Management of peri-device leak following left atrial appendage closure: A systematic review.

OBJECTIVE: This study aimed to examine the cumulative experience of peri-device leak (PDL) closure following left atrial appendage (LAA) closure. BACKGROUND: The management of PDL following LAA closure remains controversial. While PDL closure has been proposed, procedural features and clinical outcomes have not been well established. METHODS: A systematic review of all published cases of PDL closure with available anatomical, procedural, and clinical outcomes was performed. RESULTS: We identified 18 indexed publications and 110 cases between April 2013 and March 2020. 71 patients (mean age 72 ± 8 yrs), met study criteria and were included. PDL closure was most common in males, bilobar LAA morphology, and after Watchman procedures. The mean PDL size was 7.6 ± 5.8 mm (range 2-26 mm). Leaks were classified according to size: small (<5 mm; 45%), moderate (≥5-9 mm; 25%), and large (≥10 mm; 30%). Endovascular coils and endovascular plugs were used to close both small and moderate sized leaks, and second LAA closure devices were exclusively used for large PDLs. Successful PDL closure occurred in 90%, and was similar between PDL sizes and types of occluder used. Procedural complication rates were uncommon (2.8%). No strokes were reported following PDL closure at 6 months. CONCLUSIONS: In patients with PDL for whom discontinuation of OAC may be considered unsafe, percutaneous closure using a tailored approach with either endovascular coils, plugs, or second occluder represents a safe, and feasible alternative associated with favorable clinical outcomes.

A systematic review on the use of ultrasound enhancing agents with transesophageal echocardiography to assess the left atrial appendage prior to cardioversion.

BACKGROUND: Assessment of the left atrium and atrial appendage (LAA) for thrombus by transesophageal echocardiography (TEE) may be suboptimal due to difficult imaging windows and ultrasound artifacts. The present study analyzed the benefit of using ultrasound enhancing agents (UEAs) with TEE to improve diagnostic accuracy and image quality. METHODS: A systematic review of studies published through December 2020 was performed, and included investigations comparing the number of cases deemed indeterminate for visualization of LAA thrombi on TEE pre- versus post-UEAs prior to cardioversion for atrial fibrillation or flutter (AF). Study results were pooled where the number of indeterminate cases by conventional TEE were re-classified as thrombus present, indeterminate, or thrombus excluded following administration of UEAs. RESULTS: Three studies with a total of 399 patients were identified. Of these, 83 (26%) participants met the inclusion criteria. The mean age of the study population from the three studies was 66 ± 12 years, 29% were female, and prevalence of congestive heart failure or neurologic events was 22% and 5%, respectively. Use of UEAs with TEE re-classified 66% (55/83) of cases initially deemed to be indeterminate for LAA thrombus on conventional TEE. Thrombus was present in 13% (11/83) and excluded in 53% (44/83) of cases; 34% (28/83) of cases remained indeterminate on TEE post-UEAs. There were no complications reported with the administration of UEAs. CONCLUSION: Adjunctive use of UEAs with TEE can facilitate the diagnosis or exclusion of LAA thrombus, and improve the procedural confidence and cost-efficiency of cardioversion for AF.

Long-term clinical outcomes and prognostic indicators for focal impulse and rotor modulation guided ablation: A single-center observational study.

BACKGROUND: Electrophysiologists have developed a computational mapping approach to localize sources that may perpetuate persistent atrial fibrillation (AF). Focal impulse and rotor modulation (FIRM)-guided ablation of these sources have produced variable results. The current study further assesses single-procedure success rates of FIRM-guided ablation for preventing AF or atrial tachyarrhythmia recurrence and analyzes different baseline characteristics as prognostic indicators for individuals experiencing these undesired outcomes. METHODS: Seventy-one consecutive patients (mean age 64.58 ± 9.05 years and 36.6% female) with drug-refractory persistent AF with and without prior history of pulmonary vein antral isolation (PVAI) underwent FIRM-guided ablation. Patients without prior history of PVAI underwent FIRM-guided ablation in addition to de novo PVAI. Patients with prior history of PVAI had the pulmonary veins reassessed at the time of FIRM-guided ablation for reconnection as well as re-isolation, when necessary. These patients were then prospectively followed for AF and atrial tachyarrhythmia recurrence. RESULTS: FIRM analysis revealed rotors in the right atrium in 66.2% (1.77 ± 1.53 mean rotors per patient) and in the left atrium in 85.9% (2.65 ± 1.52 mean rotors per patient) of patients analyzed in the current study. After a single FIRM-guided ablation procedure, AF and atrial tachyarrhythmia recurrence was demonstrated in 21.1% (15/71) and 33.8% (24/71) of patients, respectively. The entire cohort of patients were followed for a mean duration of 23.20 ± 8.38 months with the mean time to AF recurrence found to be 12.35 ± 10.44 months. Furthermore, valvular heart disease (i.e. moderate mitral or tricuspid regurgitation) was found to be a statistically significant independent predictor for AF recurrence following FIRM-guided ablation (p = .033). CONCLUSIONS: FIRM-guided ablation in combination with PVAI is a suitable and effective approach for symptomatic individuals with drug-refractory persistent AF with and without prior history of PVAI. Randomized controlled studies are warranted.

Dual vs Single Cardioversion of Atrial Fibrillation in Patients With Obesity: A Randomized Clinical Trial.

Importance: Atrial fibrillation and obesity are common, and both are increasing in prevalence. Obesity is associated with failure of cardioversion of atrial fibrillation using a standard single set of defibrillator pads, even at high output. Objective: To compare the efficacy and safety of dual direct-current cardioversion (DCCV) using 2 sets of pads, with each pair simultaneously delivering 200 J, with traditional single 200-J DCCV using 1 set of pads in patients with obesity and atrial fibrillation. Design, Setting, and Participants: This was a prospective, investigator-initiated, patient-blinded, randomized clinical trial spanning 3 years from August 2020 to 2023. As a multicenter trial, the setting included 3 sites in Louisiana. Eligibility criteria included body mass index (BMI) of 35 or higher (calculated as weight in kilograms divided by height in meters squared), age 18 years or older, and planned nonemergent electrical cardioversion for atrial fibrillation. Patients who met inclusion criteria were randomized 1:1. Exclusions occurred due to spontaneous cardioversion, instability, thrombus, or BMI below threshold. Interventions: Dual DCCV vs single DCCV. Main Outcomes and Measures: Return to sinus rhythm, regardless of duration, immediately after the first cardioversion attempt of atrial fibrillation, adverse cardiovascular events, and chest discomfort after the procedure. Results: Of 2079 sequential patients undergoing cardioversion, 276 met inclusion criteria and were approached for participation. Of these, 210 participants were randomized 1:1. After exclusions, 200 patients (median [IQR] age, 67.6 [60.1-72.4] years; 127 male [63.5%]) completed the study. The mean (SD) BMI was 41.2 (6.5). Cardioversion was successful more often with dual DCCV compared with single DCCV (97 of 99 patients [98%] vs 87 of 101 patients [86%]; P = .002). Dual cardioversion predicted success (odds ratio, 6.7; 95% CI, 3.3-13.6; P = .01). Patients in the single cardioversion cohort whose first attempt failed underwent dual cardioversion with all subsequent attempts (up to 3 total), all of which were successful: 12 of 14 after second cardioversion and 2 of 14 after third cardioversion. There was no difference in the rating of postprocedure chest discomfort (median in both groups = 0 of 10; P = .40). There were no cardiovascular complications. Conclusions and Relevance: In patients with obesity (BMI ≥35) undergoing electrical cardioversion for atrial fibrillation, dual DCCV results in greater cardioversion success compared with single DCCV, without any increase in complications or patient discomfort. Trial Registration: ClinicalTrials.gov Identifier: NCT04539158.

First Experience Using a Nonfenestrated Cardioform Septal Occluder for Closure of Giant Mitral Paravalvular Leak.

A variety of fenestrated vascular plugs have been used to seal paravalvular leaks with meaningful success; however, incomplete closure and refractory hemolysis remains a common problem. We describe the feasibility and rationale of their first experience using a nonfenestrated Cardioform Septal Occluder (Gore Medical, Flagstaff, Arizona) to treat a giant mitral paravalvular leak. (Level of Difficulty: Advanced.).

Central sleep apnea and atrial fibrillation: A review on pathophysiological mechanisms and therapeutic implications.

Precipitating factors and chronic diseases associated with atrial fibrillation (AF) are detailed in the literature. Emerging evidence over the last several decades suggests a potential causal relationship between central sleep apnea (CSA) and AF. Mechanisms including apnea-induced hypoxia with intermittent arousal, fluctuating levels of carbon dioxide, enhanced sympathetic/neurohormonal activation and oxidative stress causing inflammation have been implicated as etiologic causes of AF within this subpopulation. CSA affects the efficacy of pharmacologic and catheter-based antiarrhythmic treatments, which is why treating CSA prior to these interventions may lead to lower rates of AF. Subsequently, a reduction in the AF burden with transvenous phrenic nerve stimulation (TPNS) has become a topic of interest. The present review describes the relationship between these conditions, pathophysiologic mechanisms implicating the role of CSA in development of AF, and emerging therapeutic interventions.

When "Blue Babies" Grow Up: Complications After Surgical Repair of Tetralogy of Fallot.

Tetralogy of Fallot (TOF) is a complex congenital cardiac defect. Surgical correction is well established as the treatment of choice and has resulted in a rapidly growing group of adults living with TOF. We describe potential complications of patients who have undergone TOF repair and were lost to follow-up. (Level of Difficulty: Intermediate.).

Levo-transposition of the Great Arteries in an Adult Patient: Management Considerations and Treatment Strategy.

Levo-transposition of the great arteries (L-TGA) is a rare congenital heart anomaly associated with the increased risk of developing heart failure (HF) as well as complete heart block at a young age. Due to limited data regarding the treatment strategy in the adult L-TGA sub-population, shared medical decision-making should occur between the patient and a team of physicians. Clinical status, age, and associated cardiac lesions or rhythm disturbances can affect patient outcomes. These factors should be considered prior to pursuing a surgical versus a medicinal approach.

Will Mary Jane Leave You Heartbroken? Marijuana Use and Risk of Takotsubo Cardiomyopathy.

Takotsubo cardiomyopathy (TTC) is prevalent in 2% of patients who present with symptoms suggestive of acute myocardial infarction. It may be triggered by stressful events, resulting in catecholamine surges, myocardial stunning, and disturbances in contractility. TTC in males has been associated with marijuana use and leads to a fivefold increased risk of cardiac events. Marijuana is thought to generate a similar surge in catecholamines leading to tachycardia and elevation of both systolic and diastolic blood pressure. The question remains whether this catecholamine surge is sufficient enough to cause TTC. It is apparent a correlation between marijuana use and TTC may exist. Exogenous cannabinoid stimulation may lead to myocardial stunning via stimulation seen with hypercatecholaminergic states. Understanding the risk factors involved and increasing awareness of cardiovascular complications related to cannabinoid substances becomes more relevant as its use is increasing both recreationally and medically.  We present a case of a 50 year-old African-American male with hypertension and regular marijuana use who presented with chest pain radiating to the back. Due to abnormal electrocardiogram and positive cardiac biomarkers concerning for acute coronary syndrome, the patient underwent subsequent coronary angiography that showed no significant coronary obstruction; however, left ventriculogram showed the characteristic apical ballooning of TTC. Our case highlights the pathophysiological mechanism suspected to trigger TTC.

Comparison of Cardiovascular Outcomes by Dialysis Modality: A Systematic Review and Meta-Analysis.

Debates exist regarding the merit of starting one dialysis modality over the other for improved cardiovascular outcomes. Five previously published prospective and retrospective cohort studies have reported inconsistent conclusions on this topic. The aim of this systematic review and meta-analysis is to evaluate the influence initiation of hemodialysis (HD) vs peritoneal dialysis (PD) may have on the relative risk (RR) of subsequent development of adverse cardiovascular events (ACVE) in patients with end-stage renal disease (ESRD). Of the 518 records identified, 5 cohort studies, assessing a total of 47,062 patients were included in the meta-analysis. With regard to the subsequent development of ACVE following initiation on the different dialysis modalities, the pooled RR was found to be non-significant. Peritoneal dialysis is a suitable and cost-effective alternative to HD for ESRD patients at risk of cardiovascular disease.

Thromboembolic Outcomes of Different Anticoagulation Strategies for Patients with Atrial Fibrillation in the Setting of Hypertrophic Cardiomyopathy: A Systematic Review.

OBJECTIVE: Limited data is available assessing the efficacy and safety of different anticoagulation (AC) strategies for prevention of thromboembolic events, major bleeding, and all-cause mortality in patients with hypertrophic cardiomyopathy (HCM) and atrial fibrillation (AF). In this systematic review, we conducted a literature search to examine the possible association between different AC strategies and prevention of these adverse outcomes. METHODS: Scientific databases (PubMed, EMBASE, and Scopus) were searched using relevant medical subject headings and keywords to retrieve studies published through September of 2019. Studies assessing the outcomes of interest in patients with HCM and AF receiving AC, no AC as well as direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) were selected. RESULTS: This review identified 14 observational studies evaluating thromboembolic events by AC strategies in 8,479 participants with concomitant HCM and AF. The use of AC was associated with a lower pooled incidence rate of total thromboembolic events at 9.5% (112 events in 1,175 patients) compared to 22.1% with no AC (108 events in 489 patients). In addition, the use of DOACs was associated with a lower pooled incidence rate of thromboembolic events at 4.7% (169 events in 3,576 patients) compared to 8.7% with VKAs (281 events in 3,239 patients). Furthermore, the use of DOACs compared to VKAs was associated with a lower pooled incidence rate of major bleeding and all-cause mortality at 3.8% (136 events in 3,576 patients) versus 6.8% (220 events in 3,239 patients) and 4.1% (124 events in 3,008 patients) versus 16.1% (384 events in 2,380 patients), respectively. CONCLUSIONS: AC of patients with concomitant HCM and AF was associated with a lower incidence of thromboembolic events when compared to antiplatelet therapy or no treatment. Treatment with DOACs was also associated with a lower incidence of thromboembolic events, major bleeding, and all-cause mortality when compared to VKAs.

Eosinophilic Colitis Associated with Emtricitabine/Tenofovir.

Eosinophilic gastroenteritis (EGE) is a rare disease occurring commonly in patients with a history of allergies, asthma, food sensitivities, or parasite exposure. The condition has been postulated to occur when eosinophils accumulate at the intestinal epithelium resulting in inflammation, recruitment and degranulation of mast cells, and further propagation of eosinophil activation. While laboratory and microbiological data may point to the diagnosis, the condition is only confirmed via biopsy demonstrating the eosinophilic infiltration of the intestinal epithelium. Multiple medications have previously been implicated in causing EGE; however, this is the first documented case associated with emtricitabine/tenofovir.