Left atrial appendage exclusion in atrial fibrillation.

Although oral anticoagulants (OACs) are first-line therapy for stroke prevention in patients with atrial fibrillation (AF), some patients cannot be treated with OACs due to absolute or relative contraindications. Left atrial appendage (LAA) exclusion techniques have been developed over the years as a therapeutic alternative for stroke prevention. In this paper, we review the evolution of surgical techniques, employed as an adjunct to cardiac surgery or as a stand-alone procedure, as well as the recently introduced and widely utilized percutaneous LAA occlusion techniques. Until recently, data on surgical LAAO were limited and based on non-randomized studies. We focus on recently published randomized data which strongly support an add-on surgical LAAO in eligible patients during cardiac surgery and could potentially change current practice guidelines. In recent years, the trans-catheter techniques for LAA occlusion have emerged as another, less invasive alternative for patients who cannot tolerate oral anticoagulation. We review the growing body of evidence from prospective studies and registries, focusing on the two systems which are in widespread clinical use nowadays: the Watchman and Amulet type devices. These data show favorable results for both Watchman and Amulet devices, setting them as an important tool in our arsenal for stroke reduction in AF patients, especially in those who have contraindications for OACs. A better understanding of the different therapeutic alternatives, their specific benefits, and downfalls in different patient populations can guide us in tailoring the optimal therapeutic approach for stroke reduction in our AF patients.

Long-Term Prognosis in Young Patients with Acute Coronary Syndrome Treated with Percutaneous Coronary Intervention.

BACKGROUND: Acute coronary syndrome (ACS) at a young age is uncommon. Limited data regarding the long-term follow-up and prognosis in this population are available. Our objectives were to evaluate the long-term clinical outcomes of patients presenting with ACS at a young age and to assess factors that predict long-term prognosis. METHODS: A retrospective analysis of consecutive young patients (male below 40 and female below 50 years old) that were admitted with ACS and underwent percutaneous coronary intervention (PCI) between the years 1997 and 2009. Demographics, clinical characteristics, and clinical outcomes including major cardiovascular (CV) events and mortality were analyzed. Multivariable cox proportional hazard model was performed to identify predictors of long-term prognosis. RESULTS: One-hundred sixty-five patients were included with a mean follow-up of 9.1±4.6 years. Most patients were men (88%), and mean age (years) was 36.8±4.2. During follow-up, 15 (9.1%) died, 98 (59.4%) patients had at least one major CV event, 22 (13.3%) patients had more than two CV events, and the mean number of recurrent CV events was 1.4±1.48 events per patient. In multivariate analysis, the strongest predictors of major CV events and/or mortality were coronary intervention without stent insertion (HR1.77; 95% CI 1.09-2.9), LAD artery involvement (HR 1.59; 95% CI 1.04-2.44) and hypertension (HR 1.6; 95% CI 1.0-2.6). CONCLUSION: Patients with ACS in young age are at high risk for major CV and/or mortality in long-term follow-up with a high rate of recurrent CV events. Close follow-up and risk factor management for secondary prevention have a major role, particularly in this population.

Influenza Vaccination and Outcome in Heart Failure.

Influenza virus infection is associated with significant morbidity and mortality in patients with chronic diseases including heart failure (HF). Annual influenza vaccination is recommended to prevent infection during the winter months. Data regarding its clinical benefit in HF patients are sparse. The purpose of the study was to evaluate the effect of influenza vaccination on clinical outcome in patients with HF. Consecutive patients with HF at a health maintenance organization were evaluated for influenza vaccination status during the winter season of 2017/2018 and its association with cardiac-related hospitalizations and death during 1-year after vaccination. The study cohort included 6,435 HF patients. A total of 4,440 patient were vaccinated during the winter season (69% of the HF cohort). The vast majority (96%) were vaccinated before the winter months (September to November). Patients vaccinated were older patients with more co-morbidities. Cox regression analysis after adjustment for clinically significant predictors demonstrated that vaccination was associated with reduced mortality (hazard ratio [HR] 0.77, 95% confidence interval [CI] 0.65 to 0.91, p <0.01) as well as reduced death and cardiovascular hospitalizations (HR 0.83 95% CI 0.76 to 0.90, p <0.001). Adjustment for drug therapy demonstrated a similar result with improved outcome with influenza vaccine. Propensity score matched control analysis demonstrated that vaccination was associated with improved survival (HR 0.80, 95% CI 0.67 to 0.95, p <0.01) and reduced death and cardiovascular hospitalizations (HR 0.86, 95% CI 0.79 to 0.94, p <0.001). In conclusion, Influenza vaccination in patients with HF was associated with improved clinical outcome including improved survival and reduced death and hospitalizations.

Low serum albumin: A significant predictor of reduced survival in patients with chronic heart failure.

BACKGROUND: Low serum albumin is common in patients with chronic heart failure (HF). HYPOTHESIS: Albumin may have an impact on clinical outcome in HF. We evaluated the effect of albumin levels on clinical outcome in a real-world cohort of patients with HF. METHODS: All patients with HF at a health maintenance organization were followed for cardiac-related hospitalizations and death. RESULTS: A total of 5779 HF patients were included in the study; mean follow-up was 576 days; median serum albumin was 4.0 g/dL (interquartile range 3.7-4.2), and 12% of the patients had hypoalbuminemia (albumin<3.5 g/dL). Low albumin was associated with increasing age, higher urea and C-reactive protein, lower sodium, hemoglobin, iron, less treatment with angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, reduced right ventricular function, and pulmonary hypertension. Cox regression analysis after adjustment for significant predictors demonstrated that decreasing quartiles of albumin was significantly associated with mortality: Lowest quartile compared to highest: hazard ratio (HR) 5.74, 95% confidence interval (CI) 4.08 to 8.07, P < 0.001. Cox regression analysis of albumin as a continuous parameter using restricted cubic splines after adjustment for significant parameters demonstrated that reduced albumin levels were directly associated with increased mortality (P < 0.001 for the adjusted model). Decreasing quartiles of albumin were also a significant predictor of increased cardiac-related hospitalizations. A decrease in albumin on follow-up was an independent predictor of increased mortality by Cox regression analysis: HR 2.58, 95% CI 2.12 to 3.14, P < 0.001. CONCLUSIONS: Low albumin provides important information regarding several detrimental processes in HF and is a significant predictor of a worse outcome in these patients.