Bleeding and thrombotic risk of different antiplatelet regimens posttranscatheter edge-to-edge mitral valve repair in patients with an indication for oral anticoagulation: Results from an all-comers national registry

BACKGROUND

Evidence-based recommendations for antithrombotic treatment in patients who have an indication for oral anticoagulation (OAC) after transcatheter edge-to-edge mitral valve repair (TEER) are lacking.

AIMS

To compare bleeding and thrombotic risk for different antithrombotic regimens post-TEER with MitraClip in an unselected population with the need for OACs.

METHODS

Bleeding and thrombotic complications (stroke and myocardial infarction) up to 3 months after TEER with mitraclip were evaluated in 322 consecutive pts with an indication for OACs. These endpoints were defined by the Mitral Valve Academic Research Consortium criteria and were compared between two antithrombotic regimens: single antithrombotic therapy with OAC (single ATT) and double/triple ATT with a combination of OAC and aspirin and/or clopidogrel (combined ATT).

RESULTS

Collectively, 108 (34%) patients received single ATT, 203 (63%) received double ATT and 11 (3%) received triple ATT. Bleeding events occurred in 67 patients (20.9%), with access site related events being the most frequent cause (37%). Bleeding complications were observed more frequently in the combined ATT group than in the single ATT group: 24% versus 14% [p = 0.03, adjusted RR: 0.55 (0.3-0.98)]. Within the combined group, the bleeding risk was 23% in the double ATT and 45% in the triple ATT group. Thrombotic complications occurred in only three patients (0.9%), and all belonged to the combined ATT group.

CONCLUSIONS

In patients with an indication for OACs, withholding of antiplatelet therapy post-TEER with Mitraclip was associated with a 45% reduction in bleeding and without a signal of increased thrombotic risk.

90 Transient severe mitral regurgitation caused by an exclusively dopamine secreting paraganglioma

INTRODUCTION

A 93 year old woman presented to the hospital because of severe dyspnea with a sudden onset. Her medical history was positive for a sick sinus syndrome for which she received a DDD pacemaker in 2014. Furthermore an intra-abdominal paraganglioma (PGL) was discovered a year earlier which was treated conservatively because of her age and lack of symptoms.

On physical examination, a sinus rhythm of 88 bpm (pacemaker rhythm) and oxygen saturation of 80% was noted. Blood pressure was 66/38 mmHg. An urgent blood gas analysis showed an elevated blood lactate concentration of 5.5 mmol/l. Her signs and symptoms were compatible with a cardiogenic shock.

Transthoracic echocardiography (TTE) revealed a notable hyperdynamic left ventricular (LV) function and a severe mitral regurgitation (MR) (ERO 0,7 cm2), based on restriction and tenting of both the anterior and posterior mitral leaflet with a systolic pulmonary artery pressure (PAPs) of 70mmHg + CVP.

Because of her age and a written declaration of will, only a supportive therapy with oxygen and morphine was given. After 45minutes however, the patient suddenly and completely recuperated. Her vital signs stabilized with a blood pressure of 110/60 mmHg and oxygen saturation of 95%. A second TTE showed only a mild MR without any restriction of the mitral leaflets and a normalized PAPs of 30mmHg +CVP. The patient was hospitalized for further investigation.

COURSE DURING HOSPITALIZATION

During the next 48 hours, four similar episodes with acute dyspnea and signs and symptoms of cardiogenic shock were documented. Each time, TTE revealed a hyperdynamic LV function with a severe MR, based on tenting of both mitral valve leaflets. These episodes always terminated spontaneously with only a mild residual MR afterwards. An angiography was performed and showed no coronary lesions.

DIFFERENTIAL DIAGNOSIS

Because of the paroxysmal episodes, documentation of a hyperdynamic LV function with severe hypotension and the known PGL, a 24h urine collection was performed. The results demonstrated a markedly elevated urine dopamine concentration (5300 µg/l) with normal concentrations of adrenaline (3.5 µg/l) and noradrenaline (64.3 µg/l). 3-Methoxytyramine, the metabolite of dopamine, was also highly elevated (4700 µg/l). As such, the diagnosis of a dopamine producing PGL was made. The patient refused any treatment and she went home in a palliative setting.

CONCLUSION

Dopamine-secreting PGL is a very rare entity without a classic clinical presentation. This is the first case report showing a severe MR with cardiogenic shock, leading to the diagnosis of a dopamine secreting PGL. The mechanism of the MR is still unclear, but strain measurements did show an exacerbation of the RV pacing induced dyssynchrony during the episodes of shock, hypothesizing that dopamine release exacerbated the pacing induced asynchrony of the papillary muscles, leading to a functional MR.

Dual antiplatelet therapy after percutaneous left atrial appendage occlusion: single center experience with the Amplatzer Cardiac Plug

BACKGROUND

Percutaneous left atrial appendage occlusion (LAAO) is an alternative to anticoagulation in atrial fibrillation patients at high bleeding risk. Dual antiplatelet therapy (DAPT) is generally recommended in the months following the procedure to prevent thrombotic complications. The aim of this study was to evaluate the safety and efficacy of DAPT after LAAO in a single-centre population of high bleeding risk patients.

METHODS

All patients who received DAPT after LAAO using the Amplatzer Cardiac Plug at Jessa Hospital (Hasselt, BE) between February 2011 and October 2016 were included. Patient characteristics, procedural outcome and clinical events (bleeding, stroke and adverse events) were prospectively followed. Changes in antithrombotic and/or anticoagulant regimens were assessed.

RESULTS

Thirty-nine patients (77 ± 7 years, 51% male, CHA₂DS₂-VASc 5(3-6), Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol Concomitantly (HAS-BLED) 3(3-4)) were included. An initial strategy of one month DAPT (n = 2) was changed to six months DAPT (n = 37) after one thrombotic complication (device thrombosis) at 4.5 months. Post-procedural DAPT duration was 6.1 ± 3.7 months, after which aspirin monotherapy (62%), no antiplatelet/anticoagulant therapy (15%) or a tailored antithrombotic regimen was maintained. At mean follow-up of 21 ± 13 months, seven patients had died (18%), no strokes had occurred (0%) and nine bleedings of which four were major (10%). All major bleedings occurred within the first six months after the procedure during DAPT.

CONCLUSION

Antithrombotic therapy after percutaneous LAAO is needed to prevent thrombotic complications, yet these impose bleeding complications in this high-risk population. Further efforts are needed to define the optimal duration of DAPT, aimed at reducing bleeding complications while maintaining a low thrombosis rate.

Percutaneous closure of inter-atrial communications (atrial septal defect and patent foramen ovale): single-centre experience and mid-term follow-up

BACKGROUND

Percutaneous closure of atrial septal defect (ASD) and patent foramen ovale (PFO) are increasingly being performed. Effective closure rate depends on the anatomy of the interatrial septum and the device used, but its relationship with outcome is poorly described. This study aimed at evaluating: (1) effective ASD and PFO closure rate, (2) factors related with effective closure rate, and (3) factors related with mid-term outcome.

METHODS

All patients who underwent percutaneous ASD or PFO closure at Jessa Hospital Hasselt between April 2002 and February 2014 were enrolled. Closure rate was evaluated using consecutive contrast echocardiography studies. Adverse events were defined as a composite of all-cause mortality, hospitalization for heart failure, atrial arrhythmias and thrombo-embolic event.

RESULTS

One-hundred and two patients (52 +/- 12 y, 42% male, 75 PFO and 27 ASD) were included in the study. Moderate residual shunt was present in 6% and 10% 6 years after ASD and PFO closure, respectively. The presence of an aneurysmatic interatrial septum was associated with residual shunt after PFO closure (HR 0.57 95% CI 0.33-0.96; P=0.031). Pulmonary hypertension (HR 1.09 95% CI 1.01-1.17; P=0.017) and a history of atrial arrhythmias in ASD (HR 4.28 95% CI 1.06-17.40; P=0.046) and age at closure (HR 1.09 95% CI 1.02-1.16; P=0.012) in PFO patients were related with adverse events. The highest rate of adverse events was observed after placement of a Helex Septal Occluder. Amplatzer and Occlutech devices yielded higher effective closure rates.

CONCLUSIONS

Effective closure rates were acceptable 6 years after ASD and PFO closure. The presence of an aneurysmatic septum is associated with residual shunting after PFO closure. Pulmonary hypertension in ASD and older age at closure in PFO are associated with adverse outcome. Adverse events are more frequent with the Helex occluder and effective closure rate depends on the device used.

Coronary embolization of the membrane fixing a "Multilink" stent to its delivery balloon

We report on a case of coronary embolization of an elastic membrane fixing the ACS RX Multilink stent over its balloon, after a successful stent delivery. The membrane was dislodged from the balloon in the ostium of the right coronary artery as the delivery balloon was being pulled back into the guiding catheter. All attempts to retrieve the membrane, to cover it with another stent, or to push it into a terminal segment of the artery to limit the jeopardized myocardial mass were unsuccessful. No CABG was performed because the left coronary system was normal and the procedure occurred 2 months after an incomplete inferior myocardial infarction. There was no increase in cardiac enzymes nor electrocardiographic signs of a new myocardial infarction at discharge or at 1-mo follow-up. It seems preferable to avoid further use of stents tied to their balloons with an intermediary, and possibly detachable, element.

Pulmonary migration following periurethral polytetrafluoroethylene injection for urinary incontinence

We report a case of clinically significant migration of polytetrafluoroethylene (Teflon) paste particles to the lungs after periurethral injection. These particles were identified by standard and polarized light microscopy. Since the long-term effects in humans are not sufficiently known, we strongly warn against the use of polytetrafluoroethylene paste in children or young adults with a normal life expectancy.