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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

Background

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

Purpose

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

Methods

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

Results

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

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

Conclusions

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

Funding Acknowledgement

Type of funding sources: None.

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

Background

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Funding Acknowledgement

Type of funding sources: None.

Distal Versus Conventional Radial Access for Coronary Angiography and Intervention: The DISCO RADIAL Trial

BACKGROUND

Currently, transradial access (TRA) is the recommended access for coronary procedures because of increased safety, with radial artery occlusion (RAO) being its most frequent complication, which will increasingly affect patients undergoing multiple procedures during their lifetimes. Recently, distal radial access (DRA) has emerged as a promising alternative access to minimize RAO risk. A large-scale, international, randomized trial comparing RAO with TRA and DRA is lacking.

OBJECTIVES

The aim of this study was to assess the superiority of DRA compared with conventional TRA with respect to forearm RAO.

METHODS

DISCO RADIAL (Distal vs Conventional Radial Access) was an international, multicenter, randomized controlled trial in which patients with indications for percutaneous coronary procedure using a 6-F Slender sheath were randomized to DRA or TRA with systematic implementation of best practices to reduce RAO. The primary endpoint was the incidence of forearm RAO assessed by vascular ultrasound at discharge. Secondary endpoints include crossover, hemostasis time, and access site-related complications.

RESULTS

Overall, 657 patients underwent TRA, and 650 patients underwent DRA. Forearm RAO did not differ between groups (0.91% vs 0.31%; P = 0.29). Patent hemostasis was achieved in 94.4% of TRA patients. Crossover rates were higher with DRA (3.5% vs 7.4%; P = 0.002), and median hemostasis time was shorter (180 vs 153 minutes; P < 0.001). Radial artery spasm occurred more with DRA (2.7% vs 5.4%; P = 0.015). Overall bleeding events and vascular complications did not differ between groups.

CONCLUSIONS

With the implementation of a rigorous hemostasis protocol, DRA and TRA have equally low RAO rates. DRA is associated with a higher crossover rate but a shorter hemostasis time.

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

BACKGROUND

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

METHODS AND RESULTS

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

CONCLUSIONS

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