Left atrial appendage morphology assessment for risk stratification of embolic stroke in patients with atrial fibrillation: A meta-analysis

Background Thromboembolic event (TE) risk stratification is performed by using CHA2DS2VASc score. It has been suggested that left atrial appendage (LAA) morphology independently influences TE risk in patients with nonvalvular atrial fibrillation. LAA morphology has been classified into 4 types: chicken wing, cauliflower, windsock, and cactus. Objective The purpose of this study was to determine TE risk for each LAA morphology in patients with atrial fibrillation with low to intermediate TE risk. Methods A systematic review of MEDLINE, Cochrane Library, and Embase for studies that used computed tomography, tridimensional transesophageal echocardiography, and cardiac magnetic resonance imaging to categorize the LAA morphologies with assessment of TE prevalence. Odds ratio (OR) and 95% confidence intervals (CIs) were measured using the Mantel-Haenszel method. The fixed effects model was used, and if heterogeneity (I2) was >25%, effects were analyzed using a random model. Results Eight studies with 2596 patients were included. Eighty-four percent (n=1872) of patients had a CHADS2 score of <2. TE risk was lower in chicken wing morphology than in non-chicken wing morphology (OR 0.46; 95% CI 0.36-0.58). Likewise, chicken wing morphology had lower TE risk than did other morphologies (chicken wing vs cauliflower: OR 0.38; 95% CI 0.26-0.56; chicken wing vs windsock: OR 0.48; 95% CI 0.31-0.73; chicken wing vs cactus: OR 0.49; 95% CI 0.36-0.66). Conclusion Patients with chicken wing LAA morphology are less likely to develop TE than patients with non-chicken wing morphology. LAA morphology may be a valuable criterion in predicting TE and could affect the stratification and anticoagulation management of patients with low to intermediate TE risk

Electroanatomic mapping systems (CARTO/EnSite NavX) vs. conventional mapping for ablation procedures in a training program

Background: Three-dimensional electroanatomic mapping (EAM) systems reduce radiation exposure when radio frequency catheter ablation (RFCA) procedures are performed by well-trained senior operators. Given the steep learning curve associated with complex RFCA, trainees and their mentors must rely on multiple imaging modalities to maximize safety and success, which might increase procedure and fluoroscopy times. The objective of the present study is to determine if 3-D EAM (CARTO and ESI-NavX) improves procedural outcomes (fluoroscopy time, radio frequency time, procedure duration, complication, and success rates) during CA procedures as compared to fluoroscopically guided conventional mapping alone in an academic teaching hospital. Methods: We analyzed a total of 1070 consecutive RFCA procedures over an 8-year period for fluoroscopic time stratified by ablation target and mapping system. Multivariate logistic regression and adjusted odds ratios were calculated for each variable. Results: No statistically significant differences in acute success rates were noted between conventional and 3-D mapping cases [CARTO (p = 0.68) or ESI-NavX (p = 0.20)]. Moreover, complication rates were also not significantly different between CARTO (p = 0.23) and ESI-NavX (p = 0.53) when compared to conventional mapping. Procedure, radio frequency, and fluoroscopy times were significantly longer with CARTO and ESI-NavX versus conventional mapping [fluoroscopy time: CARTO, 28.3 min; ESI, 28.5 min; and conventional, 24.3 min; p < 0.001)]. Conclusions: The use of 3-D EAM systems during teaching cases significantly increases radiation exposure when compared with conventional mapping. These findings suggest a need to develop alternative training strategies that enhance confidence and safety during catheter manipulation and allow for reduced fluoroscopy and procedure times during RFCA

Pyrethroid insecticides along the Southwestern Atlantic coast: Guiana dolphin (Sotalia guianensis) as a bioindicator

The presence of pyrethroid compounds in hepatic tissue of Guiana dolphins (Sotalia guianensis) is reported for the first time. Twelve pyrethroids were determined in 50 animals from eight locations of the Brazilian coast. The highest average concentration of total pyrethroids (∑PYR) was 1166 ng.g−1 lw, with values ranging from 148 to 5918 ng.g−1 lw, in Ilha Grande Bay, Rio de Janeiro State, while the Espírito Santo State had the highest median, 568 ng.g−1 lw. Permethrin was the predominant compound in most areas, contributing for 42% to 81% of the ∑PYR, whereas cypermethrin was the most abundant compound in Guanabara and Sepetiba bays (79% and 81%, respectively), both located in Rio de Janeiro State. Biological factors were not correlated with pyrethroids concentration. Tetramethrin and es/fenvalerate compounds were negatively correlated to the age, suggesting degradation/metabolization capacity in these animals that increases throughout life. Despite being metabolized and excreted, the wide use of these pollutants is reflected in relevant concentrations found in Guiana dolphins. This is the first study evaluating pyrethroids in a representative number of hepatic samples and covering >2600 km of coast. The overall lack of information on pyrethroids in cetaceans highlights the importance of understanding the profile and distribution of these pollutants in dolphins which exclusively inhabit the Southwestern Atlantic coast.This work was supported by the Spanish Ministry of Science and Innovation (Project CEX2018-000794-S) and by the Generalitat de Catalunya (Consolidated Research Group Water and Soil Quality Unit 2017 SGR 1404). The authors thank the Rio de Janeiro State Government Research Agency (FAPERJ) for financing part of this study. A.F. Azevedo, J. Lailson-Brito and T.L Bisi thank the National Council for Scientific and Technological Development (CNPq) for grants PQ-1B, 1C and 2, respectively; FAPERJ (CNE and JCNE, respectively) and UERJ (Prociência). We also thank the students from Aquatic Mammal and Bioindicator Lab (UERJ - Brazil), Environmental Chemistry Lab (CSIC - Spain) and Radioisotope Lab (UFRJ - Brazil). L.G.Vidal thanks the Coordination for the Improvement of Higher Education Personnel (CAPES - Finance Code 001) for providing her PhD grant.Peer reviewe

Comparison of the use of blood pressure telemonitoring versus standard medical care in the achievement of short-term therapeutic goals in blood pressure in patients with uncontrolled hypertension: An open-label clinical trial

Background In Mexico less than half of the treated hypertensive patients reach blood pressure (BP) targets. Most hypertensive individuals rely on the standard medical care (SMC) to achieve the BP control goals; however, the efficacy of BP telemonitoring (BPT) to achieve BP targets has been poorly studied. Aim To compare the efficacy of BPT versus SMC to achieve BP goals in patients with uncontrolled hypertension. Methods A two-arm, open-label clinical trial was conducted in patients ≥18 years with uncontrolled hypertension. The participants were randomized to 2 arms (BPT vs SMC) and followed for 12 weeks. For the statistical analysis, the chi-squared test and covariance were used. Results One hundred and seventy-eight participants were included, BPT (n = 94) and SMC (n = 84), after 12 weeks of follow up, we observed a baseline-adjusted reduction in systolic BP with both BPT (−13.5 [1.3] mmHg) and the SMC (−5.9 [1.4] mmHg; p < 0.001) but a greater decrease with BPT (p < 0.001). Likewise, we found a baseline-adjusted reduction of diastolic BP with BPT (−6.9 [0.9] mmHg) and SMC (−2.7 [0.9] mmHg) (p = 0.007) with a more significant percentage change from baseline with BPT (−6.8% [1.0] vs 2.5% [1.1]; p = 0.007). In the BPT arm, a larger proportion of patients achieved the BP target versus SMC (30.5% vs 12.8%; p = 0.005). Conclusion BPT showed a greater proportion of patients achieving office BP control goals (<140/90 mmHg), compared to standard medical care