A novel clock-face method for characterizing peridevice leaks after left atrial appendage occlusion.

OBJECTIVES: To propose a novel method for mapping leak location and frequency to a clock-face representation of the left atrial appendage (LAA) ostium. BACKGROUND: LAA occlusion with the Watchman device (WD) is an established therapy to reduce thromboembolic events in patients with atrial fibrillation (AF) and intolerance to long-term oral anticoagulation. Postimplantation leaks are known sequelae, but leak locations and characteristics are poorly described. METHODS: We retrospectively reviewed 101 consecutive WD implants from April 2015 to February 2018. Leak locations from 6-week post-implant transesophageal echocardiograms were mapped to a clock-face representation of the LAA ostium: 12:00 as cranial near the limbus, 3:00 as anterior toward the pulmonary artery, 6:00 as caudal near the mitral annulus, and 9:00 as posterior. Patient demographics, LAA dimensions, and procedural characteristics were also collected. RESULTS: Thirty-four patients had ≥1 leak totaling 45 leaks at 6-week follow-up. Baseline patient demographics showed a mean age 77, CHA2 DS2 VASc 4.69, and 64% of patients with permanent AF. No patient had a detectable leak at the time of implant. At 6 weeks, mean leak size was 2.67 ± 0.89 mm with no leak over 5 mm (largest 4.60 mm). Most leaks occurred along the posterior 6:00-12:00 segment (39/45) and the 6:00-9:00 quadrant (16/45). CONCLUSION: Six-week post-WD implant leaks localize to the posterior LAA ostium. This could result from the elliptical LAA orifice, differential LAA tissue composition, or implantation technique. This study provides a novel method for describing the location of post-implant leaks and serves as the basis for further investigations.

Relationship Between Psychosocial Stressors and Atrial Fibrillation in Women >45 Years of Age.

Negative emotions have been linked to the development of atrial fibrillation (AF), and positive effect may be protective. However, there are few large-scale studies examining the association between psychosocial stressors that may provoke these emotions and the occurrence of AF. We examined the cross-sectional relation between psychosocial stress and AF in 24,809 women participating in the Women's Health Study. Participants answered questions about work stress (e.g., excessive work, conflicting demands), work-family spillover stress (e.g., too stressed after work to participate in activities with family), financial stress (e.g., difficulty paying monthly bills), traumatic life events (e.g., death of a child), everyday discrimination (e.g., less respect, poor service), intimate partner stress (e.g., how judgmental is your spouse/partner), neighborhood stress (e.g., neighborhood safety, trust), negative life events within 5 years (e.g., life threatening illness, legal problems), and cumulative stress (a weighted measure of the stress domains). The prevalence of confirmed AF was 3.84% (N = 953) and risk factor profiles differed by AF status. Women with AF reported significantly higher financial stress, traumatic life events, and neighborhood stress (peach < 0.05). Only traumatic life events (odds ratio 1.37, 95% confidence interval 1.19 to 1.59) was significantly associated with AF after adjustment for cardiovascular risk factors, socioeconomic and psychosocial status. These large-scale cross-sectional data thus indicate a potential relationship between traumatic life events and AF in older women.

Interval From Imaging to Treatment Delivery in the Radiation Surgery Age: How Long Is Too Long?

PURPOSE: The purpose of this study was to evaluate workflow and patient outcomes related to frameless stereotactic radiation surgery (SRS) for brain metastases. METHODS AND MATERIALS: We reviewed all treatment demographics, clinical outcomes, and workflow timing, including time from magnetic resonance imaging (MRI), computed tomography (CT) simulation, insurance authorization, and consultation to the start of SRS for brain metastases. RESULTS: A total of 82 patients with 151 brain metastases treated with SRS were evaluated. The median times from consultation, insurance authorization, CT simulation, and MRI for treatment planning were 15, 7, 6, and 11 days to SRS. Local freedom from progression (LFFP) was lower in metastases with MRI ≥ 14 days before treatment (P = .0003, log rank). The 6- and 12-month LFFP rate were 95% and 75% for metastasis with interval of <14 days from MRI to treatment compared to 56% and 34% for metastases with MRI ≥ 14 days before treatment. On multivariate analysis, LFFP remained significantly lower for lesions with MRI ≥ 14 days at SRS (P = .002, Cox proportional hazards; hazard ratio: 3.4, 95% confidence interval: 1.6-7.3). CONCLUSIONS: Delay from MRI to SRS treatment delivery for brain metastases appears to reduce local control. Future studies should monitor the timing from imaging acquisition to treatment delivery. Our experience suggests that the time from MRI to treatment should be <14 days.