Left Atrial Appendage Closure: Initial Experience with the Watchman Device

We herein present the first left atrial appendage (LAA) percutaneous closure procedure performed in our Institution with use of the Watchman device in an 82-year old woman with atrial fibrillation, unable to continue receiving anticoagulation therapy due to bleeding complications. A propos with this case, we discuss the data related to this therapeutic approach geared to prevent thromboembolism in patients with atrial fibrillation and contraindications to treatment with anticoagulants

Investigation of the use of dual antiplatelet therapy in coronary artery patients undergoing angioplasty, patient compliance and complications

Cardiovascular diseases are the first cause of death in western societies and are now the biggest problem for public health and also the leading cause of death in the European Union, with over 2 million deaths per year. Men prevail over the incidence of cardiovascular disease up to about 70 years of age.Different risk levels of ACS patients create difficulties in treating them evenly. Thus, therapeutic interventions in the individual patient should be guided by the so-called ischemic risk of this patient. A second risk that should be considered in these patients is the hemorrhagic risk due to the frequent use of intense antithrombotic therapy. Purpose: The aim of the study was to study the ischemic prognostic scores GRACE and CHA2DS2-VASc, as well as the HAS-BLED and CRUSADE hemorrhagic prognostic scores in patients underwent angioplasty to highlight which is best predicting the ischemic and hemorrhagic Risk.The compliance with the use of dual antiplatelet therapy and the occurrence of complications, was also studied.Results: The patients who participated in the study were a total of 667 with an average age of 61 ± 11 years and were followed-up for a period of 2 years. The GRACE score and its predicted incidence at 3 years, was compared to the CHA2DS2-VASc score, which predicts the annual probability of ischemic. This is the first time that the two scores are compared in a group of patients with coronary artery disease. In the limited study population (n = 667), the CHA2DS2-VASc score was able to show a marginally better prognosis of future ischemic events, with an area under the curve (AUC) of 0.624 vs 0.608 of the GRACE score. On the contrary, the predictive capacity of the haemorrhagic scores was not able to be shown in this sample of patients due to the limited number of the sample but also to the limited number of the occured bleedings (CRUCADE vs. HAS-BLED: AUC = 0.526 for both). Patient compliance for DAPT for at least one year was 79%, with the main cause of cessation being the financial crisis and bleeding. Regarding the correlation of the occurrence of the various complications with the educational level of the patients, there appeared to be a slight tendency for more hemorrhages in the patients who had higher education than in the secondary ones (10% vs. 5.2%, p = 0.102) . The first population group had a tendency for more frequent MACCE (12% vs. 6.9%, p = 0.128). Conclusions: In the specific population of this study, the CHA2DS2-VASc score was able to show a marginally higher predictive value in the emergence of future ischemic (MACCE) than the GRACE score (the predicted incidence in 3 years), in patients with angioplasty. In contrast, the hemorrhagic risk scores CRUSADE and HAS-BLED, failed to predict the observed bleeding due to a small number of these. Finally, the financial crisis played an important role in halting dual antiplatelet education before the year.Τα καρδιαγγειακά νοσήματα είναι η πρώτη αιτία θανάτου, στις δυτικές κοινωνίες και αποτελούν πλέον το μεγαλύτερο πρόβλημα για την δημόσια υγεία. Ο καρδιαγγειακός θάνατος ανέρχεται σε περισσότερους από 2.000.000 ετησίως στην Ευρωπαϊκή ένωση. Οι άνδρες υπερτερούν στη συχνότητα εμφάνισης της καρδιαγγειακής νόσου μέχρι περίπου την ηλικία των 70 ετών. Τα διαφορετικά επίπεδα κινδύνου των ασθε¬νών με ΟΣΣ δημιουργούν δυσκολίες στην ομοιόμορφη θεραπευτική τους αντιμετώπιση. Έτσι, οι θεραπευτικές παρεμβάσεις στον εκάστοτε ασθε¬νή θα πρέπει να καθοδηγούνται με βάση τον λεγό-μενο ισχαιμικό κίνδυνο του ασθενούς αυτού, δηλα¬δή τον κίνδυνο που διατρέχει να εμφανίσει ανε¬πιθύμητα καρδιαγγειακά συμβάματα (θάνατο, ΕΜ, επανέμφραγμα). Ταυτόχρονα, θα πρέπει να συνεκτιμάται στους ασθενείς αυτούς είναι και ο αιμορραγικός κίνδυνος, λόγω της συχνά χορηγούμενης έντονης αντιθρομβωτικής αγωγής. Σκοπός: Ο σκοπός της εργασίας ήταν να μελετηθούν τα ισχαιμικά προγνωστικά scores GRACE και CHA2DS2-VASc, καθώς και τα αιμορραγικά προγνωστικά scores HAS-BLED και CRUSADE, σε ασθενείς οι οποίοι υποβλήθησαν σε αγγειοπλαστική, για την ανάδειξη αυτού που καλύτερα προβλέπει τον ισχαιμικό και αιμορραγικό κίνδυνο, και την συμμόρφωση τους στην χρήση της διπλής αντιαιμοπεταλειακής αγωγής και της εμφάνισης επιπλοκών. Αποτελέσματα: Οι ασθενείς που έλαβαν μέρος στην μελέτη ήταν συνολικά 667 με μέση ηλικία 61±11ετών και μελετήθησαν παρακολουθήθηκαν για χρονικό διαστημα 2 ετών. Έγινε σύγκριση του GRACE score στην προβλεπόμενη επίπτωση του στην 3ετία και του CHA2DS2-VASc score, το οποίο προβλέπει την ετήσια πιθανότητα εμφάνισης ισχαιμικού. Είναι η πρώτη φορά που γίνεται η σύγκριση των δύο scores σε ομάδα ασθενών με στεφανιαία νόσο. Στον συγκεκριμένο περιορισμένο πληθυσμό της μελέτης (n=667), το CHA2DS2-VASc score κατάφερε να δείξει οριακά καλύτερη ικανότητα πρόβλεψης των μελλοντικών ισχαιμικών, με Area Under the Curve (AUC) 0,624 vs 0,608 του GRACE score. Αντίθετα η προβλεπτική ικανότητα των αιμορραγικών scores δεν μπόρεσε να αναδειχθεί στο δείγμα των ασθενών, λόγω του αριθμού του δείγματος, αλλά και του περιορισμένου αριθμού των αιμορραγιών που συνέβησαν (CRUCADE vs HAS-BLED: AUC= 0,526 και για τα δύο). Η συμμόρφωση των ασθενών στην DAPT για τουλάχιστον ένα έτος ήταν 79%, με κύρια αιτία διακοπής την οικονομική κρίση και τις αιμορραγίες. Όσον αφορά στην συσχέτιση της εμφάνισης των διαφόρων επιπλοκών με το μορφωτικό επίπεδο των ασθενών, φάνηκε πως υπήρξε μία μικρή τάση για περισσότερες αιμορραγίες στους ασθενείς που είχαν τριτοβάθμια εκπαίδευση σε σχέση με αυτούς της δευτεροβάθμιας (10% vs 5,2%, p=0,102). Η πρώτη πληθυσμιακή ομάδα είχε και μία τάση για συχνότερη εμφάνιση MACCE (12% vs 6,9%, p=0,128).Συμπεράσματα: Στον συγκεκριμένο πληθυσμό της εργασίας, το CHA2DS2-VASc score κατάφερε να εμφανίσει οριακά μεγαλύτερη προβλεπτική αξία στην ανάδειξη των μελλοντικών ισχαιμικών (MACCE), σε σχέση με το GRACE score (την προβλεπόμενη επίπτωση του στην 3ετία) (σε ασθενείς με αγγειοπλαστική). Αντίθετα, τα αιμορραγικά scores κινδύνου CRUSADE και HAS-BLED, δεν κατάφεραν να προβλέψουν τις παρατηρηθείσες αιμορραγίες, λόγω του μικρού αριθμού αυτών. Τέλος, η οικονομική κρίση, διαδραμάτισε σημαντικό ρόλο στην διακοπή της διπλής ανιτιαιμοπεταλειακής αγωγής προ του έτους

The Role of ECG Strain Pattern in Prognosis after TAVI: A Sub-Analysis of the DIRECT Trial

Background: The presence of an electrocardiographic (ECG) strain pattern—among other ECG features—has been shown to be predictive of adverse cardiovascular outcomes in asymptomatic patients with aortic stenosis. However, data evaluating its impact on symptomatic patients undergoing TAVI are scarce. Therefore, we tried to investigate the prognostic impact of baseline ECG strain pattern on clinical outcomes after TAVI. Methods: A sub-group of patients of the randomized DIRECT (Pre-dilatation in Transcatheter Aortic Valve Implantation Trial) trial with severe aortic stenosis who underwent TAVI with a self-expanding valve in one single center were consecutively enrolled. Patients were categorized into two groups according to the presence of ECG strain. Left ventricular strain was defined as the presence of ≥1 mm convex ST-segment depression with asymmetrical T-wave inversion in leads V5 to V6 on the baseline 12-lead ECG. Patients were excluded if they had paced rhythm or left bundle branch block at baseline. Multivariate Cox proportional hazard regression models were generated to assess the impact on outcomes. The primary clinical endpoint was all-cause mortality at 1 year after TAVI. Results: Of the 119 patients screened, 5 patients were excluded due to left bundle branch block. Among the 114 included patients (mean age: 80.8 ± 7), 37 patients (32.5%) had strain pattern on pre-TAVI ECG, while 77 patients (67.5%) did not exhibit an ECG strain pattern. No differences in baseline characteristics were found between the two groups. At 1 year, seven patients reached the primary clinical endpoint, with patients in the strain group demonstrating significantly higher mortality in Kaplan–Meier plots compared to patients without left ventricular strain (five vs. two, log-rank p = 0.022). There was no difference between the strain and no strain group regarding the performance of pre-dilatation (21 vs. 33, chi-square p = 0.164). In the multivariate analysis, left ventricular strain was found to be an independent predictor of all-cause mortality after TAVI [Exp(B): 12.2, 95% Confidence Intervals (CI): 1.4–101.9]. Conclusion: Left ventricular ECG strain is an independent predictor of all-cause mortality after TAVI. Thus, baseline ECG characteristics may aid in risk-stratifying patients scheduled for TAVI

Nickel Hypersensitivity to Atrial Septal Occluders: Smoke Without Fire?

Nickel is one of the most common contact allergens worldwide; it is used as the main component of the devices used for atrial septal defects (ASDs) and patent foramen ovale (PFO) closure. Developing nickel hypersensitivity after PFO/ASD occlusion is significantly rarer described in medical literature than typical nickel contact sensitization. The exact pathophysiological mechanism of this “device syndrome” remains unknown, and many question the real incidence or even the existence of this clinical entity. Nevertheless, it has been associated with a wide spectrum of symptoms, including chest pain, migraines, palpitation, and dyspnea. Skin patch tests are the first-line approach to diagnose nickel hypersensitivity. However, diagnostic criteria for the device syndrome have not been developed, and diagnosis in reported cases is established by a process of elimination. Management-drug therapy (corticosteroids, clopidogrel, etc.) or even surgical explantation in severe cases-of patients developing such clinical manifestations after percutaneous PFO/ASD occlusion is empirical. Undoubtedly, endocardiac device-related nickel hypersensitivity requires more focused research to discover the underlying mechanism as well as to develop reliable prognostic tests for detecting high-risk patients and preventing severe nickel hypersensitivity reactions