Embolization of percutaneous left atrial appendage closure devices: Timing, management and clinical outcomes.

BACKGROUND: Left atrial appendage (LAA) occluder embolization is an infrequent but serious complication. OBJECTIVES: We aim to describe timing, management and clinical outcomes of device embolization in a multi-center registry. METHODS: Patient characteristics, imaging findings and procedure and follow-up data were collected retrospectively. Device embolizations were categorized according to 1) timing 2) management and 3) clinical outcomes. RESULTS: Sixty-seven centers contributed data. Device embolization occurred in 108 patients. In 70.4 % of cases, it happened within the first 24 h of the procedure. The device was purposefully left in the LA and the aorta in two (1.9 %) patients, an initial percutaneous retrieval was attempted in 81 (75.0 %) and surgery without prior percutaneous retrieval attempt was performed in 23 (21.3 %) patients. Two patients died before a retrieval attempt could be made. In 28/81 (34.6 %) patients with an initial percutaneous retrieval attempt a second, additional attempt was performed, which was associated with a high mortality (death in patients with one attempt: 2.9 % vs. second attempt: 21.4 %, p < 0.001). The primary outcome (bailout surgery, cardiogenic shock, stroke, TIA, and/or death) occurred in 47 (43.5 %) patients. Other major complications related to device embolization occurred in 21 (19.4 %) patients. CONCLUSIONS: The majority of device embolizations after LAA closure occurs early. A percutaneous approach is often the preferred method for a first rescue attempt. Major adverse event rates, including death, are high particularly if the first retrieval attempt was unsuccessful. CONDENSED ABSTRACT: This dedicated multicenter registry examined timing, management, and clinical outcome of device embolization. Early embolization (70.4 %) was most frequent. As a first rescue attempt, percutaneous retrieval was preferred in 75.0 %, followed by surgical removal (21.3 %). In patients with a second retrieval attempt a higher mortality (death first attempt: 2.9 % vs. death second attempt: 24.1 %, p < 0.001) was observed. Mortality (10.2 %) and the major complication rate after device embolization were high.

Prognostic impact of cardiohepatic syndrome in patients with ST-segment elevation myocardial infarction.

Background: Cardiohepatic syndrome (CHS) indicates a bidirectional interaction between the heart and liver. This study was designed to evaluate the impact of CHS on in-hospital and long-term mortality in patients with ST-segment elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention. Materials & methods: 1541 consecutive STEMI patients were examined. CHS was defined as the elevation of at least two of three cholestatic liver enzymes: total bilirubin, alkaline phosphatase and gamma-glutamyl transferase. Results: CHS was present in 144 (9.34%) patients. Multivariate analyses revealed CHS as an independent predictor of in-hospital (odds ratio: 2.48; 95% CI: 1.42-4.34; p = 0.001) and long-term mortality (hazard ratio: 2.4; 95% CI: 1.79-3.22; p < 0.001). Conclusion: The presence of CHS is a predictor of poor prognosis in patients with STEMI and should be evaluated during the risk stratification of these patients.

Performance of the Academic Research Consortium High Bleeding Risk Criteria in Patients With ST-Segment Elevation Myocardial Infarction: A Single Center Study.

We assessed the ability of predicting mortality and total in-hospital bleeding and adverse outcomes by the Academic Research Consortium High Bleeding Risk (ARC-HBR) criteria in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (pPCI). A total of 1441 STEMI patients were recruited: HBR group 354 (25%) patients and non-HBR group of 1087 (75%) patients. A total of 131 patients (9%) had a bleeding complication during hospitalization. The bleeding complications were also categorized according to other conventional bleeding scores. According to these conventional scores, all bleeding categories were associated with HBR. In univariate logistic regression analysis, female gender, diabetes mellitus, hypertension (HT) and HBR were associated with in-hospital bleeding. However, in multivariable analysis only HT (Odds Ratio [OR] 1.528, 95% CI 1.020-2.290; P = .040) and HBR (OR 1.612, 95% CI 1.075-2.428; P = .022) independently predicted total in-hospital bleeding complications. Hospital duration was longer and mortality rate was significantly higher in patients with HBR (OR 8.755, 95% CI 5.864-13.074; P < .01). The ARC-HBR criteria may predict in-hospital bleeding events and adverse outcomes in STEMI patients undergoing pPCI.

Relationship between in-hospital mortality and creatinine/albumin in patients with ST-elevation myocardial infarction without standard modifiable risk factors.

Background: Diabetes, hypertension, hyperlipidemia and smoking are associated with coronary artery disease and ST-elevation myocardial infarction (STEMI). However, patients without any classic risk factors have a higher mortality rate in the post-STEMI period. The aim of this study was to investigate the relationship between in-hospital mortality and creatinine/albumin ratio in patients with STEMI without modifiable risk factors. Materials & methods: All patients included in this study with a diagnosis of STEMI and who underwent primary percutaneous intervention between 2016 and 2020 were retrospectively analyzed. Patients were included in the standard modifiable cardiovascular risk factor (SMuRF) group if at least diabetes, hypertension, smoking or hyperlipidemia was present according to risk factors. Patients without these risk factors were considered the non-SMuRF group. Results: Creatinine/albumin ratio was found to be higher in non-SMuRF patients with mortality (p < 0.001). In multivariate logistic regression analysis, ejection fraction, hemoglobin and SMuRF were found to be inversely associated with in-hospital mortality (odds ratio [OR]: 0.48, 95% CI: 0.35-0.66, p < 0.001; OR: 0.70, 95% CI: 0.56-0.88, p = 0.002; OR: 0.57, 95% CI: 0.34-0.95, p = 0.03, respectively). Conclusion: The creatinine/albumin ratio can be used as a predictor of mortality in these patients; it can help identify high-risk patients beforehand.

Prognostic value of triglyceride/glucose index in patients with ST-segment elevation myocardial infarction.

Aim: New parameters are emerging to predict prognosis in patients with ST-segment elevation myocardial infarction (STEMI). In this study we aimed to determine and compare the prognostic values of some metabolic indices in terms of predicting long-term mortality in patients with STEMI. Method: A total of 1900 nondiabetic patients who presented with STEMI and underwent percutaneous coronary intervention were included in the study. Multivariable Cox proportional regression analysis was used to determine and compare the predictive performance of triglyceride-glucose (TyG) index, triglyceride-high-density lipoprotein ratio (Ty/HDL) and admission glucose. Results: In multivariable Cox regression analysis, the model based on TyG index had better predictive performance than the Ty/HDL and admission blood glucose. Conclusion: The TyG index is more informative than Ty/HDL and admission glucose level to predict long-term all-cause mortality.

The association of acute--to--chronic glycemic ratio with no-reflow in patients with ST--segment elevation myocardial infarction undergoing primary percutaneous coronary intervention.

BACKGROUND: No­reflow (NR) is a strong and independent predictor of poor cardiovascular outcomes among patients with ST­segment elevation myocardial infarction (STEMI). AIMS: The aim of the study was to investigate the association of the acute­to­chronic (A/C) glycemic ratio with no­reflow (NR) in STEMI patients following primary percutaneous coronary intervention (PCI). METHODS: This retrospective study included 905 patients with STEMI. The A/C glycemic ratio was determined as admission blood glucose (ABG) divided by the estimated average glucose (eAG). We evaluated 2 primary models (full model and reduced model). The primary outcome was the presence of NR. RESULTS: The incidence of NR was 22.7% (206 cases) in the present study. We divided the study population into 3 tertiles (T1, T2, and T3) based on the ABG/eAG ratio. There was a stepwise increase of the frequency of NR from the T1 to T3 group (36 patients [12%] vs 70 patients [23%] vs 100 patients [33%]; respectively [P <0.001, for each group comparison]). In a full model, the ABG/eAG ratio (OR, 2.274; 95% CI, 1.587-3.26; P <0.001) was associated with NR. After the performance of a step-down backward variable selection method, the thrombus grade, the ABG/eAG ratio, the infarct­related artery diameter, and age remained in the reduced model. The ABG/eAG ratio (contributing 25.3% of the explainable outcome in the model) was one of the strong predictors of NR in the reduced model. CONCLUSIONS: To our knowledge, this might be the first study showing a significant relationship between the ABG/eAG ratios with NR in patients with STEMI after primary PCI.

Two-dimensional speckle-tracking echocardiography-based left atrial strain parameters predict masked hypertension in patients with hypertensive response to exercise.

OBJECTIVE: We aim to study left atrial (LA) strains in patients with hypertensive response to exercise (HRE) and determine their usefulness in predicting masked hypertension (HT). METHODS: Ninety-eight normotensive patients who had HRE were included and were divided into two groups after masked HT had been diagnosed by ambulatory blood pressure monitoring. Conventional echocardiographic parameters and two-dimensional speckle-tracking echocardiography-based LA strain parameters were compared. RESULTS: Patients with masked HT have higher left ventricle mass index (LVMI) (88.1±11.3 vs. 82.5±8.7 g/m, P<0.05), left atrium maximum volume index (LAVI) (34.5±5.1 vs. 30.2±5.6 ml/m, P<0.001), lower global longitudinal LA strain during ventricular systole (GLAs-res) (32.5±8.9 vs. 40.2±9.1%, P<0.001), and lower global longitudinal LA strain during late diastole (GLAs-pump) (15.8±4.1 vs. 18.1±5.8%, P<0.05). In univariate analysis, a good negative correlation was found between GLAs-res versus LAVI (r=-0.451, P<0.001), GLAs-res versus LVMI (r=-0.457, P<0.001) and a moderate negative correlation was present between GLAs-pump versus LAVI (r=-0.317, P<0.001) and GLAs-pump versus LVMI (r=-0.288, P<0.05). GLAs-res and LAVI were found to be independent predictors of masked HT. Receiver-operating characteristic analysis was carried out. Area under the curve to predict masked HT was 0.729 (95% confidence interval: 0.623-0.832, P<0.001). GLAs-res less than 33.1% predicted masked HT with 73% sensitivity and 61.5% specificity. CONCLUSION: LA strain parameters were impaired in patients with masked HT and can be used to predict the presence of masked HT in patients with HRE.

Clinical and echocardiographic evaluation of mitral valve aneurysms: a retrospective, single center study.

Mitral valve aneurysms (MVAs) are rarely encountered in echocardiography laboratories. Although they are commonly associated with endocarditis of the aortic valve, various mechanisms have been suggested for the etiopathogenesis of MVAs associated with non-infectious conditions. 5,887 patients who underwent transesophageal echocardiography (TEE) between 2007 and 2012 were evaluated retrospectively for MVA. Mitral valve aneurysm is defined as a localized saccular bulging of the mitral leaflet towards the left atrium with systolic expansion and diastolic collapse. The color flow Doppler image of a perforation was described as a high-velocity turbulent jet traversing a valve leaflet in systole. We found that 12 of 5,887 patients (0.204 %) had MVA in TEE examinations. The mean age of patients with MVA was 53 years (range 21-80 years), including four females and eight males. Nine patients presented with symptoms of endocarditis. On TEE, aneurysms were located in the anterior mitral leaflet in 11 patients, and in the posterior mitral leaflet in one patient. Eight patients had severe, three had moderate, and one had trace mitral regurgitation. Of the nine patients with perforated leaflets, eight patients had severe and one patient had moderate mitral regurgitation. Aortic regurgitation was present in nine patients, being severe in three, moderate in two, mild in two, and trace in two patients. Two patients without severe mitral regurgitation were followed-up conservatively, while nine patients underwent surgery. Two patients died from septic shock, one in the postoperative period and the other one prior to surgery. Although MVAs occur during the course of aortic valve endocarditis and, in particular, due to aortic regurgitation jet, it should be borne in mind that they may develop as an isolated valvular pathology and may be misdiagnosed as chordal rupture, other cardiac masses, or vegetation. Thus, MVAs may not be so infrequent as they are thought; they may justify to be considered in the differential diagnosis of masses seen on the mitral valve on echocardiographic examination.

Impaired left ventricular mechanics in nonalcoholic fatty liver disease: a speckle-tracking echocardiography study.

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) encompasses a disease spectrum ranging from simple steatosis to nonalcoholic steatohepatitis (NASH). We aimed to evaluate left ventricular (LV) systolic function using two-dimensional speckle-tracking echocardiography (2D-STE) in patients with NAFLD and to investigate whether any changes exist among the subgroups of NAFLD. MATERIALS AND METHODS: We included 55 NAFLD patients and 21 healthy controls. The diagnosis of NAFLD was made on the basis of liver biopsy. After the patients were categorized into groups according to their histopathological analysis (simple steatosis, borderline NASH, and definitive NASH), all patients underwent echocardiography. In the 2D-STE analysis of the LV global longitudinal strain (G-LS), strain rate in systole (G-SRsys), strain rate in early diastole (G-SRearly), and strain rate in late diastole (G-SRlate) values were obtained. RESULTS: G-LS and G-SRsys values were lower in the NAFLD group. Although there was a significant difference in the G-LS between controls and simple steatosis, borderline NASH, and definitive NASH, no significant differences were found between NAFLD groups. To investigate whether impaired LV systolic dysfunction, determined using 2D-STE, is the consequence of NAFLD components, we included a subgroup. A total of 11 patients with NAFLD who were normotensive, nondiabetic, nonobese, and had a normal lipid profile and low homeostasis model assessment of insulin resistance (HOMA-IR) values were included. Echocardiographic abnormalities in systolic function were not different between this subgroup of NAFLD and healthy individuals. CONCLUSION: Patients with NAFLD and its subgroups have evidence of subclinical myocardial dysfunction in relation to the presence of insulin resistance. 2D-STE could not be used for differentiation of the NAFLD subgroups.

Infective endocarditis complicating hypertrophic obstructive cardiomyopathy: is antibiotic prophylaxis really unnecessary?

Infective endocarditis is a relatively rare complication of hypertrophic cardiomyopathy. Infective endocarditis in hypertrophic cardiomyopathy is almost always seen in patients with outflow obstruction and is more common in those with both outflow obstruction and atrial dilatation. We present a case of culture negative mitral valve endocarditis in a previously asymptomatic woman with hypertrophic cardiomyopathy who died in the course of the disease.

The prognostic value of serum albumin levels on admission in patients with acute ST-segment elevation myocardial infarction undergoing a primary percutaneous coronary intervention.

OBJECTIVES: Hypoalbuminemia is associated with a poor prognosis in patients with end-stage renal disease, chronic ischemic heart disease, heart failure (HF), and stroke. We aimed to investigate its prognostic value in patients with acute ST-segment elevation myocardial infarction (STEMI) treated by a primary percutaneous coronary intervention (p-PCI). MATERIALS AND METHODS: We retrospectively enrolled 1706 patients with STEMI treated by p-PCI. We prospectively followed up the patients for a median duration of 40 months. RESULTS: On admission, hypoalbuminemia (<3.5 g/dl) was present in 519 (30.4%) patients. The incidence of final TIMI grade 3 flow (84 vs. 91.4%, P<0.001) was lower in the patients with hypoalbuminemia. In-hospital mortality (9.4 vs. 2%), HF (20.2 vs. 8.6%), and major bleeding (6 vs. 2.5%) rates were significantly higher in patients with hypoalbuminemia. However, in-hospital stroke and reinfarction rates were similar in both groups. At long-term follow-up (median duration: 42 months), all-cause mortality (23.3 vs. 8.4%, P<0.001), reinfarction (11.6 vs. 7.7%, P=0.013), stroke (2.6 vs. 1.1%, P=0.031), and advanced HF (13.3 vs. 6.1%, P<0.001) rates were significantly higher in patients with hypoalbuminemia. In the Cox proportional hazard model, hypoalbuminemia was determined as an independent predictor of long-term mortality [hazard ratio 2.98, 95% confidence interval 1.35-6.58, P=0.007) and development of advanced HF (hazard ratio 2.96, 95% confidence interval 1.44-6.08, P=0.003). CONCLUSION: Hypoalbuminemia on admission is a strong independent predictor for long-term mortality and development of advanced HF in patients with STEMI undergoing p-PCI.

Clinical outcomes and effectiveness of renal artery stenting in patients with critical atherosclerotic renal artery stenosis: does it improve blood pressure control and renal function assessed by estimated glomerular filtration rate?

INTRODUCTION: Atherosclerotic renal artery stenosis (ARAS) is associated with uncontrolled hypertension and chronic renal failure. AIM: To evaluate the influence of gender and presence of chronic renal failure on the outcomes of percutaneous transluminal renal artery stenting (PTRAS) due to atherosclerosis. MATERIAL AND METHODS: A total of 28 ARAS patients underwent PTRAS and 36 stents were placed. Basal characteristics, laboratory data and blood pressure of patients were recorded. The differences between genders and improvement/deterioration of renal functions and blood pressure were analyzed. The predictors of outcomes were determined. RESULTS: Baseline characteristics were similar between men and women. Significant improvement of systolic and diastolic blood pressure control was achieved after PTRAS (153.04 ±17.07 mm Hg vs. 124.75 ±11.40 mm Hg, p = 0.001 and 92.50 ±10.76 mm Hg vs. 77.54 ±8.23 mm Hg, p < 0.001, respectively). Although mean estimated glomerular filtration rate (eGFR) and creatinine levels did not significantly improve at the 6-month follow-up visit compared to baseline values, of the 28 patients 13 (46.4%) patients had improvement of renal functions. CONCLUSIONS: Our results suggest that PTRAS is a safe procedure and may offer blood pressure control but beneficial effects of PTRAS on renal function may be anticipated in a selected group of patients, especially those with a low eGFR.

Acute anterior myocardial infarction in an 85-year-old male patient, complicated by the deadly duo: ventricular septal rupture and pseudoaneurysm.

Ventricular septal rupture and ventricular pseudoaneurysm formation are rare complications of acute myocardial infarction. Immediate intervention is mandatory in these circumstances. Our case is a unique presentation of an anterior myocardial infarction in an 85-year-old male, complicated by ventricular septal rupture and ventricular pseudoaneurysm formation.

An incomplete heart with incomplete lungs.

Congenital hypoplasia or agenesis of mitral valves is a very rare condition. It is sometimes seen together with other congenital anomalies. We present a demonstrative case of posterior mitral leaflet hypoplasia seen together with congenital lungs anomaly.