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).

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P regnancy is associated with increased risk of thrombosis among women with mechanical prosthetic heart valves. 1 The largest literature review of women with a prosthetic heart valve who were on anticoagulation during pregnancy reported that thromboembolic complications occurred in 3.9% of women taking only warfarin, 9.2% of women who received unfractionated heparin in the first trimester followed by warfarin, and one fourth of women treated with unfractionated heparin throughout their pregnancy. Maternal death was observed in these groups in 2%, 4%, and 15%, respectively, and was usually related to prosthetic valve thrombosis (PVT).2 Similarly, 15% of pregnant women developed PVT while using low-molecular-weight heparin. The guidelines suggest optimizing anticoagulation in noncritically ill patients with recent subtherapeutic anticoagulation. Surgery is recommended when anticoagulation fails, for critically ill patients with obstructive thrombosis, or for patients with large (≥10 mm) nonobstructive PVT complicated by embolism. Fibrinolysis is recommended for either critically ill patients when 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, 25-100 mg). 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.

Fragmentation of QRS complexes on ECG is associated with intraventricular systolic dyssynchrony and subendocardial fibrosis in NDCM patients with a narrow QRS interval and sinus rhythm.

Background: Medical literature searches provide critical information for clinicians. However, the best strategy for identifying relevant high-quality literature is unknown. Objectives: We compared search results using PubMed and Google Scholar on four clinical questions and analysed these results with respect to article relevance and quality. Methods: Abstracts from the first 20 citations for each search were classified into three relevance categories. We used the weighted kappa statistic to analyse reviewer agreement and nonparametric rank tests to compare the number of citations for each article and the corresponding journals' impact factors. Results: Reviewers ranked 67.6% of PubMed articles and 80% of Google Scholar articles as at least possibly relevant (P = 0.116) with high agreement (all kappa P-values < 0.01). Google Scholar articles had a higher median number of citations (34 vs. 1.5, P < 0.0001) and came from higher impact factor journals (5.17 vs. 3.55, P = 0.036). Conclusions: PubMed searches and Google Scholar searches often identify different articles. In this study, Google Scholar articles were more likely to be classified as relevant, had higher numbers of citations and were published in higher impact factor journals. The identification of frequently cited articles using Google Scholar for searches probably has value for initial literature searches.

Although large-scale heart failure (HF) studies in Hispanic Americans are lacking, some compelling data indicate that they are a particularly vulnerable population and underscore the need for further research. Hispanics comprise the largest and fastest-growing ethnic group in the U.S., in whom the impact of this burgeoning public health problem may be magnified. Current data show that Hispanics with HF are more likely to be younger and underinsured than non-Hispanic whites. They have higher rates of readmissions but have lower in-hospital and short-term mortality rates. Epidemiologic studies demonstrate that Hispanics have excessive rates of diabetes, obesity, dyslipidemia, and metabolic syndrome. Although hypertension and ischemic heart disease are established risk factors in this ethnic group, it may be considered that insulin resistance plays a significant role in the pathogenesis of HF in Hispanics, accounting for their inordinate cardiometabolic risk burden and the growing evidence of novel metabolic risk factors for HF. Hispanics encounter multiple barriers to health care influenced by socioeconomic, linguistic, and cultural factors that, in turn, have an adverse impact on disease prognosis. Recognition of predominant risk factors and health care disparities in this population is crucial to tailoring appropriate management strategies. This review summarizes epidemiologic and clinical data on Hispanics with HF, details risk factors and health care impediments, and presents an agenda for future investigation.

Patients with LVADs have frequent GI bleeds, especially from arteriovenous malformations, which can occur throughout the GI tract. Most diagnostic and therapeutic interventions can be used safely in these patients. The pathogenesis of the GI bleeding in these patients may involve the use of anticoagulant medications, the formation of arteriovenous malformations, loss of von Willebrand factor activity, and mucosal ischemia.

Patients with anaphylaxis can present with acute coronary syndrome secondary to either vasospasm or acute plaque rupture and thrombus formation. The typical patient is a man with cutaneous, respiratory and cardiac symptoms and with ST segment elevation in inferior leads. The pathogenesis involves histamine and other mast cell mediators. Management should include therapy for anaphylaxis and vasospasmolytics. The use of epinephrine requires caution.