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      Misconceptions, diagnostic challenges and treatment opportunities in bioprosthetic valve thrombosis: lessons from a case series

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          Abstract

          Bioprosthetic valve thrombosis (BPVT) is a rare but potentially life-threatening complication. Current guidelines favour surgery or thrombolysis as initial treatment. We set forth to characterize timing, diagnostic criteria and treatment strategies in BPVT.

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          Most cited references12

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          2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.

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            A comparison of outcomes in men 11 years after heart-valve replacement with a mechanical valve or bioprosthesis. Veterans Affairs Cooperative Study on Valvular Heart Disease.

            Mechanical heart valves are durable but thrombogenic, and their use requires that the patient receive anticoagulants. In contrast, bioprosthetic valves are less thrombogenic, but they have limited durability because of tissue deterioration. To compare the outcomes of patients who receive these two types of valves, we randomly assigned 575 men scheduled to undergo aortic-valve or mitral-valve replacement to receive either a mechanical or a bioprosthetic valve. The primary end points were death from any cause and any valve-related complication. During an average follow-up of 11 years, there was no difference between the two groups in the probability of death from any cause (11-year probability for mechanical valves, 0.57; for bioprostheses, 0.62; P = 0.57) or in the probability of any valve-related complication (0.65 and 0.69, respectively; P = 0.39). There was a much higher rate of structural valve failure among patients who received bioprosthetic valves (11-year probability, 0.15 for the aortic valves and 0.36 for the mitral valves) than among those who received mechanical valves (no valve failures; P < 0.001). However, this difference was offset by a higher rate of bleeding complications among patients with mechanical valves than among those with bioprosthetic valves (11-year probability, 0.42 and 0.26, respectively; P < 0.001) and by a greater frequency of peri-prosthetic valvular regurgitation among patients with mechanical mitral valves than among those with mitral bioprostheses (11-year probability, 0.17 and 0.09, respectively; P = 0.05). After 11 years, the rates of survival and freedom from all valve-related complications were similar for patients who received mechanical heart valves and those who received bioprosthetic heart valves. However, structural failure was observed only with the bioprosthetic valves, whereas bleeding complications were more frequent among patients who received mechanical valves.
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              Derivation and validation of automated electronic search strategies to identify pertinent risk factors for postoperative acute lung injury.

              To develop and validate time-efficient automated electronic search strategies for identifying preoperative risk factors for postoperative acute lung injury. This secondary analysis of a prospective cohort study included 249 patients undergoing high-risk surgery between November 1, 2005, and August 31, 2006. Two independent data-extraction strategies were compared. The first strategy used a manual review of medical records and the second a Web-based query-building tool. Web-based searches were derived and refined in a derivation cohort of 83 patients and subsequently validated in an independent cohort of 166 patients. Agreement between the 2 search strategies was assessed with percent agreement and Cohen κ statistics. Cohen κ statistics ranged from 0.34 (95% confidence interval, 0.00-0.86) for amiodarone to 0.85 for cirrhosis (95% confidence interval, 0.57-1.00). Agreement between manual and automated electronic data extraction was almost complete for 3 variables (diabetes mellitus, cirrhosis, H(2)-receptor antagonists), substantial for 3 (chronic obstructive pulmonary disease, proton pump inhibitors, statins), moderate for gastroesophageal reflux disease, and fair for 2 variables (restrictive lung disease and amiodarone). Automated electronic queries outperformed manual data collection in terms of sensitivities (median, 100% [range, 77%-100%] vs median, 87% [range, 0%-100%]). The specificities were uniformly high (≥ 96%) for both search strategies. Automated electronic query building is an iterative process that ultimately results in accurate, highly efficient data extraction. These strategies may be useful for both clinicians and researchers when determining the risk of time-sensitive conditions such as postoperative acute lung injury.
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                Author and article information

                Journal
                European Journal of Cardio-Thoracic Surgery
                European Journal of Cardio-Thoracic Surgery
                Oxford University Press (OUP)
                1010-7940
                1873-734X
                March 13 2015
                May 14 2014
                : 47
                : 4
                : 725-732
                Article
                10.1093/ejcts/ezu201
                24829402
                f8671a1b-0a45-4be7-9603-8b584e0446df
                © 2015
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