Symptomatic vs. non-symptomatic device-related thrombus after LAAC: a sub-analysis from the multicenter EUROC-DRT registry

BACKGROUND Device-related thrombus (DRT) after left atrial appendage closure (LAAC) is associated with adverse outcomes, i.e. ischemic stroke or systemic embolism (SE). Data on predictors of stroke/SE in the context of DRT are limited. AIMS This study aimed to identify predisposing factors for stroke/SE in DRT patients. In addition, the temporal connection of stroke/SE to DRT diagnosis was analyzed. METHODS The EUROC-DRT registry included 176 patients, in whom DRT after LAAC were diagnosed. Patients with symptomatic DRT, defined as stroke/SE in the context of DRT diagnosis, were compared against patients with non-symptomatic DRT. Baseline characteristics, anti-thrombotic regimens, device position, and timing of stroke/SE were compared. RESULTS Stroke/SE occurred in 25/176 (14.2%) patients diagnosed with DRT (symptomatic DRT). Stroke/SE occurred after a median of 198 days (IQR 37-558) after LAAC. In 45.8% stroke/SE occurred within one month before/after DRT diagnosis (DRT-related stroke). Patients with symptomatic DRT had lower left ventricular ejection fractions (50.0 ± 9.1% vs. 54.2 ± 11.0%, p = 0.03) and higher rates of non-paroxysmal atrial fibrillation (84.0% vs. 64.9%, p = 0.06). Other baseline parameters and device positions were not different. Most ischemic events occurred among patients with single antiplatelet therapy (50%), however, stroke/SE was also observed under dual antiplatelet therapy (25%) or oral anticoagulation (20%). CONCLUSION Stroke/SE are documented in 14.2% and occur both in close temporal relation to the DRT finding and chronologically independently therefrom. Identification of risk factors remains cumbersome, putting all DRT patients at substantial risk for stroke/SE. Further studies are necessary to minimize the risk of DRT and ischemic events

Tricuspid valve disease: diagnosis, prognosis and management of a rapidly evolving field

Tricuspid valve disease, and particularly tricuspid regurgitation, is a highly prevalent condition with a complex pathophysiology and long-term adverse consequences. Although historically neglected, tricuspid valve disease has gained increasing recognition, with important advances in the assessment and management of this disorder over the past 2 decades. Surgical treatment remains the standard of care, but it continues to have one of the the highest death rates among all cardiac valve-related procedures, and a broad range of patients still do not receive effective therapy for tricuspid valve disease in contemporary clinical practice. Therefore, several alternative, less-invasive technologies for treating patients with severe, native tricuspid valve disease at high surgical risk have been developed in the past decade, with promising early results. This Review summarizes key findings and highlights the latest developments in the diagnosis and management framework that are transforming clinical practice in the complex field of tricuspid valve disease

La organización hospitalaria, factor de eficencia

Peer Reviewe

Cierre percutáneo de seudoaneurisma ventricular izquierdo. Resolución

RESOLUCIÓN DEL CASO El caso se presentó en sesión médico-quirúrgica y, dado el alto riesgo, la paciente fue aceptada para cierre percutáneo del seudoaneurisma1,2. El procedimiento se realizó bajo anestesia general y guiado por ecocardiografía transesofágica y fusión de imagen. Como la paciente era portadora de una prótesis mitral, se planificó una estrategia de abordaje retrógrado mediante acceso arterial femoral derecho (6 Fr). Con ayuda de un catéter AL 1 (Cordis Corporation, EE.UU.) y una guía recta Terumo (Terumo Medical Corporation, EE.UU.) se cruzó la válvula aórtica nativa, avanzando el AL 1 hacia el ventrículo izquierdo. Se realizó una ventriculografía izquierda con un catéter Pigtail (Cordis Corporation, EE.UU.), que mostró una cavidad en relación con el ventrículo izquierdo con paso de contraste hacia ella (vídeo 1 del material adicional). Tras varios intentos posicionando el catéter en el origen del defecto, finalmente se consiguió cruzar a la cavidad del seudoaneurisma con ayuda de una guía Terumo curva. En este paso fue crucial la información proporcionada por la fusión de imagen, ya que permitió marcar el origen del defecto y así facilitar el cruce de la guía a la cavidad (figura 1 y figura 2). Figura 1. Localización del origen del seudoaneurisma mediante fusión de imagen (circunferencia..

Cierre percutáneo de seudoaneurisma ventricular izquierdo

PRESENTACIÓN DEL CASO Se presenta el caso de una paciente de 72 años, con antecedentes de fibrilación auricular permanente en tratamiento con acenocumarol e historia de cardiopatía valvular reumática en forma de doble lesión mitral en rango grave e insuficiencia tricuspídea grave por dilatación del anillo, sintomática para disnea. Se completa el estudio cardiológico previo a planificar cirugía de recambio valvular, que descarta la existencia de lesiones coronarias. Se presenta en el comité médico-quirúrgico y es aceptada para sustitución valvular mitral y anuloplastia tricuspídea. Se realizó la intervención de forma electiva y se implantó una prótesis mitral mecánica On-X 25 mm (Life Technologies, EE.UU.), realizando anuloplastia tricuspídea con anillo protésico. A la salida de la bomba de circulación extracorpórea se observó hemorragia por rotura del surco auriculoventricular en la proximidad con la orejuela izquierda, que fue reparado con puntos apoyados en el pericardio y teflón hasta conseguir la hemostasia. En este contexto, la paciente presentó deterioro hemodinámico y caída de la función ventricular, que precisó escalada de inotrópicos e implante de balón de contrapulsación aórtico. El posoperatorio en la unidad de cuidados críticos fue tórpido. Al quinto día de la cirugía presentó fiebre en el contexto de una neumonía asociada a ventilación mecánica...

Percutaneous closure of left ventricular pseudoaneurysm. Case resolution

CASE RESOLUTION The case was presented in the medical-surgical session and given the high risk involved the percutaneous closure of the pseudoaneurysm was decided.1-2 The procedure was performed under general anesthesia and guided by transesophageal echocardiography and fluoroscopic fusion imaging. Since the patient carried a prosthetic mitral valve, a retrograde approach strategy was decided via right femoral arterial access (6-Fr). With help from an AL 1 catheter (Cordis Corporation, FL, United States) and a Terumo straight guidewire (Terumo Medical Corporation, NJ, United States), the native aortic valve was crossed, and the AL 1 catheter was advanced towards the left ventricle. A Pigtail catheter was used to perform a left ventriculography (Cordis Corporation, FL, United States) that revealed a cavity in relation to the left ventricle with the passing of contrast towards such cavity (video 1 of the supplementary data). After several attempts trying to place the catheter at the origin of the defect, the pseudoaneurysm cavity was finally crossed using a curved Terumo guidewire. At this point, the information provided by fluoroscopic fusion imaging was crucial because it revealed the origin of the defect and facilitated guidewire crossing towards the cavity (figure 1 and figure 2). Figure 1. Location of the origin of pseudoaneurysm through..

Percutaneous closure of left ventricular pseudoaneurysm

CASE PRESENTATION This is the case of a 72-year-old woman with a past medical history of permanent atrial fibrillation treated with acenocoumarol, and rheumatic valvular heart disease that appears as a double severe mitral lesion and severe tricuspid regurgitation due to annular dilatation with dyspnea-like symptoms. The cardiologic examination completed before planning valve replacement surgery discarded the presence of coronary lesions. The case was presented to the medical-surgical committee and approved for mitral valve replacement, and tricuspid annuloplasty. Procedure was performed electively with a 25 mm On-X 25 prosthetic mechanical mitral valve (Life Technologies, GA, United States) followed by tricuspid annuloplasty with annular prosthesis. After weaning from extracorporeal support and circulation machine, a hemorrhage was revealed due to the rupture of the atrioventricular groove in the vicinity of left atrial appendage that was repaired with suture reinforcement on the pericardium and Teflon until achieving hemostasis. In this context, the patient showed hemodynamic impairment, and ventricular function deterioration that required escalating the inotropic support, and intra-aortic balloon pump implantation. The postoperative period at the critical care unit was torpid. Five days after surgery, the patient broke a fever in the context of ventilator-associated pneumonia. That is why a thoracic computed tomography scan was performed..

Role of Quantitative Flow Ratio in Predicting Future Cardiac Allograft Vasculopathy in Heart Transplant Recipients

Background: Coronary angiography is the gold standard for cardiac allograft vasculopathy (CAV) diagnosis, but it usually detects the disease at an advanced stage. We investigated the role of quantitative flow ratio (QFR), a noninvasive tool to identify potentially flow-limiting lesions, in predicting CAV development in heart transplant recipients. Methods: Consecutive heart transplant recipients with no evidence of angiographic CAV at baseline coronary angiography were retrospectively included between January 2010 and December 2015, and QFR computation was performed. The relationship between vessel QFR and the occurrence of angiographic vessel-related CAV (>= 50% stenosis) was assessed. Results: One hundred forty-three patients were included and QFR computation was feasible in 241 vessels. The median value of QFR at baseline coronary angiography was 0.98 (interquartile range, 0.94-1.00). During a median follow-up of 6.0 years (interquartile range, 4.6-7.8 years), vessel-related CAV occurred in 25 (10.4%) vessels. Receiver-operating characteristic curve analysis identified a QFR best cutoff of <= 0.95 (area under the curve, 0.81 [95% CI, 0.71-0.90]; P<0.001). QFR <= 0.95 was associated with an increased risk of vessel-related CAV (adjusted hazard ratio, 20.87 [95% CI, 5.35-81.43]; P<0.001). In an exploratory analysis, QFR <= 0.95 in at least 2 vessels was associated with higher incidence of cardiovascular death or late graft dysfunction (71.4% in recipients with 2-3 vessels affected versus 5.1% in recipients with 0-1 vessels affected, P<0.001). Conclusions: In a cohort of heart transplant recipients, QFR computation at baseline coronary angiography may be a safe and reliable tool to predict vessel-related CAV and clinical outcomes at long-term follow-up

Incidence, Clinical Characteristics, and Impact of Acute Coronary Syndrome Following Transcatheter Aortic Valve Replacement.

The authors sought to assess the incidence, predictors, management, and prognosis of acute coronary syndrome (ACS) following TAVR. About one-half of the patients undergoing transcatheter aortic valve replacement (TAVR) have concurrent coronary artery disease (CAD). However, the occurrence and clinical impact of coronary events following TAVR remain largely unknown. Consecutive patients undergoing TAVR in our institution between May 2007 and November 2017 were included. Patients were followed at 1, 6, and 12 months, and yearly thereafter. ACS was diagnosed and classified according to the Third Universal Definition of Myocardial Infarction. A total of 779 patients (mean age 79 ± 9 years, 52% male, mean STS: 6.8 ± 5.1%) were included, 68% of which had a history of CAD. At a median follow-up of 25 (interquartile range: 10 to 44) months, 78 patients (10%) presented at least 1 episode of ACS, with one-half of the events occurring within the year following TAVR. Clinical presentation was type 2 non-ST-segment elevation myocardial infarction (35.9%), unstable angina (34.6%), type 1 non-ST-segment elevation myocardial infarction (28.2%), and ST-segment elevation myocardial infarction (1.3%). Male sex (hazard ratio [HR]: 2.19; 95% confidence interval [CI]: 1.36 to 3.54; p = 0.001), prior CAD (HR: 2.78; 95% CI: 1.50 to 5.18; p = 0.001), and nontransfemoral approach (HR: 1.71; 95% CI: 1.04 to 2.75; p = 0.035) were independently associated with ACS. Coronary angiography was performed in 53 (67.9%) patients with ACS, and 30 of them (56.6%) underwent percutaneous coronary intervention. In-hospital death rate at the time of the ACS episode was 3.8%. At a median follow-up of 21 (interquartile range: 8 to 34) months post-ACS, all-cause and cardiovascular death rates were 37.3% and 25.3%, respectively. Approximately one-tenth of patients undergoing TAVR were readmitted for an ACS after a median follow-up of 25 months. Male sex, prior CAD, and nontransfemoral approach were independent predictors of ACS. ACS was associated with high midterm mortality