Update on the clinical management of atrial fibrillation: guidelines and beyond

Usefulness of CHA2DS2-VASc Scoring Systems for Predicting Risk of Perioperative Embolism in Patients of Cardiac Myxomas Underwent Surgical Treatment

Cardiac myxomas are rare but manifested with risk of embolism and often cause unexpected symptoms or sudden death. We retrospectively collected the medical records of patients diagnosed of cardiac myxomas at the cardiac center of our university. Overall 465 patients were included in this study, patients in the embolism group had significantly higher CHA₂DS₂-VASc scores (P = 0.005). In embolic group, stroke was recorded in 110 (77.14%) patients, while embolic events in the limbs were observed in 10 (2.15%) and 9(1.93%) developed splenic infarction. Patients in embolism group had older age (P = 0.021) and higher BMI (P  <0.001) than those in non-embolism group. There was no significant difference between two groups in terms of time of mechanical ventilation (P = 0.065), ICU stay (P = 0.053), hospital stay (P = 0.071) and volume of drainage (P = 0.083), blood transfusions (P = 0.060) except that patients with embolic events had significantly higher incidence of postoperative atrial fibrillation (P = 0.032) and lower survival rate (P < 0.001). Furthermore, the CHA₂DS₂-VASc score was a significant predictor of embolism in patients with cardiac myxomas (P = 0.015; P = 0.003) and the Kaplan-Meier analysis obtained a higher rate of embolism in patients with higher stratification of CHA₂DS₂-VASc scores (P = 0.002). In conclusion, CHA₂DS₂-VASc scoring scheme was strongly predictive of stroke and embolic events in patients with cardiac myxomas.

CHADS2 and CHA2DS2-VASc scoring systems for predicting atrial fibrillation following cardiac valve surgery

Objective

Clinical use of CHADS₂ and CHA₂DS₂-VASc scoring systems for predicting AF following cardiac surgery have been reported in previous studies and demonstrated well-validated predictive value. We sought to investigate whether the two scoring systems are effective for predicting new-onset of AF following cardiac valve surgery and to demonstrate its potential utility of clinical assessment.

Methods

Medical records of all patients underwent cardiac valve surgeries during the period of January 2003 and December 2013 without preoperative AF at the cardiac center of our university were reviewed. The main outcome end point of our study was the early new-onset of AF following cardiac valve surgery.

Results

There were overall 518 patients involved in this study, with 234 (45.17%) developed POAF following valve surgery. Patients with POAF had older age (P=0.23) and higher BMI (P=0.013) than those without POAF. History of heart failure (P=0.025), hypertension (P=0.021), previous stroke or TIA (P=0.032), coronary artery disease (P=0.001), carotid artery disease (P=0.024) and preoperative medication of statins (P=0.021) were significantly more recorded in POAF group. Patients with POAF also had higher LAD (P=0.013) and E/e’ ratio (P<0.001). The CHADS₂ and CHA₂DS₂-VASc scores were significantly higher in patients with POAF (P=0.002; P<0.001), and under univariate and multivariate regression analysis the CHADS₂ and CHA₂DS₂-VASc scores were significant predictors of POAF (P=0.001; P<0.001). Based on stratification of CHADS₂ and CHA₂DS₂-VASc scores, the Kaplan-Meier analysis obtained a higher POAF rate on patients with higher stratification of CHADS₂ and CHA₂DS₂-VASc scores (P<0.001; P<0.001).

Conclusion

In conclusion, CHADS₂ and CHA₂DS₂-VASc scores were directly associated with the incidence of POAF following valve surgery and a higher score was strongly predictive of POAF.

Could some geriatric characteristics hinder the prescription of anticoagulants in atrial fibrillation in the elderly?

Several studies have reported underprescription of anticoagulants in atrial fibrillation (AF). We conducted an observational study on 142 out of a total of 995 consecutive ≥75 years old patients presenting AF (14%) when admitted in an emergency unit of a general hospital, in search of geriatric characteristics that might be associated with the underprescription of anticoagulation therapy (mostly antivitamin K at the time of the study). The following data was collected from patients presenting AF: medical history including treatment and comorbidities, CHADS2 score, ISAR scale (frailty), Lawton's scale (ADL), GDS scale (mood status), MUST (nutrition), and blood analysis (INR, kidney function, and albumin). Among those patients for who anticoagulation treatment was recommended (73%), only 61% were treated with it. In the group with anticoagulation therapy, the following characteristics were observed more often than in the group without such therapy: a recent (≤6 months) hospitalization and medical treatment including digoxin or based on >3 different drugs. Neither the value of the CHADS2 score, nor the geriatric characteristics could be correlated with the presence or the absence of an anticoagulation therapy. More research is thus required to identify and clarify the relative importance of patient-, physician-, and health care system-related hurdles for the prescription of oral anticoagulation therapy in older patients with AF.

Percutaneous recanalization of totally occluded pulmonary veins after pulmonary vein isolation-intermediate-term follow-up

OBJECTIVES

Review mid-term follow-up of percutaneous intervention for post ablation total pulmonary vein occlusion (PVO).

BACKGROUND

Feasibility of percutaneous intervention for PVO has been described, but information remains limited.

METHODS

Patients with total PVO were retrospectively identified from our catheterization database. Medical records, catheterization reports, and outpatient follow-up were reviewed.

RESULTS

Between April 2005 and February 2012, 16 patients were identified with a total of 18 PVOs. Symptoms included hemoptysis in 6/16 (46%), cough in 8/16 (50%), chest pain in 8/16 (50%), dyspnea in 13/16 (81%) with mean NYHA Class of 2.6 ± 0.6. Recanalization was accomplished in 14/18 (78%) veins: 11 treated with balloon dilation and 3 with stents. Median follow-up for 13/14 veins was 13 (0-39) months (one patient with one PVO is awaiting follow-up). Reocclusion occurred in 7/13 (54%) at mean follow-up of 3.6 ± 1.6 months (6/10 post-balloon dilation and 1/3 post-stenting). Despite reocclusion, the reference vessel diameter increased from 4.8 ± 2.4 to 8.5 ± 4.2 mm (P < 0.001) between the first and second catheterization. Re-recanalization and stent placement was accomplished in 5/6 (83%), with one reocclusion not attempted. At latest follow-up 9/13 (69%) recanalized vessels remained patent and percent flow to affected lung quadrant increased from 7.4 ± 3.4% pre-intervention to 14.3 ± 4.2% (P = 0.004). Mean NYHA Class improved to 1.4 ± 0.4 (P < 0.001).

CONCLUSIONS

Recanalization of total PVO can be accomplished with reasonable mid-term patency, improved symptoms, and lung perfusion. Reocclusion is common, but vessel growth is often observed allowing placement of a reasonably sized stent at a second intervention. Staged intervention is often necessary to maintain patency.

Mechanisms of arrhythmias and conduction disorders in older adults

Aging is associated with an increased prevalence of cardiac arrhythmias, which contribute to higher morbidity and mortality in the elderly. The frequency of cardiac arrhythmias, particularly atrial fibrillation and ventricular tachyarrhythmia, is projected to increase as the population ages, greatly impacting health care resource utilization. Several clinical factors associated with the risk of arrhythmias have been identified in the population, yet the molecular bases for the increased predisposition to arrhythmogenesis in the elderly are not fully understood. This review highlights the epidemiology of cardiac dysrhythmias, changes in cardiac structure and function associated with aging, and the basis for arrhythmogenesis in the elderly.