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Saric M, Armour AC, Arnaout MS, Chaudhry FA, Grimm RA, Kronzon I, Landeck BF, Maganti K, Michelena HI, Tolstrup K. Guidelines for the Use of Echocardiography in the Evaluation of a Cardiac Source of Embolism. J Am Soc Echocardiogr 2016; 29:1-42. [PMID: 26765302 DOI: 10.1016/j.echo.2015.09.011] [Citation(s) in RCA: 225] [Impact Index Per Article: 28.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Embolism from the heart or the thoracic aorta often leads to clinically significant morbidity and mortality due to transient ischemic attack, stroke or occlusion of peripheral arteries. Transthoracic and transesophageal echocardiography are the key diagnostic modalities for evaluation, diagnosis, and management of stroke, systemic and pulmonary embolism. This document provides comprehensive American Society of Echocardiography guidelines on the use of echocardiography for evaluation of cardiac sources of embolism. It describes general mechanisms of stroke and systemic embolism; the specific role of cardiac and aortic sources in stroke, and systemic and pulmonary embolism; the role of echocardiography in evaluation, diagnosis, and management of cardiac and aortic sources of emboli including the incremental value of contrast and 3D echocardiography; and a brief description of alternative imaging techniques and their role in the evaluation of cardiac sources of emboli. Specific guidelines are provided for each category of embolic sources including the left atrium and left atrial appendage, left ventricle, heart valves, cardiac tumors, and thoracic aorta. In addition, there are recommendation regarding pulmonary embolism, and embolism related to cardiovascular surgery and percutaneous procedures. The guidelines also include a dedicated section on cardiac sources of embolism in pediatric populations.
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Affiliation(s)
- Muhamed Saric
- New York University Langone Medical Center, New York, New York
| | | | - M Samir Arnaout
- American University of Beirut Medical Center, Beirut, Lebanon
| | - Farooq A Chaudhry
- Icahn School of Medicine at Mount Sinai Hospital, New York, New York
| | - Richard A Grimm
- Learner College of Medicine, Cleveland Clinic, Cleveland, Ohio
| | | | | | | | | | - Kirsten Tolstrup
- University of New Mexico Health Sciences Center, Albuquerque, New Mexico
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Almedawar MM, Isma'Eel HA, Nasreddine L, Olabi A, Badr KF, Arnaout MS. AN ATTEMPT TO HALT THE EVER-INCREASING PREVALENCE OF MORBIDITIES RESULTING FROM EXCESS DIETARY SODIUM INTAKE. The Lebanese Experience. J Med Liban 2016; 64:63-64. [PMID: 30452141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
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Arnaout MS, Serhan M, Saade C. A case of a 42-year-old patient with anomalous origin of the left main coronary artery from the pulmonary artery who delivered three times with no complications: presentation, diagnosis, and review. CLIN EXP OBSTET GYN 2016; 43:889-892. [PMID: 29944246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
An anomalous origin of the left coronary artery (LCA) from the pulmonary artery or Bland-White-Garland (BWG) syndrome is a rare congenital cardiac anomaly, which is unusual to survive to adulthood if left uncorrected. The authors report an unusual case of a multiparity patient who delivered several times without any complications presenting at the age of 42 years with recurrent dyspnea on exertion in which echocardiographic findings of diastolic flow near the origin of the pulmonary valve were suggestive of anomalous origin of the LCA. A CT angiography confirmed that the left main coronary artery arises from the undersurface of the pulmonary flow close :o its origin and gives rise to a left anterior descending (LAD) and left circumflex arteries.
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Isma'eel H, Taher A, Alam S, Arnaout MS. Massive pulmonary embolism in a Lebanese patient doubly heterozygous for MTHFR and Factor V Leiden presenting with syncope and treated with tenecteplase. J Thromb Thrombolysis 2014; 21:179-84. [PMID: 16622615 DOI: 10.1007/s11239-006-4663-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Hussain Isma'eel
- American University of Beirut Medical Center, P.O. Box: 11- 0236/A19, Riad El Solh, 11072020, Beirut, Lebanon
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Arnaout MS, Almahmeed W, Ibrahim M, Ker J, Khalil MT, Van Wyk CT, Mancia G, Al Mousa E. Hypertension and its management in countries in Africa and the Middle East, with special reference to the place of β-blockade. Curr Med Res Opin 2011; 27:1223-36. [PMID: 21504302 DOI: 10.1185/03007995.2011.576239] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The prevalence and clinical consequences of hypertension in countries in Africa and the Middle East have not been studied as well as in other regions. SCOPE We have reviewed the literature on the epidemiology and management of hypertension and related cardiovascular complications in countries within Africa and the Middle East. A PubMed search for countries in the region and 'hypertension' was supplemented by articles identified from reviews, and by literature suggested by the authors. FINDINGS The prevalence of hypertension is >20% in some countries in the Middle East and Africa, despite an average population age that is some 10-15 years lower than those of developed countries. Hypertension in these countries is associated with an increased risk of cardiovascular risk factors and cardiovascular disease, as elsewhere. Awareness rates of hypertension are low. Hypertension and its complications are undertreated, and mortality rates from cardiovascular disease are higher than in developed countries. CONCLUSION Available resources should be brought to bear on the management of hypertension in these countries. In particular, a recent downgrading of the importance of β-blockers in hypertension management guidelines needs to be reassessed. These agents are as effective as other antihypertensive classes both on blood pressures and on cardiovascular event rates. General concerns over an increased rate of new-onset diabetes with β-blockers have been overstated, although these agents should be avoided in metabolic syndrome.
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Affiliation(s)
- M Samir Arnaout
- American University of Beirut Medical Center, Department of Internal Medicine, Division of Cardiology, Beirut, Lebanon.
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Isma'eel H, Shamseddeen W, El Khoury M, Dimassi A, Nasrallah A, Arnaout MS. Diabetes supersedes dobutamine stress echocardiography in predicting cardiac events in female patients. CLIN EXP OBSTET GYN 2010; 37:197-200. [PMID: 21077524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
BACKGROUND The many available choices for testing for coronary artery disease (CAD) brought about several questions regarding suitability of certain tests for different groups of patients and the prognostic value of obtained results in predicting events and mortality. The aim of this study is to describe the prognostic value of dobutamine stress echocardiography (DSE) results in predicting cardiac events and mortality in > or = 60-year-old females. METHODS 49 women (> or = 60 years old) who were referred for DSE were included in the study. Data including CAD risk factors, and results of tests and a follow-up of events (MI, unstable angina, progression of CHF) and death. RESULTS Eleven patients were considered to have a positive DSE result. There was no difference between DSE (+) and DSE (-) patients in cardiac events and cardiac death. However when interventions were included to events, analysis showed DSE (+) to have more overall events. Non-cardiac deaths and "all deaths" were 11 and 8 times more common among DSE (+) patients compared with DSE (-) patients p < 0.01. Multivariable logistic regression showed that diabetics and DSE (+) patients were 32 (p = 0.01) and 23 (p = 0.02) times more likely to have an event compared with non-diabetics and DSE (-) patients, respectively. CONCLUSION DSE is a safe procedure to be used in > or = 60-year-old female patients and can provide informative prognostic information regarding all-cause deaths and cardiac events (including interventions) over a 4-year period. In addition we find that diabetes is a strong predictor of events regardless of DSE result.
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Affiliation(s)
- H Isma'eel
- Division of Cardiology, Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
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Abstract
BACKGROUND The putative theory is that the clinical syndrome of unstable angina is caused by rupture of the atherosclerotic plaque with superimposed thrombus formation. It is characterized by angiographically complex coronary lesions in the majority of patients. HYPOTHESIS This study aimed at assessing the correlation between C-reactive protein (CRP) and the complexity of culprit coronary lesions in unstable angina. METHODS We identified culprit lesion complexity in 96 patients with unstable angina and normal creatine kinase (CK) and CK-MB mass. Serum concentrations of CRP (N < 5.0 mg/l) and cardiac troponin T (cTnT; N < 0.1 ng/ml) were measured on admission. RESULTS There was a trend toward a higher grade of anatomical complexity of the culprit lesion in patients with elevated CRP (p = 0.007) and cTnT levels (p = 0.027). Patients who had intermediate- or high-grade lesion severity had a higher level of CRP (8.5 +/- 5.7 mg/l) and cTnT (0.118 +/- 0.205 ng/ml) on admission than those who had normal or low-grade lesions (5.7 +/- 4.0 mg/l, 0.017 +/- 0.021 ng/ml, respectively); Mann-Whitney U, p = 0.002 and p < 0.001, respectively. Furthermore, the likelihood of having intermediate- or high-grade complexity of the culprit lesion was higher when CRP levels were elevated in all patients (p = 0.007, odds ratio [OR] = 4.286; 95% confidence interval [CI] 1.492-12.310) and in those with normal cTnT levels (p = 0.025, OR = 3.876; 95% CI 1.185-12.678). Also, higher CRP levels strongly correlated with the need for revascularization interventions (p < 0.0005). CONCLUSION Elevated CRP level on admission is a marker for anatomic complexity of culprit lesions and need for revascularization interventions in unstable angina.
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Affiliation(s)
- G V Moukarbel
- Department of Internal Medicine, American University of Beirut, Lebanon
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Isma'eel H, Zebian R, El-Accaoui R, Dimassi A, Rashid K, Alam S, Taher A, Khoury M, Arnaout MS. Anticoagulation clinics are needed in developing countries. Int J Cardiol 2007; 115:410-1. [PMID: 16757043 DOI: 10.1016/j.ijcard.2006.04.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2006] [Accepted: 04/26/2006] [Indexed: 11/18/2022]
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Isma'eel H, Abdelbaki K, Obeid M, Arnaout MS. Prevalence of variety of cardiac tumors presenting to tertiary care center in Eastern Mediterranean area over 21 years. Int J Cardiol 2007; 114:121-2. [PMID: 16352353 DOI: 10.1016/j.ijcard.2005.11.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2005] [Accepted: 11/05/2005] [Indexed: 11/28/2022]
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Abstract
We are reporting a case of Pemphigus vulgaris with extensive thrombosis of deep veins, pulmonary veins, and cardiac chambers complicated by myocardial infarction. The extensive skin lesions prohibited the administration of thrombolytics and coronary intervention. The patient was treated conservatively with heparin, and oral anticoagulation in addition to steroids and cyclosporine with significant resolution of thrombosis.
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Affiliation(s)
- M Samir Arnaout
- Division of Cardiology, American University of Beirut- Medical Center, P.O Box: 11-0236/A19, Riad El Solh, 11072020 Beirut, Lebanon.
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Isma'eel H, Arnaout MS, Shamseddeen W, Mahfouz R, Zeineh N, Jradi O, Taher A. Screening for inherited thrombophilia might be warranted among Eastern Mediterranean sickle-beta-0 thalassemia patients. J Thromb Thrombolysis 2006; 22:121-3. [PMID: 17008978 DOI: 10.1007/s11239-006-8953-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The role of genetic thrombophilia in the development of both micro and macro vascular complications in patients with hemoglobinopathies (Sickle cell disease and thalassemia) have been investigated with some studies negating its role while others suggesting it. Lebanon is known to harbor sickle cell disease, thalassemia and sickle beta-thalassemia hemoglobinopathy patients along with a documented high prevalence of genetic thrombophilia mutations. METHODS Twelve sickle beta-0-thalassemia patients with no pervious history of thrombotic events were selected. These patients underwent a physical examination with history, echo Doppler, along with blood withdrawal for complete blood count and PCR analysis of a sample of DNA for Factor V Leiden G1691A, Factor II G20210A, and MTHFR C677T. Results were compared to a historical control of 50 Lebanese controls and 50 LebaneseThalassemia Intermedia (TI) patients. RESULTS The results showed that 42%, 59%, and 8% of patients carried heterozygous Factor V Leiden, abnormal (homozygous & heterozygous) MTHFR, and heterozygous Factor II mutations respectively. The sickle-thalassemia patients were 5.24 and 4.39 times more likely to have Factor V Leiden as compared to the normal controls and TI patients respectively (p < 0.05). DISCUSSION The increased prevalence of more than one prothrombotic genetic mutation among the group indicates a probable clustering phenomenon, unknown to us to which the high consanguinity rate (77%) may have contributed. The role of the specific MTHFR and Factor V Leiden double heterozygous combination in incidence, recurrence, and guidance of duration of therapy in VTE is not well defined in the literature despite the recognized higher risk of thrombosis among this patient population. Our findings suggest that genetic thrombophilia workup is necessary in patients with sickle-beta zero thalassemia presenting with thrombotic events and studies that include a larger number of patients are necessary in order to define specific guidelines.
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Isma'eel H, El Accaoui R, Shamseddeen W, Taher A, Alam S, Mahfouz R, Arnaout MS. Genetic thrombophilia in patients with VTE in eastern Mediterranean located tertiary care center; is it time to change the algorithm for thrombophilia work up decision making? J Thromb Thrombolysis 2006; 21:267-70. [PMID: 16683219 DOI: 10.1007/s11239-006-5537-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Genetic thrombophilia work up performance is subject to debate because of the utility of the information it provides regarding prognosis of recurrence of venous thromboembolism (VTE) and guidance of duration of therapy with anticoagulation. Certain algorithms have been locally developed to guide decision making process to increase the yield of thrombophilia work up. These algorithms are not based on locally derived data. Data from the Eastern Mediterranean area (Lebanon) have shown high prevalence of thrombophilia mutations. Therefore the aim of this study was to describe the experience of a tertiary care center in thrombophilia work up among patients diagnosed with VTE. METHODS A retrospective chart analysis of the cases diagnosed with pulmonary embolism or deep venous thrombosis with radiological confirmation. RESULTS A total of 133 patients' charts were reviewed, 27 patients had thrombophilia work up performed, 56% had heterozygous MTHFR mutation, 44% were heterozygous for the Factor V Leiden mutation and 3.2% were found to have Factor II heterozygous mutations, and a total of 33.3% of patients had more than one genetic mutation. The common causes of provoked VTE were 59.53% malignancy, 22.64% post surgery, 12.98% bed ridden patients, and 4.85% oral contraceptive pills. Only 14% of patients with a malignancy who presented with VTE where receiving prophylactic heparin. DISCUSSION Doubly heterozygous prothrombotic genetic mutations are commonly present among Eastern Mediterranean patients with VTE. A prospective study to determine the predictive (negative and positive) power of the currently followed algorithm for genetic thrombophilia work up remains of significant importance. Stressing the favorable role of VTE prophylaxis among patients suffering from malignancies remains a target for raising awareness among oncologists.
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Affiliation(s)
- H Isma'eel
- American University of Beirut Medical Center, Beirut, Lebanon
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Isma'eel H, Taher A, Shamseddeen W, Khoury M, Gharzuddine W, Arnaout MS, Alam S. SAECG parameters and left ventricular chamber sizes: lesson from anemia conditions in thalassemia major patients. Int J Cardiol 2006; 113:E102-4. [PMID: 16887209 DOI: 10.1016/j.ijcard.2006.06.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2006] [Accepted: 06/02/2006] [Indexed: 11/16/2022]
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Arnaout MS, Khalil A, Alam SE. Influence of angiotensin converting enzyme inhibitors on stable myocardial ischemia in menopausal cardiac patients. CLIN EXP OBSTET GYN 2003; 30:43-6. [PMID: 12731744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
PURPOSE OF INVESTIGATION OBJECTIVE The aim of the study was to investigate the influence of angiotensin converting enzyme inhibitor (Captopril) on stable demand ischemia in menopausal cardiac female patients. METHODS In a prospective non-randomized evaluation of the effect of angiotensin converting enzymes inhibitors (ACE-I) (Captopril) on demand myocardial ischemia, 16 normotensive menopause female patients, mean age of 52 years with stable angina and known coronary artery disease (CAD) but normal left ventricular function, underwent a treadmill exercise test (Bruce Protocol), at baseline (T1) and one week following (50-75 mg) a daily dose of Captopril (CAPT2). Onset of symptoms, duration of exercise, magnitude of peak ST depression and homodynamic parameters were monitored. RESULTS Captopril significantly increased the duration of exercise from (467 +/- 169 to 536 +/- 145 seconds, (p value < 0.02), but with increased peak of ST segment depression (from -1.4 +/- 0.6 mm to -1.93 +/- 1.2 mm, p value < 0.15). The double product remained unchanged (251 x 103 +/- 55 in T1 and 248 x 103 +/- 55 in CAPT2; the p value was < 0.8. All adverse effects on the treadmill were noted. CONCLUSION Although captopril tends to significantly effect prolongation of exercise time, there is no amelioration of the markers of ischemia.
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Affiliation(s)
- M S Arnaout
- Department of Internal Medicine (Cardiology Division), American University of Beirut-Medical Center, Beirut, Lebanon
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Abstract
A 30-year-old white man with schizophrenia developed anorexia and nausea, and was admitted to hospital for confusion and delirium. He was on olanzapine, 10 days prior to admission. On admission, typical neuroleptic malignant syndrome (NMS) developed with elevated body temperature (39.7 degrees C), obtundation, tremor, rigidity, diaphoresis, fluctuating pupillary diameter, tachycardia, labile hypertension, elevated serum creatine kinase and severe hypernatremia (190 meq/l). Olanzepine was stopped few days after admission to the hospital and the NMS manifestations resolved by hospital day 12. The patient had all of the major manifestations of NMS. There was no other likely explanation for his illness. This is the first case reported in which NMS was associated with olanzapine and extremely elevated levels of serum sodium. Copyright 2001 John Wiley & Sons, Ltd.
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Affiliation(s)
- M. Samir Arnaout
- Department of Internal Medicine, American University of Beirut-Medical Centre, Beirut-Lebanon
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Shabb B, Arnaout MS. Thombosed mechanical heart valve prosthesis in the mitral position. Ann Thorac Surg 2000; 70:1448-9. [PMID: 11081929 DOI: 10.1016/s0003-4975(00)01959-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Abstract
Ampullary tumors can occasionally ulcerate and present as frank gastrointestinal bleeding. The most common clinical presentation is jaundice like in other tumors of the biliary tree. We report on a 68-year-old man who presented with severe upper gastrointestinal hemorrhage secondary to an asymptomatic mass of the ampulla of Vater. An endoscopic biopsy specimen revealed a villous adenoma with moderate dysplasia. A curative resection was performed, and pathological work-up revealed the presence of an infiltrating, moderately differentiated ampullary adenocarcinoma.
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Affiliation(s)
- K Ashkar
- Department of Family Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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Arnaout MS, Kazma H, Khalil A, Shasha N, Nasrallah A, Karam K, Alam SE. Is there a safe anticoagulation protocol for pregnant women with prosthetic valves? CLIN EXP OBSTET GYN 1998; 25:101-4. [PMID: 9856311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
We studied the outcome of 41 pregnancies in an attempt to identify an appropriate and safe anticoagulant regimen for pregnant women with cardiac valve prosthesis. The cumulative number of events: (neonatal death, premature deliveries, intrauterine fetal death and spontaneous abortion) was 66.6%, 20%, 12.5% and 20% in the Coumadin, Fraxiparine, Heparin and porcine valve groups, respectively. We conclude that in pregnant women with mechanical heart valves, low molecular weight heparin therapy is a superior strategy compared to warfarin.
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Affiliation(s)
- M S Arnaout
- Department of Internal Medicine, American University of Beirut, Medical Centre, Lebanon
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