Long-Term Imaging and Clinical Outcomes of Surgical Left Atrial Appendage Occlusion With AtriClip.

Surgical left atrial appendage (LAA) occlusion with an AtriClip (AtriCure, West Chester, Ohio) is frequently performed for stroke prophylaxis in patients with atrial fibrillation (AF). We conducted a retrospective analysis of all patients with long-standing persistent AF who underwent hybrid convergent ablation and LAA clipping. Contrast-enhanced cardiac computed tomography was performed at 3 to 6 months after LAA clipping to assess the degree of complete closure and the residual LAA stump. A total of 78 patients (64 ± 10 years, 72% male) underwent LAA clipping as part of hybrid convergent AF ablation, from 2019 to 2020. Median size of AtriClip used was 45 mm. Mean LA size was 4.6 ± 1 cm. At 3-to-6 months follow-up computed tomography, 46.2% of patients (n = 36) had a residual stump proximal to the deployed LAA clip. Mean depth of residual stump was 3.95 ± 5.5 mm, with 19% of patients (n = 15) having a stump depth of ≥10 mm and 1 patient requiring more endocardial LAA closure owing to large stump depth. During 1-year follow-up, 3 patients developed stroke; device leak of 6 mm was noted in 1 patient; and none of the patients had a thrombus proximal to the clip. In conclusion, high incidence of residual LAA stump was observed with AtriClip. Larger studies with long-term follow-up are needed to better assess the thromboembolic implications of a residual stump after AtriClip placement.

Same-day discharge following catheter ablation and venous closure with VASCADE MVP: A postmarket registry.

INTRODUCTION: Early and safe ambulation can facilitate same-day discharge (SDD) following catheter ablation, which can reduce resource utilization and healthcare costs and improve patient satisfaction. This study evaluated procedure success and safety of the VASCADE MVP venous vascular closure system in patients with atrial fibrillation (AF). METHODS: The AMBULATE SDD Registry is a two-stage series of postmarket studies in patients with paroxysmal or persistent AF undergoing catheter ablation followed by femoral venous access-site closure with VASCADE MVP. Efficacy endpoints included SDD success, defined as the proportion of patients discharged the same day who did not require next-day hospital intervention for procedure/access site-related complications, and access site sustained success within 15 days of the procedure. RESULTS: Overall, 354 patients were included in the pooled study population, 151 (42.7%) treated for paroxysmal AF and 203 (57.3%) for persistent AF. SDD was achieved in 323 patients (91.2%) and, of these, 320 (99.1%) did not require subsequent hospital intervention based on all study performance outcomes. Nearly all patients (350 of 354; 98.9%) achieved total study success, with no subsequent hospital intervention required. No major access-site complications were recorded. Patients who had SDD were more likely to report procedure satisfaction than patients who stayed overnight. CONCLUSION: In this study, 99.7% of patients achieving SDD required no additional hospital intervention for access site-related complications during follow-up. SDD appears feasible and safe for eligible patients after catheter ablation for paroxysmal or persistent AF in which the VASCADE MVP is used for venous access-site closure.

Outcomes of cardiac surgery with left atrial appendage occlusion versus no Occlusion, direct oral Anticoagulants, and vitamin K Antagonists: A systematic review with Meta-analysis.

Surgical left atrial appendage occlusion (LAAO) is being used increasingly in the setting of atrial fibrillation but has been associated with procedural complications. This systematic review and meta-analysis compared the outcomes of surgical LAAO with those of no LAAO and the use of direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) using the PRISMA guidelines. A literature search was undertaken for relevant studies published between January 1, 2003, and August 15, 2021. Primary clinical outcomes were all-cause mortality, embolic events, and stroke. Secondary clinical outcomes included major adverse cardiac events (MACE), postoperative atrial fibrillation, postoperative complications, reoperation for bleeding, and major bleeding. There was a statistically significant 34% reduction in incidence of embolic events (odds ratio [OR] 0.66, 95% confidence interval [CI] 0.57-0.77, p < 0.001) and a significant 42% reduction in risk of MACE (OR 0.58, 95% CI 0.38-0.88, p = 0.01) in patients who underwent LAAO.Surgical LAAO has the potential to reduce embolic events and MACE in patients undergoing cardiac surgery for atrial fibrillation. However, complete replacement of DOACs and warfarin therapy with surgical LAAO is unlikely despite its non-inferiority in terms of minimizing all-cause mortality, embolic events, MACE, major bleeding, and stroke in patients on oral anticoagulation therapies.

Impact of new-onset versus pre-existing atrial fibrillation on outcomes after transcatheter aortic valve replacement/implantation.

Patients with aortic stenosis who undergo transcatheter aortic valve replacement/transcatheter aortic valve implantation (TAVR/TAVI) experience a high incidence of pre-existing atrial fibrillation (pre-AF) and new-onset atrial fibrillation (NOAF) post-operatively. This systematic review and meta-analysis aimed to update current evidence concerning the incidence of 30-day mortality, stroke, acute kidney injury (AKI), length of stay (LOS), and early/late bleeding in patients with NOAF or pre-AF who undergo TAVR/TAVI. PubMed, Google Scholar, JSTOR, Cochrane Library, and Web of Science were searched for studies published between January 2012 and December 2020 reporting the association between NOAF/pre-AF and clinical complications after TAVR/TAVI. A total of 15 studies including 158,220 adult patients with TAVI/TAVR and NOAF or pre-AF were identified. Compared to patients in sinus rhythm, patients who developed NOAF had a higher risk of 30-day mortality, AKI, early bleeding events, extended LOS, and stroke after TAVR/TAVI (odds ratio [OR]: 3.18 [95% confidence interval [CI] 1.58, 6.40]) (OR: 3.83 [95% CI 1.18, 12.42]) (OR: 1.70 [95% CI 1.05, 2.74]) (OR: 13.96 [95% CI, 6.41, 30.40]) (OR: 2.51 [95% CI 1.59, 3.97], respectively). Compared to patients in sinus rhythm, patients with pre-AF had a higher risk of AKI and early bleeding episodes after TAVR/TAVI (OR: 2.43 [95% CI 1.10, 5.35]) (OR: 17.41 [95% CI 6.49, 46.68], respectively). Atrial fibrillation is associated with a higher risk of all primary and secondary outcomes. Specifically, NOAF but not pre-AF is associated with a higher risk of 30-day mortality, stroke, and extended LOS after TAVR/TAVI.

Comparative Assessment of Transvenous versus Subcutaneous Implantable Cardioverter-defibrillator Therapy Outcomes: An Updated Systematic Review and Meta-analysis.

BACKGROUND: Subcutaneous (S-ICD) and transvenous (TV-ICD) implantable cardioverter-defibrillator devices effectively reduce the incidence of sudden cardiac death in patients at a high risk of ventricular arrhythmias. This study aimed to evaluate the safe replacement of TV-ICD with S-ICD based on updated recent evidence. METHODS: We systematically searched EMBASE, JSTOR, PubMed/MEDLINE, and Cochrane Library on 30 July 2021 following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS: We identified 26 studies that examined 7542 (58.27%) patients with S-ICD and 5400 (41.72%) with TV-ICD. The findings indicated that, compared to patients with TV-ICD, patients with S-ICD had a lower incidence of defibrillation lead failure (odds ratio [OR], 0.12; 95% confidence interval [CI], 0.01-0.98; p = 0.05), lead displacement or fracture (OR, 0.25; 95% CI, 0.12-0.86; p = 0.0003), pneumothorax and/or hemothorax (OR: 0.22, 95% CI 0.05, 0.97, p = 0.05), device failure (OR: 0.70, 95% CI 0.51, 0.95, p = 0.02), all-cause mortality (OR: 0.44 [95% CI 0.32, 0.60], p < 0.001), and lead erosion (OR: 0.01, 95% CI 0.00, 0.05, p < 0.001). Patients with TV-ICD had a higher incidence of pocket complications than patients with S-ICD (OR, 2.13; 95% CI, 1.23-3.69; p = 0.007) and a higher but insignificant incidence of inappropriate sensing (OR, 3.53; 95% CI, 0.97-12.86; p = 0.06). CONCLUSIONS: The S-ICD algorithm was safer and more effective than the TV-ICD system as it minimized the incidence of pocket complications, lead displacement or fracture, inappropriate sensing, defibrillation lead failure, pneumothorax/hemothorax, device failure, lead erosion, and all-cause mortality. Future studies should explore the scope of integrating novel algorithms with the current S-ICD systems to improve cardiovascular outcomes.

Same Day versus Overnight Discharge in Patients Undergoing Ablation for Atrial Fibrillation (SODA) Study.

Patients undergoing catheter ablation for atrial fibrillation (AF) are routinely admitted for observation overnight in the hospital. With the rising incidence of AF among the population, increased volumes of procedures are placing increased demands on hospital resources. The purpose of this study was to evaluate the efficacy and safety of same day discharge in patients undergoing ablation for AF when compared to patients admitted for overnight observation. We performed a retrospective analysis using a multicenter cohort among patients who were discharged home after elective pulmonary vein isolation (PVI) ablation for AF. In our analysis, we found no statistically significant difference between patients discharged on the day of their procedure when compared to patients admitted for overnight observation in terms of 90-day readmission, major adverse cardiovascular events and death. This study shows that same day discharge after AF ablation is a feasible option. Future studies are needed to elicit the appropriate protocol to use.

Accentuated vagal antagonism paradoxically increases ryanodine receptor calcium leak in long-term exercised Calsequestrin2 knockout mice.

BACKGROUND: Long-term aerobic exercise alters autonomic balance, which may not be favorable in heart rate (HR)-dependent arrhythmic diseases including catecholaminergic polymorphic ventricular tachycardia (CPVT) because of preexisting bradycardia and increased sensitivity to parasympathetic stimulation. OBJECTIVE: The purpose of this study was to determine whether long-term exercise-induced autonomic adaptations modify CPVT susceptibility. METHODS: We determined exercise-induced parasympathetic effects on HR, arrhythmia incidence, and intracellular sarcoplasmic reticulum (SR) Ca2+ leak in atrial (ACM) and ventricular (VCM) cardiomyocytes, in exercised (EX) calsequestrin knockout (CASQ2-/-) mice, a model of CPVT. RESULTS: Although 8-week treadmill running improved exercise capacity in EX CPVT mice, the incidence and duration of ventricular tachycardia also increased. HR variability analyses revealed an increased high-frequency component of the power spectrum and root mean square of successive differences in R-R intervals indicating accentuated vagal antagonism during ß-adrenergic stimulation resulting in negligible HR acceleration. In EX CASQ2-/- VCM, peak amplitude of Ca2+ transient (CaT) increased, whereas SR Ca2+ content decreased. Aberrant Ca2+ sparks occurred at baseline, which was exacerbated with isoproterenol. Notably, although 10 µM of the cholinergic agonist carbachol prevented isoproterenol-induced Ca2+ waves in ACM, CaT amplitude, SR Ca2+ load, and isoproterenol-induced Ca2+ waves paradoxically increased in VCM. In parallel, ventricular ryanodine receptor (RyR2) protein expression increased, whereas protein kinase A- and calmodulin-dependent protein kinase II-mediated phosphorylation of RyR2 was not significantly altered, which could imply an increased number of "leaky" channels. CONCLUSION: Our novel results suggest that long-term exercise in CASQ2-/- mice increases susceptibility to ventricular arrhythmias by accentuating vagal antagonism during ß-adrenergic challenge, which prevents HR acceleration and exacerbates abnormal RyR2 Ca2+ leak in EX CASQ2-/- VCM.

Impact of statin use on heart failure mortality.

BACKGROUND: There is conflicting data regarding the mortality benefit of statins in patients with heart failure. The objectives of our study were to determine whether statin therapy is associated with decreased all-cause mortality and to assess the effect of incremental duration of therapy. METHODS: We studied 10,510 consecutive patients from the Veterans Affairs health system with a diagnosis of heart failure from January 2002 through December 2006. Mean follow-up was 2.66 years. Statin use and duration of therapy were identified. Veterans were classified into four groups based on duration of statin use during the study period (none, 1-25%, 26-75% and >75% use of statins). Logistic regression was performed to identify the association between incident statin use and all-cause mortality following a diagnosis of heart failure. The Kaplan-Meier method was employed to assess for differences in survival time between the four statin use classifications. RESULTS: Statin use was significantly associated with decreased all-cause mortality following a diagnosis of heart failure after controlling for age, gender, concurrent medications and comorbid diagnoses [χ(3)(2) (N = 10,510) = 1077.82, p < 0.001]. The benefit was seen within a relatively short duration (within 1 year) after starting statins, and in patients with <25% use of statins, there was no mortality benefit. CONCLUSION: Veterans who were not exposed to statin therapy at any time during the study period were 1.56 times more likely to suffer all-cause mortality.

Thoracic aortic pseudoaneurysm following noncardiovascular surgery: a rare complication that can mimic common chest emergencies.

Pseudoaneurysm of the thoracic aorta is an extremely rare and potentially fatal condition that can mimic acute coronary syndrome, aortic dissection, or pulmonary embolism. Chest trauma and aortic surgery are the usual predisposing factors. Rarely, noncardiovascular thoracic surgeries can result in aortic pseudoaneurysm secondary to unrecognized perioperative injury. Clinical presentation is very variable, and a high index of suspicion is necessary for diagnosis. Computed tomography or magnetic resonance angiography is the preferred diagnostic test. In this paper, we report the case of a 58-year-old woman who presented with atypical chest pain due to a thoracic aortic pseudoaneurysm, most likely a result of previous nonvascular surgery.

C-Reactive Protein and The Risk of Atrial Fibrillation: A Systematic Review and Meta-Analysis.

There is increasing evidence linking C-reactive protein (CRP) and atrial fibrillation (AF). Despite the abundance of literature, confusion exists regarding this association because of inconsistent results. MEDLINE and Cochrane Controlled Trials Register databases were carefully searched through July, 2009 combining the following terms "C-reactive protein" and "atrial fibrillation". Reference lists of selected articles and reviews were also screened to identify additional relevant studies. Of the 129 studies initially identified, 8 studies with 7507 subjects (719 with AF) were included in the meta-analysis. Analysis yielded a relative risk of 1.63 (1.43, 1.86) for occurrence of AF when CRP level was above a cut off of 3-3.5 mg/l. When 3 studies with data on a higher cut off of 4.5-5.0 mg/l were analyzed separately, the relative risk was 4.03 (3.1, 5.25). Our study suggests that elevated CRP is associated with increased risk for AF. The risk appears incremental with higher CRP levels conferring proportionately increased risk. There is an urgent need for further large scale, well designed prospective studies to assess the relationship between CRP and AF.

Acute eosinophilic myocarditis mimicking myocardial infarction.

Eosinophilic myocarditis is characterized by progressive myocardial damage that results in heart failure and death. Herein, we present the case of a 54-year-old man who presented with symptoms of acute myocardial infarction. Normal coronary angiographic results and the presence of elevated levels of peripheral-blood eosinophilia prompted an endomyocardial biopsy that revealed acute eosinophilic myocarditis. The early initiation of steroid therapy resulted in the patient's substantial clinical improvement and survival. Early diagnosis of eosinophilic myocarditis and its treatment with steroid agents in some patients can lead to a favorable outcome. We discuss the challenge of diagnosing and identifying the characteristics of this variant of necrotizing eosinophilic myocarditis before the condition proves fatal.

Comprehensive left atrial appendage optimization of thrombus using surface echocardiography: the CLOTS multicenter pilot trial.

BACKGROUND: The aim of this study was to determine the ability to identify thrombus within the left atrial appendage (LAA) in the setting of atrial fibrillation (AF) using transthoracic echocardiography (TTE). In AF, the structure and function of the LAA has historically been evaluated using transesophageal echocardiography (TEE). The role of TTE remains undefined. METHODS: The Comprehensive Left Atrial Appendage Optimization of Thrombus (CLOTS) multicenter study enrolled 118 patients (85 men; mean age, 67 +/- 13 years) with AF of >2 days in duration undergoing clinically indicated TEE. On TEE, the LAA was evaluated for mild spontaneous echo contrast (SEC), severe SEC, sludge, or thrombus. Doppler Tissue imaging (DTI) peak S-wave and E-wave velocities of the LAA walls (anterior, posterior, and apical) were acquired on TTE. Transthoracic echocardiographic harmonic imaging (with and without intravenous contrast) was examined to determine its ability to identify LAA SEC, sludge, or thrombus. RESULTS: Among the 118 patients, TEE identified 6 (5%) with LAA sludge and 2 (2%) with LAA thrombi. Both LAA thrombi were identified on TTE using harmonic imaging with contrast. Anterior, posterior, and apical LAA wall DTI velocities on TTE varied significantly among the 3 groups examined (no SEC, mild SEC, severe SEC, sludge or thrombus). An apical E velocity < or = 9.7 cm/s on TTE best identified the group of patients with severe SEC, sludge, or thrombus. An anterior S velocity < or = 5.2 cm/s on TTE best identified the group of patients with sludge or thrombus. CONCLUSIONS: The CLOTS multicenter pilot trial determined that TTE is useful in the detection of thrombus using harmonic imaging combined with intravenous contrast (Optison; GE Healthcare, Milwaukee, WI). Additionally, LAA wall DTI velocities on TTE are useful in determining the severity of LAA SEC and detecting sludge or thrombus.

Transient midventricular ballooning: a case report and review of the literature.

BACKGROUND: We describe a case of transient left midventricular ballooning in 68-year-old male patient presented with picture of acute coronary syndrome. CASE PRESENTATION: The left ventriculogram showed mid ventricular akinesis and dilatation along with hypercontractile apex and basal segments. Follow up echocardiogram after one month showed resolution of wall motions abnormalities and normalization of the left ventricular function. CONCLUSION: This is considered as a new variant of previously reported transient left ventricular apical ballooning; the only difference in our case is the location of wall motions abnormalities.

Association of atheroma as assessed by intraoperative transoesophageal echocardiography with long-term mortality in patients undergoing cardiac surgery.

AIMS: To determine whether the presence and severity of aortic atheroma predict long-term all-cause mortality among patients undergoing cardiac surgery. METHODS AND RESULTS: We followed 8,581 patients who underwent cardiac surgery and had routine intraoperative transoesophageal echocardiography for 2.8 years (range 0.06-6.0 years). Data regarding multiple potential confounders were prospectively collected and electronically recorded. There were 2,878 (34%) patients with no atheroma; 4,129 (48%) patients with mild atheroma; 1,215 (14%) with moderate atheroma; and 359 (4%) with severe atheroma. There were 1000 deaths. Death rates were increased in patients with moderate [relative risk (RR) 3.29, 95% CI 2.50-4.32, P < 0.0001) and severe atheroma (RR 5.21, 95% CI 3.65-7.41, P < 0.0001). After adjusting for multiple other confounders, severe atheroma remained modestly predictive of risk (adjusted RR 1.46, 95% CI 1.07-2.00, P = 0.02); but moderate atheroma and mild atheroma were not predictive of increased risk. In a propensity analysis that matched patients with comparable range of variables, severe atheroma was no longer predictive of risk (adjusted RR 1.39, 95% CI 0.87-2.23, P = 0.17). CONCLUSION: Our study shows that severe atheroma is associated with increased long-term mortality in patients undergoing cardiac surgery; however, the relationship is weak using propensity analysis, suggesting no causal association.

Utility of transesophageal echocardiography in identification of thrombogenic milieu in patients with atrial fibrillation (an ACUTE ancillary study).

The ACUTE trial randomly assigned patients who had atrial fibrillation (AF) of >2 days' duration to a transesophageal echocardiographically guided or a conventional strategy before cardioversion. In the 571 patients who underwent transesophageal echocardiography (TEE) in the ACUTE trial, we assessed the relative predictive value of baseline data derived by history, transthoracic echocardiography, and TEE for prediction of thrombus and adjudicated embolism (thromboembolism) as a composite end point. TEE was performed at 70 centers in 571 patients, 549 in the transesophageal echocardiographically guided group and 22 crossovers in the conventional group. Six patients (1.1%) who had embolism and 79 (13.8%) who had thrombi were identified in this group. Thrombus was completely resolved in 76.5% of patients who had repeat transesophageal echocardiographic procedures after 31.7 +/- 7.5 days of anticoagulation. For patients who had embolic events, none had a transesophageal echocardiographically identified thrombus; 5 of 6 (83.3%) had >/=1 transesophageal echocardiographic risk factors (including spontaneous echocardiographic contrast, aortic atheroma, patent foramen ovale, atrial septal aneurysm, mitral valve strands), and 4 of 6 (66.66%) had subtherapeutic anticoagulation or no anticoagulation. Clinical, transthoracic echocardiographic, and transesophageal echocardiographic risk factors contributed significantly to the prediction of composite thrombus/embolism. However, transesophageal echocardiographic thromboembolic risk factors were the strongest predictors of thromboembolism and provided statistically significant incremental value (chi-square 38.0, p <0.001) for identification of risk. Thus, in addition to thrombus identification, TEE has significant incremental value in the identification of patients who had high thromboembolic risk. In conclusion, this study supports the role of TEE and anticoagulation monitoring in patients who have atrial fibrillation and is useful for identifying thromboembolic risk factors.

Transient left ventricular apical ballooning: a novel heart syndrome.

A novel cardiac syndrome of left ventricular apical ballooning (Takotsubo cardiomyopathy-ampulla cardiomyopathy) involves reversible left ventricular apical ballooning (during systole) of acute onset with chest pain, electrocardiographic changes, and minimal elevation of cardiac enzymes resembling acute myocardial infarction, but without evidence of myocardial ischemia or injury. Patients have no angiographic evidence of coronary artery stenosis and there is almost always a complete recovery of left ventricular function in days to weeks. The precise etiologic basic of this syndrome is not clear but most likely it is a non-ischemic, metabolic syndrome caused by stress-induced activation of the cardiac adrenoceptors in absence of ischemia and reperfusion. Reported here is a case of stress-induced transient left ventricular apical ballooning syndrome in a young woman.

Relation of C-reactive protein correlates with risk of thromboembolism in patients with atrial fibrillation.

The relation between C-reactive protein, an inflammatory marker, and thromboembolic risk factors was investigated in 104 patients with atrial fibrillation and found that patients with transesophageal echocardiography identified thromboembolic risk factors had greater C-reactive protein levels than those without (1.00 vs 0.302 mg/dl). C-reactive protein also correlated with clinical stroke risk factors. Increased C-reactive protein levels were also independently associated with transesophageal echocardiographic thromboembolic risk factors.

Constrictive pericarditis: etiology and cause-specific survival after pericardiectomy.

OBJECTIVES: We sought to determine the association of etiology of constrictive pericarditis (CP), pericardial calcification (CA), and other clinical variables with long-term survival after pericardiectomy. BACKGROUND: Constrictive pericarditis is the result of a spectrum of primary cardiac and noncardiac conditions. Few data exist on the cause-specific survival after pericardiectomy. The impact of CA on survival is unclear. METHODS: A total of 163 patients who underwent pericardiectomy for CP over a 24-year period at a single surgical center were studied. Constrictive pericarditis was confirmed by the surgical report. Vital status was obtained from the Social Security Death Index. RESULTS: Etiology of CP was idiopathic in 75 patients (46%), prior cardiac surgery in 60 patients (37%), radiation treatment in 15 patients (9%), and miscellaneous in 13 patients (8%). Median follow-up among survivors was 6.9 years (range 0.8 to 24.5 years), during which time there were 61 deaths. Perioperative mortality was 6%. Idiopathic CP had the best prognosis (7-year Kaplan-Meier survival: 88%, 95% confidence interval [CI] 76% to 94%) followed by postsurgical (66%, 95% CI 52% to 78%) and postradiation CP (27%, 95% CI 9% to 58%). In bootstrap-validated proportional hazards analyses, predictors of poor overall survival were prior radiation, worse renal function, higher pulmonary artery systolic pressure (PAP), abnormal left ventricular (LV) systolic function, lower serum sodium level, and older age. Pericardial calcification had no impact on survival. CONCLUSIONS: Long-term survival after pericardiectomy for CP is related to underlying etiology, LV systolic function, renal function, serum sodium, and PAP. The relatively good survival with idiopathic CP emphasizes the safety of pericardiectomy in this subgroup.