Feasibility of Left Atrial Appendage Closure in Atrial Fibrillation Patients with a History of Intracranial Bleeding: A Systematic Review of Observational Studies.

BACKGROUND: Left atrial appendage occlusion (LAAO) is performed in patients with nonvalvular atrial fibrillation to reduce the risk of ischemic stroke. The patients with a history of intracranial hemorrhage were excluded from the pioneer randomized controlled trials. The purpose of this systemic review was to evaluate the data from observational studies reporting the efficacy and safety of LAAO in patients with a history of intracranial hemorrhage. METHODS: Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Web of Science Core Collection, Scopus, Global Index Medicus, and ClinicalTrials.gov data sources were utilized for data collection. RESULTS: A total of 12 studies met the inclusion criteria that included seven retrospective observational and five prospective observational studies. A total of seven hundred and twenty-seven patients with a history of intracranial hemorrhage underwent percutaneous left atrial appendage occlusion. There were 11 events of recurrent intracranial hemorrhage, 12 ischemic strokes, 4 transient ischemic attacks, and 26 all-cause deaths. The duration of follow-up varied from 3 months to 3.6 years in the included studies. CONCLUSION: Left atrial appendage occlusion can potentially be an effective and relatively safe treatment option to reduce the risk of ischemic stroke in selected patients with nonvalvular atrial fibrillation patients and history of intracranial hemorrhage. Future prospective randomized trials are needed to validate this approach.

Safety and predictors of next-day discharge after elective transfemoral transcatheter aortic valve replacement.

OBJECTIVES: We sought to determine the predictors of next-day discharge (NDD) for selected patients undergoing elective transfemoral transcatheter aortic valve replacement (TF-TAVR). BACKGROUND: Techniques have rapidly evolved over the last several years to simplify TF-TAVR allowing for a subset of patients to be discharged the next day. METHODS: Baseline and procedural characteristics, in-hospital and 30-day follow-up outcomes, complications and readmission rates of 100 TF-TAVR cases were assessed. Patients selected for NDD all met the following criteria: no procedural complications, same day ambulation, strong family support with home supervision, and access to our valve coordinator post discharge. RESULTS: There were 22 patients in NDD and 78 in later-day discharge (LDD) groups respectively. The mean length of stay was 3.4days for LDD. There were no significant differences in baseline, pre-procedural characteristics, or frailty indices of the two groups. However, there were more baseline oxygen dependent patients in LDD (p=0.004). Procedural characteristics included more balloon expandable valves (p=0.005), less fluoroscopy time (p=0.008), and higher use of moderate sedation (p=0.0001) in NDD group. There were more minor vascular complications (p=0.04) and new permanent pacemaker implantations (p=0.016) in the LDD group. There were no vascular complications, stroke or blood transfusions in the NDD group. The 30-day re-admission and mortality rates were similar in both groups. In logistic analyses only moderate sedation was a strong predictor of next day discharge after TF-TAVR (p=0.003). CONCLUSION: Carefully selected patients without complications following TF-TAVR can be discharged safely the next day.

Utility of indium-111 octreotide to identify a cardiac metastasis of a carcinoid neoplasm.

Carcinoid heart disease is classically described as right-sided valvular pathology. Solid cardiac metastases from carcinoid tumors are seldom reported. A multimodality imaging approach is needed to diagnose and localize this disease. Biopsy remains the gold standard to confirm the diagnosis of carcinoid. Octreotide uptake is characteristic of carcinoid tumor but not myxoma; thus, an indium-111 octreotide scan is very specific for the diagnosis of carcinoid tumor and helps in assessing the extent of carcinoid disease. We present a case in which an indium-111 octreotide scan revealed uptake in three distinct masses in the colon, liver, and right ventricle. The results of the scan were contradictory to the biopsy results, which were diagnostic for hepatic carcinoid and cardiac myxoma.

Transcatheter aortic valve replacement: When invasive surgery is not an option.

Aortic stenosis is a common problem that typically results from calcification and degenerative changes of the aortic valve that occur with advancing age. Because medical therapies have no clinically proven role, the management of severe aortic stenosis has primarily been surgical. For patients who are too high-risk for surgical aortic valve repair, transcatheter aortic valve repair (TAVR), approved by the FDA in 2011, may be an option. This article outlines what clinicians need to know about TAVR.

Percutaneous coronary intervention and the management of acute coronary syndromes in patients with von Willebrand disease.

BACKGROUND: Von Willebrand disease (vWD) results from quantitative or qualitative deficiency of von Willebrand factor (vWF). The occurrence of myocardial infarction is very rare in patients with vWD. A few case reports of acute coronary syndrome (ACS) in vWD patients are present in the literature, but no definite management recommendations are available for such patients. CASE REPORT: We report a case of successful percutaneous coronary intervention (PCI) with bare-metal stent (BMS) implantation in a 46-year-old woman with type 1 vWD and history of coronary artery disease (CAD). She received periprocedural dual-antiplatelet therapy for 2 weeks and then continued aspirin without any bleeding complications. MANAGEMENT PROPOSAL: The optimal management of patients with vWD and ACS is complex and presents a therapeutic challenge. We propose that dual-antiplatelet therapy can be used safely in most vWD patients presenting with ACS as most of them are type 1 vWD. PCI with BMS can be done safely. Long-term management of these patients requires a systemic approach including hematological consultation, ascertaining vWF levels, as well as patient education and close outpatient follow-up.

Circumferential strut fracture as a mechanism of "crush" bifurcation restenosis.

The "Crush" procedure is a 2-stent technique for the treatment of bifurcation lesions with greater rates of in-stent restenosis than the Culotte technique. In conclusion, we report a possible mechanism for this discrepancy in the case of severe Crush stent fracture with associated focal restenosis identified by postmortem microcomputed tomography and histologic examination.

Iatrogenic hepatic pneumovenogram.

Accidental air entry during central venous catheterization is a preventable iatrogenic complication that can cause venous air embolism (VAE). Many cases of VAE are subclinical with no adverse outcome and thus go unreported. Usually, when symptoms are present, they are nonspecific, and a high index of clinical suspicion of possible VAE is required to prompt investigations and initiate appropriate therapy. Occasionally large embolism can lead to life-threatening acute cor pulmonale, asystole, sudden death, and arterial air embolism in the presence of shunt or patent foramen ovale. This paper discusses VAE during emergency central line placement and the diagnostic dilemma that it can be created in critically ill patients. All necessary precautions have to be strictly followed to prevent this iatrogenic complication.