Left Atrial Appendage Occlusion in Patients With Anticoagulation Failure vs Anticoagulation Contraindication

BACKGROUND

Left atrial appendage occlusion (LAAO) provides mechanical cardioembolic protection for atrial fibrillation (AF) patients who cannot use oral anticoagulation therapy (OAT). Patients with a thrombotic event despite OAT are at high risk for recurrence and may also benefit from LAAO.

OBJECTIVES

This study sought to investigate the efficacy of LAAO in AF patients with a thrombotic event on OAT compared to: 1) LAAO in AF patients with a contraindication for OAT; and 2) historical data.

METHODS

The international LAAO after stroke despite oral anticoagulation (STR-OAC LAAO) collaboration included patients who underwent LAAO because of thrombotic events on OAT. This cohort underwent propensity score matching and was compared to the EWOLUTION (Evaluating Real-Life Clinical Outcomes in Atrial Fibrillation Patients Receiving the WATCHMAN Left Atrial Appendage Closure Technology) registry, which represents patients who underwent LAAO because of OAT contraindications. The primary outcome was ischemic stroke. Event rates were compared between cohorts and with historical data without OAT, yielding relative risk reductions based on risk scores.

RESULTS

Analysis of 438 matched pairs revealed no significant difference in the ischemic stroke rate between the STR-OAC LAAO and EWOLUTION cohorts (2.5% vs 1.9%; HR: 1.37; 95% CI: 0.72-2.61). STR-OAC LAAO patients exhibited a higher thromboembolic risk (HR: 1.71; 95% CI: 1.04-2.83) but lower bleeding risk (HR: 0.39; 95% CI: 0.18-0.88) compared to EWOLUTION patients. The mortality rate was slightly higher in EWOLUTION (4.3% vs 6.9%; log-rank P = 0.028). Relative risk reductions for ischemic stroke were 70% and 78% in STR-OAC LAAO and EWOLUTION, respectively, compared to historical data without OAT.

CONCLUSIONS

LAAO in patients with a thrombotic event on OAT demonstrated comparable stroke rates to the OAT contraindicated population in EWOLUTION. The thromboembolic event rate was higher and the bleeding rate lower, reflecting the intrinsically different risk profile of both populations. Until randomized trials are available, LAAO may be considered in patients with an ischemic event on OAT.

Left atrial appendage occlusion after thromboembolic events or left atrial appendage sludge during anticoagulation therapy: Is two better than one? Real-world experience from a tertiary care hospital

BACKGROUND

The role of left atrial appendage occlusion (LAAO) for atrial fibrillation patients that during oral anticoagulant therapy (OAC) suffer from ischemic events or present LAA sludge, and the best postinterventional anticoagulant regimen, need to be defined. We present our experience with a hybrid approach of LAAO+ lifelong OAC therapy in this cohort of patients.

METHODS

Out of 425 patients treated with LAAO, 102 underwent LAAO because, despite OAC, suffered from ischemic events or presented with LAA sludge. Patients without high bleeding risk were discharged with the aim of maintaining lifelong OAC. This cohort was then matched to a population who underwent LAAO in primary ischemic events prevention. The primary endpoint was the composite of all-cause death and major adverse cardiovascular events consisting of ischemic stroke, systemic embolism (SE), and major bleeding.

RESULTS

Procedural success was 98%, and 70% of patients were discharged with anticoagulant therapy. After a median follow-up of 47.2 months, the primary endpoint occurred in 27 patients (26%). At multivariate analyses, coronary artery disease (OR 5.1, CI 1.89-14.27, p = .003) and OAC at discharge (OR 0.29, CI 0.11-0.80, p = .017) were associated with the primary endpoint. After propensity score matching, no significant difference was found in the survival free from the primary endpoint according to the indication for LAAO (p = .19).

CONCLUSIONS

In this high-ischemic risk cohort, LAAO + OAC seem a long-term safe and effective therapeutical approach, with no difference in the survival free from the primary endpoint according to the indication for LAAO in a matched cohort.

Peri-procedural and mid-term follow-up age-related differences in leadless pacemaker implantation: Insights from a multicenter European registry

BACKGROUND

Age-related differences on leadless pacemaker (LP) are poorly described. Aim of this study was to compare clinical indications, periprocedural and mid-term device-associated outcomes in a large real-world cohort of LP patients, stratified by age at implantation.

METHODS

Two cohorts of younger and older patients (≤50 and > 50 years old) were retrieved from the iLEAPER registry. The primary outcome was to compare the underlying indication why a LP was preferred over a transvenous PM across the two cohorts. Rates of peri-procedural and mid-term follow-up major complications as well as LP electrical performance were deemed secondary outcomes.

RESULTS

1154 patients were enrolled, with younger patients representing 6.2% of the entire cohort. Infective and vascular concerns were the most frequent characteristics that led to a LP implantation in the older cohort (45.8% vs 67.7%, p < 0.001; 4.2% vs 16.4%, p = 0.006), while patient preference was the leading cause to choose a LP in the younger (47.2% vs 5.6%, p < 0.001). Median overall procedural (52 [40-70] vs 50 [40-65] mins) and fluoroscopy time were similar in both groups. 4.3% of patients experienced periprocedural complications, without differences among groups. Threshold values were higher in the younger, both at discharge and at last follow-up (0.63 [0.5-0.9] vs 0.5 [0.38-0-7] V, p = 0.004).

CONCLUSION

When considering LP indications, patient preference was more common in younger, while infective and vascular concerns were more frequent in the older cohort. Rates of device-related complications did not differ significantly. Younger patients tended to have a slightly higher pacing threshold at mid-term follow-up.

68 LEFT ATRIAL APPENDAGE OCCLUSION AFTER THROMBOEMBOLIC EVENTS OR LEFT ATRIAL APPENDAGE SLUDGE DURING ANTICOAGULATION THERAPY: TWO IS BETTER THAN ONE. REAL-WORLD EXPERIENCE FROM A TERIARY CARE CENTER

Background

Although, in recent years, the indications for left atrial appendage occlusion (LAAO) have expanded, its role for patients that during oral anticoagulant (OAC) therapy suffer from ischemic events or present LAA sludge is still to be defined. Moreover, data on the best anticoagulant regiment post-LAAO for these patients is scarce.

Purpose

Aim of this study was to present our experience with a hybrid approach consisting of LAAO+ lifelong OAC therapy in this cohort of high-ischemic risk patients.

Methods

At our center, from January 2013 to June 2022, 102 patients underwent percutaneous LAAO because, despite optimal OAC, suffered from ischemic events or were found to have LAA sludge. In the absence of a high bleeding risk, patients were then discharged with the aim of maintaining lifelong OAC. Moreover, to confirm the feasibility and the long-term efficacy of LAAO in this cohort, the group was matched 1:1 to a patient population who underwent LAAO in our center to prevent ischemic events and without sludge at preprocedural TEE. The primary endpoint was the composite of all-cause death (ACD) and major adverse cardiovascular events (MACE) consisting of ischemic stroke, systemic embolism (SE) and major bleeding

Results

Procedural success was achieved in 98% of patients. 70% of patients were discharged with anticoagulant therapy, while 30% only with antiplatelet therapy. After a median follow-up of 47.2 months, none of the patients discharged with OAC had stroke, SE or device-related thrombosis. The primary composite endpoint of ACD+ MACE occurred in 27 patients (26%). Patients affected by the primary outcome had more history of coronary artery disease (CAD, p&lt;0.001), diabetes mellitus (DM p=0.003), left ventricular systolic dysfunction (LVSD, p=0.004) and were more often discharged without OAC (p=0.005) compared to those who weren't. After univariate and multivariate analyses, CAD (OR 5.1, CI 1.89- 14.27, p=0.003) and OAC at discharge (OR 0.29, CI 0.11- 0.80, p=0.017) were independently associated with the primary endpoint. At survival analyses, there was a constant trend toward a longer survival free from the primary composite endpoint for patients discharged in anticoagulant therapy compared to those without, but not reaching statistical significance (p=0.41). Finally, after propensity score matching, Kaplan Meyer curves showed that there was no significant difference in the long-term survival free from the primary composite EP according to the indication for LAAO (p=0.19).

Conclusions

We report our experience on the management of patients with ischemic events or LAA sludge despite OAC. Percutaneous LAAO was feasible with a high procedural success. Our hybrid therapeutical approach consisting of LAAO+ lifelong OAC, if feasible in the absence of high bleeding risk, was safety and effective in reducing clinical ischemic events after a long-term follow-up.

Long-Term Follow-Up of Catheter Ablation for Premature Ventricular Complexes in the Modern Era: The Importance of Localization and Substrate

Background: Large-scale studies evaluating long-term recurrence rates in both idiopathic and non-idiopathic PVC catheter ablation (CA) patients have not been reported. Objective: To evaluate the efficacy and safety of idiopathic and non-idiopathic PVC CA, investigating the predictors of acute and long-term efficacy. Methods: This retrospective multicentric study included 439 patients who underwent PVC CA at three institutions from April-2015 to December-2021. Clinical success at 6 months’ follow-up, defined as a reduction of at least 80% of the pre-procedural PVC burden, was deemed the primary outcome. The secondary aims of the study were: clinical success at the last available follow-up, predictors of arrhythmic recurrences at long-term follow-up, and safety outcomes. Results: The median age was 51 years, with 24.9% patients being affected suffering from structural heart disease. The median pre-procedural PVC burden was 20.1%. PVCs originating from the RVOT were the most common index PVC observed (29.1%), followed by coronary cusp (CC) and non-outflow tract (OT) LV PVCs (23.1% and 19.0%). The primary outcome at 6 months was reached in 85.1% cases, with a significant reduction in the 24 h% PVC burden (−91.4% [−83.4; −96.7], p < 0.001); long-term efficacy was observed in 82.1% of cases at almost 3-year follow-up. The presence of underlying structural heart disease and non-OT LV region origin (aHR 1.77 [1.07−2.93], p = 0.027 and aHR = 1.96 [1.22−3.14], p = 0.005) was independently associated with recurrences. Conclusion: CA of both idiopathic and non-idiopathic PVCs showed a very good acute and long-term procedural success rate, with an overall low complication. Predictors of arrhythmic recurrence at follow-up were underlying structural heart disease and non-OT LV origin.

Left atrial appendage occlusion versus standard of care in patients with atrial fibrillation and a prior thrombo-embolic event despite oral anticoagulant therapy: a propensity score matched comparison

Introduction

Patients with atrial fibrillation (AF) that suffer from ischemic stroke despite oral anticoagulant (OAC) therapy have a very high risk of recurrent stroke and better prevention strategies are needed. Left atrial appendage occlusion (LAAO) is a promising secondary prevention strategy that may provide mechanical protection in patients that suffer from thrombo-embolic events under OAC. However, evidence showing effectiveness of LAAO in this population is scarce and the current international guidelines only consider LAAO in patients with a contra-indication for OAC.

Purpose

To compare percutaneous LAAO to standard-of-care including continuing/switching anticoagulation therapy for secondary stroke prevention in patients with AF and a prior thrombo-embolic event and/or LAA thrombus under OAC therapy.

Methods

The STR-OAC LAAO cohort is an international collaboration combining a selection of patients from multiple LAAO registries (22 participating centers). Patients that underwent percutaneous LAAO because of a thrombo-embolic event and/or LAA thrombus on OAC were included. Propensity score matching (optimal matching method, 1:1 ratio) with a previously published multi-center dataset of patients continuing/switching anticoagulation treatment after a thrombo-embolic event was performed to adjust for imbalances in age, sex, hypertension, diabetes mellitus and CHA2DS2-VASc score. The primary outcome was ischemic stroke. Time-to-event analysis was performed with Kaplan-Meier curves and Cox-proportional-hazard regression analyses.

Results

A total of 404 patients underwent LAAO between 2010–2021 and were included in the STR-OAC LAAO cohort. Mean age was 72±9 years; 44% was female and mean CHA2DS2-VASc and HAS-BLED score were 4.8±1.7 and 2.5±1.4, respectively. Most patients received a Watchman or Amplatzer device (53% and 43%). Oral anticoagulation was discontinued after LAAO at discharge or after confirmation of adequate LAA closure at 1–3 months follow-up in 44% or 20%, respectively. The remaining 35% of patients continued OAC after LAAO as an adjunctive strategy. All LAAO patients were propensity-score matched and included in the primary outcome analysis. Baseline characteristics were well balanced after matching (Table 1). During follow up including 1406 patient-years (LAAO 1007; control 399) a total of 61 patients experienced an ischemic stroke: 2.2% per patient-year in LAAO group versus 9.8% per patient-year in the control group. LAAO was associated with a significantly lower risk of ischemic stroke (HR 0.33, 95% CI [0.19–0.59], p&lt;0.001) compared to standard-of-care (Figure 1).

Conclusion

In this propensity-score matched study, LAAO was associated with a lower risk of ischemic stroke compared to standard-of-care in patients with a thrombo-embolic event and/or LAA thrombus despite OAC treatment. Randomized controlled trial data may further confirm the effectiveness of LAAO in this very high-risk population.

Funding Acknowledgement

Type of funding sources: None.

Patients with Cardiac Implantable Electronic Device Undergoing Radiation Therapy: Insights from a Ten-Year Tertiary Center Experience

Background: The number of patients with cardiac implantable electronic devices (CIEDs) receiving radiotherapy (RT) is increasing. The management of CIED-carriers undergoing RT is challenging and requires a collaborative multidisciplinary approach. Aim: The aim of the study is to report the real-world, ten-year experience of a tertiary multidisciplinary teaching hospital. Methods: We conducted an observational, real-world, retrospective, single-center study, enrolling all CIED-carriers who underwent RT at the San Raffaele University Hospital, between June 2010 and December 2021. All devices were MRI-conditional. The devices were programmed to an asynchronous pacing mode for patients who had an intrinsic heart rate of less than 40 beats per minute. An inhibited pacing mode was used for all other patients. All tachyarrhythmia device functions were temporarily disabled. After each RT session, the CIED were reprogrammed to the original settings. Outcomes included adverse events and changes in the variables that indicate lead and device functions. Results: Between June 2010 and December 2021, 107 patients were enrolled, among which 63 (58.9%) were pacemaker carriers and 44 (41.1%) were ICD carriers. Patients were subjected to a mean of 16.4 (±10.7) RT sessions. The most represented tumors in our cohort were prostate cancer (12; 11%), breast cancer (10; 9%) and lung cancer (28; 26%). No statistically significant changes in device parameters were recorded before and after radiotherapy. Generator failures, power-on resets, changes in pacing threshold or sensing requiring system revision or programming changes, battery depletions, pacing inhibitions and inappropriate therapies did not occur in our cohort of patients during a ten-year time span period. Atrial arrhythmias were recorded during RT session in 14 patients (13.1%) and ventricular arrhythmias were observed at device interrogation in 10 patients (9.9%). Conclusions: Changes in device parameters and arrhythmia occurrence were infrequent, and none resulted in a clinically significant adverse event.

Prognostic value of right atrial pressure-corrected cardiac power index in cardiogenic shock

AIM

The pulmonary artery catheter (PAC)-derived cardiac power index (CPI) has been found of prognostic value in cardiogenic shock (CS) patients. The original CPI equation included the right atrial pressure (RAP), accounting for heart filling pressure as a determinant of systolic myocardial work, but this term was subsequently omitted. We hypothesized that the original CPI formula (CPI_RAP ) is superior to current CPI for risk stratification in CS.

METHODS AND RESULTS

A single-centre cohort of 80 consecutive Society for Cardiovascular Angiography and Interventions (SCAI) B-D CS patients with available PAC records was included. Overall in-hospital mortality was 21.3%. Results showed CPI_RAP to be the strongest haemodynamic predictor of in-hospital death (p_adj  = 0.038), outperforming CPI [area under the receiver operating characteristic (ROC) curves: 0.726 and 0.673, P-for-difference = 0.025]. When the population was stratified according to the identified CPI_RAP (0.28 W/m² ) and accepted CPI (0.32 W/m² ) thresholds, the cohort with discordant indexes (low CPI_RAP and high CPI) comprised a group of 13 patients featuring a congested phenotype with frequent right ventricle or biventricular involvement. In this group, in-hospital mortality was high (30.8%) similar to those with concordant low CPI and CPI_RAP .

CONCLUSION

Incorporating RAP in CPI calculation (CPI_RAP ) improves the prognostic yield in patients with CS SCAI B-D. A cut-off of 0.28 W/m² identifies patients at higher risk of in-hospital mortality. The improved prognostic value of CPI_RAP may derive from identification of patients with more intravascular congestion who may experience substantial in-hospital mortality, uncaptured by the commonly used CPI equation.

Impact of the rs73598374 polymorphism of the adenosine deaminase gene on platelet reactivity and long-term outcomes among patients with acute coronary syndrome treated with ticagrelor

BACKGROUND

The positive interaction of ticagrelor with the metabolism of adenosine has been claimed for the large antithrombotic and antiischemic benefits of this antiplatelet agent in acute coronary syndromes (ACS). Adenosine catabolism is regulated by the activity of the adenosine deaminase enzyme (ADA), for which several polymorphisms have been identified. Therefore, the aim of our study was to explore the impact of the rs73598374 polymorphism of ADA gene on platelet reactivity in ACS patients treated with ticagrelor.

METHODS

We included consecutive patients receiving ASA and ticagrelor after an ACS and coronary intervention. Platelet reactivity was evaluated by impedance aggregometry at 30-90 days post-discharge. The genetic analysis was carried out by PCR and RFLP. Clinical endpoints were mortality, cardiovascular death, recurrent myocardial infarction or coronary revascularization at the maximum available follow-up.

RESULTS

Our population is represented by 464 patients, of whom 33.4% were A-heterozygotes and 6 homozygotes. A-allele carriers showed a greater prevalence of renal failure (p = 0.02) and a lower rate of previous coronary artery bypass graft (p = 0.03) and statin treatment (p = 0.02). No differences in the mean values of platelet reactivity or HRPR on ticagrelor were found according to the ADA genotype (11.3%vs13.9%, p = 0.45; adjusted OR[95% CI] = 1.17[0.64-2.14], p = 0.61). At follow up, patients carrying the A-allele showed a non-significantly lower incidence of ACS and repeated unplanned revascularization, although with no effect on mortality.

CONCLUSIONS

In the present study the rs73598374 polymorphism of the ADA gene did not affect platelet reactivity or the long-term prognosis in patients with ACS receiving dual antiplatelet therapy with ASA and ticagrelor.

[Day surgery in breast reconstructive surgery: our experience]

Breast cancer is the most common tumour in Italy in the female population, counting for about 40000 new cases every year. The psychological aspects of breast mutilation and the social and economic implications are receiving increasing attention. Despite of the diffusion of screening programs to detect pre-clinical breast cancers, 30% of patients still undergo radical interventions. Therefore, many women present serious limitations of their social-life that can lead to severe depression since, in occidental countries, the biological function of the breast is less considered than its primary role of femininity and sexuality. The gold-standard is to conceal oncological radicality and aesthetic preservation. The Authors present their experience analysing the techniques employed.

[Posterior mediastinum neoplasms: a case of schwannoma]

The Authors report the case of a 33-year-old male affected with an asymptomatic schwannoma of the posterior mediastinum, and review the relevant Literature, discussing the difficulties in making the differential diagnosis of the posterior mediastinum lesions, particularly in the pre-clinical phase. Neurogenic tumors represent about 75 percent of all tumors of mediastinum and about one third of all tumors of the mediastinum. They can originate from the peripheral nervous system group, from the sympathetic nervous system group or, in rare cases, from the vagus nerve. In adult patients, they are usually found by chance during radiographic examination of the thorax, and they are usually asymptomatic and benign. During preoperative evaluation, a magnetic resonance examination of rachis should be done to exclude the possibility of intraspinal involvement. If there are no contraindications, the treatment of choice should be surgical resection by means of thoracoscopy or thoracotomy, when size and location of the tumors allow it in order to prevent malignant evolution.

[Therapeutic strategies in neoplasms of the distal bile duct and the Vater's ampulla]

Malignant periampullary and ampullary tumors represent an anatomic and clinical entity of complex surgical approach due to the difficulty in setting out an early diagnosis, for the back of symptoms at early stages. The Authors at the Department of Surgery and Medical Technology Applications "F. Durante", University of Rome "La Sapienza", since 1990 to 2001 observed 19 cases. The results of surgical treatment of these tumors are here reported. By the analysis of the cases it is evident that long-term survival if mainly conditioned by prompt diagnosis stage of the tumor, and patient status before the operation.

[Atrial fibrillation and hyperthyroidism: results after thyroidectomy]

Hyperthyroidism patients can develop atrial fibrillation (AF) with a frequency range between 10 and 25%. The Authors consider 256 hyperthyroid patients operated in their Department, from 1985 to 2001. Before and after surgery, thyroid examination, routine blood tests and common diagnostic evaluations were performed. The follow-up has been 12 months and during this period a L-Thyroxine (50-200 mg/die) therapy has been arranged. Before surgery 59 patients (23%) showed an AF associated with palpitations (76%), asthenia (66%), tremors (54%) and dyspnea (43%). The onset of AF was less than 1 months in 18% of cases, less than 3 months in 30% and chronic in remaining 52%. The 87% of patients was already pharmacologically treated. All the patients were treated with anticoagulants, with a INR value between 2 and 3. After the surgery, 47% of patients presented a restoration of the sinusal rhythm, while the 53% showed a stronger therapeutic responsiveness to specific antiarrhythmic therapy. Treatment of FA hyperthyroid patients with FA tends to normalize the function of the thyroid gland (euthyroidism). In our experience the restoring of sinusal rhythm usually develops in patients with 50 years of age (45 +/- 5 years), while in older patients AF tends to be resistant to treatment.

[Neurinoma of the brachial plexus: 2 case reports]

Neurinomas, also referred to as neurilemmomas and schwannomas, are rare benign tumours of the peripheral nerves. A small percentage of these lesions arise from the brachial plexus. The Authors report two cases of schwannoma arising from the brachial plexus. Such lesions, usually asymptomatic, may cause sensitivity alterations or, less frequently, motor deficits in the involved arm. Tumour enucleation, avoiding damage to any of the nervous fascicles, is the treatment of choice.

Papillomatosis and breast cancer: a case report and a review of the literature

Papillomatosis is a relatively common (22%) benign microscopic lesion in the breast and rarely seen in women less than 30 years old. It is a papillary proliferation of the ductal epithelium which partly fills up smaller ducts and to degree distends them. The histological classification of this entity is controversial because similar or identical lesions have been classified using different terms such as epitheliosis and epithelial hyperplasia, and interpretation of published series has been difficult due to imprecise definition of this term. Clinical, radiological and histological patterns of this entity are often sufficient to raise concern as to possible malignancy. Moderate or florid hyperplasia without atypia is considered to carry slight (1,5-2 times) increase in risk of later developing cancer, while in the atypical hyperplasia the risk is four to five times that of the general population. The authors describe a case of papillonlatosis recentely observed in a 67 years old female patient and, confirmed the importance to establish an accurate preoperative diagnosis. It is important that the surgeon works with the pathologist to produce clear descriptive report of epithelial changes from normal through hyperplasia to atypias in order to establish a precise surgical indication.