Prognostic Role of Preoperative Tricuspid Annular Plane Systolic Excursion (TAPSE) in Mitral Valve Replacement (MVR) for Rheumatic Mitral Stenosis Patients

Tricuspid annular plane systolic excursion has been proposed as a simple and reproducible parameter for quantitative assessment of the right ventricular ejection fraction. The prognostic importance of preoperative TAPSE in patients with mitral valve replacement for rheumatic mitral stenosis patients is still under focused. Therefore, the objective of the study was to predict the outcome after MVR in rheumatic mitral stenosis patients in relation to preoperative TAPSE. This comparative cross-sectional study was conducted at the Department of Cardiac Surgery, National Heart Foundation Hospital and Research Institute. A total of 72 patients of rheumatic mitral stenosis patients who underwent mitral valve replacement were included in the study. They were divided into two groups: Group A and B. Group A included 36 patients with TAPSE 0.05) except for the preoperative TAPSE. Mean TAPSE of Group A was 13.17 (±1.40) and Group B was 18.61 (±1.57), the difference was statistically significant (p 0.05). Among the postoperative complications, including postoperative atrial fibrillation was higher in Group A (30.56%) than Group B (11.11%), mean ventilation time was higher in Group A (27.78%) than Group B (5.56%), length of intensive care was higher in Group A (33.33%) than Group B (11.12%), and hospital stay was higher in Group A (25.0%) than Group B (5.56%), (p < 0.05). Higher preoperative TASPE could be used as a prognostic tool for MVR in rheumatic mitral stenosis patients in our settings.

Univariate Risk Factors for Prolonged Mechanical Ventilation in Patients Undergoing Prosthetic Heart Valves Replacement Surgery

Data from 736 patients undergoing prosthetic heart valve replacement surgery and concomitant surgery （combined surgery） from January 1998 to January 2004 at Union Hospital were retrospectively reviewed. Univariate logistic regression analyses were conducted to identity risk factors for prolonged mechanical ventilation. The results showed that prolonged cardiopulmonary bypass duration, prolonged aortic cross clamp time and low ejection fraction less than 50 percent （50 %） were found to be independent predictors for prolonged mechanical ventilation. Meanwhile age, weight, and preoperative hospital stay （days） were not found to be associated with prolonged mechanical ventilation. It was concluded that. for age and weight, this might be due to the lower number of old age patients （70 years and above） included in our study and genetic body structure of majority Chinese population that favor them to be in normal weight, respectively.

The Effects of Lower Intensity Anticoagulation Therapy on Coagulation System in Patients With Mechanical Prosthetic Valves

Summary: To evaluate the effect of lower intensity anticoagulation therapy in patients with mechanical prosthetic valves, laboratory based hematological assays including prothrombin time (PT), activity of factor X, antithrombin Ⅲ (AT Ⅲ), D dimer, fibrinogen (Fg) and platel et al pha granular membrane protein (GMP 140) were performed in 65 patients who had been on warfarin treatment for over one month. The patients were assigned to 3 groups on the basis of their International Normalized Ratios (INR), ranging from 2.00 to 2.50; 2.51 to 3.00; 3.01 to 4.50, respectively. The results showed that the D dimer, Fg, GMP 140 levels were higher after mechanical valve replacement than those before operation, indicating the activation of coagulation and fibrinolysis system and the damage of platelets. Lower intensity anticoagulation therapy (INR 2 00 to 2.50) could effectively inhibit the activity of factor X and increase the level of AT Ⅲ. There were no appreciable differences among D dimer, Fg, GMP 140 and AT Ⅲ in the 3 anticoagulation intensity groups. These results suggest that in patients with new generation mechanical prosthetic valves, target anticoagulation level (INR 2 00 to 2.50) may result in good protection from thrombo embolism.

Importance of concomitant functional mitral regurgitation on survival in severe aortic stenosis patients undergoing aortic valve replacement

BACKGROUND Mitral regurgitation(MR)is commonly seen in patients with severe aortic stenosis(AS)undergoing aortic valve replacement(AVR).But the long-term implications of MR in AS are unknown.AIM To investigate MR’s impact on survival of patients undergoing surgical AVR for severe AS.METHODS Of the 740 consecutive patients with severe AS evaluated between 1993 and 2003,287 underwent AVR forming the study cohort.They were followed up to death or till the end of 2019.Chart reviews were performed for clinical,echocardiographic,and therapeutic data.MR was graded on a 1-4 scale.Mortality data was obtained from chart review and the Social Security Death Index.Survival was analyzed as a function of degree of MR.RESULTS The mean age of the severe AS patients who had AVR(n=287)was 72±13 years,46%women.Over up to 26 years of follow up,there were 201(70%)deaths,giving deep insights into the determinants of survival of severe AS who had AVR.The 5,10 and 20 years survival rates were 75%,45%and 25%respectively.Presence of MR was associated with higher mortality in a graded fashion(P=0.0003).MR was significantly associated with lower left ventricular(LV)ejection fraction and larger LV size.Impact of MR on mortality was partially mediated through lower LV ejection fraction and larger LV size.By Cox regression,MR,lower ejection fraction(EF)and larger LV end-systolic dimension were independent predictors of higher mortality(χ^(2)=33.2).CONCLUSION Presence of greater than 2+MR in patients with severe AS is independently associated with reduced survival in surgically managed patients,an effect incremental to reduced EF and larger LV size.We suggest that aortic valve intervention should be considered in severe AS patients when>2+MR occurs irrespective of EF or symptoms.

Echocardiographic Monitoring of Cardiac Parameters after Mitral Valve Replacement with the Preservation of Subvalvular Structures

To date many monitoring techniques have been used to determine the efficacy of surgical correction of mitral valve disease. The most common non-invasive method in use is echocardiography which can assess the myocardial and mitral valve function changes after mitral valve replacement procedures. In this study, we investigated the five-year follow-up echocardiographic results of 143 patients undergoing mitral valve replacement with preservation of subvalvular apparatus to analyze the recovery of myocardial and mitral valve functions.

INFLUENCE OF MIMIC CARDIAC RATE ON HYDRODYNAMICS OF DIFFERENT MECHANICAL PROSTHETIC CARDIAC VALVES IN VITRO

Objective To assess the influence of mimic cardiac rate on hydrodynamics of different mechanical prosthetic cardiac valves. Methods US-made CarboMedics bileaflet valve, China-made Jiuling bileaflet valve and C-L tilting disc valve were tested via a pulsatile flow simulator in the aortic position. Testing conditions were set at mimic cardiac rates of 55 bpm, 75 bpm, 100 bpm with a constant mimic cardiac output of 4 L/min. The mean pressure differences (ΔP), leakage volumes (LEV) and closing volumes (CLV) across each valve, and effective orifice areas (EOA) were analyzed. Results Within physiological range, ΔP, LEV, and CLV decreased as mimic cardiac rate increased, with a large extent of variance. EOA increased along with an increase in mimic cardiac rate. It was a different response in terms of cardiac rate alteration for different types of mechanical prosthetic cardiac valves. Conclusion Mimic cardiac rate change affects hydrodynamics of mechanical prosthetic cardiac valves. Within physiological range, the hydrodynamic of prosthetic bileaflet valve is better than that of tilting disc valve.

Noninvasive Assessment of Cardiac Index with Transesophageal Echocardiography in Patients Undergoing Mitral Valve Replacement: A Comparison between Determinations at the Mitral Valve and the Ascending Aorta

Methods: Sixteen patients with American Society of Anesthesiologists status (ASA) II-III, age ≤ 70 yr, male or female, preoperatively NYHA II-III and EF ≥ 45%, scheduled for mitral valve replacement (MVR) were studied. Complete intravenous general anesthesia was used for induction and anesthesia maintenance. After anesthesia induction we put the TEE probe into the esophagus. The cardiac index was determined at three periods following MVR: T1 30 minutes later following cessation of bypass, T2 60 minutes after cessation of bypass, T3 90 minutes after cessation of bypass. Statistical analysis was made with the Bland and Altman method. Results: Ninety-six measurements were compared. The cardiac index values at the level of prosthesis mitral valve (CIMV) ranged from 1.3 to 5.5 L·min-1·m-2 (mean 2.6 ± 0.9). The Values of cardiac index at aortic valve (CIAA) ranged from 2.7 to8.8 L·min-1·m-2 (mean 4.9 ± 1.7). Bias was -2.3 L·min-1·m-2 and limits of agreement -5.6 to 1.0 L·min-1·m-2. Conclusion: During mitral valve replacement, doubtful correlations were observed between values of cardiac index at the mitral valve and the ascending aorta using TEE.

Role of thrombus precursor protein in assessment of anticoagulation in patients with atrial fibrillation after mechanical heart valve replacement

Objective: To explore the role of thrombus precursor protein (TpP) in assessment of anticoagulation and predict the risk of thromboembolism in the patients with atrial fibrillation (AF) after mechanical heart valve replacement. Methods: TpP plasma concentration and international normalization ratio (INR) were measured in 45 patients with atrial fibrillation and 45 patients with sinus rhythm both after mechanical heart valve replacement. Twenty patients with non valvular heart diseases were selected as the control. Furthermore, the patients with AF were divided into groups based on different TpP plasma concentration and TpP plasma concentration and INR were analyzed. Results: After mechanical heart valve replacement, those with AF had higher TpP plasma concentration than those with sinus rhythm. It was found that discordancy existed between INR and TpP plasma concentration in the patients with AF. There were 28 AF patients with TpP plasma concentration lower than 6 μg/ml and without bleeding, who might be at the optimal anticoagulant state. The 95% confidence of the mean INR value was 1.90-2.30 in these patients and TpP plasma concentration was between 2.84-5.74 μg/ml. Conclusion: Patients with AF might face higher risk of thromboembolism after mechanical valve replacement; INR between 1.90-2.30 and TpP plasma concentration between 2.84-6 μg/ml might be the optimal anticoagulant range for patients with AF after mechanical valve replacement.

Successful Tavi in Patients with Previous Mitral Valve Replacement

Background: Transcatheter aortic valve implantation (TAVI) is a new method for patients with severe aortic stenosis at high surgical risk, such as previous cardiac surgery. The presence of mechanical mitral prosthesis might complicate TAVI because of possible interference between both prostheses. Some reports have already demonstrated the feasibility of TAVI in such patients. Case Reports: We report 2 patients with severe symptomatic aortic stenosis who had prior mitral valve replacement that successfully underwent TAVI with Edwards Sapien and CoreValve aortic prosthesis, re- spectively. Computed tomographic angiography (CTA) was useful for the assessment of the distance between both aor- tic and mitral prosthesis annuli. Transesophageal echocardiography was crucial for precise positioning of TAV. There were no special technical tips besides precise positioning of the valve prosthesis. In case of Core Valve the goal was the positioning at “zero point” and in case of Edwards Sapien valve a “half-on-half” position according to natural aortic valve. We observed no deformation or dysfunction of aortic and mitral prosthesis in any of the patients. Balloon valvu- loplasty prior to implantation helps to observe the mutual effect of the new aortic valve and pre-existent mitral prosthe- sis. Conclusions: We conclude that TAVI can be safely and successfully performed in patients with mechanical mitral prosthesis carefully considering the altered anatomical conditions. Skillfulness and TAVI experience of the operators should not be neglected.

Isolated mitral valve replacement with Guangdong-Ⅰ porcine bioprostheses in rheumatic heart valve disease: analysis of 166 cases with long-term follow-up

Objective To study the long-term effects of mitral valve replacement with bioprostheses in rheumatic heart valve disease. Methods 166 patients with rheumatic heart valve disease underwent isolated mitral valve replacement from Jan. 1978 to Dec. 1985. 79 Patients were male and 87 female. Patients’ age ranged from 11 to 53 years [mean (29.4 ± 9.9) years]. The patients were classified into two groups: group 1 (age【 30 years) included 84 patients, group 2 (age≥30 years) 82 cases. Mean CTR is 0.68 *0.08. Most patients were in NYHA function class Ⅲ-Ⅳ. 76. 3% of patients had atrial fibrillation. 6 patients had pre-operative cerebral vascular accidents. Postoperative deaths were excluded. Follow-up extended from 0.4 year to 19.4 years. Results Actuarial estimate of survival rate at 14 years is (52.5 ± 7.0)%. Heart function was improved to class Ⅰ - Ⅱ in most of patients. Late structural valve deterioration occurred in 89 patients. Among them, 59 were re-operated. Actuarial estimate of freedom from

A novel case of transcatheter mitral valve-in-valve replacement using Mi-thos^TM system

Transcatheter mitral valve replacement(TMVR)has become an alternative to surgical mitral valve replacement for the treatment of patients with severe mitral insufficiency(MI)who are at very high or prohibitive surgical risk.[1]Because of impaired left ventricular dysfunction and previous cardiac surgery,some aged patients with degenerated bioprosthetic mitral valve and mitral regurgitation were refused to redo surgery.[2]Increasing demand are required for minimally invasive treatment of these patients.Hundreds of patients worldwide have been treated with a transcatheter mitral valve-in-ring or valve-in-valve procedure using transcatheter aortic valve.[3]However,rare case of transcatheter mitral valve-in-valve/ring replacement using transcatheter mitral valve system was reported.Here,we reported a successfully case of transcatheter mitral“valve-in-valve”replacement for the treatment of bioprosthetic mitral valve degeneration and severe regurgitation with domestic Mithos^TM valve.

Combined Low-dose Aspirin and Warfarin Anticoagulant Therapy of Postoperative Atrial Fibrillation Following Mechanical Heart Valve Replacement

The safety and efficacy of combined low dose aspirin and warfarin therapy in patients with atrial fibrillation after mechanical heart valve replacement were evaluated. A total of 1016 patients （620 females, mean age of 36.8-4-7.7 years） admitted for cardiac valve replacement and complicated with atrial fibrillation after surgery were randomly divided into study （warfarin plus 75-100 mg aspirin） or control （warfarin only） groups. International normalized ratio （INR） and prothrombin time were main- tained at 1.8-2.5 and 1.5-2.0 times the normal values, respectively. Thromboembolic events and major bleedings were registered during the follow-up period. Patients were followed up for 24±9 months. The average dose of warfarin in the study and control groups was 2.91±0.83 mg and 2.88±0.76 mg, respec- tively （P〉0.05）. The incidence of overall thromboembolic events in study group was lower than that in control group （2.16% vs. 4.35%, P=0.049）. No statistically significant differences were found in hem- orrhage events （3.53% vs. 3.95%, P=-0.722） or mortality （0.20% vs. 0.40%, P=0.559） between the two groups. Combined low dose aspirin and warfarin therapy in the patients with atrial fibrillation following mechanical heart valve replacement significantly decreased thromboembolic events as compared with warfarin therapy alone. This combined treatment was not associated with an increase in the risk of major bleeding or mortality.

Left atrial thrombosis in an anticoagulated patient after bioprosthetic valve replacement:Report of a case

We present the case of a 74 year old woman suffering from severe mitral valve incompetence and rapid atrial fibrillation. After an appropriate vitamin K antagonist(VKA) therapy, the patient underwent mitral valve replacement by bioprosthesis. Then, the patient was rehospitalized for jaundice. Suspecting hepatotoxicity, VKA was discontinued and fondaparinux was started. During this treatment, the patient developed a symptomatic atrial thrombus. After exclusion of a hepatic disease, VKA was re-established with hemodynamic and liver enzymes normalization and atrial thrombus resolution. Caution has to be used when considering fondaparinux as an alternative strategy to VKA in patients with multiple thrombotic risk factors.

Anticoagulation early after mechanical heart valve replacement

Objective： To explore the changes of coagulation activity and the characters of anticoagulation early after mechanical heart valve replacement. Methods： All patients only took warfarin orally for anticoagulation. The predicted international normalized ratio （INR） was 1.5 to 2.0. Several coagulation markers were monitored early after valve replacement. Complications associated with anticoagulation were recorded and analyzed. The patients were divided into three groups based on the number and position of mechanical valve prothesis, including group M （mitral valve replacement）, group A （aortic valve replacement） and group D （mitral and aortic valve replacement）.Comparison was made between the three groups. Results： Three events of mild cerebral embolism and five events of mild bleeding occurred during the early postoperative period. One patient suffered from mild cerebral embolism on the 4th day after operation, accompanied by large volume of pericardial drainage. Two patients with bleeding had lower INRs than predicted range. However, INR in one patient with mild cerebral embolism was in the predicted range. There was no significant difference in thrombo time （TT）, activated partial thromboplastin time （APTT） and 1NR on the 3rd day after operation compared to those before operation; meanwhile, plasma fibrinogen （FIB） concentration was higher than that before operation （P〈0.05）. 1NR had no significant changes on the 2nd day after the beginning of anticoagulation compared to that before operation; however, 1NR was significantly elevated on the 4th day （P〈0.05）. Warfarin doses and INRs were similar among the three groups, but FIB concentrations in plasma were higher in groups M and D than in group A （P〈0.01）. Conclusion： Hypercoagulabale state exists early after mechanical heart valve replacement. When anticoagulation begins is determined by the change of coagulation markers, not by the volume of chest or pericardial drainage. INR can not accurately reflect the coagulation state sometimes, especially during the first 3 days after anticoagulation. The number and position of mechanical valve prothesis could affect coagulation state. Therefore, anticoagulation therapy should be regulated accordingly.

Early Results of Mitral Valve Replacement in Severe Pulmonary Artery Hypertension—An Institutional Prospective Study

Introduction: In patients undergoing surgery for mitral valve replacement (MVR) for valvular heart disease, pulmonary artery hypertension (PAH) has been considered a major risk factor. In this prospective study, we have studied the early hemodynamic changes and post-operative outcomes of MVR among patients with severe PAH. Methods: 68 consecutive patients who underwent mitral valve replacement for severe rheumatic mitral valve disease with severe PAH (pulmonary artery pressure (PAP) > 50 mmHg) were studied prospectively for immediate postoperative hemodynamics and outcomes. The mean age of the patients was 32.1 years. 32 (47.05%) patients had mitral stenosis, 13 (19.11%) had mitral regurgitation and 23 (33.82%) had mixed lesions. Patients were divided into two groups based on preoperative pulmonary artery pressures. In 56 patients (82.35%, group I) PAP was sub-systemic or systemic, with a mean of 58.4 mmHg. Twelve patients (17.65%, group II) had supra-systemic PAP with a mean of 82.4 mmHg. Results: After mitral valve replacement, the PAP and pulmonary vascular resistance (PVR) decreased significantly in group I to near normal levels. In group II also the PAP and PVR decreased significantly but significant residual PAH remained. Operative mortality was 3.5% in group I and 16.6% in group II. Conclusions: MVR is safe and effective at the presence of severe PAH as long as the PAP is below or equal to systemic pressures. With suprasystemic PAP, MVR carries a high risk of mortality and the patient continues to have severe PAH in the postoperative period.

Impact of prosthesis-patient mismatch on early and late outcomes after mitral valve replacement:a meta-analysis

Background Prognostic significance of prosthesis-patient mismatch(PPM)after mitral valve replacement(MVR)remains uncertain because of the limited studies reporting inconsistent or even contrary results.This meta-analysis pooled results of all available studies comparing early and late prognoses between patients with significant mitral PPM and those without.Methods Studies were identified by searching Pubmed,Excerpta Medica Database,Cochrane Central Register of Controlled Trials,and Clinical Trials.gov.Impact of PPM on postoperative hemodynamic results,thirty-day mortality,overall mortality,mortality of thirty-day survivors,and primary morbidity after MVR was evaluated via meta-analysis.Robustness of pooled estimates,source of heterogeneity,and publication bias were assessed via sensitivity analyses,meta-regression as well as subgroup analysis stratified according to methodological or clinical heterogeneity,or sequential omission method,and funnel plot or Begg's and Egger's tests,respectively.Results Nineteen cohort studies involving 9302 individuals(PPM group:n=5109,Control group:n=4193)were included for meta-analysis.Total PPM and severe PPM prevalence were 3.8%–85.9%and 1%–27%,with a mean value of 54.9%and 14.1%,respectively.As compared with control group,mitral PPM group demonstrated a poorer postoperative hemodynamic status of higher mean and peak residual transprosthetic pressure gradients(TPG),higher postoperative systolic pulmonary artery pressure(SPAP)and less reduction,higher postoperative pulmonary hypertension(PH)prevalence and less PH regression,smaller net atrioventricular compliance,less NYHA class decrease,higher postoperative functional tricuspid regurgitation prevalence and less regression.The PPM group also revealed a higher thirty-day mortality,long-term overall mortality,mortality of thirty-day survivors,and postoperative congestive heart failure prevalence,which were positively correlated with the severity of PPM if it was classified into tri-level subgroups.Left ventricular end-diastolic diameter,postoperative atrial fibrillation(AF)prevalence,and the AF regression were analogous between groups.Most pooled estimates were robust according to sensitivity analyses.Male patients and bioprosthesis implantation proportion were prominent source of between-study heterogeneity on thirty-day mortality.Publication bias was not significant in tests for all the outcomes,except for SPAP and TPG.Conclusions Mitral PPM would result in poorer postoperative hemodynamics and worse early and late prognosis.Severe PPM must be avoided since deleterious impact of mitral PPM was severity dependent.

Early Postoperative Anticoagulation by Enoxaparin after Mechanical Aortic Valve Replacement

Background: The use of low molecular weight heparin for early anticoagulation after mechanical aortic valve replacement is still a matter of debate even more that the early postoperative phase is associated with maximum of thrombo-embolic and bleeding risks. The objective of this study is to verify the efficacy and the safety of low molecular weight heparin for the early anticoagulation after mechanical aortic valve replacement. Methods and Results: It is a prospective study conducted over 6 months and interested 40 consecutive patients (32 male and 8 female) with a mean age 53.83 ± 16.93 years (19-75 years) who underwent a mechanical aortic valve replacement and received enoxaparin as bridging therapy between continuous unfractionated heparin and fully effective vitamin K antagonist therapy. There was no in-hospital death and no in-hospital thromboembolic events. We report 2 major bleeding events (5%). Conclusion: The use of low molecular weight heparin should be an alternative to explore for early anticoagulation after valve heart surgery and the results of our study must be verified by large randomized studies before drawing any hasty conclusions.

Takotsubo cardiomyopathy complicating transcatheter mitral valve-in-valve replacement

A 73-year-old female presented with symp-tomatic heart failure(NYHA class Ⅲ)due to a failed 29-mm Sorin(St.Jude Medical,St.Paul,MN)bioprosthetic heart valve surgically implanted 10-year before for severe primary mitral valve regurgitation(flail of the anterior mitral leaf-let at A2 scallop).Preprocedural echocardiography showed preserved left ventricular function with severe bioprosthetic valve stenosis and concomit-ant moderate regurgitation(Video 1 in Supplement).Because of prohibitive surgical risk,a transeptal mitral valve-in-valve(ViV)replacement was planned.

Ventricular Septal Defect after Blunt Trauma in a Case of Preexisting Prosthetic Mitral Valve

We present a case of an isolated large ventricular septal defect (VSD) following blunt chest trauma in a motor vehicle accident in the patient with preexisting mechanical mitral valve. Transthoracic echocardiography revealed a large muscular VSD with significant left to right shunt along with septal edema. Surgical repair was performed in view of Qp:Qs of 2.5 with significant hemodynamic instability despite intra-aortic balloon pump. The ventricular septal defect was found in apical muscular portion of the interventricular septum, which was closed through left ventriculotomy. We here discuss the possible mechanisms of damage and importance of timely surgery. To conclude, minor looking external injury might contain devastating damage inside, especially with patients on anti-coagulant therapy.

Thrombus precursor protein for monitoring anticoagulation in patients with mechanical valve prosthesis

Objective: To evaluate the plasma concentration of thrombus precursor protein (TPP) in patients after mechanical heart valve replacement, and to explore whether it can be used as a marker for monitoring anticoagulation. Methods: Totally 60 patients who took warfarin after mitral valve replacement and 20 control patients with non-valvular heart diseases were subjected in this study. Their plasma TPP concentration and international normalized ratio (INR) were determined, and compared not only between the anticoagulant patients and the control patients, but also between the patients with atrial fibrillaiton (AF, n=37) and the patients with sinus rhythm (SR, n=23) after mechanical valve replacement. The relationship between plasma TPP concentration and INR in the 60 anticoagulant patients was analyzed with linear regression. Results: It was found that the anticoagulant therapy effectively decreased plasma TPP concentration and elevated INR. In the anticoagulant group, the patients with AF had higher plasma TPP concentration than the others with sinus rhythm (P<0.05), although there was no significant difference in INR level between these 2 groups of patients (P>0.05). No significant correlation was found between plasma TPP concentration and INR in the anticoagulant patients (P>0.05). INR did not accord with plasma TPP concentration in several patients. Conclusion: INR can’t reflect the coagulation status and guide the anticoagulation correctly sometimes; TPP may be a valuable assistant marker for monitoring anticoagulation in patients with mechanical heart valve prothesis; Patients with AF may require higher density of anticoagulation and TPP is strongly suggested to be monitored in these patients.