Dabigatran in patients with atrial fibrillation: perioperative and periinterventional management

In any type of invasive surgery, the patient’s individual risk of thromboembolism has to be weighed against the risk of bleeding. Based on various everyday situations in clinical routine, the purpose of the present expert recommendations is to provide appropriate perioperative and periinterventional management for patients with atrial fibrillation undergoing long-term treatment with the thrombin inhibitor dabigatran. As we currently have no routine laboratory test to measure therapeutic levels of the substance or the risk of bleeding, general measures such as a standardized documentation of the patient’s history, a sufficient time interval between the last preoperative dose and the procedure, and careful control of local hemostasis should be given special attention

Effect of Systemic Hypertension With Versus Without Left Ventricular Hypertrophy on the Progression of Atrial Fibrillation (from the Euro Heart Survey).

Hypertension is a risk factor for both progression of atrial fibrillation (AF) and development of AF-related complications, that is major adverse cardiac and cerebrovascular events (MACCE). It is unknown whether left ventricular hypertrophy (LVH) as a consequence of hypertension is also a risk factor for both these end points. We aimed to assess this in low-risk AF patients, also assessing gender-related differences. We included 799 patients from the Euro Heart Survey with nonvalvular AF and a baseline echocardiogram. Patients with and without hypertension were included. End points after 1 year were occurrence of AF progression, that is paroxysmal AF becoming persistent and/or permanent AF, and MACCE. Echocardiographic LVH was present in 33% of 379 hypertensive patients. AF progression after 1 year occurred in 10.2% of 373 patients with rhythm follow-up. In hypertensive patients with LVH, AF progression occurred more frequently as compared with hypertensive patients without LVH (23.3% vs 8.8%, p = 0.011). In hypertensive AF patients, LVH was the most important multivariably adjusted determinant of AF progression on multivariable logistic regression (odds ratio 4.84, 95% confidence interval 1.70 to 13.78, p = 0.003). This effect was only seen in male patients (27.5% vs 5.8%, p = 0.002), while in female hypertensive patients, no differences were found in AF progression rates regarding the presence or absence of LVH (15.2% vs 15.0%, p = 0.999). No differences were seen in MACCE for hypertensive patients with and without LVH. In conclusion, in men with hypertension, LVH is associated with AF progression. This association seems to be absent in hypertensive women

Progression From Paroxysmal to Persistent Atrial Fibrillation. Clinical Correlates and Prognosis

Objectives: We investigated clinical correlates of atrial fibrillation (AF) progression and evaluated the prognosis of patients demonstrating AF progression in a large population. Background: Progression of paroxysmal AF to more sustained forms is frequently seen. However, not all patients will progress to persistent AF. Methods: We included 1,219 patients with paroxysmal AF who participated in the Euro Heart Survey on AF and had a known rhythm status at follow-up. Patients who experienced AF progression after 1 year of follow-up were identified. Results: Progression of AF occurred in 178 (15%) patients. Multivariate analysis showed that heart failure, age, previous transient ischemic attack or stroke, chronic obstructive pulmonary disease, and hypertension were the only independent predictors of AF progression. Using the regression coefficient as a benchmark, we calculated the HATCH score. Nearly 50% of the patients with a HATCH score >5 progressed to persistent AF compared with only 6% of the patients with a HATCH score of 0. During follow-up, patients with AF progression were more often admitted to the hospital and had more major adverse cardiovascular events. Conclusions: A substantial number of patients progress to sustained AF within 1 year. The clinical outcome of these patients regarding hospital admissions and major adverse cardiovascular events was worse compared with patients demonstrating no AF progression. Factors known to cause atrial structural remodeling (age and underlying heart disease) were independent predictors of AF progression. The HATCH score may help to identify patients who are likely to progress to sustained forms of AF in the near future. \ua9 2010 American College of Cardiology Foundation

Assessment of left ventricular ejection fraction with late-systolic and mid-diastolic cardiac phases using multi-slice computed tomography

Introduction: Multi-slice computed tomography (MSCT) is an accurate tool for the assessment of left ventricular ejection fraction (LVEF). However, in order to reduce radiation dose, prospective acquisition protocols are currently used, in which the end-systole and end-diastole are not scanned. Our aim was to study the accuracy of the assessment of LVEF using fixed late-systolic and mid-diastolic cardiac phases compared with echocardiography. Methods: MSCT-derived LVEF was measured with off-line commercially available software packages, and compared with echocardiography-derived LVEF using the Simpson's method. LVEF was categorized as normal vs. abnormal (50% cut-off) and was also analyzed as a quantitative parameter. Bland-Altman plots and Pearson correlations were used for inter-technique comparisons. Results: 58 patients were included. The sensitivity and specificity of fixed-phase MSCT when compared with echocardiography for detection of LVEF ≤50% was 79% (95% CI = 65–89%) and 43% (10–82%). Misclassification was associated with older age (68 ± 12 vs. 54 ± 13 years, p < 0.01), faster heart rate (79 ± 14 vs. 68 ± 10 bpm, p = 0.01), and LV hypertrophy (86% vs. 52%, p = 0.03). The quantitative comparison revealed no correlation (r = 0.095, p = 0.478) and a significantly different LVEF (median[IQR], 57.0[50.5–63.1]% vs. 61.0[57.3–64.3]%, p = 0.03). The observed bias between the two methods was −3.7% with broad limits of agreement (±25.5%). Conclusions: Fixed-phase MSCT assessment using late-systole and mid-diastole agreed in defining normal and abnormal LVEF in 76% of patients when compared with echocardiography. Quantitation of LVEF by this method yielded significantly lower values of LVEF and showed no correlation. Thus, accurate quantitation of LVEF by MSCT requires the acquisition of end-systolic and end-diastolic phases

Rotationplasty: Beauty is in the Eye of the Beholder

Rotationplasty is an alternative reconstructive strategy after sarcoma resection that often gets overlooked due to concerns about cosmesis. “Rotating” a distal segment 180 degrees and fixing it to a proximal segment leaves a highly-functional, durable reconstruction that functionally compares favorably to other limb-salvage techniques. Cosmetic outcomes have no discernible impact of the emotional and social functioning of cancer survivors following rotationplasty. This chapter discusses techniques of rotationplasty, as well as its oncologic, functional and emotional outcomes