Meta-analysis of safety and efficacy of oral anticoagulants in patients requiring catheter ablation for atrial fibrillation.

BACKGROUND: The ideal oral anticoagulant agent during catheter ablation (CA) for atrial fibrillation (AF) remained unclear. HYPOTHESIS: Novel oral anticoagulants (NOACs) are safer and effective compared to uninterrupted vitamin K antagonists (U-VKA) among patients requiring CA for AF. METHODS: Four randomized controlled trials (RCTs) and 9 observational studies (OS) were selected using PubMed/Medline, EMBASE and the CENTRAL data bases (Inception-December-2017). Estimates were reported as random effects risk ratio (RR) with 95% confidence interval (CI). The primary safety outcome was major bleeding and main efficacy endpoint was thromboembolism. RESULTS: In RCTs restricted analysis, NOACs significantly reduced the relative risk of major bleeding by 72% compared to U-VKA (RR, 0.28, 95% CI, 0.14-0.58, P < 0.001). This significant effect was not achieved in OS based analysis (RR, 0.86, 95% CI, 0.42-1.78, P = 0.68). In terms of thromboembolism, both anticoagulation strategies were equally effective in analysis of RCTs (RR, 0.28, 95% CI, 0.05-1.70, P = 0.17) or OS (RR, 1.43, 95% CI, 0.46-4.39, P = 0.54). In sensitivity analysis, there was no difference among uninterrupted NOACs (U-NOACs) and U-VKA in terms of major bleeding [(RCTs: RR, 0.33, 95% CI, 0.10-1.06, P = 0.06); (OS: RR, 0.70, 95% CI, 0.28-1.78, P = 0.46)] or thromboembolism [(RCTs: RR, 0.25, 95% CI, 0.03-2.29, P = 0.22); (OS: RR, 0.68, 95% CI, 0.08-5.53, P = 0.72)]. CONCLUSION: NOACs, either interrupted or un-interrupted, are safer and equally effective drugs compared to U-VKA in AF patients requiring CA.

Coronary artery perforation complicated by recurrent cardiac tamponade: a case illustration and review.

Coronary artery perforation during percutaneous intervention is a rare but potentially life threatening complication. The treatment of coronary perforation can be challenging in view of potential life threatening consequences such as cardiac tamponade or myocardial infarction. Presented is a clinical course of a 69year-old female who developed cardiac tamponade as a result of presumed wire related perforation of the posterolateral branch of the right coronary artery. Her clinical course was further complicated by recurrent tamponade, atrial fibrillation, stress induced cardiomyopathy, heparin induced thrombocytopenia and cardiogenic pulmonary edema. Based on review of the medical literature a treatment algorithm for wire perforation is suggested.

Thrombus or vegetation: A mystery causing ST elevation myocardial infarction with infective endocarditis of mechanical aortic valve.

Acute myocardial infarction (MI) in the setting of infective endocarditis (IE) of mechanical cardiac valve is a rare phenomenon. The most challenging aspect is the recognition between septic embolus versus thromboembolism from prosthesis in the setting of sub-therapeutic INR especially when the coronary vasculature is normal and etiology is not clear. We are presenting a case of 56-year-old patient who developed ST elevation MI during treatment of IE of mechanical aortic valve. Cardiac catheterization showed a very subtle blockade at most distal end of LAD therefore percutaneous coronary intervention (PCI) could not be carried out. Given the lack of clear etiology between septic embolus versus prosthesis associated thromboembolism, we opted for a successful conservative approach.