Post-cardioversion transesophageal echocardiography (POSTEC) strategy with the use of enoxaparin for brief anticoagulation in atrial fibrillation patients: the multicenter POSTEC trial (a pilot study)

Intra- and Postprocedural Multimodality Imaging in Atrial Fibrillation

Multi-modality imaging plays critical roles during and after procedures associated with atrial fibrillation. Transesophageal echocardiography is an invaluable tool for left atrial appendage occlusion during the procedure and at follow-up. Both cardiac computed tomography and cardiac magnetic resonance contribute to postprocedural evaluation of pulmonary vein isolation ablation. The present review is the second of a 2-part series where we discuss the roles of cardiac imaging in the evaluation and management of patients with atrial fibrillation, focusing on intraprocedural and postprocedural assessment, including the clinical evidence and outcomes data supporting this future applications.

Multifactorial Genesis of a Seeming Case of Pulmonary Hypertension

Herein, we report the case of a 44-year-old female with end-stage renal disease on hemodialysis. She was admitted to our hospital to evaluate if she was eligible for a kidney transplant. Transthoracic echocardiography showed a markedly dilated coronary sinus and an unexpected finding of increased right ventriculoatrial gradient. A saline contrast echocardiography to confirm the presence of persistent left superior vena cava (PLSVC) was not performed because of arteriovenous fistula (FAV) for hemodialysis on the left forearm. Therefore, computed tomography angiography was performed, and it showed the PLSVC. We also proceeded with a transesophageal echocardiography which showed an atrial septal defect (ASD) of the sinus venous type hemodynamically significant. In this case, we identified a rare association of PLSVC with a ASD; therefore, there is a right ventricular volume overload because of the ASD hemodynamically significant and high flow FAV leading to a condition of a seeming pulmonary hypertension.

Data from a multidisciplinary poll of 178 expert physicians on the usage of non-vitamin K Oral Anticoagulants in patients with atrial fibrillation and venous thromboembolism

This data article contains data from a multidisciplinary questionnaires filled in by 178 expert physicians on the usage of non-vitamin K Oral Anticoagulants in patients with atrial fibrillation (AF) and for the treatment of patients with venous thromboembolism (VTE). The questionnaire consists of 9 statements of clinical complex AF and VTE cases and informative campaign on antithrombotic therapy for stroke prevention in AF. The data are potentially valuable for the scientific community, showing the doubts of different specialists (Internists, Pneumologists, Geriatricians, Cardiologists and Neurologists) with a large experience in prescribing oral anticoagulation in difficult AF and VTE cases (see full list of participants provided). The data obtained in some particular clinical cases such as CHA2DS2-VASc=1, comorbid coronary artery disease, frailty, advanced age, risk of falling and prior haemorrhagic stroke, can be compared with indications from published guidelines and recommendations for future insight and to be considered as a benchmark for future trials in the area or oral anticoagulation for AF and VTE. The data concerning informative campaign on antithrombotic therapy for stroke prevention showed the expert panel agreement on the inclusion of self monitoring of heart rhythm by pulse taking in subjects older than 64 years of age (81% agreement, item 3); knowledge that the risk of stroke associated with AF is almost twice the risk associated with hypertension (95% agreement, item 4); knowledge that the CHA2DS2-VASc score exerts a higher influence on stroke risk compared to AF duration (92% agreement, item 5); knowledge that stroke prevention in AF with a NOAC is more effective, does not cause any higher bleeding risk, and is equally simple compared to aspirin treatment (91% agreement, item 6). Data on strategies to optimise appropriate prescription of antithrombotic therapy showed agreement on the utility of short television advertisements about the risks of stroke associated with AF (79% agreement, item 8), on a campaign encouraging regular control of cardiac rhythm by pulse taking (77% agreement, item 1), on a campaign reporting the advantages of anticoagulation over no antithrombotic therapy (98% agreement, item 2) or of NOACs over aspirin (96% agreement, item 3) or on the practical use of NOAC (93% agreement, item 6) or on stroke and bleeding risk scores (87% agreement, item 7). See Colonna et al. (2017) [1] for further interpretation and discussion.

Clinical conundrums in antithrombotic therapy management: A Delphi Consensus panel

BACKGROUND

Anticoagulants are recommended for the prevention of stroke/systemic embolism for most patients with atrial fibrillation (AF) and for the treatment of patients with venous thromboembolism (VTE). Regulatory-driven randomized trials, however, typically exclude extreme patient scenarios involving, for instance, severe bleeding, ischaemic risk, frailty or renal impairment, despite their common occurrence in clinical practice. Uncertainty in the management of such cases leads to a high degree of variability in therapeutic approaches. Consensus conferences or panels may provide insights and help bridge the gaps that separate clinical guidelines from real-world practice. In the present study, a description of challenging AF and VTE patients was submitted to a large panel of experts to investigate areas of common or divergent management.

METHOD

A modified-Delphi method was used to obtain consensus among 178 Italian AF and VTE specialists. A questionnaire was sent on the appropriateness of anticoagulant therapy in AF and VTE cases, including CHA₂DS₂-VASc=1, comorbid coronary artery disease, frailty, advanced age, risk of falling, prior haemorrhagic stroke, and low- or intermediate-risk pulmonary embolism. Strategies to improve guideline adherence were also investigated.

RESULTS

All participants completed the questionnaire. Consensus was reached on many, but not all cases, leaving uncertainty on some debated topics (conundrums) where decisions are unsupported by clinical studies or driven by controversial results.

CONCLUSIONS

The indications emerging from this large panel of experts may help guide the management of challenging AF or VTE cases. Studies are needed addressing treatment options in those cases for whom no consensus was reached.

The Evolving Role and Use of Echocardiography in the Evaluation of Cardiac Source of Embolism

This report will review the role of echocardiography in the diagnosis of cardiac sources of embolism. Embolism of cardiac origin accounts for around 15%–30% of ischemic strokes. The diagnosis of a cardioembolic source of stroke is frequently uncertain and relies on the identification of a potential cardiac source of embolism in the absence of significant autochthonous cerebrovascular occlusive disease. Transthoracic and/or transesophageal echocardiography serves as a cornerstone in the evaluation, diagnosis, and management of these patients. This article reviews potential cardiac sources of embolism and discusses the role of echocardiography in clinical practice. Recommendations for the use of echocardiography in the diagnosis of cardiac sources of embolism are given including major and minor conditions associated with the risk of embolism.

Evaluation of left atrial appendage function and thrombi in patients with atrial fibrillation: from transthoracic to real time 3D transesophageal echocardiography

The detection of embolic sources in patients with atrial fibrillation (AF) is important to guide anticoagulant therapy. Two-dimensional transesophageal echocardiography (TEE) is the gold standard to study left atrial appendage (LAA) anatomy and morphology, despite some false-positive diagnosis. We hypothesized that real time 3D TEE (RT3DTEE) is superior to 2DTEE in detecting and/or excluding LAA thrombi. We studied 93 patients with non-valvular AF (60 males, age = 67.1 ± 14.2 years) referred for electric cardioversion with transthoracic, 2DTEE and RT3DTEE. Before cardioversion, TTE allowed a confident measurement of emptying velocity of LAA (LAAeV) only in 59/93 patients (63%). On the contrary a good quality TEE LAAeV was obtained in all patients with 49/93 (53%) dysfunctional LAA (LAAeV < 40 cm/s). A subgroup of 5 patients (7.2% of the 69 effective cardioversion) presented a persistent dysfunction after cardioversion (with LAAeV values of <40 cm/s on the TEE post-CV). TEE allowed to observe a bilobed shape in 45 patients (48.4%) and three lobes in 22 patients (23.7%). In addition, besides to several additional findings, 2DTEE managed to detect thrombi with certainty in 8/93 patients (8.6%). In other 5 cases with diagnostic doubts for thrombi with 2DTEE (5/93 patients: 5.4%), the addition of the RT3DTEE mode allowed to discriminate with certainty the presence of just pectinate muscles in 4 patients RT3DTEE in patients with AF at risk of embolism is feasible, accurate and showed an additional diagnostic capability in the differential diagnosis of selected cases with suspected LAA thrombi.

The role of echocardiography in the management of the sources of embolism

The echocardiographic diagnosis of cardiac thrombi, vegetations and tumors as well as the identification of predisposing conditions such as patent foramen ovale, aortic atherosclerosis and other minor causes (e.g., mitral valve prolapse, mitral and aortic valve calcification) have crucial clinical relevance, affecting the choice of surgery and/or of pharmaceutical therapy in the setting of patients presenting embolism. The echocardiographic assessment helps not only for the retrospective diagnosis of sources of embolism but also for the prevention of events in asymptomatic patients. Echocardiography can also distinguish normal variants and artifacts from cardiac masses and tumors. Echocardiographic characterization/typology of cardiac sources of embolism is currently below par when compared with cardiac MRI, the current gold standard. Nevertheless, echocardiography remains the 'first-line' imaging tool, because of its low cost and the possibility to add easily available, functional and structural information at the patient's bedside.