Evidence-Based Case Report: The Use of D-Dimer Assay to Exclude Left Atrial Thrombus in Patient with Atrial Fibrillation >48 Hours

INTRODUCTION

Patients with atrial fibrillation (AF) for >48 hours who are a candidate for cardioversion should have transesophageal echocardiography (TEE) performed to exclude left atrial thrombus (LAT) that may cause systemic thromboembolism upon conversion to sinus rhythm. However, TEE facilities were limited, especially in developing countries.

CASE ILLUSTRATION

A 50 years-old man presented with exertional dyspnea and palpitation for 72 hours prior to admission. Electrocardiography showed AF with a ventricular rate of 140x/minute. Cardioversion was decided to be the best approach. This patient has an AF >48 hours of onset, hence, LAT should be excluded by the use of TEE. Unfortunately, there was no TEE facility nearby.

DISCUSSION

Upon comprehensive search on the use of D-Dimer assay to exclude the LAT in AF patients, we found seven studies showed increased D-dimer level in those with left atrial thrombus. In 4 studies, AUC was > 0.70, sensitivity and specificity varied from 75.9% to 89% and 73.1% to 95% respectively. However, there is no single cut-off point, due to the heterogeneity of cut-off points.

CONCLUSION

D-dimer assay combined with other variables of atrial thrombus exclusion score is valuable in excluding LAT. Previously, weeks of anticoagulation is more advisable before attempting cardioversion in the absence of nearby TEE facilities. With current evidence, a low D-dimer and ATE score of 0 is safe for cardioversion.

Direct vs preimplantation balloon valvuloplasty in transcatheter aortic valve replacement-Systematic review and meta-analysis of randomized controlled trials and prospective-matched cohorts

BACKGROUND

This systematic review and meta-analysis aimed to evaluate the efficacy and safety of direct vs preimplantation balloon valvuloplasty (predilatation) before transcatheter aortic valve replacement (TAVR).

METHODS

We performed a systematic literature search up until March 2020 from PubMed, SCOPUS, EuropePMC, Cochrane Central Database, ProQuest, and ClinicalTrials.gov. We included randomized controlled trial (RCT) and prospective-matched cohorts that compared direct TAVR and preimplantation balloon valvuloplasty before TAVR. The primary outcome was the device success as defined by Valve Academic Research Consortium 2. The secondary outcome was a patient-prosthesis mismatch, the need for balloon postdilatation, composite adverse events, and 1-year mortality.

RESULTS

There were a total of 3078‬ patients from eight studies. This meta-analysis showed that direct TAVR has a similar device success rate (P = .63), the need for postdilatation (P = .82), and composite adverse events (P = .98) compared with preimplantation balloon valvuloplasty. Subgroup analysis for balloon-expandable valves showed lower need for balloon postdilatation (risk ratio [RR], 0.63 [0.47, 0.84]; P = .002; I2 , 0%) in direct TAVR group but higher incidence of acute kidney injury (RR, 3.23 [1.25, 8.40]; P = .02; I2 , 0%) and major/life-threatening bleeding (RR, 1.54 [1.17, 2.02]; P = .002; I2 , 0%). Subgroup analysis for the RCTs alone and RCTs + propensity-matched cohorts showed similar device success and composite adverse events in both groups. However, pooled RCTs showed a higher need for balloon postdilatation in direct TAVR (RR, 1.83 [1.03, 3.24]; P = .04; I2 , 0%).

CONCLUSION

Direct TAVR has similar efficacy and safety to preimplantation balloon valvuloplasty. However, better-designed RCTs are required before drawing a definite conclusion.

Ethanol infusion into the vein of Marshall reduced atrial tachyarrhythmia recurrence during catheter ablation: A systematic review and meta-analysis

BACKGROUND

Ethanol infusion into the vein of Marshall (EIVoM) may increase mitral isthmus bidirectional block (MIBB) and cause local autonomic denervation that may improve outcome.

OBJECTIVE

This meta-analysis aimed to investigate whether the addition of EIVoM to atrial fibrillation (AF) ablation led to a better outcome.

METHODS

Systematic literature search was performed using PubMed, Scopus, ScienceDirect, and Europe PMC for studies that compared the addition of EIVoM during AF ablation with radiofrequency ablation. The primary outcome was atrial tachyarrhythmia (ATa) recurrence, defined as AF/atrial flutter/atrial tachycardia after the blanking period.

RESULTS

There were 2821 patients from 11 studies, and EIVoM was successful in 77% (95% confidence interval [CI] 62%-92%). ATa recurrence was 27% (95% CI 20%-34%) in the EIVoM group and 42% (95% CI 33%-51%) in ablation-only group. EIVoM reduced ATa recurrence (odds ratio [OR] 0.52; 95% CI 0.36-0.76; P < .001; I2 = 76.92). The rate of MIBB was 85% (95% CI 77%-94%) in the EIVoM group and 73% (95% CI 61%-85%) in the ablation-only group, which was significantly higher (OR 3.87; 95% CI 1.46-10.28; P < .001; I2 = 83.68). The mitral isthmus reconnection rate (OR 0.44; 95% CI 0.15-1.29; P = .14; I2 = 63.6) and repeat procedure rate (OR 0.76; 95% CI 0.53-1.08; P = .12; I2 = 48) were similar; however, a leave-one-out sensitivity analysis showed P < .05 for both. The benefits of EIVoM were not affected by age, left atrial diameter, and left ventricular ejection fraction (P > .05). Age (P = .029) and left atrial diameter (P = .042) were inversely associated with EIVoM benefits in terms of repeat ablation and mitral isthmus reconnection (age; P = .003).

CONCLUSION

The addition of EIVoM to ablation increased MIBB and reduced ATa recurrence.

Very-high-power Short-duration Ablation versus Conventional Ablation for Pulmonary Vein Isolation in Atrial Fibrillation: Systematic Review and Meta-analysis

The aim of this study was to compare the effectiveness and safety of very-high-power short-duration (VHPSD) ablation (70-90 W/4-7 s) with conventional ablation (30-40 W/>20 s, 50 W/7-11 s) for pulmonary vein isolation (PVI) in patients with AF. A total of 13 studies were included in this analysis (1,527 patients). AF recurrence occurred in 14% (95% CI [11-18%]) of the VHPSD group. VHPSD was associated with lower AF recurrence (OR 0.65; 95% CI [0.48-0.89]; p=0.006) compared with the conventional ablation group. Subgroup analysis showed that additional ablation beyond PVI had a similar rate of AF recurrence (16% versus 10%) compared with PVI alone. Procedure and ablation durations were significantly shorter in the VHPSD group with a mean differences of -14.4 minutes (p=0.017) and -14.1 minutes (p<0.001), respectively. Complications occurred in 6% (95% CI [3-9%]) of the VHPSD group, and the rate was similar between the two groups (OR 1.03; 95% CI [0.60-1.80]; p=0.498). VHPSD ablation resulted in less AF recurrence and a shorter procedure time. Additional ablation beyond PVI alone in VHPSD may not provide additional benefits.

Fragmented QRS and QRS Duration As a Marker of Myocardial Reperfusion Measured by Myocardial Blush Grade in Reperfusion Therapy: Systematic Review and Meta-Analysis

Myocardial blush grade (MBG) is an indicator of microvascular perfusion and patency and an independent predictor of cardiac outcomes. QRS duration and fragmented QRS (fQRS) before reperfusion and its changes after reperfusion are shown to be associated with MBG. We aimed to assess the latest evidence on the association between fQRS and QRS duration with MBG in reperfusion therapy. We performed a comprehensive search on the association between fQRS and QRS duration in successful/impaired reperfusion measured by MBG. There were a total of 1,311 patients from six studies. A shorter QRS duration immediately and at 60 minutes after reperfusion attempt was associated with successful reperfusion, with a mean difference (MD) of -10.62 ms ([-15.55, -5.70]; p  < 0.001; I 2  = 69%) and -15.66 ms ([-19.96, -11.37]; p  < 0.001; I 2  = 77%), respectively, and upon sensitivity analysis, with exclusion of a study, heterogeneity decreases to 33 and 0%. QRS narrowing immediately and 60 minutes after reperfusion attempt was correlated with reperfusion, with an MD of -10.72 ([-16.57, -4.88] ; p  < 0.001; I 2  = 97%) and -10.93 ([-14.00, -7.85]; p  < 0.001; I 2  = 97%), lesser in impaired reperfusion, respectively. QRS duration on admission was not associated with reperfusion outcome. Two studies reported that fQRS was associated with impaired perfusion, with an odds ratio of 9.88 ([5.62-17.38]; p  < 0.0001) and 4.74 ([2.45-9.20]; p  < 0.0001), respectively. A longer QRS duration immediately and at 60 minutes after reperfusion attempt was associated with impaired perfusion. QRS narrowing after reperfusion attempt was correlated with successful reperfusion. fQRS was also associated with a higher probability of impaired perfusion.

The impact of empirical superior vena cava isolation in addition to pulmonary vein isolation on outcomes in atrial fibrillation - Systematic review, meta-analysis, and meta-regression

BACKGROUND

Atrial tachyarrhythmia (ATa) recurrence remains high after pulmonary vein isolation (PVI), with the superior vena cava (SVC) being a common source of non-pulmonary vein foci.

OBJECTIVE

This meta-analysis aimed to synthesize the latest evidence and provide elaborate comparative analysis and meta-regression analysis regarding the empirical SVC isolation (eSVCi) versus no eSVCi in atrial fibrillation (AF) ablation.

METHODS

A systematic review was conducted on studies comparing eSVCi to no eSVCi (PVI-only or adjunctive SVC isolation). The primary outcome was ATa recurrence, defined as AF/atrial flutter/atrial tachycardia lasting over 30 s after a blanking period. Secondary outcomes included procedural duration, fluoroscopic duration, and complications.

RESULTS

Thirteen studies involving 2,176 patients were analyzed, with a mean follow-up of 18 ± 9.6 months. ATa recurrence was significantly lower with eSVCi (OR 0.54 [95 % CI: 0.41, 0.72], p < 0.001; I2 = 40.7 %). Subgroup analysis revealed eSVCi reduced ATa recurrence in observational studies but not in RCTs, and in initial ablations but not repeat procedures. eSVCi was beneficial in both PVI-only and adjunctive SVC isolation subgroups. Meta-regression showed the benefit of eSVCi was less in patients with non-paroxysmal AF (p = 0.044) and hypertension (p = 0.012). Procedural time, fluoroscopic time, and complications were similar between the two groups.

CONCLUSION

eSVCi potentially reduce ATa recurrence compared to no eSVCi, without increasing complications or prolonging procedural times.

Prevention of Contrast-induced Nephropathy in Patients Undergoing Percutaneous Coronary Intervention

Contrast-induced nephropathy (CIN) or contrast-induced acute kidney injury has varying definitions, but in general, increased serum creatinine level by ≥ 0.3 mg/dL (26.5 µmol/L) or 1.5x of baseline value or urine output <0.5 mL/kg/h within 1-7 days after contrast media (CM) administration can be considered as CIN. CIN is one of the most common complications and is associated with increased mortality in patients undergoing percutaneous coronary intervention (PCI). Thus, risk stratification for CIN should be made and preventive strategies should be employed in which the intensity of the approach must be tailored to patient's risk profile. In all patients, adequate hydration is required, nephrotoxic medications should be discontinued, and pre-procedural high-intensity statin is recommended. In patients with an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2, IV hydration should be started 12 hours pre-procedure up until 12-24 hours after the procedure. Remote ischemic preconditioning may be performed pre-procedurally. Radial first approach for vascular access is recommended. During the procedure, low or iso-osmolar CM should be used and its volume should be limited to eGFR x 3.7. In patients at high risk for CIN, additional contrast-sparing strategies may be applied, such as using a contrast reduction system, 5 Fr catheter with no sideholes, CM dilution, limiting test injection, confirming placement using guidewire, use of stent enhancing imaging technology, using metallic/software roadmap to guide PCI, use of IVUS or dextran-based OCT, and coronary aspiration. A more advanced hydration technique based on central venous pressure, left ventricular end-diastolic pressure, or using furosemide-matched hydration, might be considered.

Preoperative Third Ventricle Floor Bowing is Associated with Increased Surgical Success Rate in Patients Undergoing Endoscopic Third Ventriculostomy - A Systematic Review and Meta-analysis

BACKGROUND

Endoscopic third ventriculostomy (ETV) is a procedure that involves devising an opening in the third ventricle floor, allowing cerebrospinal fluid to flow into the prepontine cistern and the subarachnoid space. Third ventricular floor bowing (TVFB) serves as an indicator of intraventricular obstruction in hydrocephalus and existence of pressure gradient across third ventricular floor, which is the prerequisite of a successful ETV.

OBJECTIVE

In this systematic review and meta-analysis, we aimed to synthesize the latest evidence on the TVFB as a marker for surgical success in patients undergoing ETV.

MATERIAL AND METHODS

We performed a comprehensive search on topics that assesses the association of TVFB with the surgical success in patients undergoing ETV from several electronic databases.

RESULTS

There was a total of 568 subjects from six studies. TVFB was associated with 85% (81-88%) ETV success. TVFB was associated with OR 4.13 [2.59, 6.60], P < 0.001; I2: 6% for ETV success. Subgroup analysis on pediatric patients showed 86% (82-91%) success rate. In terms of value for ETV success compared to ETV Success Score (ETVSS), a high ETVSS does not significantly differ (P = 0.31) from TVFB and TVFB was associated with OR 3.14 [1.72, 5.73], P < 0.001; I2: 69% compared to intermediate/moderate ETVSS. Funnel plot analysis showed an asymmetrical funnel plot due to the presence of an outlier. Upon sensitivity analysis by removing the outlier, the OR was 3.62 [2.22, 5.89], P < 0.001; I2: 0% for successful surgery in TVFB.

CONCLUSIONS

TVFB was associated with an increased rate of successful surgery in adults and children undergoing ETV.

Left atrial posterior wall isolation in addition to pulmonary vein isolation using a pentaspline catheter in pulsed-field ablation for atrial fibrillation: A systematic review and meta-analysis

BACKGROUND

Persistent atrial fibrillation (AF) may require extensive ablation strategies. Left atrial posterior wall isolation (LAPWI) might address potential substrates for recurrence during pulsed-field ablation (PFA).

OBJECTIVE

This meta-analysis aimed to investigate the feasibility and effectiveness of LAPWI in addition to pulmonary vein isolation (PVI) using a pentaspline catheter in PFA for AF.

METHODS

Comprehensive search was conducted using PubMed, SCOPUS, ScienceDirect, and EuropePMC for studies reporting LAPWI+PVI using a pentaspline catheter in PFA ablation for AF. The primary outcome was atrial tachyarrhythmia (ATa) recurrence, defined as AF/atrial flutter/atrial tachycardia after blanking period.

RESULTS

There were 882 patients from 7 studies. The success rate of LAPWI was 100% using mean/median of 16 to 20 added PFA applications with no reported acute left atrial posterior wall reconnection and esophageal complications. In mean follow-up of 240 ± 91 days, ATa recurrence was 21% (95% CI 13%-29%; I2 = 84.8%) in the LAPWI+PVI group. Meta-regression analysis showed that age, left ventricular ejection fraction, and repeat procedure did not significantly influence ATa recurrence (P > .05). Each 1-mm increase in left atrial diameter, increases the chance of ATa recurrence by 6% (R2 = 100%, P < .001, I2 = 0%). Meta-analysis showed no difference in terms of ATa recurrence among LAPWI+PVI patients compared with those without LAPWI (odds ratio 0.78, 95% confidence interval 0.50-1.21, P = .27; I2 = 0%, P = .86). Procedure time and fluoroscopy time did not significantly differ (P > .05).

CONCLUSION

LAPWI using a pentaspline catheter during PFA was feasible and did not prolong the procedure/fluoroscopy but did not reduce ATa recurrence. LAPWI may be considered during PFA, although the benefit is uncertain.

The role of probucol preventing contrast-induced nephropathy in patients undergoing invasive coronary procedures - Systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

The aim of this meta-analysis was to synthesize the latest evidence on the effect of probucol on the incidence of contrast-induced nephropathy (CIN) in patients undergoing coronary angiography (CAG)/percutaneous coronary intervention (PCI).

METHODS

A systematic literature search of PubMed, ScienceDirect, EuropePMC, ProQuest, and Clinicaltrials. gov was performed to retrieve studies that assessed probucol and CIN in CAG/PCI.

RESULTS

Four studies that compared probucol with hydration alone, comprising 1270 subjects, were identified and analyzed. There was no significant difference between probucol and control groups in the baseline level of creatinine and at 48 hours; however, a significant difference was observed at 72 hours (mean difference: -3.87 μmol/L; 95% confidence interval [CI]: -6.58, -1.15; p=0.005). The meta-analysis indicated that probucol did not reduce the CIN incidence (odds ratio [OR]: 0.46; 95% CI: 0.20, 1.08; p=0.08). After performing a leave-one-out sensitivity analysis, removal of a study resulted in a lower risk of CIN (OR: 0.33; 95% CI: 0.19, 0.56; p<0.001). Probucol did not reduce the CIN incidence in a pooled adjusted effect estimate (OR: 0.75; 95% CI: 0.15, 3.87; p=0.73). There was no significant difference in the rate of major adverse events between the 2 groups (OR: 0.39; 95% CI: 0.05, 3.05; p=0.37). Funnel plot results were asymmetrical, indicating possible publication bias. Grading of Recommendations, Assessment, Development and Evaluations qualification demonstrated a low and very low certainty of evidence in unadjusted and adjusted effect estimates, respectively.

CONCLUSION

Probucol did not reduce the incidence of CIN; however, due to the low certainty of evidence, further study is required for a definite conclusion. Although the p value was not significant, the confidence interval showed a nonsignificant trend toward benefit. However, this trend might have been due to publication bias.

Pediatric infective endocarditis initially presenting as hemorrhagic stroke

Infective endocarditis refers to infection of the heart valves. While its incidence is low, it may cause serious complications. Despite advances in its management and diagnosis, this condition still retains high mortality and significant morbidity. Considerable controversy remains regarding antimicrobial prophylaxis to prevent infective endocarditis in patients with congenital heart disease. Neurologic complications are the second most common complication in patients with infective endocarditis, occurring in approximately 33% of cases.1 These include encephalopathy, meningitis, stroke, brain abscess, cerebral hemorrhage, and seizures. The vegetation formed as a consequence of endocarditis may dislodge and cause embolization. Vegetation size alone is an unreliable marker for embolization risk, however, size, in addition to location, mobility, infecting agent, and presence of antiphospholipid antibodies have the potential to be prognostic markers. The brain is the most frequent site of embolization. Furthermore, advances in medical approaches have resulted in an increase of patients at risk of endocarditis due to the now common and widely available indwelling intravascular approaches in medicine. In this report, we present a case of infective endocarditis in a child first presenting with hemorrhagic stroke.1,2