Objectives : A pharmacotherapeutic system for safe and proper use of warfarin was developed through physician-pharmacist cooperative practice ; its effects on patient adherence to therapeutic regimens and the therapeutic benefit of warfarin were assessed.
Methods : Subjects were 12 outpatients or home-care patients receiving warfarin. Patients' level of understanding of warfarin therapy and time in therapeutic range (TTR) were used as indices of adherence and therapeutic benefit, respectively. Before the physician examination, patients were interviewed by pharmacists using point-of-care testing with the CoaguChek ^®XS to check their prothrombin time-international normalized ratio (PT-INR). Pharmacists reported status of warfarin administration, any adverse effects, and medication management status to each patient's physician using the medication record or inter-institute information exchange sheet. Patient adherence was assessed before and after the pre-examination interview and changes in TTR were evaluated.
Results : Levels of understanding of warfarin therapy were significantly higher after pharmacists provided medication counseling (immediately before 4.8±1.9 vs 24 weeks after 6.8±2.4 ; P=0.0079, Wilcoxon signed-rank test). TTR significantly improved at 24 weeks after the interview (pre-interview 20.9±29.8% vs post-interview 60.5±30.5%, respectively ; P=0.0024, Wilcoxon signed-rank test).
Conclusion : The results suggest that patients'adherence to warfarin regimens and the therapeutic benefit of warfarin is improved by pharmacists'obtaining information on PT-INR before patients'medical examinations, as well as by utilizing this information to establish a cooperative pharmacotherapeutic system for good TTR management, as supported by a common protocol across pharmacies and medical institutions.

A new technique of left atrial plication (LAP) for giant left atrium (GLA) resulting from mitral regurgitation (MR) is reported. A 66-year-old man was found to have NYHA class III resulting from severe MR, mild TR and GLA with a left atrial diameter (LAD) of 107mm on echocardiogram. Chest X-ray showed the cardiothoracic ratio (CTR) to be 92%, and the right side CTR was 88.4%. Surgery was performed under general anesthesia with endotracheal intubation. Under cardiac arrest established by antegrade and retrograde cardioplegia, mitral repair was performed first through a superior transseptal approach. Left atrial resection was continued paralell to the mitral posterior annulus and to the right side wall of the left atrium, following the right side resection. Simultaneously the left atrial wall was incised 3 to 4cm in width all the way along the resection line and it was closed by a running suture of 3-0 prolene. The continuous line of the left atrial plication formed a spiral shape. A prominent portion of the atrial septum resulted from the LAP and the right atrial wall was also resected and plicated. The postoperative course was uneventful, and the postoperative CTR reduced to 71% with a right side CTR of 54.4% with reduction of LAD to 67mm on ultrasound cardiogram (UCG). This spiral LAP was considered more effective to reduce all dimensions of the giant left atrium dilated in all directions in comparison with other LAP methods previously reported.

A retrospective review was performed on 43 patients on hemodialysis undergoing valve surgery between May 1999 and August 2004. Ages ranged from 36 to 80 years (mean, 63.8 years). Twenty aortic, 9 mitral, 8 aortic and mitral and 6 valvuloplasties were performed. Twenty-three aortic mechanical valves, 5 aortic bioprosthetic valves, 13 mitral mechanical valves and 4 mitral bioprosthetic valves were implanted. Twenty-five of the 28 aortic valve replacement were hypoplasia of the aortic valve ring. There were 3 hospital deaths (heart failure, pneumonia and sepsis). There were 10 late deaths (2 heart failure, 2 pneumonia, wound infection, cerebral infarction, 2 cancer, arteriosclerosis obliterans and unknown death). Survival at 1, 3 and 5 years was 81%, 74% and 47%. There were three documented major bleedings or thromboembolisms in the 29 patients with mechanical valves (10%) and none in the 9 patients with bioprosthetic valves (0% no significance). Three reoperations were performed for premature degeneration of bioprosthetic valve (19, 24 and 50 months) due to accelerated calcification. These results demonstrate that the prosthetic valve-related major bleedings and strokes in hemodialysis patients are similar for both mechanical and bioprosthetic valves, and that bioprosthetic valves will undergo premature degeneration. Therefore, preference should be given to mechanical valve prostheses in hemodialysis patients.

A 71-year-old man had been repeatedly admitted to our hospital with congestive heart failure, cerebral infarction and pneumonia. Under a diagnosis of mitral regurgitation and tricuspid regurgitation by echocardiography and catheter examination, mitral valve replacement and tricuspid annuloplasty were performed. Pathohistological study revealed a direct insertion of the papillary muscle into the anterior mitral leaflet (DPM) in addition to post-rheumatic valvular disease. These findings suggest that the increased rigidity of the scarring valve leaflets in combination with direct insertion of DPM lead to inadequate leaflet coaptation and apposition. This is the first report of mitral valve replacement for mitral regurgitation due to post-inflammatory valvular disease with DPM.