Quantification of Mitral Regurgitation in Mitral Valve Prolapse by Three-Dimensional Vena Contracta Area: Derived Cutoff Values and Comparison With Two-Dimensional Multiparametric Approach

BACKGROUND

Echocardiographic grading of mitral regurgitation (MR) in mitral valve prolapse (MVP) is challenging. Three-dimensional (3D) vena contracta area (VCA) has been proposed as a valuable method. However, data defining the cutoff values of severity and validation in the subset of patients with MVP are scarce. The aim of this study was to validate the 3D VCA by 3D color-Doppler transesophageal echocardiography (TEE) in patients with MVP and to define the cutoff values of severity grading. The secondary aim was to compare 3D VCA to the effective regurgitant orifice area estimation by proximal isovelocity surface area (EROA-PISA) method.

METHODS

A total of 1,138 patients with at least moderate MR who underwent TEE were included. Three-dimensional VCA was measured, and the cutoff value and area under the curve (AUC) for the prediction of severe MR were estimated by receiver operating characteristic curve using a guideline-suggested multiparametric approach as the reference standard. In a subgroup of patients, 3D regurgitant volume (RV) and 3D fraction were calculated from mitral and left ventricular outflow tract stroke volumes to further validate 3D VCA against a 3D volumetric reference standard.

RESULTS

The optimal 3D VCA cutoff value for predicting severe MR was 0.45 cm2 (specificity, 0.87; sensitivity, 0.90) with an AUC of 0.95 using a multiparametric approach as reference. Three-dimensional VCA had a good linear correlation with EROA-PISA (r = 0.62, P < .05) with larger values compared to EROA-PISA (0.63 cm2 vs 0.44 cm2, P < .05). A cutoff of 0.50 cm2 (AUC of 0.84; sensitivity, 0.78; specificity, 0.78) predicts an EROA-PISA of 0.40 cm2. Three-dimensional VCA had a good linear correlation with 3D RV (r = 0.56, P < .01), with an AUC of 0.86 to predict a 3D fraction >50%.

CONCLUSIONS

The present study suggests 0.45 cm2 as the best cutoff value of 3D VCA to define severe MR in patients with MVP, showing an optimal agreement with the reference standard multiparametric approach and 3D RV.

LEFT ATRIAL APPENDAGE CLOSURE IN PATIENTS WITH MECHANICAL MITRAL VALVE PROSTHESIS: A MULTICENTER ITALIAN PILOT STUDY

INTRODUCTION

In patients with atrial fibrillation (AF) on vitamin K antagonist (VKA) therapy and therapeutical INR range the incidence of cardiac thromboembolism is not negligible and the subgroup carrying a mechanical prosthetic mitral valve (PMV) has the highest risk. We aimed to assess the long-term effects of left atrial appendage closure (LAAC) in AF patients carriers of mechanical PMV who experienced a failure of VKA therapy.

METHODS

In this retrospective, multicenter study, patients underwent LAAC because of thrombotic events including TIA/stroke, systemic embolism and evidence of left atrial appendage thrombosis/sludge despite VKA therapy were enrolled. Patients with mechanical PMV were included and compared with those affected by non valvular AF. The primary endpoint was the composite of all-cause death, major cardiovascular events and major bleedings at follow-up. Feasibility and safety of LAAC was also assessed.

RESULTS

55 patients (42% females; mean age 70 ± 9 years) including 12 carriers of mechanical PMV were enrolled. The most frequent indication to LAAC (71%) was LAA thrombosis or sludge. Procedural success was achieved in 96% of overall cases and in 100% of patients with PMV. In 35 patients a cerebral protection device was used. During a median follow-up of 6.1 ± 4.3 years, 4 patients with PMV and 20 patients without PMV reported adverse events (HR 0.73 [95% CI 0.25 - 2.16, p=0.564]).

CONCLUSION

LAAC seems to be a valuable alternative in AF carriers of mechanical PMV with failure of VKA therapy. This off-label, real-world clinical practice indication deserve validation in further studies.

Baseline Characteristics and 3-Year Outcome of Nonvalvular Atrial Fibrillation Patients Treated with the Four Direct Oral Anticoagulants (DOACs)

Direct oral anticoagulants (DOACs) represent the cornerstone therapy for cardioembolic events prevention in patients with nonvalvular atrial fibrillation (NVAF). In practice, the choice of one DOAC over another is guided by the decision-making process of the physician, which considers specific patient and drug characteristics. This study aimed to evaluate the clinical features and long-term outcomes of a real-world population treated with DOACs, where the use of the 4 different DOACs is quite equal. We conducted a retrospective observational, single-center, multidisciplinary study enrolling consecutive NVAF patients treated with one of the 4 DOACs. From an initial number of 753 patients, we excluded 72 patients because of loss to follow-up, at the end we enrolled 681:174 (23%) treated with dabigatran, 175 (23%) with apixaban, 190 (25%) with rivaroxaban, and 214 (29%) with edoxaban. Patients treated with apixaban were significantly older, more women represented (p <0.001), and with a higher cardioembolic and bleeding risk (p <0.001). Dabigatran was preferred in patients with liver failure (p = 0.008), whereas Apixaban and Edoxaban were chosen in chronic kidney disease (p = 0.002). At 3-year follow-up, 20 patients (2.7%) experienced a systemic thromboembolic event without significant differences in the 4 DOACs. In the same period, an International Society of Thrombosis and Hemostasis classification major bleeding event occurred in 26 patients (3.6%), more statistically correlated to edoxaban (6.1%) (p = 0.038). Thromboembolic events or major bleeding were higher in the edoxaban group (10%) compared with the others (p = 0.014). In our single-center real-world experience, the choice of the DOAC for a patient with NVAF was tailored to specific clinical features and drug pharmacokinetics of the patient. As a result, a small number of adverse events were observed.

Direct oral anticoagulants versus percutaneous left atrial appendage occlusion in atrial fibrillation: 5-year outcomes

BACKGROUND

LAAO is an emerging option for thromboembolic event prevention in patients with NVAF. We previously reported data on comparison between LAAO and DOAC at two-year follow-up in NVAF patients at HBR (HAS-BLED ≥3).

AIMS

Limited data are available on long term follow-up. We aimed to evaluate the efficacy and safety of DOACs versus LAAO indication after 5 years.

METHODS

We enrolled 193 HBR treated with LAAO and 189 HBR patients with DOACs. At baseline, LAAO group had higher HAS-BLED (4.2 vs 3.3, p < 0.001) and lower CHADS-VASc (4.3 vs. 4.7, p = 0.005). After 1:1 PSM, 192 patients were included (LAAO n = 96; DOACs n = 96).

RESULTS

At 5-year follow-up the rate of the combined safety and effectiveness endpoint (ISTH major bleeding and thromboembolic events) was significantly higher in LAAO group (p = 0.042), driven by a higher number of thromboembolic events (p = 0.047). The rate of ISTH-major bleeding events was similar (p = 0.221). After PSM no significant difference in the primary effectiveness (LAAO 13.3% vs DOACs 9.5%, p = 0.357) and safety endpoint (LAAO 7.5% vs DOACs 7.5%; p = 0.918) were evident. Overall bleeding rate was significantly higher in DOACs group (25.0% vs 13.7%, p = 0.048), while a non-significant higher number of TIA was reported in LAAO group (5.4% vs 1.1%, p = 0.098). All-cause and cardiovascular mortality were higher in LAAO group at both unmatched and matched analysis.

CONCLUSION

We confirmed safety and effectiveness of both DOAC and LAAO in NVAF patients at HBR, with no significant differences in thromboembolic events or major bleeding were at 5-year follow-up. The observed increased mortality after LAAO warrants further investigations in RCTs.

Accuracy and Reliability of Left Atrial Appendage Morphology Assessment by Three-Dimensional Transesophageal Echocardiographic Glass Rendering Modality: A Comparative Study With Computed Tomography

BACKGROUND

Contrast-enhanced computed tomography is the reference-standard imaging technique to assess left atrial appendage (LAA) morphology. The aim of this study was to evaluate the accuracy and reliability of two-dimensional and new three-dimensional (3D) transesophageal echocardiographic rendering modalities in assessing LAA morphology.

METHODS

Seventy consecutive patients who underwent both computed tomography and transesophageal echocardiography (TEE) were retrospectively enrolled. The traditional LAA morphology classification system (LAAcs; chicken wing, cauliflower, cactus, and windsock) and a new simplified LAAcs based on the LAA bend angle were used for the analysis. LAA morphology was independently assessed by two trained readers using three different modalities: two-dimensional TEE, 3D TEE with multiplanar reconstruction, and a new 3D transesophageal echocardiographic rendering modality with improved transparency (Glass). The new LAAcs and traditional LAAcs were compared in terms of intra- and interrater reliability.

RESULTS

With the new LAAcs, two-dimensional TEE was fairly accurate in identifying LAA morphology (κ = 0.43, P < .05), with moderate interrater (κ = 0.50, P < .05) and substantial intrarater (κ = 0.65, P < .005) agreement. Three-dimensional TEE showed higher accuracy and reliability: 3D TEE with multiplanar reconstruction had almost perfect accuracy (κ = 0.85, P < .001) and substantial (κ = 0.79, P < .001) interrater reliability, while 3D TEE with Glass had substantial accuracy (κ = 0.70, P < .001) and almost perfect (κ = 0.84, P < .001) interrater reliability. Intrarater agreement was almost perfect for both 3D transesophageal echocardiographic modalities (κ = 0.85, P < .001). Accuracy was considerably lower when the traditional LAAcs was used, with 3D TEE with Glass being the most reliable technique (κ = 0.75, P < .05). The new LAAcs showed higher inter- and intrarater reliability compared with the traditional LAAcs (interrater, κ = 0.85 vs κ = 0.49; intrarater, κ = 0.94 vs κ = 0.68; P < .05).

CONCLUSIONS

Three-dimensional TEE is an accurate, reliable, and feasible alternative to computed tomography in assessing LAA morphology with the new LAAcs. The new LAAcs shows higher reliability rates than the traditional one.

Potential Cardiologic Protective Effects of Acetylcholinesterase Inhibitors in Patients With Mild to Moderate Dementia

In patients with mild to moderate dementia, acetylcholinesterase inhibitors (AChE-I) are used to improve cognitive functions, but bradycardia, conduction abnormalities, and hypotension are possible side effects because of the peripheral muscarinic M2 receptor stimulation. This study aimed to evaluate the main cardiologic clinical outcomes in patients with dementia who are on AChE-I. In this retrospective, monocentric, observational cohort study, 2 groups were considered: (1) patients with dementia because of the typical and atypical forms of Alzheimer disease treated with AChE-I and (2) cognitively unimpaired, matched control group. The primary end point was a composite of cardiovascular death, nonfatal acute myocardial infarction, myocardial revascularization, occurrence of stroke and/or transient ischemic attacks, and hospitalization for heart failure occurring during a mean of 3.1 years of follow-up. The secondary end points were each individual component of the primary end point, total mortality, noncardiovascular death, and incidence of pacemaker implant. Each group included 221 patients who were homogeneous in terms of age, gender, and main cardiovascular risk factors. Major adverse cardiovascular events occurred in 24 patients with dementia (2.1 per 100 patient-years) compared with 56 in control group (5.0 per 100 patient-years), p = 0.036. Even if not significant, the difference was mainly driven by myocardial revascularization (3.2% vs 6.8%) and hospitalization for heart failure (4.5% vs 14.5%). As expected, noncardiovascular mortality was significantly higher in the treatment group (13.6% vs 2.7% p = 0.006). No significant difference between the groups was observed in terms of other secondary outcomes. In conclusion, in patients with dementia, the use of AChE-I may be protective for cardiovascular outcomes, especially in reducing heart failure hospitalization and myocardial revascularization.

Personalized pulmonary vein antrum isolation guided by left atrial wall thickness for persistent atrial fibrillation

AIMS

Pulmonary vein (PV) antrum isolation proved to be effective for treating persistent atrial fibrillation (PeAF). We sought to investigate the results of a personalized approach aimed at adapting the ablation index (AI) to the local left atrial wall thickness (LAWT) in a cohort of consecutive patients with PeAF.

METHODS AND RESULTS

Consecutive patients referred for PeAF first ablation were prospectively enrolled. The LAWT three-dimensional maps were obtained from pre-procedure multidetector computed tomography and integrated into the navigation system. Ablation index was titrated according to the local LAWT, and the ablation line was personalized to avoid the thickest regions while encircling the PV antrum. A total of 121 patients (69.4% male, age 64.5 ± 9.5 years) were included. Procedure time was 57 min (IQR 50-67), fluoroscopy time was 43 s (IQR 20-71), and radiofrequency (RF) time was 16.5 min (IQR 14.3-18.4). The median AI tailored to the local LAWT was 387 (IQR 360-410) for the anterior wall and 335 (IQR 300-375) for the posterior wall. First-pass PV antrum isolation was obtained in 103 (85%) of the right PVs and 103 (85%) of the left PVs. Median LAWT values were higher for PVs without first-pass isolation as compared to the whole cohort (P = 0.02 for left PVs and P = 0.03 for right PVs). Recurrence-free survival was 79% at 12 month follow-up.

CONCLUSION

In this prospective study, LAWT-guided PV antrum isolation for PeAF was effective and efficient, requiring low procedure, fluoroscopy, and RF time. A randomized trial comparing the LAWT-guided ablation with the standard of practice is in progress (ClinicalTrials.gov, NCT05396534).

Performances of HEART score to predict 6-month prognostic of emergency department patients with chest pain: a retrospective cohort analysis

Chest pain is a frequent cause of patient admissions in emergency departments (EDs). Clinical scores can help in the management of chest pain patients with an undefined impact on the appropriateness of hospitalization or discharge when compared to usual care. The aim of this study was to assess the performances of the HEART score to predict the 6-month prognostic of patients presenting to the ED of a tertiary referral university hospital with non-traumatic chest pain. From 7040 patients presenting with chest pain from 1 January 2015 to 31 December 2017, after applying exclusion criteria (ST-segment elevation >1 mm, shock, absence of telephone number) we selected a sample of 20% chosen randomly. We retrospectively assessed the clinical course, definitive diagnosis, and HEART score according to ED final report. Follow-up was made by telephone interview with discharged patients. In hospitalized patients, clinical records were analyzed to evaluate major adverse cardiac events (MACE) incidence. The primary endpoint was MACE, comprising cardiovascular death, myocardial infarction, or unscheduled revascularization at 6 months. We assessed the diagnostic performance of the HEART score in ruling out MACE at 6 months. We also assessed the performance of ED usual care in the management of chest pain patients. Of 1119 screened, 1099 were included for analysis after excluding patients lost to follow-up; 788 patients (71.70%) had been discharged and 311 (28.30%) were hospitalized. Incident MACE was 18.3% (n = 205). The HEART score was retrospectively calculated in 1047 patients showing increasing MACE incidence according to risk category (0.98% for low risk, 38.02% for intermediate risk, and 62.21% for high risk). Low-risk category allowed to safely exclude MACE at 6 months with a negative predictive value (NPV) of 99%. Usual care diagnostic performance showed 97.38% sensitivity, 98.24% specificity, 95.5% positive predictive value, and 99% NPV, with an overall accuracy of 98.00%. In ED patients with chest pain, a low HEART score is associated with a very low risk of MACE at 6 months.

A new echocardiographic index to select patients for PFO suture-mediated percutaneous closure

OBJECTIVES

To identify a simple echocardiographic predictor of procedural success to select patient for percutaneous suture-mediated patent fossa ovalis (PFO) closure.

BACKGROUND

Percutaneous suture-mediated PFO closure has been shown as a safe and advantageous alternative to device-based PFO closure, yet its overall success is slightly lower in unselected patients.

METHODS

Preprocedural transesophageal echocardiogram (TEE) of 302 patients (113 men, 45 ± 12 years) who underwent percutaneous suture-mediated PFO closure were reviewed.

RESULTS

At echocardiographic follow-up (3-6 months), residual right-to-left shunt (RLS) ≥2 was found in 60 (19.9%) patients. At multivariable analysis, only two anatomical variables measured at preprocedural TEE were found as independent predictors of residual RLS ≥ 2 at follow-up: PFO maximum width (odds ratio [OR] 1.89, 95% confidence interval [CI] 1.16-3.40, p = 0.02) and PFO minimal septa overlapping (OR 0.58, 95% CI 0.35-0.88, p = 0.02). An index based on the ratio of PFO maximum width to PFO minimum septal overlapping (W/SO) proved to be the most powerful predictor of RLS ≥ 2 at follow-up (OR 48.1, 95% CI 9.3-352.2, p < 0.01). The ROC curve for the W/SO ratio was found to have an AUC of 0.84 (95% CI 0.75-0.93) and a cut-off value of 0.61 yielding a sensitivity of 80% and specificity of 78% with a negative predictive value of 94%. A decision tree methodology's AUC was 0.75 (95% CI 0.67-0.83).

CONCLUSIONS

The results of this study indicate that the ratio between the maximum amplitude of the PFO and the minimum overlap of the septa is the best predictive index of a favorable result by using one stitch only.

Atrial function analysis after percutaneous umbrella device and suture-mediated patent fossa ovalis closure

BACKGROUND

Atrial fibrillation is an undesirable event following percutaneous patent fossa ovalis (PFO) closure with metallic occluders, suggesting that implanting a rigid closure device could alter atrial function. Suture-mediated PFO closure is a new technique, achieving closure of the PFO by means of a simple suture. Aim of this study was to evaluate left atrial function after closure of PFO by direct suture and traditional occluders.

METHODS

We studied 40 age and sex homogeneous patients, 20 undergoing PFO closure by device (OCL) and 20 by suturing (NS). Twenty healthy sex-age matched subjects made up the control group (CT). Left atrial function was evaluated by using volumetric and speckle-tracking analysis assessing the following parameters: total emptying fraction (EF), Expansion Index (EI), active emptying fraction (AEF), strain values of the reservoir (r-ED), conduit (cd-ED) and contraction phase (ct-ED).

RESULTS

Compared to CT and NS, OCL patients had significantly worst indices of left atrial reservoir function (EF P=0.001, EI P=0.003, r-ED P<0.001), conduit function (cd-ED P=0.018) and contraction function (AEF P=0.010; ct-ED P<0.001). No significant differences were observed in left atrial function indices between CT and NS patients.

CONCLUSIONS

Suture-mediated PFO closure does not alter left atrial function. Conversely, metallic occluder is associated with worse left atrium function. This detrimental effect on atrial function could favor the development of atrial arrhythmias.

A simplified echocardiographic formula to estimate cardiac index in the intensive care unit

BACKGROUND AND AIM

Measurement of cardiac index (CI) is crucial in the hemodynamic assessment of critically ill patients in the intensive care unit (ICU). The most reliable trans-thoracic echocardiography (TTE) technique for CI estimation is the left ventricular outflow tract (LVOT) Doppler method that requires, among other parameters, the LVOT cross-sectional area (CSA) measurement. However, inherent and practical disadvantages, mostly related to the ICU setting, hamper LVOT-CSA assessment. In this study, we aimed to validate a simplified formula, leveraging on LVOT-velocity time integral (VTI) and heart rate (HR) only, for non-invasive estimation of CI in ICU patients.

METHODS AND RESULTS

We prospectively enrolled 50 consecutive patients admitted to our ICU requiring pulmonary artery catheterization (PAC) over a one-year period. For each patient we measured the CI by PAC (CI_PAC) and TTE. The latter was obtained both with the "traditional formula" (traditional CI_TTE), requiring LVOT-CSA assessment, and our new "simplified formula" (simplified CI_TTE). The correlation between the simplified CI_TTE and CI_PAC was strong (r = 0.81) and resulted significantly greater than the traditional CI_TTE and CI_PAC correlation (r = 0.70; p < 0.05 for Pearson r coefficients comparison). Both TTE-based CI showed an acceptable agreement (+0.19 ± 0.48 L/min/m² for simplified CI_TTE and - 0.18 ± 0.58 L/min/m² for traditional CI_TTE) with the reference CI_PAC.

CONCLUSION

In this study, we validated a practical approach, leveraging on TTE LVOT-VTI and HR only, for non-invasive estimation of CI in ICU patients.

A comprehensive and easy-to-use ECG algorithm to predict the coronary occlusion site in ST-segment elevation myocardial infarction

BACKGROUND

Several electrocardiogram (ECG) criteria have been proposed to predict the location of the culprit occlusion in specific subsets of patients presenting with ST-segment elevation myocardial infarction (STEMI). The aim of this study was to develop, through an independent validation of currently available criteria, a comprehensive and easy-to-use ECG algorithm, and to test its diagnostic performance in real-world clinical practice.

METHODS

We analyzed ECG and angiographic data from 419 consecutive STEMI patients submitted to primary percutaneous coronary intervention over a one-year period, dividing the overall population into derivation (314 patients) and validation (105 patients) cohorts. In the derivation cohort, we tested >60 previously published ECG criteria, using the decision-tree analysis to develop the algorithm that would best predict the infarct-related artery (IRA) and its occlusion level. We further assessed the new algorithm diagnostic performance in the validation cohort.

RESULTS

In the derivation cohort, the algorithm correctly predicted the IRA in 88% of cases and both the IRA and its occlusion level (proximal vs mid-distal) in 71% of cases. When applied to the validation cohort, the algorithm resulted in 88% and 67% diagnostic accuracies, respectively. In a real-world comparative test, the algorithm performed significantly better than expert physicians in identifying the site of the culprit occlusion (P = .026 vs best cardiologist and P < .001 vs best emergency medicine doctor).

CONCLUSIONS

Derived from an extensive literature review, this comprehensive and easy-to-use ECG algorithm can accurately predict the IRA and its occlusion level in all-comers STEMI patients.

402 A SIMPLIFIED ECHOCARDIOGRAPHIC FORMULA TO ESTIMATE CARDIAC INDEX IN THE INTENSIVE CARE UNIT

Background and aim

Measurement of cardiac index (CI) is crucial in the hemodynamic assessment of critically ill patients in the intensive care unit (ICU). The most reliable trans-thoracic echocardiography (TTE) technique for CI estimation is the left ventricular outflow tract (LVOT) Doppler method that requires, among other parameters, the LVOT cross-sectional area (CSA) measurement. However, geometrical assumptions inherent limitations and practical disadvantages related to the ICU setting, hamper LVOT-CSA assessment. In this study, we aimed to validate a simplified formula, leveraging only on LVOT-velocity time integral (VTI) and heart rate (HR) variables, for the non-invasive estimation of CI in ICU patients.

Methods and Results

We prospectively enrolled 50 consecutive patients admitted to our ICU requiring PAC over a one-year period. For each patient we measured the CI by PAC (CIPAC) and TTE. The latter was obtained both with the “traditional formula” (traditional CITTE), requiring LVOT-CSA assessment, and our new “simplified formula” (simplified CITTE). The correlation between the simplified CITTE and CIPAC was strong (r = 0.81) and resulted significantly greater than the traditional CITTE and CIPAC correlation (r = 0.70; p &lt; 0.05 for Pearson r coefficients comparison). Both TTE-based CI showed an acceptable agreement (+0.19±0.48 L/min/m2 for simplified CITTE and -0.18±0.58 L/min/m2 for traditional CITTE) with the reference CIPAC.

Conclusion

In this study, we propose an easy-to-use and practical approach, leveraging on TTE LVOT-VTI and HR only, for non-invasive estimation of CI in ICU patients.

Atrial function analysis after percutaneous umbrella device and suture-mediated patent fossa ovalis closure: a prospective study

Background

Suture-mediated patent fossa ovalis (PFO) closure is a new technique, achieving closure of the PFO by means of a simple suture. The difference between traditional occluders and a simple suture might have different impact on atrial structure, geometry and function.

Purpose

Aim of this study was to evaluate bi-atrial function after closure of PFO by direct suture and traditional occluders.

Methods

We studied 40 age and sex matched patients, 20 undergoing PFO closure by device and 20 by suturing. Only patients with no residual right-to-left shunt, assessed by contrast-enhanced echocardiography, were included. Left and right atrial function was evaluated by using speckle-tracking analysis assessing the following parameters: strain values of the reservoir (r-ED), conduit (cd-ED) and contraction phase (ct-ED). All patients underwent transthoracic echocardiographic examination the day before and 1 year after the procedure. All exams and measurements were conducted by two echocardiographers and validated with common consent by two other expert operators.

Results

Compared with values baseline PFO closure, at one year follow-up, patients underwent occluder implantation had significantly worst indices of left (LA) and right (RA) atrial reservoir function (LA r-ED p&lt;0.001; RA r-ED p&lt;0.001), conduit function (LA cd-ED p&lt;0.001; RA cd-ED p&lt;0.001) and contraction function (LA ct-ED p&lt;0.05; RA ct-ED p&lt;0.05).

In patients underwent suture-mediated PFO closure, no significant differences were observed in the same indices of reservoir (LA r-ED p=0.848; RA r-ED p=0.183), conduit (LA cd-ED p=0.156; RA cd-ED p=0.419) and contraction function (LA ct-ED p=0.193; RA ct-ED p=0.375).

Conclusions

Suture-mediated PFO closure does not alter atrial function. Conversely, PFO closure by metallic occluders is associated with worse atrial function. This detrimental effect on atrial function could favor the development of atrial arrhythmias.

Funding Acknowledgement

Type of funding sources: None.

Single predictor of residual right-to-left shunt to optimally select patients for suture-mediated percutaneous patent fossa ovalis closure

Background

In patients with patent fossa ovalis (PFO) and paradoxical embolism, percutaneous closure of the interatrial communication has been proven more effective than medical treatment only to reduce recurrent thromboembolic events. Percutaneous suture-mediated PFO closure has been proved to be a safe and advantageous alternative to device-based PFO closure, yet its overall success rate is slightly lower in unselected patients. Hence, it is extremely important to define baseline features associated with unsatisfactory results to appropriately select patients suitable for this technique.

Purpose

Systematic assessment of PFO anatomy in the largest series of consecutive patients undergoing suture-mediated percutaneous PFO closure to identify a single baseline predictor of significant residual right-to-left shunt (procedural failure) for optimal selection of patient to be submitted to this procedure.

Methods

Pre-procedural transesophageal echocardiogram (TEE) of 302 consecutive patients (113 men, 45±12 years) who underwent percutaneous suture-mediated PFO closure at a single institution were accurately reviewed to assess a series of parameters: presence and grade of spontaneous right-to-left shunt (RLS), PFO length and width, presence of atrial septal aneurysm and its maximal bulge, and presence of an embryonic or fetal remnant (Chiari network or Eustachian valve).

Results

At echocardiographic follow-up (3–6 months from the closure procedure), a residual RLS ≥2 was found in 60 (19.9%) patients. At multivariable analysis, only two anatomical variables measured at pre-procedural TEE were found as independent predictors of residual RLS ≥2 at follow-up: PFO maximum width (OR 1.89, 95% CI 1.16–3.40, p=0.019) and PFO minimum length (OR 0.58, 95% CI 0.35–0.88, p=0.018). An index based on the ratio of PFO maximum width to PFO minimum septal overlapping (W/SO) was found to be the most powerful predictor of RLS ≥2 at follow-up (OR 48.1, 95% CI 9.3–352.2, p&lt;0.001). The ROC curve for the W/SO ratio was found to have an AUC of 0.84 (95% CI 0.75–0.93) and a cut-off value of 0.61 yielding a sensitivity of 80% and specificity of 78% with a negative predictive value of 94%.

Conclusions

Baseline pre-procedural TEE assessment provides essential information for the selection of patients most suitable to undergo suture-mediated PFO closure. Our results indicate that the ratio between the maximum amplitude of the PFO and the minimum overlap of the septa is the optimal single baseline index to optimally select patient for an effective percutaneous PFO closure.

Funding Acknowledgement

Type of funding sources: None.

A comprehensive and easy-to-use ECG algorithm to predict the coronary occlusion site in ST-segment elevation myocardial infarction

Background

Several electrocardiogram (ECG) criteria have been proposed to predict the location of the culprit occlusion in specific subsets of patients presenting with ST-segment elevation myocardial infarction (STEMI).

Purpose

The aim of this study was to develop, through an independent validation of currently available criteria, a comprehensive and easy-to-use ECG algorithm, and to test its diagnostic performance and reliability in real-world clinical practice.

Methods

We analyzed ECG and angiographic data from 408 consecutive STEMI patients submitted to primary percutaneous coronary intervention, dividing the overall population into derivation (306 patients) and validation (102 patients) cohorts. In the derivation cohort, we tested &gt;60 previously published ECG criteria, using the decision-tree analysis to develop the algorithm that would best predict the infarct-related artery (IRA) and its occlusion level. We further assessed the new algorithm diagnostic performance and reliability in the validation cohort.

Results

In the derivation cohort, the algorithm correctly predicted the IRA in 91% of cases and both the IRA and its occlusion level (proximal vs. mid-distal) in 73% of cases. When applied to the validation cohort, the algorithm resulted in 90% and 69% diagnostic accuracies, respectively. In a real-world comparative test, the algorithm performed significantly better than expert physicians in identifying the site of the culprit occlusion (p=0.026 vs. best cardiologist and p&lt;0.001 vs.best emergency medicine doctor). The algorithm showed almost perfect reliability (Cohen's kappa 0.86) between a cardiologist and an ambulance paramedic.

Conclusions

Derived from an extensive literature review, this comprehensive and easy-to-use ECG algorithm can accurately predict the IRA and its occlusion level in all-comers STEMI patients.

Funding Acknowledgement

Type of funding sources: None.

Accuracy and reliability of left atrial appendage morphology assessment by new 3D transesophageal echocardiographic rendering modalities: a comparative study with computed tomography

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction. Left atrial appendage (LAA) morphology assessed by contrast-enhanced computed tomography (CT) has been associated to the risk of cardioembolic stroke in non-valvular atrial fibrillation. Subsequent studies with the traditional LAA classification system (CS) into 4 morphologies (Chicken wing, Cauliflower, Cactus and Windsock) yielded mixed results in terms of reliability and stroke risk association. Recently, a simple LAA morphology CS (new-LAAcs) based on the LAA bend angle measurement has been suggested. Three-dimensional transesophageal echocardiography (3D TOE) quality imaging has been improved and new volume rendering modalities developed.

Purpose. Aim of this study was to evaluate the accuracy and reliability of 2D and new 3D TOE rendering modalities compared to CT in assessing LAA morphology. We used and validated a new simple LAA morphology classification system (new-LAAcs) based on the LAA bend angle in contrast to the traditional CS.

Methods. 50 consecutive patients who underwent both cardiac CT and TOE were enrolled. LAA morphology was assessed by three different TEE modalities: (1) 2D TOE inspective evaluation (2D TOE), (2) 3D TOE multiplanar reconstruction (3D TOE MPR) and (3) 3D TOE Philips TrueVue Glass rendering (3D TOE GLASS). We assessed TOE accuracy compared to CT by sensitivity, specificity, accuracy, and Cohen’s kappa. Two trained readers independently adjudicated LAA morphologies in the new-LAAcs and the inter-rater reliability was obtained by percentage agreement and Cohen’s kappa. The reliability of the new- vs. traditional-LAAcs was assessed by CT in terms of reliability rates and influence on LAA morphology prevalence.

Results. CT and TOE imaging analyses were feasible in all patients. 2D TOE was fairly accurate in identifying LAA morphology (κ 0.38, p = 0.022) and had only moderate inter-rater (κ 0.46, p = 0.027) and substantial intra-rater (κ 0.62, p = 0.003) reliability rates. 3D TOE showed high validity: 3D TOE MPR had an almost perfect accuracy (κ 0.84, p &lt; 0.001) and substantial (κ 0.77, p &lt; 0.001) inter-rater reliability; 3D TOE GLASS substantial accuracy (κ 0.67, p &lt; 0.001) and almost perfect (κ 0.82, p &lt; 0.001) inter-rater reliability. Intra-rater agreement was almost perfect for both 3D TOE modalities (κ 0.84, p &lt; 0.001). In the comparison among CS the traditional-LAAcs inter-rater reliability was moderate (κ 0.47, p &lt; 0.001) and the intra-rater reliability substantial (κ 0.68, p &lt; 0.001) while the new-LAAcs yielded an almost perfect reliability level (inter-rater κ 0.84, p &lt; 0.001 and intra-rater κ 0.93, p &lt; 0.001). With the traditional-LAAcs, the prevalence of CW LAA was 30 (60%), while with the new-LAAcs the prevalence of low-risk-LAA was 13 (26%), leading to classify 17 (57%) CW morphologies as high-risk-LAA.

Conclusions. 3D TOE is an accurate, reliable, and feasible alternative to CT in assessing LAA morphology with the new-LAAcs. The new-LAAcs shows higher reliability rates than the traditional one. Abstract Figure.  Abstract Figure.

Left atrial appendage closure: a new strategy for cardioembolic events despite oral anticoagulation

BACKGROUND

Patients with non-valvular atrial fibrillation (nvAF) who experienced a cardioembolic (CE) event despite adequate oral anticoagulation (OAC) are at high risk of recurrence, and further prevention strategies are deemed necessary. The present study aimed to evaluate the safety and efficacy of off-label use of left atrial appendage closure (LAAC) in this subset of patients.

METHODS AND RESULTS

Seventy-five consecutive patients with nvAF who experienced a CE event despite adequate OAC therapy were retrospectively enrolled from two Italian centers. Patients were divided according to the treatment strategy following the index event: DOAC group (49 patients who continued OAC therapy with DOACs) and LAAC group (26 patients who underwent LAAC procedure). 1:1 propensity-score matching between the two groups was performed. LAAC group was made up of two subgroups according to the post-procedural pharmacological regimen: (a) dual antiplatelet therapy (DAPT) for 3 months followed by indefinite single antiplatelet therapy (LAAC+SAPT) or (b) aspirin plus DOAC for 3 months followed by indefinite DOAC therapy (LAAC+DOAC). The primary endpoint was a composite of CE event, major bleeding, or procedurerelated major complication. During a median follow-up of 3.4 years (IQR 2.0-5.3), LAAC was a predictor of primary endpoint-free survival (HR 0.28, 95%CI 0.08-0.97; p=0.044); within LAAC group, no procedure-related major complication occurred. Moreover, a trend toward a lower rate of both CE events and major bleedings was observed in LAAC group, particularly in the subgroup LAAC+DOAC.

CONCLUSIONS

LAAC is a reasonable therapeutic option in nvAF patients who suffered a CE event despite adequate OAC therapy.

Renal arteries denervation: from the treatment of resistant hypertension to the treatment of atrial fibrillation

Renal denervation (RDN) is a therapeutic strategy for patients with uncontrolled arterial hypertension characterized by considerable fluctuations during its progression. After initial strong enthusiasm, the procedure came to an abrupt halt following the publication of the Symplicity HTN-3 study results. The results of recently published studies highlight the reduction in blood pressure values after RDN and justify the inclusion in the Guidelines of new recommendations for the use of RDN in clinical practice, in selected patients. Additionally, RDN findings are summarized in view of other potential indications such as atrial fibrillation. Six prospective, randomized studies are presented that evaluated RDN as an adjunct therapy to pulmonary vein isolation for the treatment of atrial fibrillation. In five studies, patients had uncontrolled hypertension despite therapy with three antihypertensive drugs. The analysis of these studies showed that RDN reduced the recurrence of atrial fibrillation (AF) by 57% compared to patients with pulmonary vein isolation (PVI) only. Modulation of the autonomic nervous system by RDN has been shown not only to reduce blood pressure but also to have an antiarrhythmic effect in symptomatic AF patients when the strategy is combined with PVI, thus opening up new therapeutic scenarios.

Kounis syndrome after almonds ingestion: From the diagnostic approach to new therapeutic options

Acute coronary syndromes can develop with an unusual and challenging presentation. Kounis syndrome is a mostly overlooked Acute Coronary Syndrome (ACS) in the setting of anaphylactic or anaphylactoid reactions in response to an allergic insult that can lead to severe complications including cardiac arrest. A 52-yearold- man presented to the emergency department of our hospital because of acute transient loss of consciousness that developed some minutes after almonds ingestion. The complex diagnostic workup led to the diagnosis of vasospastic Kounis syndrome, an infrequent type of acute coronary syndrome, mostly overlooked, with challenging diagnostic and therapeutic features. Peculiarities on clinical presentation, the approach adopted by the emergency physician and the consultant cardiologist to achieve the correct diagnosis and our proposed management with a brief revision of the literature will be reported. Unusual clinical presentations of acute coronary syndromes represent part of the pitfalls that an emergency physician can face during the everyday practice. Prompt identification of these conditions is always struggling but of crucial importance to improve patient prognosis with a correct diagnostic work-up and therapeutic management.

Predictors of Residual Right-to-Left Shunt After Percutaneous Suture-Mediated Patent Fossa Ovalis Closure

OBJECTIVES

This study sought to assess patent fossa ovalis (PFO) anatomy by transesophageal echocardiography (TEE) in patients undergoing percutaneous suture-mediated PFO closure to identify predictors of post-procedural residual atrial right-to-left shunt (RLS).

BACKGROUND

Percutaneous suture-mediated PFO closure has been proven to be a safe and effective technique in most PFO patients.

METHODS

From June 2016 to October 2019, 247 consecutive patients underwent percutaneous suture-mediated PFO closure at our institution. Of them, 230 (46 ± 13 years of age, 146 women) had complete and technically evaluable pre-procedural TEE. The following parameters in short-axis view were assessed: presence and grade of spontaneous RLS, PFO length and width, presence of atrial septal aneurysm and its maximal bulge, and presence of an embryonic or fetal remnant (Chiari network or Eustachian valve).

RESULTS

At the first follow-up transthoracic echocardiography performed between 3 and 6 months from the closure procedure, a residual RLS ≥2 grade was found in 37 (16%) patients. Grade of pre-procedural spontaneous RLS (hazard ratio: 1.99; 95% confidence interval: 1.14 to 3.48; p = 0.016) shunt and PFO width (hazard ratio: 2.52; 95% confidence interval: 1.85 to 3.43; p < 0.001) were both found to be significantly associated with significant residual RLS at multivariable analysis. The presence of atrial septal aneurysm and its maximal bulge and of congenital remnants was not associated with significant residual RLS.

CONCLUSIONS

Percutaneous suture-mediated PFO closure is feasible in the majority of septal anatomies; however, PFO >5 mm in width and spontaneous large RLS are less likely to be closed with 1 stitch only.

Percutaneous suture-mediated Patent Fossa Ovalis (PFO) closure: two-year clinical follow-up

BACKGROUND

Percutaneous suture-mediated patent fossa ovalis (PFO) closure has been recently introduced in clinical practice showing a favorable efficacy and safety profile in most PFO cases. The aim of this study was to assess the long-term outcomes of PFO closure by direct suture in a large consecutive series of patients.

METHODS

We extracted all consecutive patients who underwent percutaneous closure of the PFO by suture technique (HeartStitch, Fountain Valley, CA, USA) from June 2016 with a follow up of at least 2 years. After PFO closure, patients were followed-up clinically at 1, 6 and up to 12 months and microbubble transthoracic echocardiography (TTE) scheduled between 3 and 6 months, and at 12-month followup. After 12 months, patients were clinically checked every 6 months.

RESULTS

As of September 1, 2020, 187 patients had undergone PFO closure with suture for at least two years and, of these, 181 (121 women and 60 men, mean age 45±13 years, range 15-75 years) had complete clinical and instrumental follow-up (97%). There were no peri-procedural complications. Mean follow up was 1076±251 days (range 727-1574). At 12-month TTE, a significant residual atrial shunt was found in 39 patients (21%). At follow-up no recurrent thromboembolic or cerebral event occurred, no instrumental evidence of suture dehiscence detected and, 18 months after the procedure, one patient had an episode of transient atrial fibrillation lasting less than 24 hours and resolved spontaneously.

CONCLUSIONS

Long-term follow-up data indicate that PFO closure by direct suturing is safe and effective. Two years after the procedure, there were no significant complications, no permanent arrhythmic complications and evidence of suture dehiscence.

Lung Ultrasound in COVID-19 A Role Beyond the Acute Phase?

OBJECTIVES

Coronavirus disease 2019 (COVID-19) is a viral illness caused by severe acute respiratory syndrome coronavirus 2. With the increasing number of improved and discharged patients with COVID-19, the definition of an adequate follow-up strategy is needed. The purpose of this study was to assess whether lung ultrasound (LUS) is an effective indicator of subclinical residual lung damage in patients with COVID-19 who meet discharge criteria.

METHODS

We prospectively enrolled 70 consecutive patients with COVID-19 who had a prolonged hospitalization with inpatient rehabilitation between April 6 and May 22, 2020. All of the patients underwent an LUS evaluation at discharge. Data of patients with more severe disease during the acute phase (ie, required ventilatory support) were compared to those of patients with milder disease.

RESULTS

Among the 70 patients with COVID-19 (22 women and 48 men; mean age ± SD, 68 ± 13 years), the LUS score before discharge was still frankly pathologic and higher in patients who had more severe disease during the acute phase compared to patients with milder disease (median [interquartile range], 8.0 [5.5-13.5] versus 2.0 [1.0-7.0]; P < .001), even when both categories met internationally defined discharge criteria.

CONCLUSIONS

Lung ultrasound can identify the persistence of subclinical residual lung damage in patients with severe COVID-19 even if they meet discharge criteria. Considering the low cost, easy application, and lack of radiation exposure, LUS seems the ideal tool to be adopted in outpatient and primary care settings for the follow-up of patients with COVID-19.