Intracardiac echography for left atrial appendage closure: A step-by-step tutorial.

OBJECTIVES: We sought to provide a practical educational tool for the utilization of intracardiac echography (ICE) in the left atrium for the percutaneous closure of the left atrial appendage (LAA). BACKGROUND: Although transesophageal echocardiography (TEE) is the gold-standard imaging technique for LAA closure, ICE is stepping in to support noncoronary cardiology interventions by improving workflow and case turnover and may be more adequate for frail patients with significant and multiple comorbidities. METHODS: This article discusses the utility of ICE for LAA closure, its advantages compared to TEE, contraindications to TEE use and offers an extensive illustration of the main steps of the procedure. CONCLUSIONS: The use of ICE in the left atrium allows a feasible guidance of all steps of the percutaneous closure of LAA.

Cardiovascular risk assessment of pulmonary embolism with the GRACE risk score.

Despite the existence of several risk scores, the accurate prediction of the prognosis in pulmonary embolism (PE) remains a challenge. The Global Registry of Acute Coronary Events (GRACE) risk score has a high diagnostic performance for adverse outcomes in acute coronary syndrome. We aimed to assess the applicability and extend the use of the GRACE risk score to PE. A case-control study of 206 consecutive patients admitted with PE was performed. The GRACE, Geneva, Simplified Pulmonary Embolism Severity Index, Shock Index, and European Society of Cardiology risk scores were tested for the prediction of the primary end point: all-cause 30-day mortality. Comparisons between GRACE and the other risk scores were performed using receiver operating characteristic area under the curve and the integrated discrimination improvement index. All-cause 30-day mortality was observed in 18.9% of the patients. Unlike the other classifications, no adverse outcomes were observed in patients classified as low risk using the GRACE risk score (100% negative predictive value for GRACE risk score ≤113). The GRACE score showed greater discriminative performance than the Geneva score (area under the curve 0.623, 95% confidence interval [CI] 0.53 to 0.71), Shock Index (area under the curve 0.639, 95% CI 0.55 to 0.73), European Society of Cardiology (area under the curve 0.662, 95% CI 0.57 to 0.76), and Simplified Pulmonary Embolism Severity Index (area under the curve 0.705, 95% CI 0.61 to 0.80), although statistical significance was not reached. The integrated discrimination improvement index suggested a more appropriate risk classification with the GRACE score. In conclusion, our results have demonstrated that the GRACE risk score can accurately predict 30-day mortality in patients admitted for acute PE. Compared to previously proposed PE prediction rules, the GRACE risk score presented improved overall risk classification.

Perforation of the right ventricle during cardiac resynchronisation therapy upgrade not related to a coexisting persistent left superior vena cava.

Right ventricle (RV) perforation is a complication that may arise during device implants. We present the case of a patient undergoing cardiac resynchronisation therapy upgrade that was complicated with an RV perforation. The lead was successfully repositioned with a good final outcome. Despite being uncommon, persistence of the left superior vena cava is the most frequent venous cardiac anomaly and may pose challenges during the implant procedure, namely when the right superior vena cava (RSVC) is absent. Still, in this patient it was not related to the event, as the leads were advanced through the RSVC.

Corrected ASD: case closed?

Ellis-van Creveld syndrome (EvC) is a rare autosomal recessive chondroectodermal dysplasia, associated with mutations in the EVC1 and EVC2 genes (4p16). The management of EvC is multidisciplinary, and early diagnosis is of the utmost importance for efficient and timely treatment. The main prognostic determinant is presence of a heart defect. The authors describe the case of a 42-year-old man referred to our outpatient cardiology clinic, following surgical repair of an atrial septal defect. He had presented to different medical specialties on numerous occasions since childhood, but remained without a clear diagnosis for more than 40 years. This case reinforces the need for a holistic view when assessing a patient with congenital heart disease. Moreover, this illustrates the importance of communication and discussion between different medical specialties.