Elective direct current cardioversion delay in patients with persistent atrial fibrillation/undulation: patient's characteristic and potential causes

Fibrilacija (FA) i undulacija atrija (UA) imaju značajne zdravstvene posljedice. Sinusni je ritam moguće uspostaviti elektrokonverzijom (EK), koja se provodi nakon pripreme u svrhu prevencije tromboembolijskih komplikacija. Cilj rada bio je proučiti pristup bolesnicima s FA/UA naručenim na EK u jednom kliničkom bolničkom centru (KBC) i jednoj općoj bolnici (OB) koje oslikavaju ustanove tercijarne i sekundarne zdravstvene zaštite u Republici Hrvatskoj (RH). S tim ciljem provedena je retrospektivna analiza elektronskih i arhivskih podataka KBC Zagreb i OB Varaždin. Obuhvaćeno je 339 bolesnika (284 KBC, 55 OB). U KBC-u, priprema se temelji se na primjeni transezofagealnog ultrazvuka (modificirana u odnosu na smjernice), a u OB strategija je „klasična“ (sukladno smjernicama). Dugoročna kontrola ritma u KBC-u je sustavna (67.9%), a u OB sporadična (7.3%). Uspješnost EK (ritam) u KBC-u je viša (podešeni omjer šanse=6.51, p=0.003). U tromboprofilaksi prevladava varfarin (318/339), no dokumentacija o uspješnosti izrazito je manjkava. Uoči EK, manje od 1/3 bolesnika je adekvatno antikoagulirano. Nema sustavnih podataka o tromboembolijskim komplikacijama, pa ipak u KBC-u moždani je udar opažen u 1.5% bolesnika. Elektivna EK je rijedak terapijski postupak. Da bi se omogućila pouzdana procjena njene uspješnosti, u RH je potrebno ustrojiti sustav strukturiranog prospektivnog bilježenja pripremnih radnji (posebice tromboprofilakse) i ishoda.Atrial fibrillation (AF) and flutter (AFL) significantly reflect on morbidity and mortality. Sinus rhythm can be restored by electroconversion (EC) which requires thromboprophylaxis. The aim of this study was to assess the approach to patients with AF/AFL at one university hospital (UH) and one general hospital (GH) that represent tertiary and secondary healthcare in Croatia. We conducted a retrospective analysis of administrative databases at University Hospital Center Zagreb and General Hospital Varaždin. A total of 339 patients (284 UH, 55 GH) were embraced. Transesophageal ultrasound-assisted EC (modified vs. guidelines) is practiced at UH and a “classical” approach (in line with the guidelines) at GH. Long-term rhythm control is practiced regularly (67.9%) at UH and sporadically at GH (7.3%). The EC success rate is higher at UH (adjusted odds ratio=6.51, p=0.003). Thromboprophylaxis is almost exclusively by warfarin (318/339), but records are extremely insufficient. Immediately before EC, less than 1/3 of the patients are adequately anticoagulated. Systematic data on thromboembolic complications are non-existing, yet strokes were observed in 1.5% of the patients at UH. Elective EC is a rare procedure. To enable a reliable estimate about its efficacy in Croatia, a system of structured prospective data capturing (particularly considering thromboprohylaxis) and patient follow-up needs to be established

Elective direct current cardioversion delay in patients with persistent atrial fibrillation/undulation: patient's characteristic and potential causes

Fibrilacija (FA) i undulacija atrija (UA) imaju značajne zdravstvene posljedice. Sinusni je ritam moguće uspostaviti elektrokonverzijom (EK), koja se provodi nakon pripreme u svrhu prevencije tromboembolijskih komplikacija. Cilj rada bio je proučiti pristup bolesnicima s FA/UA naručenim na EK u jednom kliničkom bolničkom centru (KBC) i jednoj općoj bolnici (OB) koje oslikavaju ustanove tercijarne i sekundarne zdravstvene zaštite u Republici Hrvatskoj (RH). S tim ciljem provedena je retrospektivna analiza elektronskih i arhivskih podataka KBC Zagreb i OB Varaždin. Obuhvaćeno je 339 bolesnika (284 KBC, 55 OB). U KBC-u, priprema se temelji se na primjeni transezofagealnog ultrazvuka (modificirana u odnosu na smjernice), a u OB strategija je „klasična“ (sukladno smjernicama). Dugoročna kontrola ritma u KBC-u je sustavna (67.9%), a u OB sporadična (7.3%). Uspješnost EK (ritam) u KBC-u je viša (podešeni omjer šanse=6.51, p=0.003). U tromboprofilaksi prevladava varfarin (318/339), no dokumentacija o uspješnosti izrazito je manjkava. Uoči EK, manje od 1/3 bolesnika je adekvatno antikoagulirano. Nema sustavnih podataka o tromboembolijskim komplikacijama, pa ipak u KBC-u moždani je udar opažen u 1.5% bolesnika. Elektivna EK je rijedak terapijski postupak. Da bi se omogućila pouzdana procjena njene uspješnosti, u RH je potrebno ustrojiti sustav strukturiranog prospektivnog bilježenja pripremnih radnji (posebice tromboprofilakse) i ishoda.Atrial fibrillation (AF) and flutter (AFL) significantly reflect on morbidity and mortality. Sinus rhythm can be restored by electroconversion (EC) which requires thromboprophylaxis. The aim of this study was to assess the approach to patients with AF/AFL at one university hospital (UH) and one general hospital (GH) that represent tertiary and secondary healthcare in Croatia. We conducted a retrospective analysis of administrative databases at University Hospital Center Zagreb and General Hospital Varaždin. A total of 339 patients (284 UH, 55 GH) were embraced. Transesophageal ultrasound-assisted EC (modified vs. guidelines) is practiced at UH and a “classical” approach (in line with the guidelines) at GH. Long-term rhythm control is practiced regularly (67.9%) at UH and sporadically at GH (7.3%). The EC success rate is higher at UH (adjusted odds ratio=6.51, p=0.003). Thromboprophylaxis is almost exclusively by warfarin (318/339), but records are extremely insufficient. Immediately before EC, less than 1/3 of the patients are adequately anticoagulated. Systematic data on thromboembolic complications are non-existing, yet strokes were observed in 1.5% of the patients at UH. Elective EC is a rare procedure. To enable a reliable estimate about its efficacy in Croatia, a system of structured prospective data capturing (particularly considering thromboprohylaxis) and patient follow-up needs to be established

Detection of early cardiac allograft vasculopathy in a high-risk transplant patient using optical coherence tomography

Introduction: Cardiac allograft vasculopathy (CAV) is a common cause of late graft failure and mortality in heart transplant recipients. Concentric intimal proliferation that reflects immune-mediated vascular damage in the early post-transplant years is difficult to recognize by conventional coronary angiography. Optical coherence tomography (OCT) is a high resolution intravascular imaging technique that has the potential to identify subtle early vessel wall changes and shape the therapeutic approach that may improve patients’ outcomes. Case report: 68-year-old male patient underwent heart transplantation with positive lymphocyte crossmatch and Luminex that detected anti-HLA class I (A1, A25, B8, B57) donor-specific antibodies with MFI up to 2500. The patient was treated with steroid, antilymphocyte (rATG) induction, tacrolimus, and mycophenolate mofetil, in combination with IVIG and plasmapheresis. Graft function was preserved, biopsies showed no or mild cellular-mediated rejection (1R) with no signs of antibody-mediated rejection (AMR) with negativization of anti-A1 and -A25 antibodies. However, control biopsy after 6 months became positive for AMR. The patient was treated with steroid pulse, IVIG, plasmapheresis, and rituximab. The following biopsies were negative for AMR and the patient remained with preserved graft function. One year after transplantation we performed control coronary angiography with OCT. While coronary angiography was interpreted as normal, control OCT showed significant diffuse intimal thickening with maximal intimal thickness up to 920 μm and intima/media cross-sectional media of ≥1 (Figure 1). This finding prompted a change in therapy with the maximization of statin dose and introduction of everolimus in the maintenance immunosuppressive regimen. Conclusion: This case report indicates the limitation of conventional coronary angiography in the early detection of transplant vasculopathy. OCT is able to establish the diagnosis and trigger specific therapeutic interventions like the introduction of everolimus before vascular changes become visible on conventional coronary angiography and resistant to treatment. Unfortunately, we still lack clearly defined OCT criteria for both diagnosis and treatment, but the progress in this field of transplant cardiology is promising