The patients with mechanical prosthetic valve replacement need anticoagulant therapy for all their life. The incidence of thromboembolism and anticoagulation-related bleeding events still account for major postoperative complications after mechanical heart valve replacement. Most of the complications happen in the first half year after operation. Therefore, early anticoagulation therapy is very important. Of course, so far most guidelines focus stating their opinions on long-term anticoagulant therapy. However, there is no consensus about anticoagulant therapy in the early period of postoperation. In this review, we summarize early anticoagulant therapy of the patients with mechanical heart valve replacement through consulting domestic and abroad relevant research in recent years and give an overview of the present situations of early anticoagulant therapy.
Objective To systematically assess literature regarding the relationship between ovulation induction and the risk of ovarian cancer. Methods We searched MEDLINE, EMbase, The Cochrane Library, CBM and CNKI (from inception to Feb, 2012). Cohort or case-control studies were identified according to the inclusion and exclusion criteria. Then the quality of the included studies was assessed, and the data was extracted. Meta-analysis was performed by RevMan 5.0 software. The incorporated RR (relative risk) and 95%CI (confidence interval) of the included cohort studies and incorporated OR (odds ratio) and 95%CI of case-control studies were calculated, respectively. Results Four cohort studies and four case-control studies were included. Result of meta-analysis on cohort studies showed ovulation induction didn’t increase the risk of ovarian cancer (RR=1.07, 95%CI 0.81 to 1.42, P=0.63). Besides, result of meta-analysis on case-control studies showed ovulation induction was not associated with the incidence of ovarian cancer (OR=1.28, 95%CI 0.78 to 2.08, P=0.33). But the risk of borderline ovarian tumors increased when compared with general population controls (OR=1.71, 95%CI 1.05 to 2.79, P=0.03). Conclusion Ovulation induction does not increase the risk of ovarian cancer, but may relate to the incidence of borderline ovarian cancer. However, more high-quality studies, especially perspective cohort studies are required because of the limited quantity of the included studies.
Objective To investigate the classification of atlas pedicles and the methods of the pedicle screw fixation. Methods To study the classification of atlas pedicles, 48 dry adult atlas specimens were measured. By atlas 3D-CT reconstruction, two transverse sections were establ ished by going through the one third of the lateral atlas pedicle and 2 mmbelow the vertebral artery sulcus. By setting 3.50 mm and 1.75 mm as the standardized diameter and radius for the screwand according to the thickness of bone substance of vertebral artery sulcus that went through the one third of the lateralatlas pedicle, the anatomical morphology of atlas pedicles were classified into three types: general type with 40 specimens (83%), l ight variation type with 6 specimens (13%), and severe variation type with 2 specimens (4%). The entry pathway was confirmed by the intersection l ine of the two transverse sections that went through the lateral one third of the atlas pedicle and 2 mm below the vertebral artery sulcus. The project-point of the entry pathway on the atlas posterior arch was considered to be the entry point. Forty-eight dry atlas specimens were used to measure the following relevant anatomic data with an electronic cal iper: the distance between the entry point and the posterior margin of the lateral mass (L1), the height of atlas pedicle at the entry point (L2), the vertical distance between the entry point and the inferior articular facet of the lateral mass (L3), the mass height at the entry point (L4), the mass width at the entry point (L5), the width of the atlas pedicle at the entry point (L6), the thickness of the pedicle under the vertebral artery sulcus at the entry pathway (H1). To research the method of the pedicle screw fixation, 12 fresh-frozen adult atlas specimens were adopted to simulate the fixation of the pedicle screw. The thickness of the bone substance of vertebral artery sulcus on both the left and the right sides of the pathway was grinded into 3 types: 1.5 mm and 2.5 mm, 1.5 mm and 4.0 mm, 2.5 mm and 4.0 mm, and each type had four specimens. The entry pathway was confirmed by the intersection l ine of two transverse sections that went through the lateral one third of atlas pedicle and 2 mm below the vertebral artery sulcus. Results On the left side, L1 was (5.79 ± 1.24) mm, L2 (4.55 ± 1.29) mm, L3 (5.12 ± 1.06) mm, L4 (12.43 ± 1.01) mm, L5 (12.66 ± 1.37) mm, L6 (7.86 ± 0.77) mm, and H1 (4.11 ± 1.25) mm. On the right side, L1 was (5.81 ± 1.26) mm, L2 (4.49 ± 1.22) mm, L3 (5.15 ± 1.05) mm, L4 (12.49 ± 0.98) mm, L5 (12.65 ± 1.38) mm, L6 (7.84 ± 0.78) mm, and H1 (4.13 ± 1.29) mm. There was no significant difference between the two sides (P gt; 0.05). After simulation of inserting screws, no screw in the specimens was found to break the bone substance in the sulcus of vertebral artery. Conclusion For the pedicle screw fixation of those patients whose atlas posterior arches are not high enough, we might partly drill through or beyond the atlas posterior arch. The entry point should be ascertained by preoperative 3D-CT reconstruction and intra-operative exploration.
ObjectiveTo investigate effect of cardiac function and tricuspid regurgitation (TR) degree of concomitant tricuspid annuloplasty for patients with tricuspid valve annulus dilation and mild TR underwent mitral valve replacement (MVR), and provide an objective basis for clinical decision about concomitant tricuspid annuloplasty for patients with tricuspid valve annulus dilation and mild TR underwent MVR. MethodsA total of 36 patients who underwent MVR from April to October 2013 in Department of Cardiovascular Surgery, West China Hospital, Sichuan University were enrolled in this study. Preoperative echocardiography showed mild TR and tricuspid valve annular end-diastolic dimension (TVAEDD)/body surface area (BSA)>21 mm/m2. All the 36 patients were randomly divided into a tricuspid annuloplasty group (TAPG group, n=18, including 7 males and 11 females) and a no tricuspid annuloplasty group (NTAPG group, n=18, including 6 males and 12 females). One week and 6 months postoperative echocardiography were recorded. ResultsThere were no statistical differences in age, gender, heart rate, body surface area, preoperative cardiac function (NYHA), left atrium dimension (LAD), left ventricular dimension (LVD), maximal long-axis of RA (RAmla), mid-RA minor distance (RAmmd), right ventricle dimension (RVD2), left ventricular ejection fraction (LVEF), left ventricular fractional shortening (LVFS) between the two groups (P>0.05). Six-months postoperative left atrial-ventricular diameter significantly reduced than that before surgery in the two groups (P<0.05). In the TAPG group, six-months postoperative right ventricle dimension (RVD1), right ventricular wall thickness (RVWT), tricuspid valve annular end-diastolic dimension (TVAEDD), tricuspid valve annular end-systolic dimension (TVAESD) significantly decreased, while percent shorting of tricuspid valve annulus (PSTVA) did not change significantly (P>0.05), TR degree improved significantly (P<0.05), right ventricular fractional area change (RVFAC) and right ventricular ejection fraction (RVEF) significantly increased (P<0.05). In the NTAPG group, compared with preoperative data, six-months postoperative RVD1, RVWT significantly increased, TVAEDD, TVAESD, PSTVA did not change significantly (P>0.05), RVEF reduced significantly (P<0.05), RVFAC increased significantly but less than that in the TAPG group at the same period, constituent ratio of TR changed significantly (P<0.05), but postoperative moderate or more TR were recorded in 6 patients. ConclusionConcomitant tricuspid annuloplasty for patients with tricuspid valve annulus dilation and mild TR underwent mitral valve replacement (MVR) can help to decrease RVD1, RVWT, TVAEDD and TVAESD, improve the constituent ratio of TR, and increase RVFAC and RVEF.
Objective To investigate the influence of preoperative assessment by transrectal ultrasound (TRUS) on the development of operative procedures for rectal cancer. Methods A total of 110 patients with pathologically proven rectal cancer and distance between tumor to dentate line ≤10 cm were enrolled and randomized into group A (n=55) and group B (n=55) according to a computer-generated random sequence. Both TRUS staging and Clinical Staging System (CS staging) were performed preoperatively in group A, while only CS staging was conducted in group B. Preoperative TRUS stage, CS stage, and proposed operative procedures were recorded to compare with the postoperative pathological stage and practical operative procedures. Results A total of 99 patients were assessed. They were randomized into group A (n=49) and B (n=50), and there were no significant differences in baseline characteristics between the two groups. The difference in staging accuracy was statistically significant (P=0.000) between group A (91.8%) and group B (48.0%). Statistically significant improvement (P=0.013) in the accuracy of proposing operative procedures for rectal cancer was observed in group A (93.9%) compared with group B (76.0%). Conclusion TRUS is evidently superior to CS staging in preoperative assessment for rectal cancer, and may remarkably enhance the accuracy of proposing operative procedures. Therefore, TRUS is valuable in preoperative assessment which may help to guide the selection of operative procedures for rectal cancer surgery.
ObjectiveTo evaluate the reasonableness of anticoagulation management strategy in patients after mechanical heart valve replacement. MethodsAll patients were followed and registered continually at outpatient clinic from July 2011 to February 2013, with a minimum of 6 months after surgery. Targeted international normalized rate (INR) 1.60 to 2.20 and warfarin weekly dosage adjustment were used as the strategy of anticoagulation management. Except bleeding, thrombogenesis and thromboembolism, time in therapeutic range (TTR) and fraction of TTR (FTTR) were adopted to evaluate the quality of anticoagulation management. ResultsA total 1 442 patients and 6 461 INR values were included for data analysis. The patients had a mean age of 48.2±10.6 years (14-80 years) and the following up time were 6 to 180 months (39.2±37.4 months) after surgery. Of these patients, 1 043 (72.3%) was female and 399 (27.7%) was male. INR values varied from 0.90-8.39 (1.85±0.49) and required weekly doses of warfarin were 2.50-61.25 (20.89±6.93 mg). TTR of target INR and acceptable INR were 51.1% (156 640.5 days/306 415.0 days), 64.9% (198 856.0 days/306 415.0 days), respectively. FTTR of target INR and acceptable INR were 49.4% (3 193 times/6 461 times), 62.6% (4 047 times/6 461 times). There were 8 major bleeding events, 7 mild bleeding events, 2 thromboembolism events, and 2 thrombogenesis in the left atrium. ConclusionIt is reasonable to use target INR 1.60-2.20 and warfarin weekly dosage adjustment for patients after mechanical heart valve replacement.
Objective To evaluate the quality of anticoagulant therapy in patients with mechanical prosthetic valve replacement during early period through time in therapeutic range(TTR) and fraction of time in therapeutic range(FTTR), and to provide an objective evidence for further improving quality of anticoagulant therapy. Methods All the patients were followed and registered in hospital and at outpatient clinic from July 2012 through April 2014, with a maximum of 6 months after surgery. Targeted international normalized rate (INR) was 1.60 to 2.20, acceptable INR was 1.50 to 2.30. And warfarin weekly dosage adjustment was used as the strategy of anticoagulation management. Adjusting the warfarin dosage when INR was beyond acceptable INR. Events of bleeding, thrombogenesis and thromboembolism, TTR and FTTR of these patients during the follow-up were collected to evaluate quality of anticoagulant therapy in these patients. Results A total 477 patients and 2 755 reports of INR values were included for data analysis. The follow-up time was 78 918 days. Values of INR varied from 0.92 to 7.72(1.83±0.64). Required weekly doses of warfarin in target INR and acceptable INR were 5.00–35.00(18.15±3.99) mg/week and 5.00–39.38(18.29±4.08) mg/week. TTR of target INR and acceptable INR was 36.85%(27 079.5 d/78 918.0 d) and 49.84% (39 331.5 d/78 918.0 d), respectively. FTTR of target INR and acceptable INR was 37.31% (1 028 times/2 755 times), 50.01% (1 378 times/2 755 times), respectively. TTR of target INR and acceptable INR was 46.04%(3 902.5 d/8 475.5 d), 59.49%(5 042 d/8 475.5 d) when the patients’ follow-up was up to six months and FTTR of target INR and acceptable INR value of these patients was 46.81%(206 times/440 times), 60.45%(266 times/440 times). During the follow-up, there were 3 thromboembolism events, 1 transient physical abnormal activity, and 1 thrombogenesis in the left atrium, and there was no bleeding and death events. Conclusion The strategy of anticoagulation management used in our study is reasonable. In order to further improve the patients’ quality of anticoagulant therapy, it is necessary to start anticoagulation after operation as soon as possible, to strengthen the education of patients with anticoagulant knowledge and to increase INR test frequency properly.
Objective Influence factors of the stable warfarin dose in the early period after mechanical prosthetic valve replacement were analyzed to guide the anticoagulation therapy for these patients. Methods A total of 288 patients within 6 months after mechanical prosthetic valve replacement in West China Hospital were followed up and registered at outpatient department from July 2012 to April 2014, including basic information (name, sex, age, height, weight, etc.), general clinical data (cardiac function, heart rate, surgery pattern, etc.) and related data about anticoagulation therapy. The target international standardized ratio (INR) range was 1.60 to 2.20 and the acceptable INR was 1.50 to 2.30. The sex, age, height, body weight, body mass index (BMI), body surface area (BSA) and related clinical factors were analyzed to find the relationship with the dose of warfarin. Results Sex was found to have a significant effect on the stable warfarin dose (P<0.05). Women needed a lower stable warfarin dose than men during the early anticoagulation therapy. There was no significant difference in the stable warfarin dose of patients with different ages, rhythms, NYHA classification, surgery pattern and diseases before operation; but the stable warfarin dose was lower in the patients with radiofrequency ablation during valve replacement procedures than the patients with single valve replacement (P<0.05). There was an association between age, height, weight, BMI, BSA and the stable warfarin dose withR2 of 1.2%, 3.2%, 3.5%, 1.1%, 4.2%, respectively and they could explain 6.1% of variability in warfarin dose. Conclusion During early anticoagulation therapy in patients with mechanical prosthetic valve replacement, it is necessary to consider the effects of various preoperative factors, drug factors and demographic factors on warfarin dose. Even though there is an association between age, height, weight, BMI, BSA and the stable warfarin dose, which can only explain 6.1% of variability in warfarin dose, thus cannot guide the postoperative anticoagulation of these patients.