Percutaneous Left Atrial Appendage Occlusion: What the Practising Physician Should Know.

Non-valvular AF is a common clinical condition associated with an increased risk of thromboembolic complications. As a consequence, oral anticoagulant therapy (OAT) is the cornerstone of non-valvular AF management. Despite the well-established efficacy of OAT, many patients cannot receive this preventive therapy due to bleeding or a high risk of bleeding. The fact that more than 90% of thrombi are formed in the left atrial appendage has led to the development of alternative methods to reduce the embolic risk. Left atrial appendage occlusion (LAAO) is a non-pharmacological option for preventing cardioembolic events in patients with non-valvular AF with a contraindication to OAT. The demand for LAAO procedures is growing exponentially and clinicians should consider this alternative option when managing patients with a contraindication to OAT. This review summarises the current thinking about LAAO.

Some good reasons to proceed with the occlusion of the auricle.

Atrial fibrillation (AF) is the most common arrhythmia. The most fearful complication of AF is represented by cardio-embolic stroke and 30% of ischaemic strokes are attributable to AF. The prevention of cardio-embolic risk is therefore based on oral anticoagulant therapy (OAT). Some categories of patients do not benefit from OAT. These are patients at increased bleeding risk and with varying degrees of contraindication to long-term anticoagulant therapy. On the opposite are those patients who develop an embolic event related to AF despite a well-conducted OAT. These types of patients benefit from an interventional approach, percutaneous closure of the left auricle (LAAO), aimed at eliminating what is the primary source of AF-related thrombo-embolism, precisely the left auricle. Percutaneous closure of the left auricle has proven to be an effective and safe procedure, significantly reducing the bleeding risks of patients who, after the procedure, will no longer have to take OAT. Furthermore, it has been shown to be effective in reducing cardio-embolic risk. Uncertainty still remains as to what is the optimal antithrombotic therapy after LAAO. In any case, LAAO represents a valid alternative to OAT for those patients in whom it is contraindicated or ineffective.

Stent Dislodgment and Retrieval During Percutaneous Coronary Intervention.

During PCI, stent entrapment and dislodgment in the coronary arteries is a rare but potentially fatal complication that can lead to emergent cardiac surgery. Percutaneous stent retrieval is an alternative way to solve this challenging complication while avoiding cardiac surgery.

Allergic Myocardial Infarction: An Unusual Cause of Stent Thrombosis.

Our case confirms that an allergic insult can cause an acute myocardial infarction in a stable coronary disease setting. It also suggests that type 3 Kounis syndrome must be suspected in cases of apparently unexplained "very late" stent thrombosis.

Predictors of inappropriate shock in Brugada syndrome patients with a subcutaneous implantable cardiac defibrillator.

BACKGROUND: Subcutaneous implantable cardioverter defibrillators (S-ICDs) avoid complications secondary to transvenous leads, but inappropriate shocks (ISs) are frequent. Furthermore, IS data from patients with Brugada syndrome (BrS) with an S-ICD are scarce. OBJECTIVE: We aimed to establish the frequency and predictors of IS in this population. METHODS: We analyzed the clinical and electrocardiographic characteristics, automated screening test data, device programming, and IS occurrence in adult patients with BrS with an S-ICD. RESULTS: Thirty-nine patients were enrolled (69% male, mean age at diagnosis 46 ± 13 years, mean age at implantation 48 ± 13 years). During a mean follow-up of 26 ± 21 months, 18% patients experienced IS. Patients with IS were younger at the time of diagnosis (36 ± 8 vs. 48 ± 13 years, p = .018) and S-ICD implantation (38 ± 9 vs. 50 ± 23 years, p = .019) and presented with spontaneous type 1 Brugada electrocardiogram pattern more frequently at diagnosis or during follow-up (71% vs. 25%, p = .018). During automated screening tests, patients with IS showed lower QRS voltage in the primary vector in the supine position (0.58 ± 0.26 vs. 1.10 ± 0.35 mV, p = .011) and lower defibrillator automated screening score in the primary vector in the supine (123 ± 165 vs. 554 ± 390 mV, p = .005) and standing (162 ± 179 vs. 486 ± 388 mV, p = .038) positions. Age at diagnosis was the only independent predictor of IS (hazard ratio = 0.873, 95% confidence interval: 0.767-0.992, p = .037). CONCLUSION: IS was a frequent complication in patients with BrS with an S-ICD. Younger age was independently associated with IS. A more thorough screening process might help prevent IS in this population.

Vascular Assisted Tracking for Challenging Transradial Percutaneous Intervention.

BACKGROUND: TRA is recommended as the preferred approach to perform coronary angiography and PCI. Despite this, TRA-PCI is burdened by a high access site crossover rate. Assisted-tracking techniques (balloon-assisted tracking and pigtail-assisted tracking) have showed to solve some of the issues related with challenging TRA procedures, but few data exist about procedural outcomes. Aim of the study was to evaluate the efficacy and safety of the assisted-tracking (AsTra) techniques during transradial (TRA) percutaneous coronary intervention (PCI). METHODS: From January 2016 to December 2019, 1682 TRA-PCI procedures were performed. Starting from January 2018, AsTra techniques were adopted in 72 cases of challenging TRA-PCI, and clinical data, procedural results and 30 days follow-up data were retrospectively collected. Because not all interventionalists used AsTra techniques, we had the opportunity to evaluate if their utilization influenced TRA-PCI rates. To this purpose, we identified two groups of interventionalists and tested the hypothesis that these techniques could lead to a significant improvement in TRA-PCI rates. RESULTS: Between January 2016 and December 2019, TRA-PCI rates increased from 68.5% to 95%. The TRA-PCI success rate increased significantly for interventionalists who adopted assisted-tracking techniques (p-value < 0.0001 for year 2019; p-value = 0.003 for year 2018). CONCLUSIONS: Assisted-tracking techniques appear to be effective in increasing TRA-PCI rates. Their use is associated with low complication and low access crossover rates.

Left atrial appendage occlusion in atrial fibrillation patients with previous intracranial bleeding: A national multicenter study.

BACKGROUND: Intracranial hemorrhage (ICH) represents the most serious complication of oral anticoagulant therapy (OAT) in patients with atrial fibrillation (AF), and AF patients with previous ICH are a challenge for clinicians. Left atrial appendage (LAA) occlusion has emerged as an alternative option for AF patients not suitable for OAT. Currently, few data are available on long term outcomes after LAA occlusion in this population. We evaluated the safety and efficacy of LAA occlusion in a cohort of patients with AF and previous ICH. METHODS: This is a multicenter, observational, retrospective study involving 5 LAA occlusion centers in Italy. It includes all consecutive patients (n = 120) with previous ICH who underwent LAA occlusion for nonvalvular AF and high thromboembolic risk. Procedural outcomes, post-procedural therapies and 12-months follow-up data were analyzed. RESULTS: The device was successfully implanted in 100% of cases, with a 6% of major peri-procedural complications. 59% had a prior ICH during OAT. The sample had a high risk of stroke (5.18%/year) and bleeding (6.62%/year). 30% were discharged on single and 54.2% on dual antiplatelet therapy. The expected annual risk for thromboembolism was 5.1%. Excluding periprocedural ischemic complications, the stroke annual rate was 1.8%. The expected annual risk of bleeding was 6.7%. The observed annual bleeding rate was 5.45%. CONCLUSIONS: Percutaneous LAA occlusion is an effective option for AF patients and previous intracranial hemorrhage. After LAA occlusion, a single antiplatelet therapy strategy could be considered for patients with the highest risk of recurrent bleeding.

Conservative Management of Spontaneous Coronary Artery Dissection.

Spontaneous coronary artery dissection (SCAD) is caused by separation of the vessel wall and hematoma development. We demonstrate that SCAD often resolves spontaneously, with an average period of 35 days from the event usually sufficient to demonstrate angiographic healing.

Left Atrial Appendage Occlusion in High Bleeding Risk Patients.

OBJECTIVES: The aim of this study was to investigate the outcomes of left atrial appendage occlusion (LAAO) in high bleeding risk patients suffering atrial fibrillation (AF) and to analyze the different antithrombotic therapies following the intervention. BACKGROUND METHODS: This monocentric study included 68 patients with nonvalvular AF with an absolute contraindication to OAT or at high bleeding risk. Follow-up was done with a clinical visit at 3-6-12 months. RESULTS: Successful LAAO was achieved in 67/68 patients. At discharge, 32/68 patients were on dual antiplatelet therapy (APT), 34/68 were without any antithrombotic therapy or with a single antiplatelet drug, and 2/68 were on anticoagulant therapy. At three-month follow-up visit, 73.6% of the patients did not receive dual APT, of whom 14.7% had no thrombotic therapy and 58.9% were on single antiplatelet therapy. During a follow-up of 1.4 ± 0.9 years, 3/62 patients had late adverse effects (2 device-related thrombus without clinical consequences and 1 extracranial bleeding). The device-related thrombosis was not related to the antithrombotic therapy. CONCLUSIONS: LAAO is feasible and safe and prevents stroke in patients with AF with contraindication to oral anticoagulant therapy. After LAAO, single antiplatelet therapy seems to be a safe alternative to dual antiplatelet therapy, especially in patients at high bleeding risk. No benefit has been observed with dual APT.

Rendered OCT Imaging of an Impressive Stent Malapposition in the Left Main Coronary Artery.

This case emphasizes the need to use intravascular imaging to optimize stent implantation in the left main coronary artery. Despite recommendations, intravascular imaging is still widely under-utilized. The recently developed stent apposition OCT software (OPTIS Stent Optimization Software; Abbott Vascular) confirmed its usefulness in optimizing stent implantation in unprotected left main PCI.

Anomalous Origin of Right Coronary Artery From Left Sinus of Valsalva.

We present the imaging series of a 52-year-old woman with no cardiovascular risk factors who was admitted for acute coronary syndrome without persistent ST elevation (NSTEMI). Coronary angiography and cardiac computed tomography demonstrated anomalous origination of the coronary artery from the opposite sinus (ACAOS), which is an uncommon coronary anomaly; the incidence is about 1.07% in general, and only 0.12%-0.9% in the case of right ACAOS. The clinical consequences can be relevant if the ectopic artery has intramural intussusception or courses between the aorta and pulmonary artery.

[Cerebral amyloid angiopathy and atrial fibrillation: a dangerous union]. / Angiopatia amiloide cerebrale e fibrillazione atriale: un pericoloso connubio.

Intracranial hemorrhage (ICH) is the major complication of oral anticoagulant therapy. Cerebral amyloid angiopathy (CAA) is an age-related disease characterized by the pathological deposition of ß-amyloid protein in leptomeningeal and cortical cerebral vessels. Such vascular alterations expose to the risk of spontaneous vascular rupture. The main clinical manifestations are represented by ICH, cognitive decline and transient focal neurological episodes (TFNE). In the patient subgroup with TFNE, a misdiagnosis with transient ischemic attack may have catastrophic consequences, resulting in a significant increase in the risk of spontaneous ICH within weeks after clinical onset, with potentially devastating consequences if anticoagulant therapy is started.The prevention of bleeding complications related to CAA is based on disease knowledge. This is particularly relevant because non-pharmacological treatment options, including percutaneous left atrial appendage occlusion, are emerging as an alternative to traditional anticoagulant therapies in patients at high bleeding risk.

[Atrial fibrillation in severe and end stage renal disease: from oral anticoagulation therapy to percutaneous left atrial appendage occlusion].

Non-valvular atrial fibrillation (AF) is the most frequent arrhythmia in the general population and its prevalence increases with age. The prevalence and incidence of AF is high in patients with chronic kidney failure (CKD). The most important complication associated with AF, both in the general population and in that with CKD, is thromboembolic stroke. For this reason, in patients with AF, the Guidelines indicate oral anticoagulant therapy (OAT) with vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs) for thromboembolic risk prevention. Patients with severe CKD and, in particular, with end stage renal disease (ESRD) undergoing renal replacement therapy, often have both a high thromboembolic and hemorrhagic risk and therefore present both an indication and a contraindication to OAT. In addition, patients with severe or ESRD were excluded from trials that showed the efficacy of different antithrombotic drugs in patients with AF. Thus there is no evidence of the effectiveness of OAT in this population. This review deals with the issues related to OAT in patients with severe or end stage CKD and the possible use of percutaneous closure of the left auricula (LAAO), recently proposed as an alternative in patients with an absolute contraindication of OAT in this population.

Hidden culprit lesion: beyond coronary angiography.

: Coronary imaging is a useful tool to identify wall vessel disease also in the absence of obstructive stenosis.

Challenging Aorto-Coronary Occlusion: Which Solution?

Aorto-coronary occlusion is a particularly difficult lesion to treat, especially in an emergent setting. To our knowledge, this is the first description of the use of a microcatheter not to support the guidewire, but to open an aorto-coronary calcific occlusion with anterograde approach in an emergent situation.

Nonvalvular atrial fibrillation in high-hemorrhagic-risk patients: state of the art of percutaneous left atrial appendage occlusion.

: Atrial fibrillation is the most common cardiac arrhythmia and its prevalence is constantly increasing. The main complications related to atrial fibrillation are death and major stroke. Oral anticoagulant therapy is the cornerstone of management of atrial fibrillation patients at increased stroke risk. Unfortunately, a significant proportion of patients do not receive adequate anticoagulant therapy due to increased or prohibitive hemorrhagic risk. The observation that most thrombi are generated in the left atrial appendage (LAA) had led to the consideration of surgical or percutaneous occlusion as an alternative. During recent years, the WATCHMAN percutaneous occlusion device has proven to be not inferior to anticoagulant therapy for the prevention of thromboembolic events, with the added benefit of a lower rate of hemorrhagic events. Numerous data showed the same results for the AMPLATZER cardiac plug and Amulet devices. Left atrial appendage occlusion (LAAO) often represents the only therapeutic strategy in this group of patients. We describe the current state of the art of percutaneous LAAO in atrial fibrillation patients with a high hemorrhagic risk.

Percutaneous Management of Left Atrial Appendage Perforation: Keep Calm and Think Fast.

Left atrial appendage (LAA) perforation is a possible complication not only after release of the closure device, but also during the diagnostic phase due to sheath positioning in the LAA. We present an 83-year-old woman with permanent atrial fibrillation and high thromboembolic and bleeding risk who was admitted for elective percutaneous LAA closure. During angiographic study, she suddenly became hypotensive. Heart perforation with leakage of contrast in the pericardial space was evident and imaging confirmed cardiac tamponade. Rapid release of the closure device and pericardial evacuation allowed the operators to successfully manage the cardiac tamponade and avoid a surgical option.