Is transesophageal echocardiography necessary before electrical cardioversion in patients treated with non-vitamin K antagonist oral anticoagulants? Current evidence and practical approach

According to current guidelines, non-vitamin K antagonist oral anticoagulants (NOACs) should be used at least 3 weeks before planned electrical cardioversion. In accordance with international atrial fibrillation (AF) guidelines, transesophageal echocardiography (TEE) is a pre-procedural examination recommended as an alternative to adequate oral anticoagulation. The strategy related to qualifying patients treated with NOACs for pre-procedural TEE differs in individual centers. Therefore, it is necessary to create an algorithm that will standardize estimation of left atrial appendage thrombus (LAAT) prevalence risk and thereby qualify NOAC-treated patients to TEE in the most effective way. We assessed the available studies on LAAT predictors. Risk factors for LAAT formation are not necessarily the same as the risk factors for thromboembolic events in patients with AF. The main risk factor for LAAT are as follows: previous intracardiac thrombus, irregular use of NOAC, inappropriate dose reduction of NOAC, previous stroke, CHA2DS2-VASc score ≥ 3 points, glomerular filtration rate < 60 mL/min/1.73 m², reduced left ventricular ejection fraction, or left atrial enlargement. Based on available evidence, we proposed algorithm guarantees more systematic approach to performing TEE in patients undergoing electrical cardioversion.

The prognostic value of soluble suppression of tumourigenicity 2 and galectin-3 for sinus rhythm maintenance after cardioversion due to persistent atrial fibrillation in patients with normal left ventricular systolic function

AIMS

Soluble suppression of tumourigenicity 2 (sST2) and galectin-3 are involved in cardiac fibrosis, inflammation, and remodelling. However, the place of sST2 and galectin-3 in predicting the outcomes of electrical cardioversion of atrial fibrillation (AF) is uncertain. We evaluated whether these biomarkers could predict sinus rhythm (SR) maintenance after cardioversion of persistent AF in patients with normal left ventricular systolic function.

METHODS AND RESULTS

The study included 80 patients with persistent AF, who underwent cardioversion from February 2016 to August 2018. The blood concentrations of sST-2 and galectin-3 were measured with ELISA and the ASPECT-PLUS assays. Clinical and electrocardiographic follow-up was performed at months 1, 6, and 12. Patients who maintained SR at 12 months had significantly lower concentrations of sST2, measured by ELISA and ASPECT-PLUS assays, than the remaining patients (16.9 ± 9.8 vs. 28 ± 22.9 ng/mL; P < 0.001; 28.7 ± 13.4 vs. 40 ± 25.1 ng/mL; P = 0.003); the concentration of galectin-3 did not differ between these patients. Multivariable logistic regression showed that log-transformed sST2 ELISA was a significant predictor of SR maintenance at 12 months [odds ratio 0.14; 95% confidence interval (CI) 0.03-0.58; P = 0.006]. On receiver-operating characteristic curve analysis, the areas under the curve for the concentration of sST2 was 0.752 (95% CI 0.634-0.870; P < 0.001). The concentrations of sST2 measured with the two assays were strongly correlated (rho = 0.8; CI 95% 0.7-0.87; P = 0.001).

CONCLUSION

Soluble suppression of tumourigenicity 2, but not galectin-3, can be used to predict SR maintenance after cardioversion of AF in patients with normal left ventricular systolic function. The measurements of sST2 concentrations with the rapid lateral flow and enzyme-linked immunoassays were consistent.

Characteristics and Treatment of Atrial Fibrillation with Respect to the Presence or Absence of Heart Failure. Insights from the Multicenter Polish Atrial Fibrillation (POL-AF) Registry

Background: We aimed to assess characteristics and treatment of AF patients with and without heart failure (HF). Methods: The prospective, observational Polish Atrial Fibrillation (POL-AF) Registry included consecutive patients with AF hospitalized in 10 Polish cardiology centers in 2019–2020. Results: Among 3999 AF patients, 2822 (71%) had HF (AF/HF group). Half of AF/HF patients had preserved ejection fraction (HFpEF). Compared to patients without HF (AF/non–HF), AF/HF patients were older, more often male, more often had permanent AF, and had more comorbidities. Of AF/HF patients, 98% had class I indications to oral anticoagulation (OAC). Still, 16% of patients were not treated with OAC at hospital admission, and 9%—at discharge (regardless of the presence of HF and its subtypes). Of patients not receiving OAC upon admission, 61% were prescribed OAC (most often apixaban) at discharge. AF/non–HF patients more often converted from AF at admission to sinus rhythm at discharge compared to AF/HF patients (55% vs. 30%), despite cardioversion performed as often in both groups. Class I antiarrhythmics were more often prescribed in AF/non–HF than in AF/HF group (13% vs. 8%), but still as many as 15% of HFpEF patients received them. Conclusions: Over 70% of hospitalized AF patients have coexisting HF. A significant number of AF patients does not receive the recommended OAC.

Symptomatic and Asymptomatic Patients in the Polish Atrial Fibrillation (POL-AF) Registry

BACKGROUND

Atrial fibrillation (AF) can cause severe symptoms, but it is frequently asymptomatic. We aimed to compare the clinical features of patients with asymptomatic and symptomatic AF.

METHODS

A prospective, observational, multicenter study was performed (the Polish Atrial Fibrillation (POL-AF) registry). Consecutive hospitalized AF patients over 18 years of age were enrolled at ten centers. The data were collected for two weeks during each month of 2019.

RESULTS

A total of 2785 patients were analyzed, of whom 1360 were asymptomatic (48.8%). Asymptomatic patients were more frequently observed to have coronary artery disease (57.5% vs. 49.1%, p < 0.0001), heart failure with preserved ejection fraction (39.8% vs. 26.5%, p < 0.0001), a previous thromboembolic event (18.2% vs. 13.1%, p = 0.0002), and paroxysmal AF (52.3% vs. 45.2%, p = 0.0002). In multivariate analysis, history of electrical cardioversion, paroxysmal AF, heart failure, coronary artery disease, previous thromboembolic event, and higher left ventricular ejection fraction were predictors of a lack of AF symptoms. First-diagnosed AF was a predictor of AF symptoms.

CONCLUSIONS

In comparison to symptomatic patients, more of those hospitalized with asymptomatic AF had been previously diagnosed with this arrhythmia and other cardiovascular diseases. However, they presented with better left ventricular function and were more frequently treated with cardiovascular medicines.

Risk of left atrial appendage thrombus in older patients with atrial fibrillation

Introduction

We aimed to compare the prevalence of left atrial appendage (LAA) thrombus and its predictors between old and young patients with atrial fibrillation (AF).

Material and methods

The study included 1970 patients aged ≥ 65 (n = 822 (41.7%)) and < 65 (n = 1148 (58.3%)) referred for AF cardioversion or ablation preceded by transoesophageal echocardiography (TEE).

Results

Oral anticoagulation (OAC) was prescribed in 799 (97.2%) patients aged ≥ 65 years and in 1054 (91.8%) of those aged < 65 years (p < 0.001). In patients treated with OAC, those aged ≥ 65 years less often received vitamin K antagonist (VKA) (267 (33.4%) vs. 416 (39.5%)) and more often non-VKA-OAC (NOAC) (532 (66.6%) vs. 638 (60.5%), p = 0.008, p = 0.008) compared to patients < 65 years. On TEE, LAA thrombus was more often observed in patients aged ≥ 65 years than those aged < 65 years (63 (7.7%) vs. 46 (4.0%), p < 0.001), with an absolute but not statistically significant difference between patients aged 65-74 and ≥ 75 years (47 (7.3%) vs. 16 (8.8%), p = 0.528). In patients aged ≥ 65 years, there was no difference in the prevalence of LAA thrombus between patients treated with VKA and NOAC, in contrast to patients aged < 65 years, in whom such a difference was observed (27 (6.5%) vs. 16 (2.5%), p = 0.002). In multivariate logistic regression, predictors of LAA thrombus in both age groups were older age, non-paroxysmal AF, and heart failure, whereas only in patients aged < 65 years - VKA use, and in those aged ≥ 65 years - lower glomerular filtration rate and platelet count.

Conclusions

Despite OAC use, older patients with AF remain at high risk of LAA thrombus formation. Older age, non-paroxysmal AF, and heart failure are predictors of LAA thrombus, irrespective of age.

Elective cardioversion of atrial fibrillation is safe without transesophageal echocardiography in patients treated with non-vitamin K antagonist oral anticoagulants: Multicenter experience

BACKGROUND

Current guidelines recommend electrical cardioversion (ECV) in patients with atrial fibrillation (AF) after at least 3 weeks of adequate non-vitamin K antagonist oral anticoagulant (NOAC) treatment without prior transesophageal echocardiography (TEE). However, in clinical practice in some centres, TEE is performed before ECV in patients with AF. The aim of the study was to evaluate prevalence of thromboembolic and hemorrhagic complications in patients with AF treated with NOACs and undergoing ECV without prior TEE.

METHODS

This observational, multicentre study included consecutive patients with AF treated with NOACs who were admitted for ECV without prior TEE. Thromboembolic events and major bleeding complications were investigated during a 30-day follow-up.

RESULTS

In the study group there were 611 patients, mean age was 66.3 ± 9.2 years, 40% were women. 52 (8.5%) patients had a low thromboembolic risk, 148 (24.2%) patients had an intermediate thromboembolic risk and 411 (67.2%) patients had a high thromboembolic risk. In the study group 253 (41.4%) patients were treated with rivaroxaban, 252 (41.2%) patients were treated with dabigatran and 106 (17.3%) patients were treated with apixaban. Reduced doses of NOACs were administered to 113 (18.9%) patients. In the entire study group, there were no thromboembolic events or major bleeding complications during the in-hospital stay and the 30-day follow-up.

CONCLUSIONS

In this "real-world" study of AF patients treated with NOACs, it was proved that ECV is safe without a preceding TEE, regardless of the risk of thromboembolic complications and of the type of NOAC used.

Antithrombotic therapy in patients with atrial fibrillation undergoing percutaneous coronary intervention, including compliance with current guidelines-data from the POLish Atrial Fibrillation (POL-AF) Registry

Background

Although triple antithrombotic therapy (TAT) is recommended in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI), guidelines allow an option of dual antithrombotic therapy (DAT). This study assesses the everyday practice of 10 cardiology departments in antithrombotic therapy in AF patients undergoing PCI and its agreement with current guidelines.

Methods

This analysis included medical data of AF patients enrolled in the prospective, observational registry (The POLish Atrial Fibrillation-POL-AF) that underwent PCI [elective or due to acute coronary syndrome (ACS)].

Results

Of the 3,999 consecutive subjects included, a final analysis was performed on 359 patients that underwent PCI: 148 with urgent PCI due to ACSand 211 patients with elective PCI. Eighty patients in the ACS-group and 120 patients in the elective-PCI group were treated with TAT, although guidelines also allowed DAT. Of 316 patients treated with oral anticoagulants as a part of combination therapy, 275 were on non-vitamin K antagonist oral anticoagulant (NOAC). Reduced doses of NOAC were used in 74 patients treated with rivaroxaban, 60 patients with dabigatran, and 54 patients with apixaban. The proportion of patients treated with reduced NOAC doses adequately to the guidelines was 29%, 100%, and 33% for rivaroxaban, dabigatran, and apixaban, respectively. Inappropriate low doses of NOACs were used in 71% of subjects on rivaroxaban and 67% on apixaban.

Conclusions

In patients with AF undergoing PCI, NOACs are definitely preferred over vitamin-K antagonists (VKAs) in TAT/DAT, and an aggressive antithrombotic strategy with TAT is frequently chosen even if DAT is permissible by the guidelines. Label adherence of using reduced NOAC dose during combination therapy is not satisfactory for apixaban and rivaroxaban and probably results from too cautious an approach to the known indications for reduced therapy. The study is registered in the database Clinical Trials-NCT04419012.

Left atrial wall dyskinesia assessed during contractile phase as a predictor of atrial fibrillation recurrence after electrical cardioversion performed due to persistent atrial fibrillation

Direct current cardioversion (DCCV) is one of the basic methods for restoring sinus rhythm (SR) in patients with atrial fibrillation (AF). Left atrial (LA) strain is one of the parameters used to assess the risk of AF recurrence following DCCV. Assessing the strain also allows for the detection of segmental disorders of LA wall contractility, including dispersion or dyskinesia. In the present study, we determined the predictive value of LA wall dyskinesia in assessing the risk of AF recurrence after DCCV. We performed a comprehensive echocardiography in 89 patients with persistent AF following successful DCCV. We assessed the strain and strain rate in the reservoir (r), conduit, and contractile (ct) phases by using speckle tracking echocardiography. Dyskinesia was diagnosed when the strain rate of any segment of the LA wall displayed positive values during contraction. After 12 months, 47.2% of patients maintained SR. Patients who maintained SR had a significantly lower LA strain (LAS)r assessed in the apical 4-chamber view (4c) (11.38 ± 4.63 vs 14.54 ± 5.11; P = .004) and 2-chamber view (2c) (11.05 ± 4.1 vs 14.93 ± 6.82%; P = .006), LASct4c (2.51 ± 2.3 vs 5.09 ± 3.29%; P < .001), LASct2c (3.6 ± 2.98 vs 5.67 ± 4.23%; P = .008), peak strain rate (pLASR) ct4c (0.36 ± 0.24 s vs 0.62 ± 0.4; P < .001) and pLASRct2c (0.49 ± 0.30 vs 0.79 ± 0.53 s; P = .01). LA dyskinesia was observed less frequently in the 4c view in patients who maintained SR (59.57 vs 17.5%; P < .001). Multivariable logistic regression showed that the LASct4c (odds ratio (OR) 0.78; 95%CI 0.63-0.97; P = .027) and LA dyskinesia observed in the 4c view (OR 3.53; 95%CI 1.16-10.76; P = .027) were significant independent predictors of AF recurrence at 12 months. We conclude that LA dyskinesia observed in the 4c view and LASct4c are independent risk factors for AF recurrence following DCCV.

Trends in the Prescription of Non-Vitamin K Antagonist Oral Anticoagulants for Atrial Fibrillation: Results of the Polish Atrial Fibrillation (POL-AF) Registry

Background: Current guidelines do not suggest in which groups of patients with atrial fibrillation (AF) individual non-vitamin K antagonist oral anticoagulants (NOACs) should be used for the prevention of thromboembolic complications. The aim of this study was to evaluate the frequency of use of apixaban, dabigatran, and rivaroxaban, and attempt to identify factors predisposing their administration. Methods: The Polish Atrial Fibrillation (POL-AF) registry is a prospective, non-interventional study, including consecutive patients with AF hospitalized in ten Polish cardiology centers during the period ranging from January to December 2019. In this study, all patients were treated with NOACs. Results: Among the 2971 patients included in the analysis, 40.4% were treated with rivaroxaban, 32% with apixaban, and 27.6% with dabigatran. The mean age of the total population was 72 ± 11.5 years and 43% were female. A reduced dose of NOAC was used in 35% of patients treated with apixaban, 39.7% of patients treated with dabigatran, and 34.4% of patients treated with rivaroxaban. Independent predictors of the use of apixaban were previous bleeding (OR 2.37, CI 1.67–3.38), GFR < 60 mL/min (OR 1.38, CI 1.25–1.64), heart failure (OR 1.38, CI 1.14–1.67) and age (per 5 years) (OR 1.14, CI 1.09–1.19). GFR < 60 mL/min (OR 0.79, CI 0.66–0.95), female (OR 0.8, CI 0.67–0.96) and age (per 5 years) (OR 0.95, CI 0.91–0.99) diminished the chance of using dabigatran. Previous bleeding (OR 0.43, CI 0.28–0.64), vascular disease (OR 0.84, CI 0.70–0.99), and age (per 5 years) (OR 0.94, CI 0.90–0.97) diminished the chance of choosing rivaroxaban. Conclusions: In hospitalized patients with AF, the most frequently chosen NOAC was rivaroxaban. Apixaban was chosen more often in patients after bleeding, and in those who were advanced in years, with heart failure and impaired renal function. Impaired renal function and female gender were factors that diminished the chance of using dabigatran. Previous bleeding and vascular disease was the factor that diminished the chance of using rivaroxaban. Dabigatran and rivaroxaban have been used less frequently in elderly patients.

Prevalence and risk factors of left atrial thrombus in patients with atrial fibrillation and lower class (IIa) recommendation to anticoagulants

Background

Oral anticoagulation therapy (OAT) prevents ischaemic incidents in patients with atrial fibrillation (AF). CHA₂DS₂-VASc risk score of ≥2 points in men and ≥3 in women is a class I indication for OAT. OAT should also be considered as a prevention of thromboembolism in AF men with a CHA₂DS₂-VASc score of 1 point and women with 2 points, but the class of recommendation is lower (IIa). This study aims to assess the occurrence of left atrial appendage thrombus (LAAT) and risk factors of its formation in patients with lower class recommendation to oral antiocoagulation treatment.

Methods

The study group consisted of 1,858 patients: 555 patients with class IIa indication to OAT (IIa group) and 1,303 patients with class I indication as a control group (I group). Patients were admitted to three cardiology departments. All subjects underwent transoesophageal echocardiography.

Results

The incidence of LAAT was comparable in both IIa and I group: LAAT was confirmed in 30 (5.4%) subjects of IIa group and in 77 (5.9%) of I group. The prevalence of LAAT in IIa group was higher on treatment with VKAs (in comparison to NOACs) (8.4% vs. 3.4%, P=0.010), and lower in case of paroxysmal AF (in comparison to non-paroxysmal AF) (2.4% vs. 9.8%, P=0.0002). Multivariate logistic regression revealed the following variables as the independent predictors of LAAT in IIa group: treatment with VKAs (OR 2.99, 95% CI: 1.33-6.69; P=0.007), paroxysmal AF (OR 0.26, 95% CI: 0.11-0.62; P=0.002) and eGFR <60 mL/min/1.73 m² (OR 3.19, 95% CI: 1.42-7.16; P=0.005).

Conclusions

The prevalence of LAAT in AF patients with lower class (IIa) recommendation to anticoagulants was comparable to higher (I). Treatment with VKAs, along with non-paroxysmal type of AF and eGFR <60 mL/min/1.72 m² were identified as the strongest predictors of LAAT in IIa group.

Stroke prevention and guideline adherent antithrombotic treatment in elderly patients with atrial fibrillation: A real-world experience

Patients aged ≥75 years with the diagnosis of atrial fibrillation (AF) are at a higher risk of stroke and, according to recent recommendations, should receive oral anticoagulant (OAC) therapy. This study aimed to assess the recommended prophylactic antithrombotic therapy among patients with AF aged ≥ 75 years and its compliance with current guidelines. We also aimed to identify predisposing factors associated with the administration of non-vitamin K antagonist oral anticoagulants (NOACs) in elderly patients with AF.This was a retrospective, single-center observational study. Patients with AF aged ≥75 years hospitalized at a reference cardiology center from 2014 to 2017 were included in the analysis.Among the 1236 eligible patients (43.4% male; mean age, 82 years), OACs were recommended in 90.1% of cases. Of these, 59.8% of patients used NOACs and 40.2% used vitamin K antagonists. Additionally, 3.3% of patients received antiplatelet (AP) therapy and 2.5% were administered low molecular weight heparin. Only 4.5% of patients did not receive any anticoagulant treatment. The majority (89.9%) of patients received relevant prophylactic antithrombotic therapy according to current guidelines; only 1.4% were overtreated and 8.7% were undertreated. The significant predictors of NOAC therapy among patients treated with anticoagulants were non-permanent AF (odds ratio [OR] = 1.68, 95% confidence interval [CI] = 1.30-2.18, P = .0001), age-by 5 years (OR = 1.33, 95% CI = 1.16-1.52, P = .0001), and glomerular filtration rate-by 5 units (OR = 1.06, 95% CI = 1.02-1.10, P = .0066).A high percentage of AF patients aged ≥75 years receive OACs, mainly NOACs. Most patients are treated according to the current guidelines; under treatment is primarily observed in patients receiving AP therapy. Non-permanent AF, age, and preservation of renal function are significant predictors of NOAC use.

Does the CHA2DS2-VASc scale sufficiently predict the risk of left atrial appendage thrombus in patients with diagnosed atrial fibrillation treated with non-vitamin K oral anticoagulants?

The CHA2DS2-VASc scale does not include potential risk factors for left atrial appendage thrombus (LAAT) formation such as a form of atrial fibrillation (AF) and impaired kidney function. The real risk of thromboembolic complications in AF patients is still unclear as well as an optimal anticoagulant treatment in males with a CHA2DS2-VASc score of 1 and females with a CHA2DS2-VASc score of 2.The aim of this study was to compare the predictive value of the CHA2DS2-VASc scale and other scales to estimate the risk of LAAT formation in AF patients treated with non-vitamin K oral anticoagulants (NOACs) and to assess the prevalence of thrombi in patients at intermediate risk of stroke.The observational study included consecutive patients with a diagnosis of non-valvular AF treated with NOACs, admitted to 3 high-reference institutions between 2013 and 2018. All individuals underwent transoesophageal echocardiography before cardioversion or ablation.Out of 1163 enrolled AF patients (62.1% male, mean age 62 years) the LAAT had been detected in 50 individuals (4.3%). Among patients with LAAT, 1 patient (2.0%) was classified as a low-risk category, 9 (18.0%) were at intermediate-risk, and 40 (80.0%) were at high risk of thromboembolic complications according to CHA2DS2-VASc scale. All patients were treated with NOACs: 51.0% rivaroxaban, 47.1% dabigatran, and 1.9% apixaban.Patients at intermediate stroke-risk with detected LAAT had higher R2CHADS2 score (2.1 ± 1.2 vs 1.2 ± 0.8, P = .007), higher CHA2DS2-VASc-RAF score (6.4 ± 4.4 vs 3.7 ± 2.6, P = .027) and more often had an estimated glomerular filtration rate below 56 mL/min/1.73 m (44.4% vs 13.2%, P = .026) compared to patients without LAAT. The receiver operating characteristics revealed that the CHA2DS2-VASc-RAF scale had better predictive ability to distinguish between patients with and without LAAT in the study group than CHA2DS2-VASc (P = .0006), CHADS2 (P = .0006) and R2CHADS2 scale (P = .0140).The CHA2DS2-VASc scale should be supplemented with an assessment of renal function and form of AF to improve stroke risk estimation. The application of additional scales to estimate the risk of LAAT might be especially useful among males with a CHA2DS2-VASc score of 1 and females with a CHA2DS2-VASc score of 2.

Thrombus in the left atrial appendage in patients with atrial fibrillation treated with non-vitamin K antagonist oral anticoagulants in clinical practice-A multicenter registry

BACKGROUND

The prevalence and predictors of left atrial appendage thrombus (LAAT) in patients with non-valvular atrial fibrillation (AF) who have been treated with non-vitamin K antagonist oral anticoagulants (NOACs) are not well defined. We aimed to assess the occurrence and predictors of LAAT on transesophageal echocardiography (TOE) in patients with non-valvular AF treated with NOACs for at least 3 weeks.

METHODS

Consecutive patients with non-valvular AF who underwent TOE before catheter ablation or electrical cardioversion in three high-reference centers between 2014 and 2018 were included. Patients on apixaban were excluded from the study due to low numbers in this category. All patients received NOACs for at least 3 weeks before TOE.

RESULTS

A total of 1148 patients (female, 38.1%; mean age, 62.1 years) referred to our centers for catheter ablation of AF (52.1%) or electrical cardioversion (47.9%) were included. Patients were on rivaroxaban (51.9%) or dabigatran (48.1%). Preprocedural TOE revealed LAAT in 4.4% of all patients. Multivariable logistic regression analysis showed the CHA2DS2-VASc score ≥2 points (OR = 2.11; 95% CI, 1.15-3.88; P = .0161), non-paroxysmal AF (OR = 6.30; 95% CI, 2.22-17.91; P = .0005), and GFR <60 mL/min/1.73 m² (OR = 2.05; 95% CI, 1.14-3.67; P = .0160) were independent predictors of LAAT in patients treated with NOACs.

CONCLUSIONS

In non-valvular AF patients treated with NOACs, the prevalence of LAAT was 4.4% before electrical cardioversion or ablation. In addition to the CHA2DS2-VASc score, the type of AF and renal function should be considered in the stratification of thromboembolism risk in AF patients and qualification for a preprocedural TOE.

Tumors of the right atrium and the inferior vena cava operated in deep hypothermic circulatory arrest

&lt;b&gt;Introduction:&lt;/b&gt; Tumors which most frequently metastasize to the heart include: malignant melanoma, lung cancer, breast cancer, ovarian cancer, kidney cancer, leukemia, lymphomas and esophageal cancer. &lt;br&gt;&lt;b&gt;Purpose:&lt;/b&gt; The purpose of this paper was clinical analysis of a group of patients operated in deep hypothermic circulatory arrest due to tumors of the right atrium and the inferior vena cava. &lt;br&gt;&lt;b&gt;Material and method:&lt;/b&gt; The study covered 7 patients operated at the Cardiac Surgery Clinic with a cardiac tumor diagnosed on the basis of an echocardiographic assessment in the years 2012-2019. Before qualifying for surgical treatment, each patient underwent: thorough interview and physical examination, 12-lead ECG, laboratory tests and echocardiography. Patients additionally underwent: computed tomography of the chest or abdomen, magnetic resonance imaging and coronary angiography on the basis of which patients with significant coronary artery changes underwent simultaneous coronary artery bypass graft. After preparation, the tumor was excised from the vena cava and right atrium with simultaneous removal of the primary tumor, most often kidney cancer. Early and distant results of treatment were analyzed in the examined group of patients to determine the following endpoints: hospital mortality and survival after surgery: after 3 months and 12 months. &lt;br&gt;&lt;b&gt;Results:&lt;/b&gt; Of all operated patients: 2 individuals died in the early postoperative period due to hemorrhagic complications (hospital mortality - 28.6%), and 5 patients (71.4%) were discharged from the Clinic in a good general condition. In total, 3-month survival was 71.4%, and 12-month survival amounted to 28.6%. &lt;br&gt;&lt;b&gt;Conclusions:&lt;/b&gt; Surgeries are very complex and challenging, and usually take on average 8-10 hours. It can improve the outcomes of palliative oncological treatment, better physical function (cardiovascular fitness) and extend life from several months to several years in more than ²/3 patients.

Risk of left atrial appendage thrombus in patients with atrial fibrillation and chronic kidney disease

Background

Atrial fibrillation (AF) and chronic kidney disease (CKD) are associated with an increased risk of ischemic stroke. The aim of this study was to compare the clinical characteristics, the incidence of left atrial appendage (LAA) thrombus and its predictors, and spontaneous echo contrast (SEC) in a population of patients with AF depending on estimated glomerular filtration rate (eGFR) values.

Methods

This study included 1962 patients who underwent transesophageal echocardiographic examination prior to cardioversion or ablation in the years 2014–2018 in three cardiac centers.

Results

More than a quarter of AF patients had decreased eGFR (< 60 mL/min/1.73 m²) and were characterized as a high-risk population, with more comorbidities, higher thromboembolic and bleeding risk compared to those with normal renal function. Oral anticoagulation (OAC) was prescribed in 97% and 93% of patients with decreased and normal eGFR, respectively, with a higher prevalence of prescribed non-vitamin K antagonist oral anticoagulants (NOACs). The incidence of LAA thrombus (24%, 9% and 4%) and SEC (25%, 25% and 19%) increases simultaneously with a decrease in eGFR (< 30, 30–59 and ≥ 60 mL/min/1.73 m², respectively). Among patients prescribed reduced doses of NOAC, those with decreased eGFR were more often observed with LAA thrombus (10% vs. 2.5%). Non-paroxysmal AF, heart failure and previous bleeding were predictors of LAA thrombus, irrespective of eGFR value. CKD was the predictor of LAA thrombus in all patients including those with non-paroxysmal AF, males, without diabetes, without hypertension and with CHA₂DS₂-VASc < 2.

Conclusions

Despite OAC, patients with concomitant AF and CKD remain at high risk for LAA thrombus formation.

Non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation in secondary stroke and systemic embolism prevention

BACKGROUND

Oral anticoagulants (OAC) are recommended in all patients with atrial fibrillation (AF) after thromboembolic events without contraindications. It is hypothesized herein, that the majority of patients with AF after thromboembolic events receive OAC and the presence of specific factors, predisposes the use of non-vitamin K antagonist oral anticoagulants (NOACs).

METHODS

This is a retrospective study, encompassing patients with AF hospitalized in a reference cardiology center over the years 2014-2017. Thromboembolic events were defined as: ischemic stroke, transient ischemic attack and systemic embolism. Inclusion criteria were the following: diagnosis of non-valvular AF at discharge from hospital, hospitalization not resulting in death.

RESULTS

Among 2834 hospitalized patients with AF, a history of thromboembolic events was identified in 347 (12.2%) patients. In the group studied, of 347 patients with AF after a thromboembolic event, 322 (92.8%) received OAC, including 133 patients on vitamin K antagonist (41.3% of patients on OAC) and 189 patients on NOACs (58.7% of patients on OAC). Among patients treated with NOACs the majority were on dabigatran (116 patients, 61.4%), followed by rivaroxaban (54 patients, 28.6%), and apixaban (19 patients, 10%). Multivariate logistic regression analysis demonstrated that the presence of arterial hypertension reduced the chance for NOACs use (OR 0.4, 95% CI 0.2-0.9, p = 0.04) and left atrial size ≤ 40 mm was a factor increasing the chance for the use of NOACs (OR 2.5, 95% CI 1.1-5.8, p = 0.03).

CONCLUSIONS

Nearly all hospitalized patients with AF received OAC in the secondary prevention of thromboembolic complications. NOACs were used for secondary prevention of stroke among patients with AF in patients with fewer comorbidities.

Atrial fibrillation type and renal dysfunction as important predictors of left atrial thrombus

OBJECTIVE

We aimed to identify predictors of left atrial appendage (LAA) thrombus in patients with atrial fibrillation (AF) and to enhance the prognostic value of the CHA₂DS₂-VASc score.

METHODS

Derivation cohort included 1033 consecutive AF patients referred for catheter ablation or direct current cardioversion, in whom transoesophageal echocardiography (TOE) was performed prior to the procedure. Logistic regression analysis was used to identify predictors of LAA thrombus on TOE. Receiver operating characteristic (ROC) curves were constructed to compare the newly developed score with the CHA₂DS₂ and CHA₂DS₂-VASc scores in the derivation and the validation (n=320) cohort.

RESULTS

On TOE, LAA thrombus was present in 59 (5.7%) patients in the derivation cohort. Aside from variables encompassed by the CHA₂DS₂-VASc score, LAA thrombus predictors included AF type (persistent/'permanent' vs paroxysmal) and renal dysfunction. These predictors were incorporated into the CHA₂DS₂-VASc score. In ROC analysis, area under the curve (AUC) for the new score (CHA₂DS₂-VASc-RAF score) was significantly higher (0.81) than those for the CHA₂DS₂ and CHA₂DS₂-VASc scores (0.71 and 0.70, respectively). In the validation cohort, the CHA₂DS₂-VASc-RAF score also performed significantly better (AUC of 0.88) than the CHA₂DS₂ and CHA₂DS₂-VASc scores (AUC of 0.63 and 0.60, respectively).

CONCLUSION

In real-world AF patients with majority on oral anticoagulation, LAA thrombus was found in approximately 6%. Two variables not included in the CHA₂DS₂-VASc score (AF type and renal dysfunction) proved strong, independent predictors of LAA thrombus and might improve thromboembolic risk stratification.

Theoretical study of nitride short period superlattices

Discussion of band gap behavior based on first principles calculations of electronic band structures for various short period nitride superlattices is presented. Binary superlattices, as InN/GaN and GaN/AlN as well as superlattices containing alloys, as InGaN/GaN, GaN/AlGaN, and GaN/InAlN are considered. Taking into account different crystallographic directions of growth (polar, semipolar and nonpolar) and different strain conditions (free-standing and pseudomorphic) all the factors influencing the band gap engineering are analyzed. Dependence on internal strain and lattice geometry is considered, but the main attention is devoted to the influence of the internal electric field and the hybridization of well and barrier wave functions. The contributions of these two important factors to band gap behavior are illustrated and estimated quantitatively. It appears that there are two interesting ranges of layer thicknesses; in one (few atomic monolayers in barriers and wells) the influence of the wave function hybridization is dominant, whereas in the other (layers thicker than roughly five to six monolayers) dependence of electric field on the band gaps is more important. The band gap behavior in superlattices is compared with the band gap dependence on composition in the corresponding ternary and quaternary alloys. It is shown that for superlattices it is possible to exceed by far the range of band gap values, which can be realized in ternary alloys. The calculated values of the band gaps are compared with the photoluminescence emission energies, when the corresponding data are available. Finally, similarities and differences between nitride and oxide polar superlattices are pointed out by comparison of wurtzite GaN/AlN and ZnO/MgO.

Band gap engineering of In(Ga)N/GaN short period superlattices

Discussion of band gap behavior based on first principles calculations of the electronic band structures for several InN/GaN superlattices (SLs) (free-standing and pseudomorphic) grown along different directions (polar and nonpolar) is presented. Taking into account the dependence on internal strain and lattice geometry mainly two factors influence the dependence of the band gap, E g on the layer thickness: the internal electric field and the hyb wells) is more important. We also consider mIn ridization of well and barrier wave functions. We illustrate their influence on the band gap engineering by calculating the strength of built-in electric field and the oscillator strength. It appears that there are two interesting ranges of layer thicknesses. In one the influence of the electric field on the gaps is dominant (wider wells), whereas in the other the wave function hybridization (narrow wells) is more important. We also consider mIn 0.33 Ga 0.67 N/nGaN SLs, which seem to be easier to fabricate than high In content quantum wells. The calculated band gaps are compared with recent experimental data. It is shown that for In(Ga)N/GaN superlattices it is possible to exceed by far the range of band gap values, which can be realized in ternary InGaN alloys.

Theoretical study of point defects in GaN and AlN; lattice relaxations and pressure effects

Native defects and some common dopants (Mg, Zn, and C) in cubic GaN and AlN are examined by means of ab initio theoretical calculations using two methods: i) the Green's function technique based on the linear muffin-tin orbital method in the atomic-spheres approximation; ii) a supercell approach in connection with the full-potential linear muffin-tin-orbital method. We apply the first method to look mainly at the energetic positions of the defect and impurity states in different charge states and their dependence on hydrostatic pressure. The second method allows us to study lattice relaxations. Whereas small relaxations are found near vacancies and substitutional Mg and Zn, the calculations predict large atomic displacements around antisite defects and the substitutional carbon impurity on the cation site.

[Myocarditis in a cachectic female, nonsteroidal anti-inflammatory drugs abuser, in a course of progressive systemic sclerosis]

A case of 70-year-old cachectic female, nonsteroid anti-inflammatory drugs abuser, with progressive systemic sclerosis, who was admitted to our hospital due to joint pain and fatigue is presented. During hospitalisation the patient developed symptoms of acute myocarditis. Angiography of coronary arteries did not reveal narrowing of the vessels. Alimentary supplementation and therapy for heart failure (diuretics, vasodilators, angiotensin-converting enzyme inhibitor and beta-blocker) were used. In repeated echocardiography examinations ejection fraction systematically improved and hemodynamic stabilisation was obtained. Scleroderma, malnutrition, toxicity of nonsteroid anti-inflammatory drugs and infectious agents were considered as a cause of myocarditis.