A Novel Risk Score Facilitates Femoral Artery Access in Transcatheter Aortic Valve Implantation: Passage-Puncture Score.

Background: Vascular complications remain high in transfemoral transcatheter aortic valve implantation (TAVI). Careful evaluation of the femoral arteries is important to select the optimal access site. Objectives: This study sought to describe a novel risk score (the passage-puncture score) for transfemoral access using a single suture-based closure system. Methods: The passage-puncture score consists of the evaluation of 1) passage feasibility of the ilio-femoral arteries (passage score) and 2) puncture site feasibility (puncture score) based on pre-TAVI computed tomography. All patients underwent fluoroscopy-guided arterial puncture and closure with a suture-based closure system. The primary endpoint was the rate of vascular complications in discharge, including minor and major vascular complications according to the definitions of the Third Valve Academic Research Consortium. Results: From September 2020 to June 2021, transfemoral TAVI was performed in 98 of 99 patients. Passage score (right) was significantly higher in patients treated by left compared to those treated by right femoral access (3 vs. 1; p <0.001). Puncture score was significantly different between patients undergoing mid-femoral as compared to nonmid-femoral puncture (0 vs. 3, p <0.001). Minor vascular complications occurred in six (6%) patients. Conclusions: The passage-puncture score is effective in defining the optimal access site for transfemoral TAVI. The systematic evaluation has the potential to further reduce access-site complications.

Long-term outcomes after echocardiography versus fluoroscopy-guided left atrial appendage closure: Is there still a role for a simplified approach?

BACKGROUND: Left atrial appendage closure (LAAC) represents an alternative to oral anticoagulation for stroke prevention in patients with non-valvular atrial fibrillation (AF). While transoesophageal echocardiography is the current standard for guiding LAAC procedures, several centers have employed fluoroscopic guidance alone. However, data on long-term outcomes are lacking. METHODS: A total of 536 patients with AF undergoing LAAC and with available data on long-term follow-up were included in the retrospective, single-center analysis. Outcomes of patients undergoing fluoroscopy-guided LAAC were compared with those undergoing echocardiography guided LAAC. Time-dependent analysis was performed with the Kaplan-Meier method. RESULTS: A total of 234 (44%) and 302 (56%) patients were treated with echocardiography and fluoroscopy guidance, respectively. Baseline characteristics did not differ between the two groups. Procedural success rates were high in both groups (97% of fluoroscopy vs. 98% of echocardiography guided procedures; p = 0.92) and rates of relevant peri-device leaks (p = 0.50) and device-related thrombus formation (p = 0.22) did not differ between groups. Median clinical follow-up time was 48 (IQR 19-73) months. Rates of all-cause mortality (p = 0.15, HR 0.83, CI 0.64-1.07) and stroke (p = 0.076, HR 2.23, CI 0.90-5.54) were comparable among groups. CONCLUSION: LAAC with fluoroscopy guidance alone is equally safe and leads to similar clinical outcome compared to LAAC with additional echocardiography guidance.

"Puncture-to-Loop" Technique to Retrieve Embolized Patent Foramen Ovale Occluder.

A 62-year-old man experienced embolization of a patent foramen ovale (PFO) occlusion device in the pulmonary artery. The device was successfully retrieved using "puncture to loop" technique, without the need of specific materials. This is a challenging retrieval situation, confirming the feasibility and flexibility of the technique. (Level of Difficulty: Advanced.).

Stroke Prevention With Left Atrial Appendage Closure in Patients With Atrial Fibrillation and Prior Intracranial Hemorrhage.

Background: Oral anticoagulation (OAC) is deemed a relative contraindication after intracranial hemorrhage (ICH) if the cause cannot be eliminated and the risk of recurrence is high. That leaves atrial fibrillation (AF) patients at high risk of thromboembolic events. Endovascular left atrial appendage closure (LAAC) can be an alternative to OAC for patients requiring stroke prevention. Methods: We performed a retrospective single-centre analysis of 138 consecutive ICH patients with nonvalvular AF and high stroke risk who underwent LAAC between 2010 and 2022 at Vancouver General Hospital. We report the baseline characteristics, procedural results, and follow-up data, comparing the observed stroke/transient ischemic attack (TIA) rate with the predicted event rate based on their CHA2DS2-VASc scores. Results: The average age was 76.1 ± 8.5 years; the mean CHA2DS2-VASc score was 4.4 ± 1.5; and the mean HAS-BLED score was 3.7 ± 0.9. The procedural success rate was 98.6%, and the complication rate was 3.6% with no periprocedural death, stroke, or TIA. The antithrombotic regimen post-LAAC consisted of short-term dual antiplatelet therapy (1-6 months) followed by aspirin alone for a minimum of 6 months in 86.2%. At mean follow-up of 14.7 ± 13.7 months, 9 deaths (6.5%, 7 cardiovascular, 2 noncardiovascular), 2 strokes (1.4%), and 1 TIA (0.7%) had occurred. The annualized observed stroke/TIA rate was 1.8%, which was lower than the adjusted predicted stroke rate of 7.0% (95% confidence interval: 4.8%-9.2%). Two patients (1.5%) suffered another ICH (both on aspirin monotherapy). One device-related thrombus (0.7%) was confirmed and treated with OAC without sequelae. Conclusion: Endovascular LAAC is a feasible alternative to OAC for stroke prevention in patients with nonvalvular AF and prior ICH.

Contexte: L'anticoagulation par voie orale (ACO) est considérée comme une contre-indication relative après une hémorragie intracrânienne (HIC) si la cause ne peut être éliminée et si le risque de récidive est élevé. Les patients souffrant de fibrillation auriculaire (FA) sont donc exposés à un risque élevé d'événements thromboemboliques. La technique de fermeture percutanée de l'appendice auriculaire gauche (AAG) peut être une solution de rechange aux anticoagulants oraux en prévention des accidents vasculaires cérébraux (AVC). Méthodologie: Nous avons réalisé une analyse rétrospective unicentrique auprès de 138 patients consécutifs qui étaient atteints d'une HIC accompagnée d'une FA non valvulaire ainsi que d'un risque élevé d'AVC et qui ont subi une fermeture de l'AAG entre 2010 et 2022 à l'hôpital général de Vancouver. Nous présentons ici les caractéristiques initiales, les résultats de l'intervention et les données de suivi, en comparant le taux d'AVC/AIT (accident ischémique transitoire) observé avec le taux prédit d'événements sur la base de leurs scores CHA2DS2-VASc. Résultats: L'âge moyen était de 76,1 ± 8,5 ans. Le score CHA2DS2-VASc moyen était de 4,4 ± 1,5, et le score HAS-BLED moyen de 3,7 ± 0,9. Le taux de réussite de l'intervention a été de 98,6 % et le taux de complications de 3,6 %, sans décès périopératoires, ni AVC ou AIT. Le traitement antithrombotique après la fermeture de l'AAG consistait en une bithérapie antiplaquettaire de courte durée (de 1 à 6 mois), suivie de la prise d'aspirine seule pendant au moins 6 mois dans 86,2 % des cas. Après un suivi moyen de 14,7 ± 13,7 mois, 9 décès (6,5 %, 7 d'origine cardiovasculaire et 2 d'origine non cardiovasculaire), 2 AVC (1,4 %) et 1 AIT (0,7 %) sont survenus. Le taux annualisé d'AVC/AIT observé était de 1,8 %, ce qui est inférieur au taux prédit d'AVC après ajustement, soit 7,0 % (intervalle de confiance à 95 % : 4,8 % à 9,2 %). Deux patients (1,5 %) ont souffert d'une autre HIC (tous deux sous aspirine en monothérapie). Un thrombus lié au dispositif (0,7 %) a été confirmé et traité par anticoagulathérapie orale sans séquelles. Conclusion: La technique de fermeture de l'AAG représente une solution de rechange à l'anticoagulation par voie orale dans la prévention des AVC chez les patients souffrant de FA non valvulaire et ayant déjà subi une HIC.

Alive and kicking: suicide rates and major soccer events in Austria, Germany and Switzerland.

BACKGROUND: Major sporting events are postulated to reduce suicide rates by increased social connectedness, by identifying with winning teams, or, conversely, to increase suicide rates by the 'broken promise effect'. METHODS: In our observational epidemiological study, we investigated changes in suicide rates between 1970 and 2017 in Austria, Germany and Switzerland during the European and World Soccer Championships in general, and on days that the home team played, won or lost. RESULTS: Combining all three studied nations no statistically significant change in the incidence of daily suicides during soccer championships compared to a control period was noted (38.29 ± 9.02 vs. 37.33 ± 10.58; incidence risk ratio = 1.03; 95% confidence interval: 1.01-1.05, P = 0.05). Essentially, no differences in the expected directions were found, and none remained statistically significant after correcting for multiple comparisons in subgroups for country, age and gender in all three studied countries. Compared to a control period, neither a significant difference in the respective national suicide rate was found after Germany's four championship victories nor after Austria's emotional only win over Germany. CONCLUSION: Our results do not support the assumption of increased social connectedness and, thus, lowered suicide risk during major sporting events or changes in suicide risk depending on the outcome of important games as predicted by the broken promise effect or changes in self-efficacy by identification with winning teams.

Cardiac CT angiography after percutaneous left atrial appendage closure: early versus delayed scanning after contrast administration.

PURPOSE: Cardiac computed tomography angiography (CCTA) is increasingly used for device surveillance after left atrial appendage closure (LAAC). While CT protocols with delayed scans are useful to diagnose thrombus in the LAA, an optimal protocol for post-procedural CCTA has not been established. Therefore, we assessed the role of delayed versus early scans for device surveillance. METHODS: We retrospectively reviewed patients who underwent LAAC at Vancouver General Hospital who had follow-up CCTAs using standard (early) and delayed scans. Scans were performed on Toshiba 320-detector (Aquilion ONE). Image quality was interpreted by 2 independent observers for anatomy, LAA contrast patency, and device-related thrombus (DRT) using VitreaWorkstationTM. A Likert scale of 1-5 was used (1= poor quality, 5= excellent) for assessment. RESULTS: We included 27 consecutive LAAC patients (9 Amplatzer, 18 WATCHMAN) with mean age 76.0±7.7 years, mean CHADS2 score 2.8±1.3, CHA2DS2-VASc score 4.4±1.6 and HAS-BLED score 3.4±1.0. Subjective quality assessments by both reviewers favored early scans for assessment of anatomy (reviewer 1: 4.63±0.63 [early] vs. 1.74±0.71 [delayed]; reviewer 2: 4.63±0.63 [early] vs. 1.89±0.64 [delayed]) and DRT (reviewer 1: 4.78±0.42 [early] vs. 3.11±1.16 [delayed]; reviewer 2: 4.70±0.47 [early] vs. 3.04±1.29 [delayed]). Inter-rater variability showed good correlation between reviewers (intraclass correlation 0.61-0.95). Mean LAA/LA attenuation ratios were significantly different between scans, with larger mean percent reduction of contrast opacification from LA to LAA in the early scans (57.0±36.6% reduction for early vs. 29.1±30.8% for delayed; p < 0.001) CONCLUSION: For CT device surveillance post-LAAC early phase imaging provides superior image quality objectively and subjectively compared with delayed scanning.

Safety and Feasibility of Same-Day Discharge After Left Atrial Appendage Closure.

Subacute or late complications > 24 hours after left atrial appendage closure (LAAC) are infrequent. We therefore created a clinical pathway to enable safe same-day discharge (SDD) after LAAC. Patients were assessed for overall physical conditioning, lack of significant frailty and comorbidities limiting physical abilities, good home support, and patient preference. Of 78 LAACs performed, 24 patients (30.8%) were discharged the same day: 21 were transesophageal echocardiography guided and 3 intracardiac echocardiography guided. SDD clinical pathway patients were discharged 395.4 ± 56.6 minutes after leaving the procedural room. There were no clinical complications at 1 month or in long-term follow-up. SDD is safe and feasible after LAAC, following a dedicated clinical pathway and surveillance in carefully selected patients.

Periprocedural Imaging for Left Atrial Appendage Closure: Computed Tomography, Transesophageal Echocardiography, and Intracardiac Echocardiography.

Percutaneous left atrial appendage closure is increasingly performed for stroke prevention for patients with nonvalvular atrial fibrillation with contraindications to oral anticoagulation. The success and complication rates with left atrial appendage closure have dramatically improved with maturing experience, growing procedural familiarity, and preprocedural planning. Multimodality imaging involving cardiac computer tomography angiography, transesophageal echocardiography, or intracardiac echocardiography in conjunction with fluoroscopy has improved the efficacy, procedural success, and safety of left atrial appendage closure in recent years. Proceduralists need to familiarize themselves with the various modalities and understand their complimentary roles and their limitations.

Spontaneous coronary artery dissection: update 2019.

PURPOSE OF REVIEW: Spontaneous coronary artery dissection (SCAD) is an important cause of myocardial infarction (MI) in women with few or no conventional cardiovascular risk factors. Lack of awareness about this condition among healthcare providers had led to significant underdiagnosis and misdiagnosis in this relatively young patient population. RECENT FINDINGS: The current review summarizes the contemporary data on cause, management strategies and outcomes of SCAD. SUMMARY: SCAD is not as rare as previously thought, accounting for up to 4% of all acute coronary syndromes. It is frequently linked with predisposing factors, such as fibromuscular dysplasia or other vasculopathies, and is often triggered by physical or emotional stress. Due to more fragile vessel architecture, coronary angiography as the first-line diagnostic tool should be performed meticulously to avoid iatrogenic dissection. Intravascular imaging may be required if angiographic findings are uncertain. Unless patients have high-risk features such as ongoing ischemia, recurrent chest pains, left main artery dissection, ventricular arrhythmias, or hemodynamic instability, a conservative treatment strategy is favored over revascularization. Close monitoring is essential after a SCAD-event as recurrent cardiovascular events post-SCAD are frequent.

Spontaneous coronary artery dissection: a review of complications and management strategies.

INTRODUCTION: Spontaneous coronary artery dissection (SCAD) accounts for up to 4% of acute coronary syndromes (ACS) on coronary angiography and predominantly affects women (>90%). SCAD most often occurs in patients with few or no conventional cardiovascular risk factors. This condition remains underdiagnosed due to a lack of awareness among health-care providers and misdiagnosis on coronary angiography. Areas covered: In this review, authors aim to summarize contemporary data on the etiology, morbidity and mortality risks, as well as management strategies in order to raise awareness. Expert opinion: The last decade of extensive research revealed that SCAD is not as rare as previously thought and needs to be in the differential diagnosis of all MI patients, especially in young to middle-aged women. Predisposing factors, such as fibromuscular dysplasia, and potential triggers like physical or emotional stresses, are frequently linked. Coronary angiography is the first-line diagnostic tool and should be performed meticulously because of more fragile vessel architecture to avoid iatrogenic dissections. If angiographic findings are uncertain, the use of intravascular imaging may be required. Conservative therapy is favored over revascularization unless patients have high-risk features. Recurrent cardiovascular events post-SCAD are frequent, and patients should be closely monitored after a SCAD event.

Propensity score-matched analysis of aortic valve replacement by mini-thoracotomy.

BACKGROUND AND AIM OF THE STUDY: Although minimally invasive aortic valve replacement (MIAVR) through an anterolateral mini-thoracotomy has been shown to reduce surgical trauma, the technique is utilized only at a few selected heart surgery centers. The study aim was to demonstrate the implementation of a MIAVR program at the Innsbruck Medical University, Austria. METHODS: Between October 2006 and January 2009, a total of 315 patients underwent elective isolated aortic valve replacement (AVR). Of these patients, 87 (27.6%) received MIAVR, while the remainder (n = 228) underwent 'conventional' AVR by full sternotomy. In the MIAVR group, 76 patients (87%) were cannulated via the femoral artery. The mean EuroSCORE was 5.7 +/- 2.2 in the MIAVR group, and 6.7 +/- 2.9 in the AVR group (p < 0.001). Propensity score matching was used to reduce the impact of treatment selection in the comparison of MIAVR with conventional AVR. The propensity score was used to yield two matched groups by means of a 1:1 sample matching. RESULTS: The total operative, cardiopulmonary bypass and aortic cross-clamp times were significantly longer in the MIAVR group compared to the matched AVR group. The actuarial one-year survival was 96% in the MIAVR group, and 98% in the propensity-matched AVR group (p = 0.57). Reoperation due to bleeding was necessary in 4.6% of the MIAVR group (four patients, three by mini-thoracotomy) compared to 5.7% in the matched AVR group (n = 5; p = 0.38). A total of six MIAVR patients (6.9%) had complications from the cannulated groin, predominantly lymphatic fistula formation. Additionally, there was a trend towards a higher rate of renal insufficiency in the MIAVR group (p = 0.07). CONCLUSION: MIAVR can be safely implemented as routine cardiac surgery procedure, although the operative times are significantly longer. The early postoperative outcome was equal to that of the sternotomy approach, but postoperative complications were predominantly associated with femoral cannulation.