Left Atrial Appendage Occlusion in Patients With Anticoagulation Failure vs Anticoagulation Contraindication.

BACKGROUND: Left atrial appendage occlusion (LAAO) provides mechanical cardioembolic protection for atrial fibrillation (AF) patients who cannot use oral anticoagulation therapy (OAT). Patients with a thrombotic event despite OAT are at high risk for recurrence and may also benefit from LAAO. OBJECTIVES: This study sought to investigate the efficacy of LAAO in AF patients with a thrombotic event on OAT compared to: 1) LAAO in AF patients with a contraindication for OAT; and 2) historical data. METHODS: The international LAAO after stroke despite oral anticoagulation (STR-OAC LAAO) collaboration included patients who underwent LAAO because of thrombotic events on OAT. This cohort underwent propensity score matching and was compared to the EWOLUTION (Evaluating Real-Life Clinical Outcomes in Atrial Fibrillation Patients Receiving the WATCHMAN Left Atrial Appendage Closure Technology) registry, which represents patients who underwent LAAO because of OAT contraindications. The primary outcome was ischemic stroke. Event rates were compared between cohorts and with historical data without OAT, yielding relative risk reductions based on risk scores. RESULTS: Analysis of 438 matched pairs revealed no significant difference in the ischemic stroke rate between the STR-OAC LAAO and EWOLUTION cohorts (2.5% vs 1.9%; HR: 1.37; 95% CI: 0.72-2.61). STR-OAC LAAO patients exhibited a higher thromboembolic risk (HR: 1.71; 95% CI: 1.04-2.83) but lower bleeding risk (HR: 0.39; 95% CI: 0.18-0.88) compared to EWOLUTION patients. The mortality rate was slightly higher in EWOLUTION (4.3% vs 6.9%; log-rank P = 0.028). Relative risk reductions for ischemic stroke were 70% and 78% in STR-OAC LAAO and EWOLUTION, respectively, compared to historical data without OAT. CONCLUSIONS: LAAO in patients with a thrombotic event on OAT demonstrated comparable stroke rates to the OAT contraindicated population in EWOLUTION. The thromboembolic event rate was higher and the bleeding rate lower, reflecting the intrinsically different risk profile of both populations. Until randomized trials are available, LAAO may be considered in patients with an ischemic event on OAT.

Persistent and Recurrent Device-Related Thrombus After Left Atrial Appendage Closure: Incidence, Predictors, and Outcomes.

BACKGROUND: Scarce data exist on the evolution of device-related thrombus (DRT) after left atrial appendage closure (LAAC). OBJECTIVES: This study sought to assess the incidence, predictors, and clinical impact of persistent and recurrent DRT in LAAC recipients. METHODS: Data were obtained from an international multicenter registry including 237 patients diagnosed with DRT after LAAC. Of these, 214 patients with a subsequent imaging examination after the initial diagnosis of DRT were included. Unfavorable evolution of DRT was defined as either persisting or recurrent DRT. RESULTS: DRT resolved in 153 (71.5%) cases and persisted in 61 (28.5%) cases. Larger DRT size (OR per 1-mm increase: 1.08; 95% CI: 1.02-1.15; P = 0.009) and female (OR: 2.44; 95% CI: 1.12-5.26; P = 0.02) were independently associated with persistent DRT. After DRT resolution, 82 (53.6%) of 153 patients had repeated device imaging, with 14 (17.1%) cases diagnosed with recurrent DRT. Overall, 75 (35.0%) patients had unfavorable evolution of DRT, and the sole predictor was average thrombus size at initial diagnosis (OR per 1-mm increase: 1.09; 95% CI: 1.03-1.16; P = 0.003), with an optimal cutoff size of 7 mm (OR: 2.51; 95% CI: 1.39-4.52; P = 0.002). Unfavorable evolution of DRT was associated with a higher rate of thromboembolic events compared with resolved DRT (26.7% vs 15.1%; HR: 2.13; 95% CI: 1.15-3.94; P = 0.02). CONCLUSIONS: About one-third of DRT events had an unfavorable evolution (either persisting or recurring), with a larger initial thrombus size (particularly >7 mm) portending an increased risk. Unfavorable evolution of DRT was associated with a 2-fold higher risk of thromboembolic events compared with resolved DRT.

Point-of-Care Ultrasound Overview and Curriculum Implementation in Internal Medicine Residency Training Programs in the United States.

Point-of-care ultrasonography (POCUS) augments physical examination and expedites diagnostic care and clinical decision-making. The use of POCUS in internal medicine (IM) appears inconsistent despite its commendable benefits. It is not fully incorporated into the IM residency core competency skills or academic curriculum. This narrative literature review explores the benefits of POCUS and evaluates the need for an IM-focused POCUS curriculum. The obstacles and a proposed curriculum are also described.

Invasive Management of Vertebrobasilar Artery Stenosis and Occlusion: A Meta-Analysis on Efficacy and Safety Endpoints.

Vertebrobasilar angioplasty and stenting or mechanical thrombectomy (MT) using a stent retriever or suction thrombectomy are effective interventions in managing acute ischemic stroke caused by vertebrobasilar artery occlusion (VBAO). This study aims to investigate the safety and efficacy of self-expanding stents and balloon angioplasty in managing ischemic stroke. We reviewed the literature for relevant clinical trials and included those reporting the following primary outcomes: successful recanalization, favorable clinical outcome, and stenosis degree change. We included 24 studies (858 patients). In the subgroup analysis, participants were divided into three main subgroups based on the type of intervention: mechanical thrombectomy (MT), percutaneous transluminal angioplasty and stenting (PTAS), and MT+PTAS. Regarding overall mortality, the incidence was 34.5%, 9.9%, and 28.9% in the MT, PTAS, and MT+PTAS groups, respectively. The incidence of arterial dissection was 3.6% in the MT group, 3.1% in the PTAS group, and 16.7% in the MT+PTAS group. Incidence of distal embolization, MT, PTAS, and MT+PTAS groups had 3.4%, 5.8%, and 9.5% incidence rates, respectively. Favorable clinical outcomes were reported in 42.8% of subjects in the MT+PTAS group, 64.7% in the PTAS group, and 39.2% in the MT group. The incidence of intracranial hemorrhage was 5.2%, 4.5%, and 15.3% in the MT, PTAS, MT + PTAS groups, respectively. The incidence of successful recanalization was 85.3% in the MT group, 99.4% in the PTAS group, and 92.7% in the MT+PTAS group. Our analysis concludes that PTAS is the most effective intervention for VBAO and is associated with a lower rate of mortality compared to mechanical thrombectomy alone.

Outcomes of cardiac surgery with left atrial appendage occlusion versus no Occlusion, direct oral Anticoagulants, and vitamin K Antagonists: A systematic review with Meta-analysis.

Surgical left atrial appendage occlusion (LAAO) is being used increasingly in the setting of atrial fibrillation but has been associated with procedural complications. This systematic review and meta-analysis compared the outcomes of surgical LAAO with those of no LAAO and the use of direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) using the PRISMA guidelines. A literature search was undertaken for relevant studies published between January 1, 2003, and August 15, 2021. Primary clinical outcomes were all-cause mortality, embolic events, and stroke. Secondary clinical outcomes included major adverse cardiac events (MACE), postoperative atrial fibrillation, postoperative complications, reoperation for bleeding, and major bleeding. There was a statistically significant 34% reduction in incidence of embolic events (odds ratio [OR] 0.66, 95% confidence interval [CI] 0.57-0.77, p < 0.001) and a significant 42% reduction in risk of MACE (OR 0.58, 95% CI 0.38-0.88, p = 0.01) in patients who underwent LAAO.Surgical LAAO has the potential to reduce embolic events and MACE in patients undergoing cardiac surgery for atrial fibrillation. However, complete replacement of DOACs and warfarin therapy with surgical LAAO is unlikely despite its non-inferiority in terms of minimizing all-cause mortality, embolic events, MACE, major bleeding, and stroke in patients on oral anticoagulation therapies.

Factors Impacting Stent Thrombosis in Patients With Percutaneous Coronary Intervention and Coronary Stenting: A Systematic Review and Meta-Analysis.

Stent thrombosis (ST) is a frequently reported complication in cardiac patients with percutaneous coronary intervention (PCI) that adversely impacts their prognostic outcomes. Medical literature reveals several baseline characteristics of PCI patients that may predict their predisposition to ST and its potential complications. Our systematic review and meta-analysis aimed to determine the diagnostic significance of these baseline parameters in terms of determining the risk of ST among adult patients with PCI.  We statistically evaluated 18 baseline characteristics of more than 15,500 PCI patients to delineate their stent thrombosis attribution. We included a number of articles focusing on baseline parameters in-stent thrombosis-related PCI scenarios. We explored the articles of interest based on inclusion/exclusion parameters across PubMed, JSTOR, Cochrane library, Google Scholar, and Embase. Medical subject headings (MeSH) words included "stent thrombosis," "percutaneous coronary intervention," and "coronary stenting." We extracted the research articles published between 2005 and 2021 on April 20, 2021. The included studies also focused on procedures and clinical factors concerning their association with PCI-related ST. Our findings ruled out the progression of abnormal left ventricular ejection fraction (LVEF)-related stent thrombosis in PCI patients (odds ratio {OR}: 9.68, 95% CI: 1.88-49.90, p=0.007). We found an insignificant clinical correlation between stent thrombosis and PCI in the setting of acute coronary syndrome (ACS). Our study outcomes further revealed the absence of stent thrombosis in PCI patients with antiplatelet prescription (OR: 32.42, 95% CI: 21.28-49.39). The findings affirmed the absence of ST in PCI patients receiving aspirin therapy (OR: 32.77, 95% CI: 18.73-57.34; OR: 4.59, 95% CI: 1.97-10.73). The majority of the included studies negated the clinical correlation of stent thrombosis with diabetes mellitus in the setting of PCI (OR: 0.49, 95% CI: 0.06-3.78). Our study did not reveal statistically significant results based on stent thrombosis in PCI patients with drug-eluting stents (OR: 2.91, 95% CI: 0.35-24.49). The findings also did not reveal the impact of cardiac biomarker elevation on stent thrombosis in PCI patients (OR: 8.42, 95% CI: 2.54-27.98, p=0.0005). Eight studies revealed a statistically insignificant correlation between myocardial infarction and stent thrombosis in PCI scenarios (OR: 2.69, 95% CI: 0.89-8.11, p=0.08). The clinical correlation between PCI and stent thrombosis/major bleeding in the setting of hypertension also proved statistically insignificant at 0.67 (OR: 1.31, 95% CI: 0.38-4.51, p=0.97). The study findings did not correlate mean body mass index and multivessel coronary artery disease with ST in PCI scenarios (OR: 1.98, 95% CI: 0.02-239.58, p=0.78; OR: 1.09, 95% CI: 0.58-2.04, p=0.80). Only two studies revealed statistically significant results confirming stent thrombosis in PCI patients with a prior history of PCI (OR: 0.49, 95% CI: 0.23-1.06; OR: 0.33, 95% CI: 0.02-5.59; p=0.03). Our findings question the clinical significance of baseline characteristics in terms of predicting stent thrombosis in PCI patients. The results support the requirement of future studies to investigate complex interactions between procedural, medicinal, genetic, and patient-related factors contributing to the development of stent thrombosis in PCI patients.

Comparative Assessment of the Long-Term Efficacy of Home-Based Versus Center-Based Cardiac Rehabilitation.

Cardiac rehabilitation programs support the health, wellness, and recovery of patients with cardiovascular conditions. This systematic review attempts to expand these findings while analyzing the latest randomized controlled trials (RCTs) focusing on the long-term advantages of home/center-based cardiac rehabilitation interventions. This study also comparatively analyzes the benefits of opting for home-based cardiac rehabilitation instead of center-based measures to improve the long-term clinical outcomes of cardiac patients. We extracted and analyzed 10 studies (based on 1,549 cardiac patients) concerning the therapeutic efficacy of center/home-based cardiac rehabilitation interventions. The included studies complied with the year range of 2000-2021. The risk of bias assessment was undertaken using the Cochrane Risk-of-Bias tool to evaluate random sequence generation, allocation concealment, blinding of subjects, outcome data completeness, and selective reporting patterns concerning the included RCTs. The findings of our systematic review confirmed the capacity of a home-based cardiac rehabilitation program to effectively improve left ventricular ejection fraction, health-related quality of life, physical fitness, recovery rate, self-efficacy, sedentary lifestyle, physical activity, satisfaction level, functional capacity, social support, and hemodynamic parameters of patients with cardiovascular diseases. Home-based cardiac rehabilitation had the potential to minimize the levels of triglycerides, anxiety, depression, waist circumference, and body mass index/weight of cardiac patients. The results of our systematic review affirmed the long-term therapeutic efficacy of a home-based cardiac rehabilitation program compared to a center-based cardiac rehabilitation program for adult cardiac patients.

Predictors of Device-Related Thrombus Following Percutaneous Left Atrial Appendage Occlusion.

BACKGROUND: Device-related thrombus (DRT) has been considered an Achilles' heel of left atrial appendage occlusion (LAAO). However, data on DRT prediction remain limited. OBJECTIVES: This study constructed a DRT registry via a multicenter collaboration aimed to assess outcomes and predictors of DRT. METHODS: Thirty-seven international centers contributed LAAO cases with and without DRT (device-matched and temporally related to the DRT cases). This study described the management patterns and mid-term outcomes of DRT and assessed patient and procedural predictors of DRT. RESULTS: A total of 711 patients (237 with and 474 without DRT) were included. Follow-up duration was similar in the DRT and no-DRT groups, median 1.8 years (interquartile range: 0.9-3.0 years) versus 1.6 years (interquartile range: 1.0-2.9 years), respectively (P = 0.76). DRTs were detected between days 0 to 45, 45 to 180, 180 to 365, and >365 in 24.9%, 38.8%, 16.0%, and 20.3% of patients. DRT presence was associated with a higher risk of the composite endpoint of death, ischemic stroke, or systemic embolization (HR: 2.37; 95% CI, 1.58-3.56; P < 0.001) driven by ischemic stroke (HR: 3.49; 95% CI: 1.35-9.00; P = 0.01). At last known follow-up, 25.3% of patients had DRT. Discharge medications after LAAO did not have an impact on DRT. Multivariable analysis identified 5 DRT risk factors: hypercoagulability disorder (odds ratio [OR]: 17.50; 95% CI: 3.39-90.45), pericardial effusion (OR: 13.45; 95% CI: 1.46-123.52), renal insufficiency (OR: 4.02; 95% CI: 1.22-13.25), implantation depth >10 mm from the pulmonary vein limbus (OR: 2.41; 95% CI: 1.57-3.69), and non-paroxysmal atrial fibrillation (OR: 1.90; 95% CI: 1.22-2.97). Following conversion to risk factor points, patients with ≥2 risk points for DRT had a 2.1-fold increased risk of DRT compared with those without any risk factors. CONCLUSIONS: DRT after LAAO is associated with ischemic events. Patient- and procedure-specific factors are associated with the risk of DRT and may aid in risk stratification of patients referred for LAAO.