Concomitant Presentation With Cardioembolic Ischemic Stroke and Non ST Elevation Myocardial Infarction in a Patient With New Onset Atrial Fibrillation

Introduction: Although Atrial Fibrillation (AF) is a common cause of ischemic stroke, it rarely causes acute coronary syndromes (ACS). Cardioembolic events from AF cause considerable morbidity and mortality. Concomitant ischemic stroke and ACS remains an exceedingly rare event. We describe the case of a patient presenting with cardioembolic ischemic stroke and acute coronary syndrome. Case Presentation: An 83 year old male with a prior history of heart failure with preserved ejection fraction, permanent pacemaker for complete heart block, and chronic kidney disease on hemodialysis presented with acute left sided facial and extremity weakness, gait ataxia and profound dysarthria. Physical examination and stroke work up demonstrated right M1 territory ischemic stroke (A). EKG demonstrated AF with ventricular pacing (B). The patient subsequently underwent emergent right middle cerebral artery thrombectomy. Device interrogation confirmed new onset AF for ten days. Hemodynamic instability and up trending troponin post-procedurally prompted an echocardiogram which demonstrated new LAD wall motion abnormality with an ejection fraction of 15%. The patient underwent cardiac catheterization with coronary thrombectomy for a 100% mid-LAD occlusion with good angiographic result (C, D). He was initiated on intravenous anticoagulation in the setting of AF. Unfortunately, given his significant comorbidities and need for multiple pressors, the patient succumbed to his profound cardiogenic shock. Discussion: This case highlights that clinicians should maintain a high degree of suspicion for coronary embolic phenomena in patients presenting with clinical or biochemical signs of acute MI in the setting of AF and its sequela. Though the most common cause of MI is atherosclerotic plaque rupture, coronary embolism is the underlying etiology in 3% of cases. Expeditious identification of at risk patients is critical to appropriate and timely intervention

Safety and efficacy of left atrial appendage closure using an epicardial suture snaring device: Systematic review and current status

INTRODUCTION: The LARIAT epicardial suture snaring device has been fraught with technical challenges and procedural complications. Over time, technique modification and improved operator experience have helped overcome many of these challenges. METHODS AND RESULTS: Studies reporting left atrial appendage epicardial closure over a 12-year period from 2009 to 2020 were evaluated. The primary efficacy outcome evaluated was left atrial appendage closure with residual flow ≤1 mm. Safety outcomes evaluated were periprocedural and long term complications after device placement. Nine studies consisting of 1430 patients were included in this analysis, of which 1386 (97%) underwent successful device placement. The mean age was 69.3 years, with a mean CHADS -VASC score of 3.78. Primary efficacy end point was achieved in 95.8% patients immediately after device placement, and in 92.8% patients on long term follow-up. Early procedural complications consisted of pericardial effusion 5.6%, cardiac perforation 2.7%, pericarditis 2.6%, and need for open heart surgery 1.5%. Long term complications consisted of all-cause mortality 2.3%, stroke 1.5%, and left atrial appendage thrombus 2.3%. Reduced complications were noted using micropuncture needles (2.20% vs. 10.14%; p \u3c .0001), a longer duration pericardial drainage, and use of anti-inflammatory medications (1.58% vs. 8.4%). Oral anticoagulation use decreased from 44.7% to 22.9% post device implantation, and to 8.5% on last clinical follow up. CONCLUSIONS: The LARIAT device is effective in epicardial closure of the left atrial appendage. Improvement in device techniques such as use of micropuncture needle, prophylactic colchicine, and maintenance of a pericardial drain have helped improve safety over time