Value of cardiac ultrafast computed tomography for detecting right atrial thrombi in chronic atrial fibrillation

We evaluated the accuracy of cardiac ultrafast computed tomography in diagnosing atrial thrombi in 70 patients with chronic atrial fibrillation, and identified the predictors of atrial thrombi from among clinical, echocardiographic, and ultrafast computed tomographic features. Ultrafast computed tomography identified 11 atrial thrombi in 9 patients: 4 patients had thrombi in the left atrium, 3 in the right, and 2 in both. Transthoracic echocardiography detected only 4 left atrial thrombi, and enlargement of the left or right atrium was associated with atrial thrombi (p <0.05).     

Distraction osteogenesis of the mandible using a submerged intraoral device: a report of three cases

OBJECTIVE: To compare the value of current transthoracic echocardiographic systems and transoesophageal echocardiography for assessing left atrial appendage function and imaging thrombi. DESIGN: Single blind prospective study. Patients were first investigated by transthoracic echocardiography and thereafter by a second investigator using transoesophageal echocardiography. The feasibility of imaging the left atrial appendage, recording its velocities, and identifying thrombi within the appendage were determined by both methods. PATIENTS: 117 consecutive patients with a stroke or transient neurological deficit. SETTING: Tertiary cardiac and neurological care centre. RESULTS: Imaging of the complete appendage was feasible in 75% of the patients by transthoracic echocardiography and in 95% by transoesophageal echocardiography. Both methods were concordant for the detection of thrombi in 10 cases. Transoesophageal echocardiography revealed two additional thrombi. In one of these patients, transthoracic echocardiography was not feasible and in the other the thrombus had been missed by transthoracic examination. In patients with adequate transthoracic echogenicity, the specificity and sensitivity of detecting left atrial appendage thrombi were 100% and 91%, respectively. Recording of left atrial appendage velocities by transthoracic echocardiography was feasible in 69% of cases. None of the patients with a velocity > 0.3 m/s had left atrial appendage thrombi. In the one patient in whom transthoracic echocardiographic evaluation missed a left atrial appendage thrombus, the peak emptying velocity of the left atrial appendage was 0.25 m/s. CONCLUSIONS: A new generation echocardiographic system allows for the transthoracic detection of left atrial appendage thrombi and accurate determination of left atrial appendage function in most patients with a neurological deficit.     

Transesophageal echocardiography to assess embolic risk in patients with atrial fibrillation. ELAT Study Group. Embolism in Left Atrial Thrombi

BACKGROUND: Transesophageal echocardiography visualizes the left atrium and its appendage, thrombi, and spontaneous echocardiographic contrast. OBJECTIVE: To assess the association of transesophageal echocardiographic characteristics with stroke or embolism in atrial fibrillation. DESIGN: Multicenter observational follow-up study. SETTING: Hospitals in Austria and Slovakia. PATIENTS: 409 outpatients with nonrheumatic atrial fibrillation and without recent stroke. INTERVENTION: Patients with thrombi received anticoagulation, and patients without thrombi received aspirin. MEASUREMENTS: Primary events were stroke or embolism. Secondary events were death not caused by stroke or embolism and need for anticoagulation. RESULTS: In the left atrium or left atrial appendage, 10 patients (2.5%) had thrombi and 47 (12%) had spontaneous echocardiographic contrast. The appendage had a mean (+/- SD) length of 44+/-10 mm, a mean width of 23+/-6 mm, and a mean area of 5.8+/-2.5 cm2. Follow-up ranged from 1 to 74 months (mean, 58 months). Fifty patients had stroke or embolism, 53 died of a cause other than stroke or embolism, and 38 required anticoagulation. On univariate analysis, thrombi (risk ratio, 3.9 [95% CI, 1.4 to 10.1]; P = 0.009), length of the left atrial appendage (risk ratio, 1.6 [CI, 1.05 to 2.5]; P = 0.03), and width of the left atrial appendage (risk ratio, 2.4 [CI, 1.2 to 4.81; P = 0.01) were associated with stroke or embolism. Multivariate analysis identified hypertension (risk ratio, 3.6 [CI, 1.8 to 8.4]; P = 0.001), previous stroke (risk ratio, 3.7 [CI, 1.5 to 7.5]; P = 0.002), and age (risk ratio, 1.1 [CI, 1.0 to 1.11; P < 0.001) as risk factors for stroke or embolism and provided evidence of an association between thrombi and stroke or embolism (risk ratio, 2.4 [CI, 0.9 to 6.9]; P = 0.09). CONCLUSIONS: In outpatients with atrial fibrillation and without recent stroke, thrombi of the left atrium or left atrial appendage and length and width of the left atrial appendage were associated with stroke or embolism in univariate analysis. In a multivariate analysis, age, hypertension, and previous stroke were risk factors for stroke or embolism, and thrombi of the left atrium or left atrial appendage were possible risk factors. In these patients, history may be more useful than transesophageal echocardiography for the assessment of embolic risk.     

Exclusion of atrial thrombus by transesophageal echocardiography does not preclude embolism after cardioversion of atrial fibrillation. A multicenter study

BACKGROUND: Transesophageal echocardiography (TEE) has been used recently to detect atrial thrombi before cardioversion of atrial arrhythmias. It has been assumed that embolic events after cardioversion result from embolism of preexisting atrial thrombi that are accurately detected by TEE. This study examined the clinical and echocardiographic findings in patients with embolism after cardioversion of atrial fibrillation despite exclusion of atrial thrombi by TEE. METHODS AND RESULTS: Clinical and echocardiographic data in 17 patients with embolic events after TEE-guided electrical (n = 16) or pharmacological (n = 1) cardioversion were analyzed. All 17 patients had nonvalvular atrial fibrillation, including four patients with lone atrial fibrillation. TEE before cardioversion showed left atrial spontaneous echo contrast in five patients and did not show atrial thrombus in any patient. Cardioversion resulted in return to sinus rhythm without immediate complication in all patients. Thirteen patients had cerebral embolic events and four patients had peripheral embolism occurring 2 hours to 7 days after cardioversion. None of the patients were therapeutically anticoagulated at the time of embolism. New or increased left atrial spontaneous echo contrast was detected in four of the five patients undergoing repeat TEE after cardioversion including one patient with a new left atrial appendage thrombus. CONCLUSIONS: Embolism may occur after cardioversion of atrial fibrillation in inadequately anticoagulated patients despite apparent exclusion of preexisting atrial thrombus by TEE. These findings suggest de novo atrial thrombosis after cardioversion or imperfect sensitivity of TEE for atrial thrombi and suggest that screening by TEE does not obviate the requirement for anticoagulant therapy at the time of and after cardioversion. A randomized clinical trial is needed to compare conventional anticoagulant management with a TEE-guided strategy including anticoagulation after cardioversion.     

Advantages of orange-labelled collagen and gelatine as substrates for rapid collagenase activity measurement

We postulated that the sensitivity of transthoracic echocardiography in detection of left atrial cavity or appendage thrombi is better in south-east asian patients with rheumatic mitral stenosis. This was considering that these patients are generally younger, have lesser body weight and thinner chest walls resulting in better transthoracic echogenecity than their western counterparts. We prospectively performed transthoracic and transoesophageal echocardiography in 150 consecutive Indian patients (mean age 28.8+/-7.2 years; 78 men) being evaluated for percutaneous transvenous mitral commissurotomy. The overall sensitivity of transthoracic echocardiography was 74% (95% C.I. 59-88%). This was significantly higher than the pooled estimate from five western reports which evaluated similar patients (overall sensitivity 12%; 95% C.I. 0-25%; P<0.0001). The sensitivity rose to 83% when patients with poor echogenecity were excluded. Amongst patients with good echogenecity (81% patients) the diagnosis of left atrial thrombi was correctly made or suspected on transthoracic examination in all patients subsequently shown to have thrombi on transoesophageal echocardiography. Significant savings in cost may be safely achieved by limiting transoesophageal echocardiography to patients in whom left atrial cavity or appendage is not adequately visualized on transthoracic examination due to poor echogenecity, or in whom there are shadows suggestive but not diagnostic of thrombi.     

Severely reduced left atrial appendage function: a cause of embolic stroke in patients in sinus rhythm?

Recently, attention has been focused on transesophageal echocardiographic detection of left atrial appendage function to assess of risk of thrombus formation because of potential benefit of anticoagulation therapy. However, most of these studies have been conducted in patients with atrial fibrillation or mitral valve disease. In this article we review cases of 2 patients without valvular disease who had embolic stroke in sinus rhythm. Transesophageal echocardiography revealed thrombi in the left atrial appendage in both patients. The left atrial appendage function in these patients was compared with that in patients with chronic atrial fibrillation and a control group in sinus rhythm. Left atrial appendage function in the patients with stroke and sinus rhythm was significantly lower than that of patients in the control group in sinus rhythm (P < .001) and was similar to the appendage function in patients with chronic atrial fibrillation. These observations provide further evidence that the finding of reduced left atrial appendage function can be a cause of stroke in patients with sinus rhythm even in the absence of mitral valve disease. Reduced left atrial appendage function may identify patients with unexplained stroke who should receive anticoagulation therapy even in the absence of detectable appendage thrombi.     

The frequency of left atrial spontaneous echo contrast and its clinical significance in mitral valve insufficiency

The authors investigated the frequency of left atrial spontaneous echo contrast in mitral valve disease. They also tested whether there was any correlation between the presence of left atrial spontaneous echo contrast and the severity of the mitral valve disease. Echocardiographic investigations were performed using both transthoracal and transesophageal echocardiographic methods employing monoplane transducer. The authors carried out 273 transesophageal investigations over a period of 2 years and found left atrial spontaneous echo contrast in 85 patients, who had mitral valve disease. Of this, in 18 cases thrombi were also detected in the left atrium and/or auricula. The diagnoses of mitral stenosis were made in 24 patients, of whom in 12 cases the stenosis were found to be severe, whilst in 12 cases to be moderate. Furthermore insufficiency of the mitral valve was detected in 35 cases. 20 patients had artificial mitral valve implanted, they received long term anticoagulant treatment. 59 patients had no spontaneous echo contrast. 14 patients had previous embolic events of which 9 were cerebral and in other cases arteries of the kidney, eye and extremities were affected. 71 patients had no history of embolism. The authors concluded that mitral valve disease, particularly mitral stenosis is frequently associated with left atrial spontaneous echo contrast. It has been also observed, that the more severe the mitral valve disease, the greater the probability of left atrial spontaneous echo contrast. In all cases where thrombi were found, left atrial echo contrast were demonstrated and the risk of embolism is high. In these cases anticoagulant therapy is suggested.     

Cytokines and bioincompatibility

OBJECTIVES: This study explored the mechanisms linking clinical and precordial echocardiographic predictors to thromboembolism in atrial fibrillation (AF) by assessing transesophageal echocardiographic (TEE) correlations. BACKGROUND: Clinical predictors of thromboembolism in patients with nonvalvular AF have been identified, but their mechanistic links remain unclear. TEE provides imaging of the left atrium, its appendage and the proximal thoracic aorta, potentially clarifying stroke mechanisms in patients with AF. METHODS: Cross-sectional analysis of TEE features correlated with low, moderate and high thromboembolic risk during aspirin therapy among 786 participants undergoing TEE on entry into the Stroke Prevention in Atrial Fibrillation III trial. RESULTS: TEE features independently associated with increased thromboembolic risk were appendage thrombi (relative risk [RR] 2.5, p = 0.04), dense spontaneous echo contrast (RR 3.7, p < 0.001), left atrial appendage peak flow velocities < or = 20 cm/s (RR 1.7, p = 0.008) and complex aortic plaque (RR 2.1, p < 0.001). Patients with AF with a history of hypertension (conferring moderate risk) more frequently had atrial appendage thrombi (RR 2.6, p < 0.001) and reduced flow velocity (RR 1.8, p = 0.003) than low risk patients. Among low risk patients, those with intermittent AF had similar TEE features to those with constant AF. CONCLUSIONS: TEE findings indicative of atrial stasis or thrombosis and of aortic atheroma were independently associated with high thromboembolic risk in patients with AF. The increased stroke risk associated with a history of hypertension in AF appears to be mediated primarily through left atrial stasis and thrombi. The presence of complex aortic plaque distinguished patients with AF at high risk from those at moderate risk of thromboembolism.     

Predictors of systemic embolism in patients with mitral stenosis. A prospective study

BACKGROUND: Most studies of the predictors of systemic embolism in patients with mitral stenosis have been retrospective. OBJECTIVE: To prospectively study factors associated with systemic embolism in mitral stenosis. DESIGN: Prospective cohort study. SETTING: University-affiliated medical institution with 3000 beds. PATIENTS: 534 consecutive patients with a mitral valve area of 2.0 cm2 or less; 132 patients were in sinus rhythm, and 402 were in atrial fibrillation. MEASUREMENTS: Nine clinical and 10 echocardiographic variables were assessed for prediction of systemic embolism over a mean (+/- SD) follow-up of 36.9 +/- 22.5 months. Diagnosis of systemic embolism was based on symptoms and signs (sudden onset of peripheral arterial ischemic or neurologic manifestations without prodromes) and on findings on computed tomography, angiography, and surgery. RESULTS: For patients in sinus rhythm, age (relative risk [RR], 1.12 [95% CI, 1.04 to 1.21]), the presence of a left atrial thrombus (RR, 37.1 [CI, 2.82 to 487.8]), mitral valve area (RR, 16.9 [CI, 1.53 to 187.0]), and the presence of significant aortic regurgitation (RR, 22.4 [CI, 2.72 to 184.8]) were positively associated with embolism. For patients in atrial fibrillation, previous embolism (RR, 3.11 [CI, 1.66 to 5.85]) was positively associated with embolism; percutaneous balloon mitral commissurotomy (RR, 0.37 [CI, 0.18 to 0.79]) was a negative predictor. CONCLUSIONS: It may be prudent to give anticoagulants not only to patients in atrial fibrillation and patients with previous systemic embolism but also to those showing a left atrial thrombus or significant aortic regurgitation on echocardiography. Early percutaneous balloon mitral commissurotomy may also help prevent systemic embolism in patients with mitral stenosis.     

Managing atrial fibrillation to prevent its major complication: ischemic stroke

Atrial fibrillation is an acute or chronic arrhythmia that occurs postoperatively or during intense emotional stress, exercise, or acute alcohol intoxication. More than 10% of Americans aged 75 and older have atrial fibrillation, which is common in elderly patients with cardiopulmonary disorders. During atrial fibrillation, uncoordinated electrical activity leads to ineffective atrial contraction, reduced atrial filling time, and decreasing cardiac output. Blood flow stasis may cause thrombi to form in the quivering atria. Cardioversion may be indicated to convert an unstable patient into sinus rhythm. However, if cardioversion converts the patient's status to sinus rhythm, thrombi may become dislodged and propelled into the bloodstream as emboli. Occlusion of a cerebral blood vessel often follows, leading to stroke. Because patients with longstanding atrial fibrillation are predisposed to stroke, anticoagulation therapy (usually with heparin, warfarin, or aspirin) should be initiated 3 weeks prior to cardioversion. Proper anticoagulation can usually prevent ischemic stroke.     

Infectious mediastinitis after cardiac operations: computed tomographic findings

BACKGROUND: Infectious mediastinitis after cardiac operations is of great concern to cardiac surgeons because of its poor prognosis. Prompt surgical interventions such as debridement and irrigation are the key to treatment of infectious mediastinitis. METHODS: We surveyed retrospectively the cases of 722 consecutive cardiac surgery patients at our hospital. Mediastinitis developed in 21 patients after the cardiac operation. We performed computed tomography in 11 of these patients before resternotomy and in 10 patients as the control 2 to 3 weeks after the cardiac operation. RESULTS: Mediastinal soft tissue swelling was seen in 7 patients, bilateral pleural effusion was found in 9 patients, sternal dehiscence or sternal erosion was observed in 8 patients, and subcutaneous fluid accumulation was found in 7 of the mediastinitis group. Unilateral pleural effusion was seen in 6 and bilateral effusion in 1, and mediastinal soft tissue swelling was seen in 1 patient of the control group. CONCLUSIONS: Our study showed that mediastinal soft tissue mass combined with bilateral pleural effusion can be a characteristic computed tomography finding in poststernotomy infectious mediastinitis, and that chest computed tomography is more sensitive to detecting sternal dehiscence, sternal erosion, and subcutaneous fluid accumulation.     

Right atrial thrombosis--a difficult diagnostic and therapeutic problem

Right atrial thrombi have been diagnosed more frequently since the widespread use of two-dimensional echocardiography. The authors present current opinions on etiology of right heart thrombi. They can originate from two sources: type A thrombi originate in deep peripheral veins; they have worm-shape and they are extremely mobile or they develop within the right heart chambers-type B-they are then parietal and immobile. Clinical significance, prognosis in both types of thrombi is discussed and the guidelines for treatment are presented. Type A patients are a high risk group because of frequent incidence of severe pulmonary embolism and excessive mortality rate so aggressive therapy is required (surgery or fibrinolysis when surgery is contraindicated). Type B thrombi are much more benign, usually they do not lead to the death and treatment with anticoagulants seems to be sufficient.     

Predicting the occurrence of adverse events after coronary artery bypass surgery

Approximately 15% of patients with mitral valve disease will experience left atrial thrombosis and its consequences. The etiology and diagnosis of left atrial thrombosis are reviewed, stressing the importance of blood stagnation as the most important etiologic factor. Atrial fibrillation, a left atrial diameter greater than 60 mm and absence of significant mitral regurgitation are predictors of left atrial thrombosis in mitral stenosis. Left atrial thrombus can be detected in 50% of patients with all three factors; all influence blood stagnation. Smoke-like echoes in the left atrium, detected by echocardiography, provide a semi-quantitative assessment of left atrial blood stagnation. The incidence of thrombi in patients with well marked smoke-like echoes is 60%, while in those without this echocardiographic finding it is only 9%. Smoke-like echoes provide an early warning system of conditions in the left atrium likely to lead to thrombosis unless the patient is anticoagulated.     

Disappearing intracardiac thrombi in both atria after mumps in a patient with Turner syndrome

A girl with Turner syndrome was admitted with an acute cerebrovascular occlusive disease 15 days after mumps infection. Imaging techniques such as Doppler echocardiography, computed tomography and angiography of the heart revealed the existence of masses in both atria. Eight days after the last radiologic study the patient had an operation, but no masses were found in either atrium. It was thought that atrial thrombi, probably formed after viral infection, had broken down to form emboli and disappeared. It is proposed that the patients with congenital cardiopathy should be regularly examined after viral infections for possible intracardiac thrombus formation. If such a mass is found and the decision is to operate, the existence of the mass must be confirmed even in the operating room just before intervention.     

Splenic and renal infarctions complicating atrial fibrillation

Splenic and renal infarctions are common manifestations of cardiac thromboembolism. Usually they remain clinically silent and are not likely to be diagnosed antemortem. Two elderly female patients, in whom nonrheumatic chronic atrial fibrillation was noted, received low-dose aspirin. Both complained of the onset of acute abdominal pain and were found to have splenic and renal infarctions on abdominal computerized tomography. An enlarged left atrium was seen on echocardiogram in both cases. Treatment consisted of hydration, analgesics, and anticoagulation. In one case, liquefactive necrosis of the splenic infarct was observed on subsequent computer tomography studies. Both patients did well and remained free of new embolic events in the following 6 and 10 months, respectively. Clinicians should readily recognize the clinical manifestations of splenic and renal infarctions in patients with atrial fibrillation. Abdominal computerized tomography can confirm the diagnosis.     

Frequency of deep vein thrombosis in patients with patent foramen ovale and ischemic stroke or transient ischemic attack

To evaluate the additional value of transesophageal (TEE) compared with transthoracic (TTE) echocardiography and the role of patent foramen ovale (PFO) and deep vein thrombosis in the work-up of embolic events, patients with presumed cardiac embolic stroke or transient ischemic attack (neurovascular etiology was excluded) were prospectively studied by transthoracic and transesophageal contrast echocardiography. If PFO was detected echocardiographically, PFO size was assessed semiquantitatively and phlebography of both legs was performed. Two hundred forty-two consecutive patients (153 men, 60 +/- 15 years) were studied. In 197 patients, neuroimaging showed evidence of embolic infarction. TEE identified 138 potential cardiac sources of embolism in 111 patients, compared with 69 by TTE (p <0.01) in 59 patients. TEE detected potential cardiac sources in 52 patients with negative TTE examination and was significantly superior compared with TTE for identifying left atrial thrombi, spontaneous echo contrast, PFO, atrial septal aneurysm, and atheroma of the ascending aorta. In patients with a positive TTE, additional diagnostic information by TEE was found in only 6 patients and did not change therapy. Phlebography was performed in 53 patients with PFO and revealed deep vein thrombosis in 5 patients (9.5%); all had medium or large PFOs. Thus, in patients with cerebral ischemia of suspected cardiogenic origin and a normal TTE examination, TEE detects potential causes of embolism in 31% of patients and is therefore of diagnostic relevance. Conversely, in the presence of a diagnostic TTE an additional TEE confers only marginal diagnostic benefit. Deep venous thrombosis was detected in nearly 10% of patients with PFO as the sole identifiable cardiac risk factor. Given that in 4 of 5 patients deep vein thrombosis was clinically silent, phlebography should be performed in patients with medium or large interatrial shunts if paradoxical embolism is suspected.     

Transient sinus node dysfunction after the Cox-maze III procedure in patients with organic heart disease and chronic fixed atrial fibrillation

OBJECTIVES: This prospective study examined types, frequency and time dependency of the electrophysiologic manifestation of the sinus node dysfunction after the Cox-maze III procedure--the technique of choice for the management of medically refractory atrial fibrillation-in patients with organic heart disease, chronic fixed atrial fibrillation and no preoperatively overt dysfunction of the sinus node. BACKGROUND: The original maze procedure was modified twice in order to reduce the high incidence of the sinus node inability to generate an appropriate sinus tachycardia in response to maximal exercise, and occasional left atrial dysfunction. Despite these modifications, postoperative disturbance of sinus node function can be frequently observed. METHODS: In 15 adult patients, standard electrocardiogram, 24-h Holter monitoring, power spectral analysis of heart variability, exercise testing, Valsalva maneuver and rapid positional changes were performed 3, 6 and 12 months after the Cox-maze III procedure and mitral valve surgery or closure of atrial septal defect. RESULTS: Electrocardiographic manifestations of sinus node dysfunction were identified in 12 patients at 3 months, in 6 patients at 6 months, and in 0 patients at 12 months after surgery. The heart rate response to exercise during the first 6 months was reduced in the maze group and became fully normal at 12 months. Power spectral analysis of heart rate variability showed very low power values at 1 month with inhibited cardiac autonomic activity and no response on sympathetic stress. A potential of recovery of cardiac autonomic activity was documented 12 months after surgery. CONCLUSIONS: The manifestations of sinus node dysfunction following the Cox-maze III procedure were time dependent and their frequency and intensity progressively decreased and disappeared within 12 months after surgery.     

Anesthesia case of the month. Analgesia for fractures until surgery can take place

OBJECTIVE: To emphasize a potentially lethal condition that is virtually impossible to diagnose preoperatively. DESIGN: Case report with review of the literature. SETTING: University Hospital. PARTICIPANT: The patient requiring urgent surgery for heart failure related to severe aortic stenosis and mild mitral stenosis with poor ventricular function. The patient was elderly and suffered from atrial fibrillation. INTERVENTIONS: Preoperative transesophageal echocardiography followed by mitral valve repair and aortic valve replacement. MEASUREMENTS: Clinical outcome and pathological results. RESULTS: Although preoperative TEE demonstrated no left atrial appendage abnormality. After cardiac manipulation prior to the institution of cardiopulmonary bypass a large left atrial mural thrombus was mobilized from the atrial wall and was free floating in the left atrium. CONCLUSIONS: For high risk patients TEE should be applied intraoperatively to avoid undiagnosed left atrial clot dislodgement.     

The recurrence of an atrial myxoma in a patient with a mechanical mitral prosthesis--apropos a case

Recurrence of cardiac myxoma after surgery is an uncommon situation, particularly if a wide excision of the tissue under the tumour has been done. The authors report a case of a 54-year-old male presenting with a left atrial myxoma near the mitral valve, which had to be replaced by a mechanical prosthetic valve during the removal of the tumour. One year later, he was admitted to hospital with persistent fever, weight loss, and congestive heart failure. After a positive hemoculture, intravenous antibiotherapy was initiated, and twice modified because of relapsing fever. Six weeks later, he was transferred to our institution, after an episode of severe acute pulmonary edema. 2D-Doppler echocardiography suggested the possibility of prosthesis dysfunction, revealing a transprothetic diastolic flow with a high peak velocity and moderately elevated pressure half-time. No intra-atrial masses were visualized. Computed tomography was also inconclusive, because of multiple artifacts produced by the prosthesis. These results led to the performance of a cardiac catheterization with contrast ventriculography, which revealed the presence of a transprothetic gradient, and mild mitral regurgitation. The patient was submitted to cardiac surgery, which revealed a recurrent pedunculated left atrial myxoma, with mechanical obstruction of the mitral prosthetic valve. No signs of endocarditis were found. Recurrent cardiac myxomas are reviewed and discussed, as well as the specific problems of the present case, namely the presence of a mechanical prosthetic mitral valve and the initial hemoculture results, with consequent diagnostic delay.     

Symptomatic zinc deficiency in breast-fed term and premature infants

This study assesses the efficacy of oral anticoagulation in resolving left atrial appendage (LAA) thrombi and evaluates clinical outcomes of percutaneous mitral valvuloplasty after resolution of LAA thrombi compared with mitral valve replacement. Warfarin therapy is successful in resolving LAA thrombi; percutaneous mitral valvuloplasty after resolution of LAA thrombi is an effective alternative to surgical treatment.