Long-Term Efficacy and Safety of Left Atrial Appendage Closure Procedures.

The aim of the present single-center, nonrandomized, retrospective study was to assess the safety and long-term efficacy of percutaneous left atrial appendage closure (LAAC) procedures and to compare the different LAAC devices and therapeutic regimes in this respect.Medical data of 136 patients (pts) (mean age, 72.5 ± 7.6 years; score for atrial fibrillation stroke risk estimation [CHA2DS2-VASc], 4.6 ± 1.6; and score for estimation of major bleeding risk for patients on anticoagulant therapy [HAS-BLED], 2.6 ± 0.9) who underwent percutaneous LAAC procedures in Gottsegen National Cardiovascular Center from January 2010 to January 2020 were analyzed.The rates of outpatient cardiac mortality, ischemic brain event, and major bleeding were 3.8, 1, and 1.9/100 pt years, respectively. The rate of successful device deployment was 96.4%. There was one case of procedural mortality (0.7%), one case of device dislocation (0.7%), one case of ischemic stroke (0.7%), and one case of myocardial infarction (0.7%). Two cases of pericardial tamponades (1.5%) and four cases of major femoral complications (3%) occurred. Although the implantation success of different occluder types was similar, significant differences were found concerning procedural characteristics. Patients on single antiplatelet therapy (SAPT) in the first 3 months after the LAAC procedure did not suffer from stroke or embolic events.The present study confirmed the safety and effectivity of percutaneous LAAC. Robust relative stroke risk reduction and less pronounced but significant bleeding risk reduction were observed. Device implantation success was high. The perioperative complication rate was relatively low. The results of long-term observations regarding ischemic events confirmed the safety of using a simplified antithrombotic regime after LAAC in pts with high bleeding risk.

Prospective evaluation of iatrogenic atrial septal defect after cryoballoon or radiofrequency catheter ablation of atrial fibrillation-"EVITA" study.

PURPOSE: Iatrogenic atrial septal defect (IASD) after catheter ablation (CA) for atrial fibrillation (AF) due to transseptal puncture (TSP) can occur. The aim of this prospective study was to describe the incidence of IASD and to detect any cerebrovascular accident (CVA) after radiofrequency (RF) and cryoballoon (CB) CA. METHODS: Between July 2014 and September 2016, 94 patients (pts) (RF; 48, CB; 46, 30 (31.9%) women, mean age = 60 ± 9.7 years) with paroxysmal AF were enrolled who underwent CA procedure for the first time. During RF ablation a single (n = 30, 62.5%) or double (n = 18, 37.5%) TSP was performed. Transoesophageal echocardiography before the procedure and at the 3-month and 12-month follow-up (FU) was accomplished. During the FU period, we evaluated the occurrence of any postprocedural CVA. RESULTS: At the 3-month FU, IASD was detected in 17/94 (18.1%) pts; in 9/48 (18.8%) pts in the RF while in 8/46 (17.4%) pts in the CB group (p = 0.866), all of them with left-to-right shunt. In the RF group, 6/30 (20%) pts with a single TSP while 3/18 (16.7%) pts in the double TSP group had IASD (p = 0.780). 14/17 (82.4%) IASDs showed high spontaneous closure rate at the 12-month FU. None of the pts died or suffered from CVA. CONCLUSION: Persistent IASD can occur rather frequently following AF CA. No significant difference was observed between the RF and CB techniques concerning the presence of IASD at 3-month. IASDs showed a high spontaneous closure rate. No cerebral thromboembolic event was observed in the 12-month FU period.

Left circumflex coronary artery occlusion due to a left atrial appendage closure device.

Nowadays, percutaneous left atrial appendage (LAA) closure is spreading, and a large number of patients with this procedure have concomitant coronary artery disease. With the presented case it could be concluded that coronary angiography is recommended before LAA closure.

[Percutaneous left atrial appendage closure after resolution of left atrial appendage thrombi with dabigatran]. / Percutan bal pitvari fülcsezárás dabigatrannal való fülcsethrombus feloldását követoen.

The "gold standard" of the prevention of atrial fibrillation related thromboembolic events is anticoagulation therapy with oral vitamin K antagonists. A certain proportion of high-risk patients with atrial fibrillation are not receiving effective antithrombotic therapy because of problems associated with its use. Resolution of subsequent left atrial appendage thrombi is quite a great challenge in patients who are not tolerating "standard" antithrombotic drugs. According to the knowledge of the authors, this is the first report of a patient with non-valvular persistent atrial fibrillation and high stroke risk, who was intolerant to "standard" anticoagulant therapy and had persistent left atrial appendage thrombi following the use of a wide variety of "standard" anticoagulants. Successful resolution of left atrial appendage thrombi with dabigatran and successful percutaneous left atrial appendage closure were performed in this case.

[Right ventricular outflow tract reconstruction in adolescents and adults after previous repair of congenital heart defects]. / A jobbkamra-kifolyási pálya rekonstrukciója elozoleg korrigált veleszületett szívhibák esetén fiatal- és felnottkorban.

UNLABELLED: Due to successful surgical treatment of congenital heart defects in infants and children, the number of patients who reach the adolescent/adult age is continuously increasing. AIMS: The authors sought to identify the short- and medium-term outcomes of reconstruction of right ventricular outflow tract in adolescents and adults who underwent surgical intervention for congenital heart defect in infancy or early childhood. METHODS: Between 2001 and 2012, 48 patients (age: 15-39, mean 21 years) (30 tetralogy of Fallot, 11 pulmonary atresia + ventricular septal defect, 6 transposition of great arteries + ventricular septal defect + left ventricular outflow tract obstruction, and 1 truncus arteriosus) had repeat operation because of right ventricular dysfunction. All patients previously underwent right ventricular outflow tract procedures in early childhood. RESULTS: In 31 patients, the small homograft, and in 9 patients the transannular-paths were replaced for "adult-size" homograft. Bioprosthetic pulmonary valve replacement was performed in pulmonary (6 patients) and homograft annuli (2 patients). In 14 patients, resection of the right ventricular outflow tract aneurism was also necessary to be performed. There was no early and mid-time (10 years) mortality. In 97.5% of patients with homograft-re-implantation, there was no need for repeat intervention for 5 years. CONCLUSIONS: The right ventricular outflow tract restoration in adolescents and adults is an effective procedure. The reconstruction should be performed in early adolescent period to prevent right ventricular dysfunction. The authors prefer using bioprosthetic pulmonary valve replacement in patients with adult-size pulmonary or homograft annulus.

Could successful cryoballoon ablation of paroxysmal atrial fibrillation prevent progressive left atrial remodeling?

BACKGROUND: Radiofrequency catheter ablation of atrial fibrillation (AF) has been proved to be effective and to prevent progressive left atrial (LA) remodeling. Cryoballoon catheter ablation (CCA), using a different energy source, was developed to simplify the ablation procedure. Our hypothesis was that successful CCA can also prevent progressive LA remodeling. METHODS: 36 patients selected for their first CCA because of nonvalvular paroxysmal AF had echocardiography before and 3, 6 and 12 months after CCA. LA diameters, volumes (LAV) and LA volume index (LAVI) were evaluated. LA function was assessed by: early diastolic velocities of the mitral annulus (Aa(sept), Aa(lat)), LA filling fraction (LAFF), LA emptying fraction (LAEF) and the systolic fraction of pulmonary venous flow (PVSF). Detailed left ventricular diastolic function assessment was also performed. RESULTS: Excluding recurrences in the first 3-month blanking period, the clinical success rate was 64%. During one-year of follow-up, recurrent atrial arrhythmia was found in 21 patients (58%). In the recurrent group at 12 months after ablation, minimal LAV (38 ± 19 to 44 ± 20 ml; p < 0.05), maximal LAV (73 ± 23 to 81 ± 24 ml; p < 0.05), LAVI (35 ± 10 to 39 ± 11 ml/m2; p = 0.01) and the maximal LA longitudinal diameter (55 ± 5 to 59 ± 6 mm; p < 0.01) had all increased. PVSF (58 ± 9 to 50 ± 10%; p = 0.01) and LAFF (36 ± 7 to 33 ± 8%; p = 0.03) had decreased. In contrast, after successful cryoballoon ablation LA size had not increased and LA function had not declined. In the recurrent group LAEF was significantly lower at baseline and at follow-up visits. CONCLUSIONS: In patients whose paroxysmal atrial fibrillation recurred within one year after cryoballoon catheter ablation left atrial size had increased and left atrial function had declined. In contrast, successful cryoballoon catheter ablation prevented progressive left atrial remodeling.

Impaired carotid artery elastic function in patients with tetralogy of Fallot.

Complex congenital heart diseases with abnormal formation of the aorticopulmonary septum are also associated with defective large artery elastogenesis. In the current study, we tested the hypothesis that carotid artery elastic function was impaired in patients with tetralogy of Fallot (ToF). The study included 45 Fallot-patients (male:female 27:18; age 21.0 ± 11.8 years) and 45 age- and gender-matched healthy control individuals. Carotid artery diameter, pulsatile distension, and intima-media thickness (IMT) were measured by echotracking device, and carotid blood pressure was determined using applanation tonometry. Carotid artery elasticity was characterized by compliance and distensibility coefficients, stiffness index ß, and incremental elastic modulus. All carotid artery elastic parameters showed significant differences between groups. The compliance coefficient was 36%, and the distensibility coefficient was 33% smaller, whereas stiffness index ß was 46% and incremental elastic modulus was 40% larger in Fallot-patients. Fallot-patients also had larger carotid artery IMT as compared to that of healthy individuals. Carotid artery is markedly stiffer in Fallot-patients suggesting that impaired elastogenesis is a component of the congenital abnormality. Increased large artery stiffness might contribute directly and indirectly (through impairment of baroreflex function) to the higher mortality found in ToF patients.

[Percutaneous closure of left atrial appendage in non-valvular atrial fibrillation--international and Hungarian experiences]. / A bal pitvari fülcse perkután zárása nonvalvularis pitvarfibrillációban--nemzetközi és hazai tapasztalatok.

In patients with non-valvular atrial fibrillation, efficacy of stroke prevention with oral anticoagulant therapy has been proved. Despite their high risk for thromboembolic events, there are substantial numbers of patients who are not candidates for long-term oral anticoagulant therapy, therefore the interest in alternative treatment strategies are in focus these days. The most common place within the heart for thrombus formation in patients with non-valvular atrial fibrillation is the left atrial appendage. Two devices specifically designed for percutaneous left atrial appendage closure are currently available in Europe: the WATCHMAN LAA system (Atritech, Inc) and the AMPLATZER Cardiac Plug (AGA Medical Corporation). Although present trial results (PLAATO, PROTECT AF) suggest that LAA closure may be performed at acceptable safety and it may reduce the long-term stroke risk, available data are still very limited. At present these procedures may be an acceptable alternative in selected high-risk patients with non-valvular atrial fibrillation who are not or suboptimal candidates for oral anticoagulant therapy. On 28. January, 2010 we performed the first three successful percutaneous left atrial appendage closure procedures in Gottsegen György Hungarian Institute of Cardiology in Hungary.

[Surgical management of congenital heart defects in adolescent and adult patients, between years 2001-2008]. / Tapasztalataink a fiatal- és felnottkori veleszületett szívhibák sebészi kezelésében 2001-2008.

UNLABELLED: The leading interventions due to congenital heart defects performed in adults are: (I) reconstructive operations, including: (a) newly diagnosed malformations, (b) previously adjudged to be inoperable defects, (c) so called "tardive" interventions due to pulmonary hypertension or right ventricle insufficiency. There is a growing number of (II) REDO operations, including: (a) correction of residual defects, (b) replacement of damaged or outgrown homografts, (c) recoarctation (aneurysm, dissection) of the aorta after surgical or catheter interventions, (d) Ross procedure, valve replacements due to previously performed aortic valvulotomy/valvuloplasty or corrections of different malformations (e.g. TGA). PATIENTS AND RESULTS: 166 of all 4496 operations were performed in adolescents and adults (age: 16-52 years, mean: 28 years) between years 2001-2008. The distribution of these interventions: Ia: 77, Ib: 15, Ic: 4, IIa: 11, IIb: 22, IIc: 9, IId: 28. Mortality rates were the following: 0 intraoperative, 4 early postoperative, 1 pulmonary hypertensive crisis, 1 malignant rhythm disturbances, 2 multi-organ failure. CONCLUSIONS: The main risk factors are pulmonary hypertension and right ventricle failure. Complex surgical solutions do not mean extreme problems for a congenital cardiac surgeon, but earlier diagnosis and the use of ECMO during therapy may improve the results.

[The first percutaneous aortic valve implantation in Hungary]. / Az elsô perkután aortabillentyû-beültetés Magyarországon.

Aortic valve replacement can produce dramatic benefit in the setting of symptomatic aortic stenosis. The potential for morbidity and mortality associated with thoracotomy, cardiopulmonary bypass, and aortotomy has fostered a search for alternatives. Early experience with transcatheter endovascular aortic valve implantation demonstrated feasibility and efficacy, but the procedure was difficult to reproduce. However, equipment, techniques, and experience have evolved rapidly. Balloon-expandable and self-expanding prostheses and percutaneous femoral artery and open left ventricular apical access have found favor, each with potential advantages and disadvantages. Procedural success rates and clinical outcomes continue to improve. Current studies suggest that morbidity and mortality rates of percutaneous aortic valve implantations are much better in comparison to conventional surgery in selected high-risk patients. On November 11, 2008, in the Gottsegen György Hungarian Institute of Cardiology we performed the first two successful percutaneous aortic valve implantations in Central and Eastern Europe, following a more than one-year preparation period. After seven days the patients were discharged in very good conditions.

[Treatment of arrhythmias associated with congenital heart disease using transcatheter ablation]. / Veleszületett szívbetegséghez társuló ritmuszavarok katéterablatiós kezelése.

UNLABELLED: Rhythm disturbances are common long after surgical repair of congenital heart disease. These arrhythmias caused by the progression of the disease itself, however, a significant proportion is a result of the presence of surgical scar. Although interventional electrophysiology procedures are complex and encounter difficulties, pharmacological therapy is often very disappointing. AIM AND METHODS: In the present study we aimed to describe our experience obtained between 2004 and 2006 in patients undergoing transcatheter ablation long after surgery for congenital heart disease. RESULTS: During this period 26 patients underwent catheter ablation. The procedure was successful in 24 out of the 26 patients (92%). Three patients required redo ablations due to arrhythmia recurrences (11%). There were no major complications related to the intervention. In four patients minor complications occurred (small hematomas). CONCLUSIONS: Our descriptive data indicate that transcatheter ablation for arrhythmias after surgery for congenital heart disease is a effective safe and more importantly curative procedure. It is associated with reasonable success rate, low complication rate, but slightly higher recurrence rate as compared to the classical electrophysiological interventions.

[Role of transoesophageal echocardiography in bacteremia caused by Staphylococcus aureus]. / A transoesophagealis echokardiográfia szerepe Staphylococcus aureus okozta bacteriaemiákban.

UNLABELLED: Treatment and prognosis of bacteremias caused by Staphylococcus aureus is different, whether only bacteremia is present or it is complicated with endocarditis. Transoesophageal echocardiography may have a role in evaluation of bacteremias caused by Staphylococcus aureus to confirm or exclude infective endocarditis. The aim of this study was to characterize patients with infective endocarditis. PATIENTS AND METHOD: We reviewed the patients studied with transoesophageal echocardiography at our institute between October 1988 and March 2002. The reason for transoesophageal echocardiography was bacteremia caused by Staphylococcus aureus. A total of 24 patients data were analyzed, 15 male and 9 female. Suspicion of infective endocarditis was in 11 patients with native valves, in 8 patients early after prosthetic valve implantation, in 2 patients late after prosthetic valve implantation and in 3 patients after pacemaker implantation. Patient's data were analyzed retrospectively. RESULTS: Thirteen patients had infective endocarditis and 7 of them had community acquired infection. Native valve, prosthetic valve and left ventricular thrombus were the infected tissues. Vegetation was present in 11 patients, one of them was infection of the left ventricular thrombus. Paravalvular leak was found in 3 patients and abscess in 2. Three out of 7 patients with native valve infective endocarditis presented on a structurally normal valve. Eleven patients had no infective endocarditis, in 9 of them there was nosocomial bacteremia. Surgery was performed in 8 patients with infective endocarditis: 3 with acute, 3 with subacute and 2 with late infection. Two patients died after surgery, one of them had acute infection. Four medically treated patients were cured and one died. From the 11 patients without infective endocarditis 7 were cured and 4 died. At the autopsy infective endocarditis was diagnosed in one out of 4 patients. Transoesophageal echocardiography was performed in this patient 4 weeks before death. CONCLUSION: The authors' date suggest, that transoesophageal echocardiography is the diagnostic tool for differentiation between bacteremia and infective endocarditis. The infective endocarditis in both community acquired and nosocomial Staphylococcus aureus bacteremia can cause infective endocarditis on native valves, in thrombus and on intracardiac materials.

[Percutaneous closure of patent foramen ovale, as secondary prevention of cryptogenic cerebral event]. / Nyitott foramen ovale katéteres záráisa, a cryptogen agyi történés szekunder prevenciója.

In patients with patent foramen ovale and cryptogenic stroke, the risk of recurrent event is about 4-5% yearly, despite of the antithrombotic treatment. Transcatheter closure of patent foramen ovale has been shown to decrease risk of recurrence. This report summarizes the first experiences in Hungary and the medium term follow up of our patients. Thirty-three patients were selected for closure. All the patients had at least one ischemic stroke, transitory ischemic attack or peripheral embolus. In 31 of them the stroke was confirmed by computer tomographic or magnetic resonance imaging. Patent foramen ovale with right-to-left shunt was diagnosed by transesophageal echocardiography. Transcatheter closure was performed under fluoroscopic and transesophageal echocardiographic control. Closure was successful in 31 patients. Passage of atrial septum did not succeed in two cases. An AV fistula at puncture site was the only early complication. There was no late complication. No device dislocation, periprocedural arrhythmia or embolic event was detected. No residual shunt could be found. During follow up of 11.3 (1-30) months no recurrent embolus was detected. Transcatheter closure of patent foramen ovale is a safe and efficient procedure to decrease the risk of recurrent ischemic events.

[Intracardiac echocardiography in clinical cardiac electrophysiology: review and first Hungarian experience]. / Az intracardialis ultrahangvizsgálat használata a szív elektrofiziológiában: attekintés az elso hazai vizsgálatok kapcsán.

During the last two decades revolutionary diagnostic and therapeutic changes were implemented in the management of patients with arrhythmias. Since the arrhythmia substrate is frequently associated with certain anatomical structures or morphological variants, improved imaging has increasing role in the improvement of these treatments. Furthermore, novel catheter ablation approaches require catheter placement to sites, which may be associated with increased complication risk. Therefore imaging has a crucial role both in guiding and improving safety of electrophysiology procedures. Recently, intracardiac echocardiography became available providing excellent accuracy in direct visualization of anatomical landmarks. Intracardiac echocardiography is therefore a potentially useful tool for guiding electrophysiology procedures. The first two Hungarian cases with intracardiac echocardiography are presented with a broad background in this comprehensive review.

Preventing complicated transseptal puncture with intracardiac echocardiography: case report.

BACKGROUND: Recently, intracardiac echocardiography emerged as a useful tool in the electrophysiology laboratories for guiding transseptal left heart catheterizations, for avoiding thromboembolic and mechanical complications and assessing the ablation lesions characteristics. Although the value of ICE is well known, it is not a universal tool for achieving uncomplicated access to the left atrium. We present a case in which ICE led to interruption of a transseptal procedure because several risk factors for mechanical complications were revealed. CASE PRESENTATION: A case of a patient with paroxysmal atrial fibrillation and atrial flutter, and distorted intracardiac anatomy is presented. Intracardiac echocardiography showed a small oval fossa abouting to an enlarged aorta anteriorly. A very small distance from the interatrial septum to the left atrial free wall was seen. The latter two conditions were predisposing to a complicated transseptal puncture. According to fluoroscopy the transseptal needle had a correct position, but the intracardiac echo image showed that it was actually pointing towards the aortic root and most importantly, that it was virtually impossible to stabilize it in the fossa itself. Based on intracardiac echo findings a decision was made to limit the procedure only to ablation of the cavotricuspid isthmus and not to proceed further so as to avoid complications. CONCLUSION: This case report illustrates the usefulness of the intracardiac echocardiography in preventing serious or even fatal complications in transseptal procedures when the cardiac anatomy is unusual or distorted. It also helps to understand the possible mechanisms of mechanical complications in cases where fluoroscopic images are apparently normal.

[Adult congenital heart program in a tertiary care facility of pediatric cardiology]. / Felnottkori congenitalis szívsebészet gyermekkardiológiai és szívsebészeti központban.

INTRODUCTION: Owing to excellent survival following primary repair over 80% of congenital cardiac patients reach adulthood, half of them requiring continuous specialist care and one-third needing further reoperation. The ample variety and complexity of lesions warrant individualised treatment strategy. OBJECTIVE: This study focuses on grown-up congential heart (GUCH) programme in the settings of a tertiary pediatric cardiac centre. METHODS: Patients underwent corrective surgical procedures in pediatric facilities (theatre, ICU, wards) with a close involvement of adult cardiology/anaesthetic team. Patients were divided into simple/complex groups. RESULTS: Simple group of comprised patients (n = 20) having ASD-II (18/20) sinus venosus ASD (2/20) repair without morbidity/mortality from right subaxillary thoracotomy in 17/20. Complex group (n = 20): corrective surgery for tetralogy of Fallot (6), LVOT-aortic valve repairs (4), allograft conduit exchange (3), TCPC (3), miscellaneous procedures (4) were performed as reoperations in 16/20 at 16.1 +/- 8.1 years following previous operations (median: 1.96, range 1-4). Postoperative right ventricle- (1), acute renal (1) failure and ARDS (1) fully recovered. One patient was lost for multi-organ-failure due to low cardiac output syndrome caused by chronic RV failure. Preoperative cyanosis was a risk factor for postoperative complications (p = 0.01). All survivors are symptom-free. No significant difference in ITU stay/LOS was observed between simple and complex groups. CONCLUSIONS: This study represents the initial experience of authors with GUCH. The number of GUCH patients is expected to rise with an upgrade shift in surgical complexity and severity requiring a multidisciplinary approach. It is advocated that complex GUCH cases should be performed by teams experienced in congenital reconstructive surgery. Patients following complex GUCH procedures have a comparable hospital course to patients undergoing simple cardiac operations.

[Successful surgical correction of tetralogy of Fallot and pulmonary atresia in adulthood after reconsidering inoperability]. / A felnottkori Fallot-tetralogia és pulmonalis atresia sikeres sebészi rekonstrukciója korábbi inoperábilitás úijraértékelése után.

UNLABELLED: A 36 year old male with tetralogy of Fallot and pulmonary atresia was corrected successfully. Previous palliative operation (Cooley shunt) was performed 35 years before. He was in NYHA functional class III. because of chronic hypoxia, polyglobulia, cerebral accident, pulmonary complications, myocardial (ventricular) dysfunction and syncopes. After an uneventful surgical reconstruction, the postoperative period was complicated with haemostasis complication and pulmonary distress syndrome. He left the hospital in NYHA functional class I on the 20th postoperative day in very good condition. CONCLUSION: Complete cardiac recovery will be possible after successful surgically reconstruction of tetralogy of Fallot and pulmonary atresia even in adulthood. The reconsideration of operability of such cases is recommended. As the patient may have different extracardiac complications in every case new complete reconsideration is necessary for the indication of surgical reconstruction.