Safety and Feasibility of Same-Day Discharge After Left Atrial Appendage Closure With the WATCHMAN Device.

BACKGROUND: As the use of left atrial appendage closure (LAAC) becomes more widespread, improvements in resource utilization and cost-effectiveness are necessary. Currently, there are limited data on same-day discharge (SDD) after LAAC. We aimed to evaluate the safety and feasibility of SDD versus non-SDD in patients with nonvalvular atrial fibrillation who underwent LAAC. METHODS: We retrospectively studied 211 patients who underwent the WATCHMAN procedure in a tertiary hospital (June 2016 to June 2019). The primary safety outcome was the composite of stroke, systemic embolism, major bleeding requiring transfusion, vascular complications requiring endovascular intervention, or death through 7 days (periprocedural) and 45 days post-procedure. The secondary outcomes were the individual components of the primary outcome and all-cause readmission. We compared the clinical outcomes of patients who had SDD and non-SDD post-procedure. RESULTS: Patients with procedure-related complications on the day of LAAC and patients who were admitted for acute clinical events before LAAC were excluded. One hundred ninety patients were included in the final analysis. Seventy-two of 190 (38%) patients had SDD, and 118 of 190 (62%) had non-SDD. There were no statistically significant differences in the primary safety outcome through 7 days (1.4% versus 5.9%; P=0.26) and 45 days post-procedure (2.8% versus 9.3%; P=0.14) between the two groups. The secondary outcomes were similar in both groups. No patients had device-related thrombus on transesophageal echocardiography at 45 days. Only 1 patient from the non-SDD group had clinically significant peri-device flow (>5 mm) at 45 days. CONCLUSIONS: In a selected cohort of patients who underwent successful elective LAAC with WATCHMAN without same-day procedure-related complications, the primary safety outcome and secondary outcomes through 7 and 45 days post-procedure were similar in the SDD and non-SDD groups. Our findings are hypothesis generating and warrant further investigation in prospective trials.

Absence of left bundle branch block and blood urea nitrogen predict improvement in left ventricular ejection fraction in patients with cardiomyopathy and wearable cardioverter defibrillators.

OBJECTIVE: To identify predictors of left ventricular ejection fraction (LVEF) improvement in patients with newly detected cardiomyopathy using wearable cardioverter defibrillators (WCDs). BACKGROUND: WCDs are useful in preventing sudden cardiac death in patients with reduced LVEF <35% while awaiting implantable cardioverter defibrillator (ICD) placement. In many patients, LVEF improves and an ICD is not indicated. METHODS: Patients who received WCDs from November 2013 to November 2015 were identified and followed over a period of 2 years. Clinical variables were examined. The primary outcome was improvement in LVEF ≥35%. Predictors of outcome were determined using a multivariate logistic regression model. RESULTS: A total of 179 patients were followed. Median age was 65 (interquartile range [IQR]: 56, 73) years, 69.3% were men. Median baseline LVEF was 20% (IQR: 15, 30). LVEF improved ≥35% in 47.5% patients, with patients being younger (62 vs 68.5 years, P = .006), having lower blood urea nitrogen (BUN) (19 vs 24 mg/dL, P = .002), fewer left bundle branch block (LBBB 9.5% vs 25.8%, P = .004), shorter QRS duration (98 vs 112 ms, P < .001), and higher use of angiotensin converting enzyme inhibitors (ACEI)/angiotensin receptor blockers (ARB) (92.9% vs 74.4%, P = .001) compared to those without LVEF improvement. Absence of LBBB (odds ratio [OR] 0.28, 95% confidence interval [CI] 0.11-0.70), lower BUN (OR 0.13, 95% CI 0.02-0.76), and ACEI/ARB use (OR 3.53, 95% CI 1.28-9.69) were identified as independent predictors. Ventricular tachycardia/ventricular fibrillation was observed in three patients, all of whom received successful WCD shocks. CONCLUSION: Absence of LBBB, lower BUN, and ACEI/ARB use predicts LVEF improvement. WCDs help treat arrhythmic events.

Tako-tsubo cardiomyopathy following electroconvulsive therapy.

A 70-year-old woman with extensive psychiatric history, including depression and bipolar disorder, and past medical history of mitral valve prolapse repair (3 years ago) was brought in from the psychiatry ward to the emergency department for evaluation of ECG changes following electroconvulsive therapy (ECT). ECG done after the procedure showed ST elevations in V2-V3 and new T-wave inversions in the precordial leads. Troponin level was 0.23 ng/ml. An echocardiogram revealed apical akinesis with segmental wall motion abnormalities and a decreased ejection fraction of 30-35%. Cardiac catheterization revealed clean coronaries. A repeat echocardiogram 6 weeks after the event showed a normal ejection fraction. A diagnosis of tako-tsubo cardiomyopathy was made. ECT causes a significant increase in bigeminy, trigeminy, and supraventricular tachycardia. ECT is associated with a low mortality rate; in the range of 0.01-0.1% and 75% of these are attributable to cardiovascular causes. To our knowledge, this is the first reported case of tako-tsubo syndrome immediately following electroconvulsive therapy.

Cardiac tamponade caused by fracture and migration of inferior vena cava filter.

A 53-year-old male presented to the emergency room with acute cardiopulmonary compromise. Echocardiography revealed cardiac tamponade. The patient was taken emergently for surgery and a 28 gauge wire of 1.5 cm was retrieved from his right ventricle. A section had fractured from the inferior vena cava (IVC) filter and migrated to the right ventricle, causing perforation and tamponade. Very few cases of fractured IVC filters that have migrated to the heart, and even fewer cases causing cardiac tamponade, have been described. The risk factors that cause migration of IVC filters need to be further elucidated.