Percutaneous left atrial appendage occlusion in atrial fibrillation patients with a contraindication to oral anticoagulation: a focused review.

Stroke is the most feared complication of atrial fibrillation (AF). Although oral anticoagulation with non-vitamin K antagonist and non-vitamin K antagonist oral anticoagulants (NOACs) have been established to significantly reduce risk of stroke, real-world use of these agents are often suboptimal due to concerns for adverse events including bleeding from both patients and clinicians. Particularly in patients with previous serious bleeding, oral anticoagulation may be contraindicated. Left atrial appendage occlusion (LAAO), mechanically targeting the source of most of the thrombi in AF, holds an immense potential as an alternative to OAC in management of stroke prophylaxis. In this focused review, we describe the available evidence of various LAAO devices, detailing data regarding their use in patients with a contraindication for oral anticoagulation. Although some questions of safety and appropriate use of these new devices in patients who cannot tolerate anticoagulation remain, LAAO devices offer a significant step forward in the management of patients with AF, including those patients who may not be able to be prescribed OAC at all. Future studies involving patients fully contraindicated to OAC are warranted in the era of LAAO devices for stroke risk reduction.

Reasons for and predictors of acute hospitalization versus elective outpatient implantable cardioverter-defibrillator implantation and subsequent differential clinical outcomes.

BACKGROUND: Implantable cardioverter-defibrillator (ICD) implantation is often an elective outpatient procedure, but previous studies have shown that approximately 30% are performed during acute hospitalizations. PURPOSE: This study aims to identify predictors of acute hospitalization versus elective outpatient ICD implantation and evaluate differential clinical outcomes. METHODS: We studied 327 first-time ICD recipients between 2011 and 2015. All patients receiving a primary prevention ICD were optimized on guideline directed medical therapy (GDMT) prior to consideration for device implantation. Using multivariate logistic regression, we examined predictors of ICD implantation during acute hospitalization. Cox proportional hazard regression was used adjusting for patient characteristics to examine associations with clinical outcomes including complications, device therapy, heart failure re-admission, and death. RESULTS: Of all patients, 132 (40.3%) underwent ICD implantation during acute hospitalization, most frequently performed for secondary prevention (n = 76, 57.6%). The most common reason for acute hospitalization ICD implantation in primary prevention patients was an indication for pacing (n = 20, 35.7%). In multivariable adjusted models, secondary prevention indication, non-single chamber device, NYHA class IV symptoms, lower diastolic blood pressure, higher BUN, and lower hemoglobin were significant predictors of ICD implantation during an acute hospitalization. In univariate analysis, acute hospitalization ICD implantation was associated with a higher risk of heart failure re-admission (HR = 1.6, 95% CI 1.1-2.4) and mortality (HR = 3.0, 95% CI 1.1-8.0) but no difference in risk of ICD therapy (HR = 1.4, 95% CI 0.9-2.3) or adverse events (HR = 1.1, 95% CI 0.6-2.1). After multivariable adjustment for potential confounders, all outcomes were no different between acute hospitalization versus elective outpatient ICD recipients. CONCLUSIONS: Among first-time ICD recipients, specific clinical characteristics predicted acute hospitalization ICD implantation. After adjustment for potential confounders, acute hospitalization ICD implantation was not associated with increased risk of morbidity or mortality.

Angiographic characteristics of definite stent thrombosis: role of thrombus grade, collaterals, epicardial coronary flow, and myocardial perfusion.

OBJECTIVES: To characterize the prevalence of thrombus burden, collateral vessels to the infarct-related artery, epicardial coronary artery flow, and myocardial perfusion in patients with angiographically confirmed definite stent thrombosis (ST), and to define their relationship with associated treatments and outcomes. BACKGROUND: Angiographic characteristics of ST are not well defined. METHODS: All cases of angiographically determined ST at five academic hospitals from 2005 to 2012 were reviewed. Demographic, procedural, and angiographic characteristics were recorded. In-hospital and 1-year follow-up data were obtained. RESULTS: Among 205 cases of angiographic definite ST (60 ± 8 years; 87% male), the majority presented with late/very late ST (69%) and STEMI (66%). High-risk angiographic findings at presentation included thrombus grade 4-5 (87%), absence of collateral vessels (76%), and reduced initial TIMI 3 flow (90%). Final TIMI 3 flow was achieved in 90% of patients and was associated with greater use of aspiration thrombectomy (60% vs. 25%; P = 0.003), glycoprotein IIb/IIIa inhibitors (80% vs. 30%, P < 0.001), and repeat stenting (67% vs. 10%, P < 0.001). A final myocardial perfusion grade of 2-3 was achieved in 79% of patients and was associated with greater use of aspiration thrombectomy (61% vs. 36%, P = 0.003). After multivariable logistic regression, aspiration thrombectomy (AOR 2.6, 95% CI 1.3-5.2) and implantation of a new stent (AOR 2.1, 95% CI 1.1-4.3) were associated with optimal combined epicardial flow and myocardial perfusion. At 1-year follow-up, significantly lower risk of repeat ST (HR 0.1; 95% CI 0.1,0.2; P < 0.001) among patients with initial TIMI 3 flow at index ST was observed. CONCLUSIONS: The majority of ST patients present with late/very late ST with high thrombus burden and STEMI. Presence of collateral vessels and low thrombus burden is cardioprotective, while reduced initial TIMI flow is associated with larger infarct size and recurrent ST. Aspiration thrombectomy and repeat stenting are associated with improved epicardial coronary artery flow and myocardial perfusion among patients treated for ST. © 2014 Wiley Periodicals, Inc.

Predictors and outcomes of recurrent stent thrombosis: results from a multicenter registry.

OBJECTIVES: The aim of this study was to determine the incidence, predictors, and outcomes of recurrent stent thrombosis (rST). BACKGROUND: Patients who had an initial stent thrombosis (ST) develop may be at high risk of rST. METHODS: We analyzed a multicenter California registry of angiographic definite ST at 5 academic hospitals from 2005 to 2013. A detailed review of the angiogram and procedure was performed of patients with and without rST. RESULTS: Among 221 patients with a median follow-up of 3.3 years, definite or probable rST developed in 29, including 19 with angiographic definite rST. The cumulative hazard ratio (HR) of definite or probable rST was 16% at 1 year and 24% at 5 years, whereas the cumulative HR of angiographic definite rST was 11% at 1 year and 20% at 5 years. Despite similar angiographic results, patients who had rST develop had significantly greater peak creatine kinase at the time of initial ST (mean, 2,655 mg/dl vs. 1,654 mg/dl; p = 0.05) than those without rST. The 3-year rate of major adverse cardiovascular events was 50% for patients with rST compared with 22% for patients with a single ST (p = 0.01). After multivariable adjustment, independent predictors of definite/probable rST were age (HR: 1.4; 95 confidence interval [CI]: 1.1 to 1.8 per 10 years), bifurcation ST (HR: 4.4; 95% CI: 1.8 to 10.9), and proximal vessel diameter (HR: 1.8; 95% CI: 1.1 to 3.2 per millimeter). CONCLUSIONS: rST represents an important cause of long-term morbidity and mortality after an initial ST. Bifurcation ST and a larger proximal reference vessel diameter are independently associated with an increased risk of rST.

Menopausal medicine clinic: an innovative approach to enhancing the effectiveness of medical education.

OBJECTIVE: The purpose of this study was to assess the effectiveness of a menopause clinic to enhance trainees' medical knowledge. METHODS: Between July 2004 and May 2007, 73 resident physicians completed a rotation that included a weekly menopause clinic and completion of a pretest and posttest examination. Each test contained questions on topics covering menopause, perimenopause, and general women's health. At the end of each testing session, a total score and a menopause score were given. RESULTS: The mean (SD) pretest menopause score and total score were 63.2% (13.3%) and 63.7% (11.3%), respectively. The mean posttest increase in the menopause score was 14%, with a median score increase of 10.2% (P < 0.0001). The posttest results ranged from a maximum decrease of 7.8% to a maximum increase of 47.1%. The mean increase in the total score was 13%, with a median increase of 10.7% (P < 0.0001). For the posttest total score, the range went from -7.2% to 39.3%. There was no correlation between the score changes and the number of clinic sessions attended, the resident specialties (obstetrics/gynecology vs non-obstetrics/gynecology), the level of training (postgraduate year 1 or 2), or the examination order (test A vs test B taken first). CONCLUSION: Menopause clinics can add to resident physician knowledge about menopause-related matters. Menopause clinics may help educate future physicians in their ability to care for postmenopausal women.