Mechanical concordance between left atrium and left atrial appendage in nonvalvular atrial fibrillation: can it be exploited to avoid transesophageal echocardiography prior to electrical cardioversion during Covid-19 pandemic?

Transesophageal echocardiography (TEE) is the gold standard for assessing left atrial appendage (LAA) mechanic and thrombosis (LAAT); however, TEE is a high-risk procedure for viral transmission during coronavirus disease 2019 (COVID-19) pandemic. We investigated whether deformation indices of left atrium (LA) at transthoracic echocardiography (TTE) correlate with those of LAA assessed by TEE in nonvalvular atrial fibrillation (NVAF) patients undergoing electrical cardioversion (ECV). Consecutive patients with NVAF of ≥ 48 h or unknown duration, who underwent TEE and TTE at our Institution before ECV were retrospectively investigated. Standard echo-Doppler and LA and LAA myocardial strain and strain rate parameters were analyzed. A total of 115 NVAF patients (71.3 ± 8.1 yr/o, 59.1% men) were included: LAAT was diagnosed in 25 (21.7%) patients. Compared to patients without LAAT, those with LAAT had significantly higher CHA2DS2-VASc Risk score (4.5 ± 1.4 vs. 3.5 ± 1.1, p < 0.001), and lower ejection fraction (46.0 ± 14.8 vs. 57.6 ± 8.6%, p < 0.001). In LAAT patients, global strain of LA (8.7 ± 2.6 vs. 16.3 ± 4.5%, p < 0.001) and LAA (7.0 ± 1.7 vs. 11.7 ± 2.0%, p < 0.001) was significantly reduced compared to non-LAAT patients. A close relationship between left atrial strain reservoir (LASr) and LAA-global strain was demonstrated (r = 0.81). By univariable analysis, CHA2DS2-VASc Risk Score (OR 2.01, 95%CI 1.34-3.00), NT-proBNP (OR 1.36, 95%CI 1.19-1.54), ejection fraction (OR 0.92, 95%CI 0.88-0.96), E/e' ratio (OR 2.07, 95%CI 1.51-2.85), and LASr (OR 0.39, 95%CI 0.25-0.62) were strongly associated with LAAT presence at TEE. By multivariable analysis, only LASr (OR 0.40, 95%CI 0.24-0.70) retained statistical significance. ROC curve analysis revealed that an LASr cut-off value ≤ 9.3% had 98.9% sensibility and 100% specificity to identify LAAT by TEE (AUC = 0.98). In patients with NVAF of ≥ 48 h or unknown duration, scheduled to undergo ECV, LA deformation assessment by TTE might substitute invasive measurement of LAA function by TEE, simplifying diagnostic approach and possibly contributing to reduce COVID-19 infection diffusion.

Evaluation of Remote Pharmacist-Led Outpatient Service for Geriatric Patients on Rivaroxaban for Nonvalvular Atrial Fibrillation During the COVID-19 Pandemic.

OBJECTIVE: This study was designed to evaluate the efficacy of remote medication management of rivaroxaban by pharmacists for geriatric patients with nonvalvular atrial fibrillation during the COVID-19 pandemic. METHODS: A single-site, prospective cohort study was conducted among patients with non-valvular atrial fibrillation who received rivaroxaban therapy from July 2019 to December 2019. Patients in the pharmacist-led education and follow-up service (PEFS) group were managed remotely by a pharmacist. In contrast, those in the usual care (UC) group were managed by other providers. Data of routine blood tests, coagulation function tests, which also included cardiac function parameters were collected. The number and type of provider encounters, interventions related to rivaroxaban therapy, the occurrence of thromboembolism or bleeding, and the time of the first outpatient visit after discharge were recorded. RESULTS: A total of 600 patients were recruited, and results of 381 patients were analyzed in the end, of which 179 patients were from the PEFS group and 202 were from the UC group. There was no significant difference between the two groups in terms of the occurrence ratio of systemic thrombosis, heart failure (LVEF < 40%), and left atrial dilation, which was defined as enlargement of left atrial diameter (LAD) > 40 mm. The cumulative incidences of bleeding complications, such as gastrointestinal tract and skin ecchymosis, were significantly higher in the UC group (12.4% vs. 6.1%, P=0.038; 4.5% vs. 0.6%, P=0.018). There was no significant difference after pharmacist intervention in terms of thrombosis occurrence ratio between the two groups (P = 0.338, HR: 0.722, 95% CI: 0.372-1.405). Remote instruction by a pharmacist reduced outpatient service frequency within the first 30 days after discharge (23.7% vs. 1.1%, P < 0.001). However, more patients in the PEFS group presented for the first outpatient revisit later than 40 days post-discharge (12.8% vs. 21.3%, P < 0.001). CONCLUSION: Remote pharmacist-led medication instruction of rivaroxaban could reduce bleeding complications of the gastrointestinal tract and skin ecchymosis and postpone the first outpatient revisit after discharge.