Should left atrial appendage closure be considered in resistant left atrial appendage thrombus cases? 'Former Foe, New Ally'

BACKGROUND

The study explores left atrial appendage closure (LAAC) as a safe and effective alternative to anticoagulation for atrial fibrillation (AF) patients at high bleeding risk. Complications, such as cardioembolic events due to left atrial appendage thrombus (LAAT), highlight the need for alternative stroke prevention strategies.

AIMS

This research assesses LAAC's safety and efficacy in patients with LAAT, aiming to offer valuable insights into its potential as a viable option for stroke prevention in such cases.

METHODS

The study included 205 patients who underwent LAAC using specific devices between September 2015 and February 2023. Among them, 32 patients had persistent LAAT. Baseline characteristics, antithrombotic medications, risk scores, and LAAC indications were documented. Patients were followed to monitor significant clinical events like stroke, cardiovascular mortality, and all-cause mortality.

RESULTS

The mean age was 71.9 and mostly female. Indications for LAAC were ischemic cerebrovascular events (CVE) despite anticoagulation (25%), bleeding complications (major/minor, 37.5% each), or both. Successful LAA closure was achieved in all cases, with minimal pericardial effusion in one. One-month follow-up showed no major events or device-related issues. Median follow-up of 16.5 months saw 21.9% non-cardiac deaths. The study underscores LAAC's efficacy for stroke prevention in patients with persistent LAAT.

CONCLUSIONS

The LAAC in cases of LAAT, whether pursued initially or as a deferred approach, demonstrates feasibility and safety, exhibiting notable procedural success and minimal incidence of periprocedural complications.

Unlocking Promising Therapies: Drug-Eluting Stents in Medically Refractory Angina Patients With Myocardial Bridging

Myocardial bridging (MB) is a congenital variation in which a coronary artery segment tunnels through the myocardium instead of following its usual epicardial route. Although MB is usually diagnosed incidentally and has a good long-term prognosis, it can lead to complications such as angina, myocardial infarction, arrhythmias, and sudden death. This study aimed to evaluate the outcomes of drug-eluting stent (DES) implantation in patients with MB and medically refractory angina. The study included 12 patients with significant MB who did not respond to maximal medical therapy and underwent DES implantation. The patients were followed up for a mean duration of 33 months. The procedural success rate was 92%, with only 1 patient experiencing acute coronary artery rupture during the procedure. During the follow-up period, none of the patients reported angina symptoms, required additional percutaneous coronary intervention, or developed stent thrombosis. One patient (8.3%) died from a non-cardiac cause. The procedure demonstrates a high procedural success rate and leads to favorable long-term outcomes, including the absence of angina symptoms and the avoidance of stent-related complications. In conclusion, this study suggests that DES implantation can serve as an effective treatment option for selected patients with medically refractory angina and significant MB.

CT dose management for neurologic events in patients with cardiac devices: Radiation exposure variation in patients with cardiac devices

PURPOSE

To compare the inter-center cranial computed tomography (CT) acquisition rates, CT findings, CT related radiation dose, and variability of CT acquisition parameters for neurologic events among patients with implantable cardioverter-defibrillator (ICD) or left ventricular assist device (LVAD).

METHODS

A total of 224 patients [ICD group (n = 155) and LVAD group (n = 69)] who had at least one cranial CT scan were enrolled from three medical centers. The variability and effect of the number, indication, and findings of cranial CT scans as well as CT acquisition parameters including tube potential, tube current, tube rotation time (TI), slice collimation (cSL), and spiral or sequential scanning techniques on CT dose index volume (CTDIvol), total dose length product (DLP) were analyzed.

RESULTS

The mean DLP value of Center A and mean CTDIvol values of Center A and C were significantly lower than Center B (p < 0.001). The mean CTDIvol and DLP values in the ICD group were substantially lower than the LVAD group (p<0.001). The most potent parameters causing the changes in CTDIvol and DLP were kV, mAs values, and CT scanning technique as sequential or spiral according to multivariate linear regression analysis.

CONCLUSION

Cranial CT acquisition parameters and radiation doses vary significantly between centers, which necessitates optimization of cranial CT protocols to overcome the cumulative radiation dose burden in patients with neurologic events.

Effects of mitral annular calcification on the outcomes of transcatheter aortic valve implantation

Background

Transcatheter aortic valve implantation (TAVI) has become the standard of care treatment in patients with severe aortic stenosis who carry intermediate or high risk for surgical aortic valve replacement. Mitral annular calcification (MAC) is frequently seen in patients with aortic stenosis and it is associated with increased cardiovascular morbidity and mortality. It is reported that MAC is an independent predictor of all cause mortality after TAVI.

Aim

The aim of this study is to both evaluate the relationship between mitral annular calcification and TAVI related complications and mortality; and to define the predictors of both all cause mortality and permanent pacemaker implantation after TAVI.

Methods

All of the patients who underwent TAVI procedure due to severe aortic stenosis between 01.01.2020 and 01.06.2020 in our University Hospital were screened and patients fullfilling including criterias were enrolled. Patients' baseline demographic datas, laboratory, echocardiography and TAVI procedure related parameters were recorded. Outcomes are identified as follows; association between mitral annular calcification and TAVI related complications, establishment of the predictors of all cause mortality and permanent pacemaker implantation, definition of the in-hospital and all cause mortality rates.

Results

A total of 245 patients including 98 males (40%) and 147 females (60%) were enrolled in the study. The mean age of the population was 76,3±8,3 years. The mean left ventricular ejection fraction was % 54,8±11,4; aortic valve area was 0,74±0,14 cm2 and mean aortic transvalvular gradient was 47,0±14,3 mmHg. MAC was detected in 148 (% 60,4) patients (Table 1). In-hospital mortality was occurred in 14 (5,7%) cases. Permanent pacemaker implantation was performed in %17,8 (n=42) patients and all cause mortality was developed in 89 (36,3%) cases during the median 23,1 (11,6–44,3) months follow-up. Pericardial effusion (26,4% vs 12,4%; p=0,013) and contrast induced nephropathy (21,6% vs 7,2%; p=0,005) were developed more frequently in patients with MAC than without MAC (Table-2). Only the presence of MAC extending to left ventricular outflow tract was detected to be independent predictor of permanent pacemaker implantation requirement (HR: 3,32; p=0,002). All cause mortality predictors were established as; use of renin-angiotensin-aldosterone system blockers (HR: p=0,012), level of hemoglobin (HR: 0,79; p=0,006), severe mitral annular calcification (HR: 1,94; p=0,024) and atrial fibrillation development after TAVI (HR: 2,39; p=0,002). There was not any correlation between aortic valve area and MAC vloume (r=0,03; p=0,689), MAC Hounsfield Unit (r=−0,007; p=0,934) and MAC Agatston score (r=−0,08; p=0,290).

Discussion

MAC is associated with all cause mortality after TAVI and MAC extending to left ventricular outflow tract is an independent predictor of permanent pacemaker implantation requirement.

Funding Acknowledgement

Type of funding sources: None.

The prediction of atrial fibrillation development in patients treated with transcatheter aortic valve implantation

Funding Acknowledgements

Type of funding sources: None.

Backround

Atrial fibrillation (AF) is associated with poor outcomes after transcatheter aortic valve implantation (TAVI). 

Purpose

This study aimed to investigate whether prolonged total atrial conduction time (PA-TDI) predicts the development of AF in TAVI-treated patients. 

Methods

A total of 307 TAVI-treated patients were enrolled. PA-TDI was defined as the duration from P wave onset on electrocardiography to peak A′ wave on tissue Doppler imaging echocardiography. 

Results

The study was conducted with 263 patients because 44 patients had pre-existing AF. Of 263, 47 (17.8%) had new-onset AF after TAVI procedure. Age, mortality and the frequency of PM implantation were higher in the AF group. LVEDD, LVEF, aortic gradients, and AVA were similar between AF and sinus rhythm groups; however, LVESD, LA diameter, and PA-TDI duration were increased in the AF group. In Kaplan–Meier analysis (Panel A), there was an increase in risk of AF with each incremental percentile of the PA-TDI duration. In multivariate analysis, age (p = 0.005) and PA-TDI duration (p = 0.002) were found to be independent risk factors for the development of AF after TAVI. AUC was 0.630 (p = 0.005), and the sensitivity and specificity were 70% and 51% respectively at a cut-off point of 123.5 ms for PA-TDI duration (Panel B). 

Conclusion

In patients treated with TAVI, post-procedural new-onset AF may lead to significant risk for morbidity and mortality. PA-TDI duration can be used for the detection of the patients with high risk of AF development.

Total (n = 263) Sinus (n = 216) AF (n = 47) p value Age (years) 78.0 ± 10.8 77.5 ± 11.2 80.6 ± 8.4 0.032 Gender (F/M) 144/119 118/98 26/21 0.932 Follow-up time (months) 2 [1-77] 2 [1-77] 1 [1-51] 0.095 Death 82 (31.2%) 59 (27.3%) 23 (48.9%) 0.004 Pacemaker implantation 44 (16.7%) 32 (14.8%) 12 (25.5%) 0.075 LV end-diastolic diameter (mm) 48.2 ± 3.5 47.9 ± 5.3 49.3 ± 5.4 0.202 LV end-systolic diameter (mm) 32.2 ± 5.5 31.7 ± 5.0 35.0 ± 6.8 0.030 LV ejection fraction (%) 55.2 ± 10.9 55.4 ± 10.9 54.2 ± 11.1 0.515 LA diameter (mm) 42.9 ± 6.5 41.9 ± 6.6 44.7 ± 6.1 0.049 Peak aortic gradient (mmHg) 78.6 ± 20.5 79.2 ± 20.5 77.2 ± 20.7 0.660 Mean aortic gradient (mmHg) 46.8 ± 13.5 46.6 ± 13.2 47.2 ± 14.3 0.838 Aortic valve area (cm2) 0.73 ± 0.15 0.73 ± 0.15 0.74 ± 0.14 0.734 PA-TDI duration (ms) 127.0 ± 26.7 125.4 ± 26.2 137.0 ± 27.2 0.009 Abstract Figure.

Echocardiographic assessment of regional right ventricular systolic function using two-dimensional strain echocardiography and evaluation of the predictive ability of longitudinal 2D-strain imaging for pulmonary arterial hypertension in systemic sclerosis patients

Systemic sclerosis (SSc) is a generalized connective tissue disorder, and SSc patients are at risk of developing pulmonary arterial hypertension (PAH). The aims of this study are to evaluate the right ventricular regional systolic function using two-dimensional speckle-tracking echocardiography (2D STE) and to determine the predictive ability of peak longitudinal systolic strain (PLSS) at the RV lateral wall for PAH in SSc patients. 80 SSc patients (mean age 51 ± 12 years) were included in the study. Echocardiography and 2D STE were performed at baseline and after 12 months. RHC was performed only in SSc patients with clinical indications. PLSS at the apical segment of the RV free wall was significantly impaired in PAH patients compared with non-PH patients (-14.6 ± 5.9 vs. - 22.2 ± 7.5%, p = 0.034). PLSS at the basal, mid, and apical segments of the RV free wall was lower in both groups at follow-up compared to baseline, but the drop in strain values was statistically significant only in the non-PH group (p < 0.05). Right atrial area (OR 1.758; p = 0.023), peak tricuspid regurgitation velocity (OR 24.23; p = 0.011) and PLSS at the apical segment of the RV lateral wall (OR 2.47; p = 0.005) were independent predictors of PAH. A cut-off value of - 14.48% PLSS at the apical segment of the RV lateral wall resulted in 100% specificity for predicting PAH in SSc patients. RV pressure overload affects RV systolic function as manifested by impaired RV longitudinal deformation. Evaluating RV regional systolic function with 2D STE could be useful as an additional echocardiographic parameter for screening PAH in SSc patients.

Assessment of cardiac arrhythmias in patients with ankylosing spondylitis by signal-averaged P wave duration and P wave dispersion

OBJECTIVE

Aortic regurgitation, conduction disturbances, increased myocardial fibrosis and pericarditis could be seen in ankylosing spondylitis (AS). However, less attention has been paid to supraventricular arrhythmias (SVA) and atrial conduction system changes. We aimed to assess SVA and conduction system changes in patients with AS.

PATIENTS AND METHODS

Twenty-eight patients (24 men; mean age, 28.7 ± 5.7 years) with AS and 30 healthy volunteers (26 men; mean age, 29.3 ± 5.8 years) were enrolled. All subjects were evaluated by 24-hour ambulatory electrocardiogram, 12 lead standard electrocardiogram (ECG) for P wave dispersion (Pd), and signal-averaged ECG (SAECG) for P wave duration (SAPWD).

RESULTS

SVAs were detected in 9 patients with AS (32%) and 3 controls (10%; p =0.02). Mean SAPWD (115.7±28.6 ms vs. 100.2 ± 18.7 ms, p =0.017) and mean Pd (11.9±4.8 ms vs. 9.3±3.6 ms, 0.023) was longer in patients with AS than the control group. When patient with AS were divided into 2 subgroups as patients with or without SVA, the Pd (16.2±5.0 vs. 9.9±3.2, p =0.001), SAPWD (151.4±7.8 vs. 98.7±16.1, p =0.001) and Bath ankylosing spondylitis disease activity index (BASDAI) (5.1±1.6 vs. 3.7±1.0, p =0.014) were significantly greater in the subgroup with arrhythmias compared to the subgroup without arrhythmias. There was a moderate positive correlation between BASDAI and SAPWD (r=0.622, p =0.001). There was also a moderate positive correlation between BASDAI and Pd (r=0.479, p =0.01).

CONCLUSIONS

SVA were detected more frequently in AS than control group. SAPWD and Pd were prolonged in patients with AS. Clinical severity assessed with BASDAI had a positive correlation with prolongation of SAPWD and Pd.

Evaluation of cardiac autonomic functions in patients with systemic lupus erythematosus

Background: Cardiovascular involvement is one of the leading causes of death among patients with systemic lupus erythematosus (SLE). In this study, we aimed to investigate cardiac autonomic functions in SLE patients. Methods: We enrolled 36 patients (25 female; mean age 34.2 ± 10.2 years) with SLE and 32 healthy subjects (23 female; mean age 35.0 ± 10.3 years). All participants underwent 24-h Holter recording. Heart rate recovery (HRR) indices were calculated by subtracting first, second, and third-minute heart rates from maximal heart rate. All patients underwent heart rate variability (HRV), heart rate turbulence (HRT) and QT dispersion analysis. The mean SLE duration was 8.4 ± 4.0 years. Results: According to the baseline demographic characteristics, both groups were similar with regard to age, gender, body mass index and left ventricular ejection fraction. Mean HRR1 (32.6 ± 10.9 vs. 42.5 ± 6.5, p = 0.038), HRR2 (51.0 ± 16.9 vs. 61.0 ± 10.8, p = 0.01) and HRR3 (52.8 ± 17.5 vs. 65.8 ± 9.8, p < 0.001) values were significantly higher in control group. When HRV was considered, SDNN, SDANN, RMSSD, PNN50 and high frequency (HF) component were significantly decreased in patients with SLE compared with healthy controls, but low frequency (LF) component and LF/HF were significantly higher in SLE patients. In addition, HRT onset and HRT slope values were significantly less negative in SLE patients. QT dispersion was significantly greater in SLE patients than healthy subjects (81.3 ± 15.8 vs. 53.2 ± 13.1, p < 0.001). Conclusion: Our study results suggest that cardiac autonomic functions are impaired in SLE patients despite the absence of overt cardiac involvement and symptoms. Further studies are needed to elucidate the prognostic significance and clinical implications of impaired autonomic functions in patients with SLE.