Persistent and Recurrent Device-Related Thrombus After Left Atrial Appendage Closure: Incidence, Predictors, and Outcomes

BACKGROUND

Scarce data exist on the evolution of device-related thrombus (DRT) after left atrial appendage closure (LAAC).

OBJECTIVES

This study sought to assess the incidence, predictors, and clinical impact of persistent and recurrent DRT in LAAC recipients.

METHODS

Data were obtained from an international multicenter registry including 237 patients diagnosed with DRT after LAAC. Of these, 214 patients with a subsequent imaging examination after the initial diagnosis of DRT were included. Unfavorable evolution of DRT was defined as either persisting or recurrent DRT.

RESULTS

DRT resolved in 153 (71.5%) cases and persisted in 61 (28.5%) cases. Larger DRT size (OR per 1-mm increase: 1.08; 95% CI: 1.02-1.15; P = 0.009) and female (OR: 2.44; 95% CI: 1.12-5.26; P = 0.02) were independently associated with persistent DRT. After DRT resolution, 82 (53.6%) of 153 patients had repeated device imaging, with 14 (17.1%) cases diagnosed with recurrent DRT. Overall, 75 (35.0%) patients had unfavorable evolution of DRT, and the sole predictor was average thrombus size at initial diagnosis (OR per 1-mm increase: 1.09; 95% CI: 1.03-1.16; P = 0.003), with an optimal cutoff size of 7 mm (OR: 2.51; 95% CI: 1.39-4.52; P = 0.002). Unfavorable evolution of DRT was associated with a higher rate of thromboembolic events compared with resolved DRT (26.7% vs 15.1%; HR: 2.13; 95% CI: 1.15-3.94; P = 0.02).

CONCLUSIONS

About one-third of DRT events had an unfavorable evolution (either persisting or recurring), with a larger initial thrombus size (particularly >7 mm) portending an increased risk. Unfavorable evolution of DRT was associated with a 2-fold higher risk of thromboembolic events compared with resolved DRT.

Predictors of Device-Related Thrombus Following Percutaneous Left Atrial Appendage Occlusion

BACKGROUND

Device-related thrombus (DRT) has been considered an Achilles' heel of left atrial appendage occlusion (LAAO). However, data on DRT prediction remain limited.

OBJECTIVES

This study constructed a DRT registry via a multicenter collaboration aimed to assess outcomes and predictors of DRT.

METHODS

Thirty-seven international centers contributed LAAO cases with and without DRT (device-matched and temporally related to the DRT cases). This study described the management patterns and mid-term outcomes of DRT and assessed patient and procedural predictors of DRT.

RESULTS

A total of 711 patients (237 with and 474 without DRT) were included. Follow-up duration was similar in the DRT and no-DRT groups, median 1.8 years (interquartile range: 0.9-3.0 years) versus 1.6 years (interquartile range: 1.0-2.9 years), respectively (P = 0.76). DRTs were detected between days 0 to 45, 45 to 180, 180 to 365, and >365 in 24.9%, 38.8%, 16.0%, and 20.3% of patients. DRT presence was associated with a higher risk of the composite endpoint of death, ischemic stroke, or systemic embolization (HR: 2.37; 95% CI, 1.58-3.56; P < 0.001) driven by ischemic stroke (HR: 3.49; 95% CI: 1.35-9.00; P = 0.01). At last known follow-up, 25.3% of patients had DRT. Discharge medications after LAAO did not have an impact on DRT. Multivariable analysis identified 5 DRT risk factors: hypercoagulability disorder (odds ratio [OR]: 17.50; 95% CI: 3.39-90.45), pericardial effusion (OR: 13.45; 95% CI: 1.46-123.52), renal insufficiency (OR: 4.02; 95% CI: 1.22-13.25), implantation depth >10 mm from the pulmonary vein limbus (OR: 2.41; 95% CI: 1.57-3.69), and non-paroxysmal atrial fibrillation (OR: 1.90; 95% CI: 1.22-2.97). Following conversion to risk factor points, patients with ≥2 risk points for DRT had a 2.1-fold increased risk of DRT compared with those without any risk factors.

CONCLUSIONS

DRT after LAAO is associated with ischemic events. Patient- and procedure-specific factors are associated with the risk of DRT and may aid in risk stratification of patients referred for LAAO.

Ticagrelor and Eptifibatide Bolus Versus Ticagrelor and Eptifibatide Bolus With 2-Hour Infusion in High-Risk Acute Coronary Syndromes Patients Undergoing Early Percutaneous Coronary Intervention

Background

In patients with non‐ST‐segment elevation acute coronary syndromes, inhibition of platelet aggregation (IPA) with a potent P2Y₁₂ inhibitor, ticagrelor, was inferior to tirofiban infusion at 2 hours, indicating that glycoprotein IIb/IIIa inhibitors are still needed. Ticagrelor and eptifibatide bolus only may maximally inhibit platelet aggregation and decrease bleeding, but IPA with ticagrelor and eptifibatide bolus versus 2‐hour infusion is unknown.

Methods and Results

A total of 70 P2Y₁₂‐naïve patients, with high‐risk non‐ST‐segment elevation acute coronary syndromes, were randomized to ticagrelor and eptifibatide bolus (group 1) versus ticagrelor and eptifibatide bolus with 2‐hour infusion (group 2). Levels of IPA with ADP, thrombin receptor‐activating peptide, collagen, and high on‐treatment platelet reactivity were measured by light transmission aggregometry at baseline and at 2, 6, and 24 hours after percutaneous coronary intervention in both groups. The primary end point, IPA with ADP 20 μmol/L at 2 hours, was 99.59±0.43% in group 1 versus 99.88±1.0% in group 2 (P<0.001 for noninferiority). High on‐treatment platelet reactivity with ADP was zero at 2, 6, and 24 hours in both groups. IPA levels with ADP, thrombin receptor‐activating peptide, and collagen were significantly higher at 2 and 6 hours than at 24 hours in both groups. Periprocedural myocardial infarction was not significantly different between the groups. Hemoglobin level was significantly less at 24 hours versus baseline in group 2 (13.35±1.8 versus 12.38±1.8 g/dL, respectively; P<0.01).

Conclusions

Ticagrelor and eptifibatide bolus maximally inhibited platelet aggregation at 2 hours, which was associated with no significant hemoglobin drop after percutaneous coronary intervention. This obviates the need for eptifibatide 2‐hour infusion and might decrease bleeding complications.

Clinical Trial Registration

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01919723.

Safety of hydrophilic guidewires used for side-branch protection during stenting and proximal optimization technique in coronary bifurcation lesions

BACKGROUND AND PROPOSE

In coronary bifurcation lesions (CBL), hydrophilic guidewires used for side-branch (SB) protection can be withdrawn from underneath the stent easier than other wires. However, the safety of which has not been investigated.

METHODS/MATERIALS

We performed scanning electron microscopic (SEM) examination of hydrophilic wires - the Whisper and Runthrough wires - used for SB protection during stenting and proximal optimization technique (POT) in 30 patients with CBL. The distal 15cm of the wire was examined every 1mm by SEM and 4500 segments were analyzed to investigate for wire fracture, polymer shearing (PS), and its correlations with post-stenting creatine kinase (CK)-MB release.

RESULTS

SEM examination showed no evidence for wire fracture. The total area of PS and the largest defect on the wire were significantly larger with the Whisper wire versus the Runthrough wire (0.15±0.04mm² vs. 0.026±0.01mm² and 0.04±0.05mm² vs. 0.01±0.01mm²; P<0.05, respectively). The total length of PS and the longest defect on the wire were significantly longer with the Whisper wire vs. the Runthrough wire (12.1±14.5mm vs. 2.7±3.0mm and 2.9±4.2mm vs. 1.0±1.2mm; P<0.05, respectively), but there were weak correlations between the extents of PS with CK-MB release.

CONCLUSIONS

Hydrophilic guidewires may be safely used for SB protection during stenting and POT in CBLs. The extent of PS was significantly greater with the Whisper wire than with the Runthrough wire, but its correlation with post-stenting CK-MB release was weak.

Learning curves for transapical transcatheter aortic valve replacement in the PARTNER-I trial: Technical performance, success, and safety

OBJECTIVES

Introduction of hybrid techniques, such as transapical transcatheter aortic valve replacement (TA-TAVR), requires skills that a heart team must master to achieve technical efficiency: the technical performance learning curve. To date, the learning curve for TA-TAVR remains unknown. We therefore evaluated the rate at which technical performance improved, assessed change in occurrence of adverse events in relation to technical performance, and determined whether adverse events after TA-TAVR were linked to acquiring technical performance efficiency (the learning curve).

METHODS

From April 2007 to February 2012, 1100 patients, average age 85.0 ± 6.4 years, underwent TA-TAVR in the PARTNER-I trial. Learning curves were defined by institution-specific patient sequence number using nonlinear mixed modeling.

RESULTS

Mean procedure time decreased from 131 to 116 minutes within 30 cases (P = .06) and device success increased to 90% by case 45 (P = .0007). Within 30 days, 354 patients experienced a major adverse event (stroke in 29, death in 96), with possibly decreased complications over time (P ∼ .08). Although longer procedure time was associated with more adverse events (P < .0001), these events were associated with change in patient risk profile, not the technical performance learning curve (P = .8).

CONCLUSIONS

The learning curve for TA-TAVR was 30 to 45 procedures performed, and technical efficiency was achieved without compromising patient safety. Although fewer patients are now undergoing TAVR via nontransfemoral access, understanding TA-TAVR learning curves and their relationship with outcomes is important as the field moves toward next-generation devices, such as those to replace the mitral valve, delivered via the left ventricular apex.

Device closure of periprosthetic paravalvular regurgitation

Periprosthetic paravalvular regurgitation is an important sequel associated with prosthetic valves whether implanted surgically or via transcatheter approach. They can remain clinically silent or manifest as clinical heart failure, intravascular hemolysis or a combination of both. Periprosthetic defects are becoming increasingly recognized as a source of morbidity and mortality in patients with prosthetic heart valves and in the last few years, the management of this condition has evolved. This review aims to address the current knowledge on the pathophysiology, imaging modalities and management of these defects. It further details the principles, methodology and outcomes of catheter-based device therapy of periprosthetic paravalvular defects.

Review of reported causes of device embolization following trans-catheter aortic valve implantation

Transcatheter heart valve (THV) embolization is a rare but serious complication of transcatheter aortic valve implantation. Studies, including case reports, case series, and original reports published between 2002 and 2013, with regard to THV embolization were identified with a systemic electronic search using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. A total of 19 publications describing 71 patients were identified. Most patients (64%) were men, with a mean age of 80 ± 6 years and a mean logistic European System for Cardiac Operative Risk Evaluation score of 22.4 ± 9.3%. Balloon-expandable valves were used in 72% of the patients. The reported transcatheter aortic valve replacement access site was transfemoral in 80% of patients. Most cases (90%) occurred <1 hour after implantation, whereas 10% had late embolization (range 4 hours to 43 days). The most common site of embolization was the ascending aorta (38%), followed by the left ventricle (31%), descending aorta (23%), and aortic arch (8%). Open-heart surgery was required in 28% for valve retrieval and replacement. The 30-day stroke and mortality rates were 11% and 17%, respectively. Ventricular embolization and urgent conversion to open-heart surgery were significantly associated with death during hospitalization (p = 0.017 and p = 0.029, respectively). Likely causes of embolization were identified in 59 patients, with positioning error as the most commonly reported (47%), followed by pacing error (13%). In conclusion, THV embolization occurred early after transcatheter aortic valve implantation. The ascending aorta was the most common site of embolization. Higher 30-day stroke and mortality rates were associated with THV embolization compared with most published series of transcatheter aortic valve implantation outcomes.

Emergent transcatheter mitral valve-in-valve implantation in a patient with cardiogenic shock secondary to a failed mitral bioprosthesis

Transcatheter valve-in-valve (VIV) implantation is emerging as a therapeutic option for treatment of failed bioprosthesis in patients that are deemed high-risk or inoperable for redo-valve replacement. It can be carried out in suitable bioprosthetic valves in any position and usually performed as an elective or semi-elective procedure. Here, we report a case of emergent transcatheter VIV implantation in a failed mitral bioprosthesis in a critically ill patient with cardiogenic shock. We conclude that transcatheter VIV implantation may also be an option for critically ill patients with failing bioprosthesis. © 2015 Wiley Periodicals, Inc.

Role of occlusive devices to prevent thromboembolism among persons with a patent foramen ovale and prior stroke

OPINION STATEMENT

Patent foramen ovale (PFO) has been linked to stroke, presumably through the mechanism of paradoxical embolism; however, data is confusing regarding the causal relationship between PFO and embolic stroke. What has come to light in the past decade of research is that PFO closure with devices that achieve a high rate of closure may reduce the risk of recurrent stroke compared with medical therapy, but this benefit has not been shown in the general population with a PFO and cryptogenic stroke. The important question now is which patient will benefit from PFO closure for stroke risk reduction. A validated risk prediction tool is needed to help physicians determine those patients who will derive benefit from closure of PFO to prevent recurrent stroke. It is clear that even in studies with a small number of individuals and a very small number of events, there is some benefit to closure. Furthermore, improvements in closure devices and techniques have made percutaneous device closure both safe and efficacious. As such, it is not necessary to wait for a patient to have two strokes prior to serious consideration of PFO closure. We would advocate that the decision to close a PFO in the setting of a cryptogenic stroke be made at an individual level, on a case-by-case basis. Patients with high-risk features may be more likely to benefit, though who exactly comprises this population is still being elucidated. The most difficult aspect of managing this disease is the substantial number of individuals with incidental PFOs, as well as the prevalence of stroke due to other etiologies. When treating this disease, the physician must be able to weigh the likelihood of benefit versus the risk of the procedure, as well as patient preference.

Tricuspid Annular Plane Systolic Excursion and Its Association with Mortality in Critically Ill Patients

BACKGROUND

Transient left ventricular dysfunction can occur under conditions of extreme emotional or physiological stress. There is little data on right ventricular function in such situations.

METHODS

One hundred twenty patients admitted to an ICU with a noncardiac illness were studied. Those with documented coronary disease, ejection fraction <40%, sepsis, or intracranial hemorrhage were excluded. Echocardiograms were performed within 24 hours of admission. Tricuspid annular plane systolic excursion (TAPSE) was measured to assess right ventricular systolic function. Plasma catecholamines (norepinephrine, epinephrine, dopamine) were measured on admission. Clinical and demographic data were collected, along with data on ICU length of stay (LOS), hospital LOS, and in-hospital and long-term mortality. TAPSE was tested for correlation with adverse outcomes and length of stay.

RESULTS

Mean TAPSE for the group was 2.05 ± 0.66 cm. Based on area under the ROC curve analysis, TAPSE <2.4 cm was the best cutoff for predicting in-hospital and long-term mortality. There were 13 in-hospital deaths, 12 in the group with TAPSE <2.4 cm and one among those with TAPSE ≥2.4 cm. On multivariate analysis, TAPSE <2.4 cm was a significant predictor of in-hospital mortality (χ(2)  = 4.6, P = 0.03). When tested against hospital LOS, an inverse correlation was found (P = 0.04). No association was found between TAPSE and catecholamine levels.

CONCLUSIONS

Right ventricular systolic function, as assessed by TAPSE, has important prognostic value in critically ill patients. Mean values were lower in patients who died in-hospital versus those who survived to discharge. In addition, patients with TAPSE <2.4 cm had a longer hospital length of stay.

Patent foramen ovale and cryptogenic stroke: many unanswered questions

Patent foramen ovale (PFO) is associated with cryptogenic stroke, but uncertainty remains about the exact relationship and the best management. Percutaneous closure of PFO is safe and effective, but this procedure has yet to be definitely proven to be better than medical therapy. The scenario of PFO and cryptogenic stroke poses unique challenges to primary care physicians and subspecialists and requires an understanding of the relationship between cryptogenic stroke and PFO, and of current data on the safety, efficacy, and comparative effectiveness of management options.

Quality of life assessment in the randomized PROTECT AF (Percutaneous Closure of the Left Atrial Appendage Versus Warfarin Therapy for Prevention of Stroke in Patients With Atrial Fibrillation) trial of patients at risk for stroke with nonvalvular atrial fibrillation

OBJECTIVES

This study sought to assess quality of life parameters in a subset of patients enrolled in the PROTECT AF (Percutaneous Closure of the Left Atrial Appendage Versus Warfarin Therapy for Prevention of Stroke in Patients With Atrial Fibrillation) trial.

BACKGROUND

The PROTECT AF (Percutaneous Closure of the Left Atrial Appendage Versus Warfarin Therapy for Prevention of Stroke in Patients With Atrial Fibrillation) trial demonstrated that in patients with nonvalvular atrial fibrillation (AF) and CHADS2 (congestive heart failure, hypertension, age, diabetes mellitus, and prior stroke, transient ischemic attack, or thromboembolism) score ≥1, a left atrial appendage closure device is noninferior to long-term warfarin for stroke prevention. Given this equivalency, quality of life (QOL) indicators are an important metric for evaluating these 2 different strategies.

METHODS

QOL using the Short-Form 12 Health Survey, version 2, measurement tool was obtained at baseline and 12 months in a subset of 547 patients in the PROTECT AF trial (361 device and 186 warfarin patients). The analysis cohort consisted of patients for whom either paired quality of life data were available after 12 months of follow-up or for patients who died.

RESULTS

With the device, the total physical score improved in 34.9% and was unchanged in 29.9% versus warfarin in whom 24.7% were improved and 31.7% were unchanged (p = 0.01). Mental health improvement occurred in 33.0% of the device group versus 22.6% in the warfarin group (p = 0.06). There was a significant improvement in QOL in patients randomized to device for total physical score, physical function, and in physical role limitation compared to control. There were significant differences in the change in total physical score among warfarin naive and not-warfarin naive subgroups in the device group compared to control, but larger gains were seen with the warfarin naive subgroup with a 12-month change of 1.3 ± 8.8 versus -3.6 ± 6.7 (p = 0.0004) device compared to warfarin.

CONCLUSIONS

Patients with nonvalvular AF at risk for stroke treated with left atrial appendage closure have favorable QOL changes at 12 months versus patients treated with warfarin. (WATCHMAN Left Atrial Appendage System for Embolic Protection in Patients With Atrial Fibrillation [WATCHMAN PROTECT]; NCT00129545).

Percutaneous therapeutic approaches to closure of cardiac pseudoaneurysms

Cardiac and aortic pseudoaneurysms are rare complications following myocardial infarction or cardiac surgery. They are characterized by a contained cardiac or aortic rupture within surrounding tissue and have a high mortality rate if left untreated. Percutaneous treatment of cardiac pseudoaneurysms might be a feasible treatment option in patients who are at high risk of reoperative surgery. There is limited literature on the outcomes and the approaches to percutaneous treatment of these pseudoaneurysms. We review nine cases of cardiac and aortic pseudoaneurysms and percutaneous techniques for closure. Pseudoaneurysms were categorized anatomically as left ventricular posterior (posterobasal or posterolateral), left ventricular outflow tract, left ventricular apical, and ascending aortic pseudoaneurysms. Two patients with posterior pseudoaneurysms (one posterobasal treated with an Amplatzer Septal Occluder device, and one wide-mouthed posterolateral pseudoaneurysm which was not closed, are described. We further describe two left ventricular outflow tract pseudoaneurysms treated successfully with percutaneous coil embolization, one left ventricular apical pseudoaneurysm treated with coils, and three ascending aortic pseudoaneurysms treated with a septal occluder device or vascular plug. We review the technical approaches, device selection strategies, outcomes, and complications with these percutaneous treatment options. The size of the pseudoaneurysm dimensions of its neck and relative anatomy, particularly to the coronaries and valves, are critical issues to be addressed before percutaneous treatment of these pseudoaneurysms.

Percutaneous Coronary Intervention for Left Main and Multivessel Coronary Artery Disease – A Review of Strategies

Patients with complex and multivessel disease present challenging clinical problems in defining treatment strategies. The Synergy between PCI with taxus and cardiac surgery (SYNTAX) trial, which included both a randomised as well as a registry experience has clarified many issues. These include the extent and severity of the disease, the clinical presentation, and the metrics used for comparison. The development, validation and application of the SYNTAX score has been of fundamental importance. In those patients with the least complex coronary anatomy, using hard endpoints such as death and myocardial infarction, the outcomes of treatment with either percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) are similar although repeat revascularisation rates remain higher with PCI. In those patients with more extensive and complex disease, coronary artery bypass remains the standard of care. It must be remembered that the drug-eluting stent tested in SYNTAX was a first generation device and that newer generations are safer and more effective. Perhaps the most important guidance in the field of treatment of complex multivessel coronary disease is the attention paid to the Heart Team concept wherein both interventional cardiologists and cardiovascular surgeons are strongly encouraged to work together in these patients to identify the optimal approach consistent with the patients needs and objectives.

Transradial access for renal artery intervention is feasible and safe

BACKGROUND

Transradial access for coronary intervention is associated with reduced access complications compared with transfemoral. Transradial access for renal artery intervention has been less well studied. Safety compared with transfemoral access is undetermined.

METHODS AND RESULTS

We evaluated the feasibility of transradial renal intervention (n = 11 patients) and compared safety parameters with a matched group of transfemoral controls (n = 44). All transradial interventions were successful with no complications. Femoral crossover was required in one due to insufficient guide length. Compared with transfemoral, there were fewer access complications in the transradial group (0 of 11 vs 3 of 44, P = .06) but no differences in fluoroscopy time or contrast volumes (25.3 ± 14.4 vs 29.0 ± 25.1 minutes, P = .47; 83.0 ± 43.7 vs 82.6 ± 35.2 cc, P = .97). At follow-up (median 6 months), radial patency was 100%. Creatinine and systolic blood pressure had decreased (mean 1.4 ± 0.5 to 1.2 ± 0.5, P = .06; 160 ± 25 to 135 ± 17, P = .009).

CONCLUSIONS

Elective transradial renal intervention is feasible and safe. Radial-renal distance is a limitation with available guides.

Acute aortic syndromes: pathophysiology and management

The acute aortic syndromes carry significant morbidity and mortality, especially when detected late. Symptoms may mimic myocardial ischemia, and physical findings may be absent or, if present, can be suggestive of a diverse range of other conditions. Maintaining a high clinical index of suspicion is crucial in establishing the diagnosis. All patients with suspected aortic disease and evidence of acute ischemia on electrocardiogram should undergo diagnostic imaging studies before thrombolytics are administered. The demonstration of an intimal flap separating 2 lumina is the basis for diagnosis. Tear detection and localization are very important because any therapeutic intervention aims to occlude the entry tear. The goals of medical therapy are to reduce the force of left ventricular contractions, decrease the steepness of the rise of the aortic pulse wave, and reduce the systemic arterial pressure to as low a level as possible without compromising perfusion of vital organs. Surgical therapy still remains the gold standard of care for type A aortic dissection, whereas in type B dissection, percutaneous aortic stenting and fenestration techniques have been developed and are sometimes used in conjunction with medical therapy in certain situations.

Clinical and echocardiographic assessment of Nigerian patients seen at the Lagos University Teaching Hospital with features of mitral valve prolapse

In a 3-year prospective echocardiographic study of patients with clinical features of mitral valve prolapse who presented to the cardiology clinic of the medical out patients clinic of the Lagos University Teaching Hospital comprising of sixty-two patients. The most common complaints found were vague chest discomfort (42%) and chest pain. (28%) Their mean body mass index was 20.8 +/- 5.56 Kg/m2. The most common auscultatory sign was apical clicks (8%). Hypertension (12%) was the most common clinical association while the anterior leaflet (87%) was more affected. Mitral regurgitation was present in 35.7% of cases, which were mostly mild in severity (93%). There were statistical differences in the chamber and wall dimension measurements of those with isolated mitral valve prolapse when compared with those associated with other clinical conditions. (p < 0.05). Subjects with isolated mitral valve prolapse were found to have significant differences in the echocardiographic measurements when compared with those with coexisting diseases suggesting that mitral valve prolapse is a relatively benign condition except coexisting with other conditions like hypertension, valvular defects and obesity. These associated conditions tended to increase cardiac risk.