2B time was significantly shorter in the intervention group (109±31 vs 130±46 minutes, P<.001) with significant reduction in false STEMI rate as well. CONCLUSION This study demonstrates that use of WhatsApp triage with activation of the cardiac catheterization laboratory was associated with shorter D2B time and results in a greater proportion of patients achieving guideline recommendations. The method is cheap, quick, and easy to operate.

The Incremental Value of RT Three-Dimensional TEE in the Evaluation of Prosthetic Mitral Valve Ring Thrombosis Complicated with Thromboembolism

Purpose: Although nonobstructive prosthetic valve thrombosis (PVT) does not develop hemodynamic compromise, it carries potential risk for thromboembolism. Real time three‐dimensional transesophageal echocardiography (RT‐3DTEE), has emerged as a complementary tool in depicting “en face” views of prosthesis compared with two‐dimensional transesophageal echocardiography (2DTEE). We aimed to evaluate the utility of RT‐3DTEE in assessment of mitral ring‐located thrombosis. Method: We present 3 cases of mechanical mitral valve thrombosis complicated by thromboembolism, who were all examined and followed‐up by 2D transthoracic echocardiography (TTE), 2DTEE, and RT‐3DTEE. Result: The consequencies of thromboembolism in the patients were coronary embolism, transient ischemic attack, and ischemic stroke, respectively. They were all inadequately anticoagulated at the time of admission. 2DTTE and TEE examination was unsatisfactory; RT‐3DTEE depicted nonobstructive mitral ring thrombosis in each of the patients. The patients were followed up under effective anticoagulation and antiplatelet therapy. RT‐3DTEE was able to demonstrate the evolution of thrombus size in each of the patients. Conclusion: Nonobstructive ring‐located PVT which poses risk for thromboembolism, may be diagnosed with certainty and imaged with clarity utilizing RT‐3DTEE.

Usefulness of Novel Hematologic Inflammatory Parameters to Predict Prosthetic Mitral Valve Thrombosis

Prosthetic valve thrombosis (PVT) is a life-threatening complication. Neutrophil/lymphocyte ratio (NLR) and platelet/lymphocyte ratio (PLR) have been studied as inflammatory biomarkers in atherosclerosis, but data regarding valvular disease are lacking. The study population included patients with mitral PVT (n = 152) versus control subjects (n = 164) with functional mitral prosthesis. Transesophageal echocardiography was performed to diagnose PVT. NLR and PLR were calculated using complete blood count. C-reactive protein (CRP) levels were also analyzed. Neutrophil and platelet levels did not differ between the groups (4.9 ± 2.0 vs 4.7 ± 1.5, p = 0.84 and 254.8 ± 89.7 vs 241.5 ± 62.8 p = 0.36, respectively), but lymphocyte levels were significantly lower in patients with PVT than the controls (1.8 ± 0.7 vs 2.2 ± 0.6, p <0.001). NLR, PLR, and CRP levels were significantly higher in patients with PVT than in controls (3.2 ± 2.1 vs 2.2 ± 0.8, p <0.001; 163 ± 77.5 vs 114.9 ± 37.3, p <0.001; and 1.97 ± 3.02 vs 1.02 ± 1.22, p = 0.01, respectively). A positive correlation was observed between NLR and PLR (r = 528, p <0.001). NLR level of >2.23, measured on admission, yielded an area under the curve value of 0.659 (95% confidence interval 0.582 to 0.736, sensitivity 66%, specificity 60%, p <0.001) and PLR level of >117.78 yielded an area under the curve value of 0.707 (95% confidence interval 0.636 to 0.777, sensitivity 70%, specificity 58%, p <0.001). Multivariate analysis showed that increased PLR and inadequate anticoagulation were independent predictors of thrombosis in patients with PVT. In conclusion, patients with PVT had increased NLR, PLR, and CRP levels compared with subjects with normofunctional prosthesis, and increased PLR was an independent predictor of mitral PVT.

A case series of prosthetic heart valve thrombosis-derived coronary embolism.

Coronary thromboembolism is a rare cause of acute coronary syndromes (ACS). The information regarding ACS in patients with prosthetic heart valves is scarce and based mainly on case reports. Although plaque rupture is the most common cause of acute myocardial infarction, coronary embolism (CE) is not a rare cause of acute myocardial infarction. There is no consensus regarding the treatment in such a situation. We present three cases of prosthetic valve thrombosis complicated with CE causing non-ST elevation ACS, who were successfully treated with thrombolytic therapy (TT). We administered low-dose (25 mg), slow-infusion (6 hours) tissue plasminogen activator (t-PA), which was shown to be safe and effective in our group in a large study. The patients benefited from TT with respect to the coronary flow, as shown by the lysis of thrombi in all three patients on coronary angiogram.

Neutrophil–lymphocyte ratio may predict in-hospital mortality in patients with acute type A aortic dissection

IntroductionInflammation has been reported to be associated with aortic dissection (AD), from the development to the prognosis of AD. In this study we aimed to find the role of the neutrophil-lymphocyte ratio (NLR) in the prediction of clinical events in patients with acute AD type A.Patients and methodsThe study comprised 37 patients who were hospitalized at our center between 2009 and 2013 with the diagnosis of acute AD type A.ResultsThe mean NLR was significantly higher in patients with pericardial effusion than those without effusion (15.6 ± 11.4 vs. 7.5 ± 4.8, p = 0.005). An NLR value > 8.51 yielded an area under the curve (AUC) value of 0.829 [95 % confidence interval (CI) 0.674–0.984, p = 0.004], which demonstrated a sensitivity of 77 % and specificity of 74 % for the prediction of mortality.ConclusionsThe novel inflammatory marker NLR could be used to predict pericardial effusion and in-hospital mortality in patients with acute AD type A.ZusammenfassungEinleitungZum Zusammenhang von Inflammation und Aortendissektion (AD) ist publiziert worden, von ihrer Entwicklung einer AD bis zu ihrer Prognose. Ziel der Studie war es, die Rolle des Verhältnisses von Neutrophilen zu Lymphozyten („neutrophil/lymphocyte ratio“, NLR) in der Prädiktion von klinischen Ereignissen bei Patienten mit akuter AD vom Typ A zu eruieren.MethodenDie Studienpopulation bestand aus 37 Patienten, die zwischen 2009 und 2013 mit der Diagnose akute AD Typ A in unsere stationäre Behandlung aufgenommen worden waren.ErgebnisseBei Patienten mit Pleuraerguss war die NLR signifikant höher als bei Patienten ohne Erguss (15,6 ± 11,4 vs. 7,5 ± 4,8, p = 0,005). Der NLR-Wert > 8,51 ergab einen AUC („area under the curve“)-Wert von 0,829 (95 %-KI 0,674–0,984; p = 0,004), entsprechend einer Sensitivität von 77 % und einer Spezifität von 74 % für die Prädiktion der Mortalität.FazitDer neue Inflammationsmarker NLR ermöglicht bei akuter AD vom Typ A eine Prädiktion von Perikarderguss und stationärer Mortalität.