Preserved Left Atrial Function Following Left Atrial Appendage Closure for Stroke Prevention

BACKGROUND

Patients with atrial fibrillation (AF) are at high risk of thromboembolism, with most thrombi forming in the left atrial (LA) appendage. LA appendage closure is an alternative therapy to oral anticoagulation for stroke prevention in AF patients with contraindication to oral anticoagulation. LA function is critical for cardiovascular function, and recent studies suggested a direct relationship between LA function and AF recurrence. Deformation imaging characterizes and quantifies myocardial function.

AIM

This study aims to investigate the impact of LA appendage closure on LA function in patients with paroxysmal AF.

METHODS

We studied patients with paroxysmal AF who underwent LA appendage closure in a single-center, retrospective study. Twelve patients (CHA2DS2-VASc score, 4.12 ± 1.1; age, 75.9 ± 6.9 years; 7 men and 5 women) were eligible. Echocardiography-derived LA global longitudinal strain analysis, LA diameter, and LA volume index were determined before and after a 6-month follow-up. All patients were in sinus rhythm during echocardiography. The LA global longitudinal strain was unchanged after LA appendage closure (from -18.9 ± 2.8% to -19.6 ± 2.6%; P=.66). No changes were observed for LA size (from 49.1 ± 6.1 mm to 50.5 ± 5.2 mm; P=.45) or for LA volume index (from 51.6 ± 4.6 mL/m² to 52.1 ± 4.1 mL/m²; P=.49), corroborating unaltered LA function after LA appendage closure.

CONCLUSION

LA function is crucial for cardiovascular function and recurrence of AF. Our study provides evidence that LA appendage closure preserves LA function, determined by strain imaging in patients with paroxysmal AF and sinus rhythm during echocardiography.

Endovascular treatment of peripheral artery disease is associated with improved central hemodynamics and ventricular function

Background

Peripheral artery disease (PAD) is a major manifestation of atherosclerosis and a risk factor for morbidity and mortality. PAD itself is associated with increased arterial stiffness with impact on cardiac functions. Previous studies have demonstrated that augmentation index (AIx) and central blood pressure (CBP) correlate with increased cardiovascular mortality. This mechanism has been described as arterio-ventricular (AV) coupling with altered ventricular afterload and a depressed ventricular function, measured by global longitudinal strain (GLS). The impact of PAD-related endovascular treatment on arterial stiffness, central hemodynamics and potential impact on AV coupling has not been elucidated until now.

Purpose

Aim of the study was to investigate, if endovascular treatment of PAD improves cardiac function via enhanced central hemodynamics and AV coupling.

Methods

To this aim 77 patients with known symptomatic PAD who underwent interventions in the iliac and femoropopliteal arteries were included in a cross-sectional study. AIx, CBP and GLS were determined using dedicated waveform analysis and echocardiography before and after endovascular treatment.

Results

Mean age was 65.1±10.4 years with 66.2% male patients. Symptoms were classified by Fontaine classification (stage IIb 80.7%, stage III 5.8% and stage IV 13.5%). Iliac vessel intervention was performed in 16 and femoropopliteal intervention in 61 cases. A stentless approach was feasible in 55 patients with DCB treatment and atherectomy.

After endovascular treatment, peripheral perfusion was enhanced (ABI 0.45±0.6 vs 0.81±0.5, p<0.0001). Moreover, central hemodynamics were improved (AIX 33.7±3% vs 27.9±2%, p=0.0008; AP 17.8±2 mmHg vs 14.0±2 mmHg, p=0.0004; central PP 52.4±6 mmHg vs 46.4±6 mmHg, p=0.0001). Impressively, left ventricular function was also significantly improved (GLS −15.7±2.3% vs −17.1±2.8%, p=0.005) with an improvement in AV coupling (PWV/GLS ratio −0.58m/sec% vs −0.56m/sec%, p<0.01).

Conclusion

Our results demonstrate that endovascular treatment of the peripheral vessels is associated with an improvement of central hemodynamics and left ventricular function via enhanced AV coupling. These prognostic relevant markers of cardiovascular disease could point to an overall potential mortality benefit through PAD treatment. Further investigation of the underlying mechanisms of AV coupling in the setting of endovascular treatment of PAD with impact on cardiovascular mortality is needed in this high-risk population.

Funding Acknowledgement

Type of funding source: None

[Approaches to atrial fibrillation with tachycardia transition]

Atrial fibrillation, the most common cardiac arrhythmia in the daily clinical routine, is a challenge in in-hospital and prehospital emergency medicine and is associated with increased morbidity and mortality if left untreated. Especially tachyarrhythmia, caused by atrial fibrillation, leads to various unspecified symptoms and in some cases to severely impaired circulation. Thus, an individualized therapeutic regimen is required. A fundamental distinction between rhythm control and rate control strategies must be made. In symptomatic but hemodynamically stable patients rate control is the method of choice. This applies in particular to patients with no pre-existing anticoagulation, especially if left atrial thrombi are not excluded. In hemodynamically unstable patients, considering the potential complications of sedation, electrical cardioversion is preferred. Pharmacological therapy of atrial fibrillation has to be divided into AV conduction modulating drugs-like short- or long-acting β‑blockers, calcium antagonists or cardiac glycosides-and the heterogeneous group of antiarrhythmic drugs aiming for rhythm control. Pulmonary vein ablation is the current long-term treatment of choice for symptomatic drug-refractory atrial fibrillation.

Impact of diabetes as a risk factor in patients undergoing subcutaneous implantable cardioverter defibrillator implantation: A single-centre study

INTRODUCTION

Patients with diabetes mellitus are known to carry an increased risk for surgical site infections and perioperative complications. The subcutaneous implantable cardioverter defibrillator is an established treatment option in patients at risk for sudden cardiac death especially with an increased risk for infection over time.

METHODS AND RESULTS

Forty-eight patients (mean age = 55.0 ± 21.3 years, 31.3% patients with diabetes mellitus, 75% male) who underwent consecutive subcutaneous implantable cardioverter defibrillator surgery between February 2016 and May 2019 were retrospectively analysed. Overall adverse events including relevant bleeding complications, any surgical wound problems and infections requiring reoperation or device malfunction were evaluated as primary combined safety endpoint. Patients with diabetes mellitus tended to be older with a higher body mass index compared to non-diabetes mellitus. Procedure duration and postsurgery hospital days were not different in diabetes mellitus versus non-diabetes mellitus patients. Analysis of the primary combined endpoint showed no significant difference but a trend towards higher event rates in the diabetes mellitus group (diabetes mellitus vs non-diabetes mellitus: 20% vs 12.1%, p = 0.119).

CONCLUSION

Diabetes mellitus is a frequent and relevant variable in patients undergoing subcutaneous implantable cardioverter defibrillator implantation represented by 31.3% in this consecutive cohort. Our results suggest that diabetes mellitus is not associated with a prolonged hospital stay or increased rate of periprocedural adverse events.

Use of pulsed electron avalanche knife (PEAK) PlasmaBlade™ in patients undergoing implantation of subcutaneous implantable cardioverter-defibrillator

Introduction

Surgical implantation of subcutaneous implantable cardioverter-defibrillators (S-ICD) requires preparation of a deeper and larger pocket. Infection and bleeding complications are reported, particularly in patients requiring antiplatelet therapy (APT) or being on oral anticoagulation (OAC), with rates up to 25%. The pulsed electron avalanche knife (PEAK) PlasmaBlade™ has been reported to reduce bleeding complications. The purpose of this study was to evaluate the safety and feasibility of a PEAK guided S-ICD implantation with respect to perioperative complications.

Methods and results

We enrolled 36 consecutive patients (75% male; mean age 52.1 ± 14.4 years) undergoing S-ICD implantation. Periprocedural safety endpoints comprised major complications including pocket hematomas, wound infections, bleeding (BARC ≥2) or events requiring interventions. Patients were divided into three groups according to management of their anticoagulation: i.) APT, n = 15 (41.7%); ii.) OAC, n = 10 patients (27.8%); iii.) none (neither OAC nor APT), n = 11 (30.6%). Mean procedure duration was 33.1 ± 13.4 min. Mean length of hospital stay was 3.3 ± 2.1 days. Overall analysis showed no differences between the 3 groups with respect to major complications, major bleeding episodes or other procedural parameters, beside a trend towards more minor hematomas in the OAC group (OAC: 22.2% vs. APT: 11.4% vs. none: 9.1%; p = 0.15).

Conclusion

The results of our pilot study suggest that intermuscular S-ICD implantation using PEAK is safe and potentially beneficial in patients receiving OAC or APT with respect to prevention of bleeding complications. These results support the rationale for large prospective controlled trials evaluating a beneficial effect of PEAK use in S-ICD implantation procedures.

Impact of anticoagulation and vasoactive medication on regained radial artery patency after catheterization: a case-control study

Background

Radial artery access is the primary approach for coronary interventions due to higher safety profile in comparison to femoral access. Radial artery occlusion (RAO) is the main complication of transradial catheterization that can lead to severe symptoms and a permanent artery occlusion. The incidence of RAO after transradial access ranges from 5 to 38% and data regarding treatment is scarce. Whether anticoagulation and vasoactive medication provides an additional benefit in recovery of radial artery patency (RAP) after catheterization has not been investigated in detail.

Aim

The objective was to investigate the impact of anticoagulation and vasoactive medication on regained patency after documented RAO following transradial catheterization.

Patients and methods

Overall 2635 patients were screened. 2215 (84%) catheterizations were performed by femoral and 420 (16%) by radial access. In 30 patients RAO was observed. In case of RAO patients were classified in three groups: Anticoagulation, anticoagulation added with alprostadil and controls. Follow-up was conducted after 3 months with ultrasound and clinical examination.

Results

Eight patients received anticoagulation and 11 patients anticoagulation together with alprostadil. Eleven patients served as controls. Recovery of RAP after catheterization was higher following either treatment (79.5%) compared to controls (0%, p = 0.006). Subgroup analysis yielded a higher RAP recovery in patients treated with anticoagulation (62.5%) as compared to controls (0%, p = 0.002). No effect on regained RAP was found with additional alprostadil therapy (33.3%) compared to anticoagulation therapy (62.5%, p = 0.229).

Conclusion

RAO should be treated with anticoagulation to regain patency. Addition of vasoactive medication does not lead to further beneficial effects. Further research is needed regarding preventive and therapeutic strategies following RAO.

Percutaneous closure of the left atrial appendage in patients with diabetes mellitus

BACKGROUND

Left atrial appendage closure is a preventive treatment of atrial fibrillation-related thrombo-embolism. Patients with diabetes mellitus have increased risk for a negative outcome in percutaneous cardiac interventions. We assessed whether percutaneous left atrial appendage closure is safe and effective in patients with diabetes mellitus.

METHODS

We included 78 patients (mean age of 74.4 ± 8.3 years) with indication for left atrial appendage closure in an open-label observational single-centre study.

RESULTS

Patients with diabetes mellitus ( n = 31) were at higher thrombo-embolic and bleeding risk (CHA₂DS₂-VASc: 4.5 ± 0.9, HAS-BLED: 4.7 ± 0.7) compared to patients without diabetes mellitus ( n = 47, CHA₂DS₂-VASc: 3.5 ± 1.0, HAS-BLED: 4.1 ± 0.8; p < 0.001 for both). Pre- and periprocedural risk was elevated in patients with diabetes mellitus (Euro II-Score: 6.6 ± 3.7 vs 3.9 ± 1.9, p < 0.01; Society of Thoracic Surgeons (STS)-Score: 4.0 ± 2.5 vs 2.6 ± 1.2, p < 0.01). Procedural success was similar. Periprocedural major adverse cardiac and cerebrovascular events occurred in one patient from the control group (2.1%), whereas patients with diabetes mellitus had no events ( p = 0.672). Follow-up of 6 months revealed no bleeding complication in both groups. No stroke occurred in follow-up, and left atrial appendage flow velocity reduction (55.6 ± 38.6 vs 51.4 ± 19.1 cm/s, p = 0.474) and rate of postinterventional leakage in the left atrial appendage were comparable (0% vs 2.1%, p = 0.672).

CONCLUSION

Despite patients with diabetes mellitus are high-risk patients, the outcome of percutaneous left atrial appendage closure is similar to patients without diabetes mellitus.