Predictors of Systemic Embolism in Patients with Mitral Stenosis: A Prospective Study

Chiang, Cheng-Wen

doi:10.7326/0003-4819-128-11-199806010-00001

Cited by 140 publications

(55 citation statements)

References 29 publications

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“…The risk factors previously shown to be associated with left atrial thrombus formation (3) were absent in our patient. Severe aortic insufficiency has been implicated as an associated with a risk for left atrial thrombi in patients with sinus rhythm, due to associated left atrial stasis (3,4), with a RR for systemic embolization of 22.4 (95% CI 2.72 to 184.8) in one study (4); however, all patients in this report had at least mild mitral valve stenosis. Our patient developed acute, severe aortic insufficiency from endocarditis, which caused an acute increase in left ventricular diastolic pressure.…”

Section: Discussioncontrasting

confidence: 43%

Left atrial appendage thrombus in a patient in sinus rhythm with endocarditis and a severe aortic valve insufficiency

Shanks¹,

Čujec²,

Choy³

2008

Canadian Journal of Cardiology

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A 66-year-old woman with recently diagnosed monoclonal gammapathy of uncertain significance and no previous cardiac history presented to a tertiary care centre with confusion, aphasia, incontinence and right-sided weakness.One month earlier, she had been admitted to the intensive care unit with a diagnosis of sepsis. At the time, blood cultures had grown Hemophilus influenzae in one of two vials. She received a two-week course of intravenous antibiotics (ampicillin, metronidazole and ciprofloxacin). The source of the bacteremia was never identified. She was on no medications before her current admission.On this presentation, her vital signs included blood pressure of 115/54 mmHg, heart rate of 114 beats/min and O 2 saturation on room air of 99%. Her initial physical examination revealed expressive aphasia, right facial droop and right arm weakness. Her lungs were clear to auscultation. On a precordial examination, her first and second heart sounds were normal, and there was a systolic murmur heard at the left lower sternal border. She had no signs of peripheral edema.Her initial bloodwork showed a white blood cell count of 6.4×10 9 /L (normal value 4×10 9 /L to 11×10 9 /L), hemoglobin 92 g/L (normal value 120 g/L to 160 g/L), mean corpuscular volume 87 L (normal value 80 L to 100 L), platelets 258×10 9 /L (normal value 140×10 9 /L to 450×10 9 /L), international normalized ratio 1.2, partial thromboplastin time 29 s (normal value 24 s to 35 s), urea 11.4 mmol/L (normal value 2.5 mmol/L to 8.0 mmol/L), creatinine 85 μmol/L (normal value 40 μmol/L to 115 μmol/L), magnesium 0.82 mmol/L (normal value 0.7 mmol/L to 1.0 mmol/L) and troponin I 0.61 μg/L (normal value less than 0.15 μg/L).An electrocardiogram showed sinus tachycardia with nonspecific T wave changes in the lateral leads ( Figure 1).Computed tomography of the head confirmed a left middle cerebral artery territory stroke involving primarily the left insular cortex and a portion of the left frontal lobe.The patient was admitted to neurology. She was started on acetylsalicylic acid 325 mg daily, and was given intravenous fluids for dehydration.Within 12 h of presentation, she suddenly developed clinical and radiographic pulmonary edema. She was found to have a loud decrescendo diastolic murmur best heard at the left lower sternal border. Her troponin I level increased to a peak of 0.71 μg/L. Her clinical findings were highly suspicious for aortic valve endocarditis with severe aortic insufficiency and associated congestive heart failure. Due to her clinical deterioration, she was transferred to a cardiology service.Subsequent investigations included a helical computed tomography scan of the lungs, which revealed a filling defect in an anterior segmental branch of the pulmonary artery in the left upper lobe, suspected to be a pulmonary embolus. In addition, a round globular filling defect measuring 1.3 cm × 1.0 cm, which was suspicious for a clot, was identified in the left atrial appendage (LAA). No deep venous thromboses in the legs were seen. The patient wa...

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Section: Discussioncontrasting

confidence: 43%

Left atrial appendage thrombus in a patient in sinus rhythm with endocarditis and a severe aortic valve insufficiency

Shanks¹,

Čujec²,

Choy³

2008

Canadian Journal of Cardiology

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“…It is interesting to note that in patients with rheumatic atrial fibrillation, valvular regurgitations are not predictors of ensuing embolization. 15) Since 51 out of 65 (78%) patients with nonrheumatic valvular atrial fibrillation in our study had moderate to severe mitral regurgitation, we speculate that the left atria in this group of patients had good reverse blood flow during the systolic phase, thereby minimizing the thrombus formation and incidence of stroke. Nevertheless, the 24.6% prevalence of stroke in this group of patients warrants anticoagulation therapy.…”

Section: Discussionmentioning

confidence: 99%

“…However, our atrial fibrillation patients with nonrheumatic valvular and nonvalvular diseases certainly received anticoagulants less often than their counterparts in western countries where 34 -98% of patients with nonvalvular atrial fibrillation underwent anticoagulation therapy. [11][12][13][14] A recent report by Chiang, et al 15) indicated that only 60% of atrial fibrillation patients with mitral stenosis in northern Taiwan received anticoagulants. In contrast, only about 10-20% of patients with atrial fibrillation in mainland China received anticoagulants.…”

Section: Discussionmentioning

confidence: 99%

Underutilization of Anticoagulation Therapy in Chronic Atrial Fibrillation.

et al. 2001

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SUMMARYAtrial fibrillation, the most common chronic arrhythmia, results in an increased risk of stroke. Anticoagulation therapy can reduce this risk, but appears to be underused. The objective of this study was to examine the use of warfarin and prevalence of stroke in patients with rheumatic, nonrheumatic valvular and nonvalvular atrial fibrillation.Between January 1993 and December 1998, 457 chronic atrial fibrillation patients with continuous follow-up in our hospital were identified as having rheumatic heart disease (n = 114); nonrheumatic valvular disease (n = 65); or nonvalvular disease (n = 278). Warfarin was used less often in patients with nonrheumatic valvular (16.7%) and nonvalvular diseases (20.1%) than in those with rheumatic heart disease (81.6%, p < 0.001). In contrast, the prevalence of stroke among patients with nonvalvular disease was 40.3% which was similar to the 33.3% found in patients with rheumatic heart disease but significantly higher than the 24.6% found in patients with nonrheumatic valvular disease (p < 0.05). A history of stroke did not alter the trend of use of warfarin among the three groups of patients. Only 20.6% of patients on warfarin received monthly monitoring of prothrombin time.In conclusion, the anticoagulation therapy in our patients with chronic atrial fibrillation, regardless of their associated valvular diseases, is significantly underutilized. This underuse could account for a high prevalence of stroke. This risk of stroke, however, is less in patients with nonrheumatic valvular disease than in those with nonvalvular atrial fibrillation. (Jpn Heart J 2001; 42: 55-65)

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“…Although risk factors like increasing age, LA thrombus, spontaneous echo contrast and an enlarged LA have been identified, it remains unclear whether therapy is effective in these subgroups. (17) As the majority of RHD patients are in sinus rhythm and are potentially at risk, future trials in this population group are clearly warranted.…”

Section: Primary Preventionmentioning

confidence: 99%

“…A study by Chiang showed that thromboembolism occurred in 9% of patients with sinus rhythm compared to 13% of patients in AF. (17) Risk factors for thromboembolism in this study included increasing age, presence of LA thrombus, decreasing mitral valve area and significant aortic regurgitation. Other echocardiographic predictors of thromboemboli include the presence of spontaneous echo contrast and a reduced LAA emptying flow velocity.…”

Section: Risk Of Thromboembolism In Sinus Rhythmmentioning

confidence: 99%

Management of rheumatic atrial fibrillation

Chin

2017

SAHJ

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Predictors of Systemic Embolism in Patients with Mitral Stenosis: A Prospective Study

Cited by 140 publications

References 29 publications

Left atrial appendage thrombus in a patient in sinus rhythm with endocarditis and a severe aortic valve insufficiency

Left atrial appendage thrombus in a patient in sinus rhythm with endocarditis and a severe aortic valve insufficiency

Underutilization of Anticoagulation Therapy in Chronic Atrial Fibrillation.

Management of rheumatic atrial fibrillation

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