Incidence and predictors of device-related thrombus after left atrial appendage closure with Watchman device.

Introduction: Left atrial appendage closure (LAAC) with Watchman device prevents thromboembolism in patients with atrial fibrillation (AF). However, thrombus may develop on the atrial surface of the device. Aim: To investigate the incidence and predictors of device-related thrombus (DRT) in patients with AF who were treated with LAAC. Material and methods: Ninety-one consecutive patients with AF underwent LAAC procedure using first-generation Watchman 2.5 device followed by antiplatelet therapy. In our analysis we have included all patients (n = 78) who had clinical follow-up visits with transesophageal echocardiography (TEE) after the procedure. Results: The median (IQR) CHA2DS2-VASc score was 4 (4.0-6.0) and HAS-BLED score was 3 (3.0-4.0). DRTs were observed in 5 (6.4%) patients. When compared with patients without DRT, those with DRT presented more often with lower median ejection fraction (40% (23.5-45.5) versus 55% (48.0-60.0); p = 0.005), lower emptying velocity of LAA (25 cm/s (17.5-27.0) versus 53 cm/s (26.5-78.0); p = 0.009), and with greater depth of implantation (18 mm (14.0-20.5) versus 8 mm (5.0-11.0); p < 0.001). Furthermore, patients with DRT had greater depth of LAA (35 mm (29.5-41.0) versus 29 mm (25.5-31.0); p = 0.003), greater mean (SD) dimension in 900 (22.4 mm (3.2) versus 19 mm (2.7); p = 0.02). Patients with DRT were also younger than those without DRT (67.4 years (7) versus 75 years (8.3), p = 0.045). Conclusions: The DRT after Watchman device implantation remains a rare complication. Its formation was related to several patient and procedural characteristics, which need to be confirmed in larger studies.

Assessment of symptom severity in psychotic disorder patients based on heart rate variability and accelerometer mobility data.

BACKGROUND: Advancement in mental health care requires easily accessible, efficient diagnostic and treatment assessment tools. Viable biomarkers could enable objectification and automation of the diagnostic and treatment process, currently dependent on a psychiatric interview. Available wearable technology and computational methods make it possible to incorporate heart rate variability (HRV), an indicator of autonomic nervous system (ANS) activity, into potential diagnostic and treatment assessment frameworks as a biomarker of disease severity in mental disorders, including schizophrenia and bipolar disorder (BD). METHOD: We used a commercially available electrocardiography (ECG) chest strap with a built-in accelerometer, i.e. Polar H10, to record R-R intervals and physical activity of 30 hospitalized schizophrenia or BD patients and 30 control participants through ca. 1.5-2 h time periods. We validated a novel approach to data acquisition based on a flexible, patient-friendly and cost-effective setting. We analyzed the relationship between HRV and the Positive and Negative Syndrome Scale (PANSS) test scores, as well as the HRV and mobility coefficient. We also proposed a method of rest period selection based on R-R intervals and mobility data. The source code for reproducing all experiments is available on GitHub, while the dataset is published on Zenodo. RESULTS: Mean HRV values were lower in the patient compared to the control group and negatively correlated with the results of the PANSS general subcategory. For the control group, we also discovered the inversely proportional dependency between the mobility coefficient, based on accelerometer data, and HRV. This relationship was less pronounced for the treatment group. CONCLUSIONS: HRV value itself, as well as the relationship between HRV and mobility, may be promising biomarkers in disease diagnostics. These findings can be used to develop a flexible monitoring system for symptom severity assessment.

Clinical and echocardiographic characterization of patients hospitalized for severe tricuspid valve regurgitation: a single tertiary-care center experience with two-year follow-up.

INTRODUCTION: Tricuspid regurgitation (TR) is a common acquired valvular heart disease. Recently new transcatheter treatment options for severe TR have emerged that could change the management of this condition, which warrants better characterization of this specific patient group. OBJECTIVES: The aim of the study was to describe the clinical and echocardiographic characteristics of patients with severe TR and to evaluate their short- and mid-term prognosis. PATIENTS AND METHODS: This retrospective, observational single-center study enrolled consecutive patients with severe TR hospitalized between January 2016 and September 2021 in the 1st Chair and Department of Cardiology, Medical University of Warsaw, Poland. The severity of heart failure (HF) was evaluated using New York Heart Association (NYHA) classification. Echocardiographic assessment was performed by experienced sonographer. EuroSCORE II and TRI-SCORE were computed for each patient. 12- and 24-month clinical outcomes were reported. RESULTS: There were 172 patients [93 female (54.1%)] included. The mean age was 76.4 (± 10.5) years. The most common comorbidities included: atrial fibrillation (84.9%), hypertension (68.0%), chronic kidney disease (54.1%), coronary artery disease (45.3%), diabetes mellitus (30.9%). The median EuroSCORE II and TRI-SCORE values were 4.68% and 14.0%, respectively. The median follow-up was 24 months. The overall mortality was 29.7% at 1 year and 47.3% at 2 years. TR grade, TAPSE <17 mm, TAPSE/SPAP <0.26 and right atrial area were significant factors associated with mortality. CONCLUSIONS: Patients presenting with severe TR are characterized by a large comorbidity burden and poor prognosis, despite intensive heart failure management.

Risk of left atrial appendage thrombus in older patients with atrial fibrillation.

Introduction: We aimed to compare the prevalence of left atrial appendage (LAA) thrombus and its predictors between old and young patients with atrial fibrillation (AF). Material and methods: The study included 1970 patients aged ≥ 65 (n = 822 (41.7%)) and < 65 (n = 1148 (58.3%)) referred for AF cardioversion or ablation preceded by transoesophageal echocardiography (TEE). Results: Oral anticoagulation (OAC) was prescribed in 799 (97.2%) patients aged ≥ 65 years and in 1054 (91.8%) of those aged < 65 years (p < 0.001). In patients treated with OAC, those aged ≥ 65 years less often received vitamin K antagonist (VKA) (267 (33.4%) vs. 416 (39.5%)) and more often non-VKA-OAC (NOAC) (532 (66.6%) vs. 638 (60.5%), p = 0.008, p = 0.008) compared to patients < 65 years. On TEE, LAA thrombus was more often observed in patients aged ≥ 65 years than those aged < 65 years (63 (7.7%) vs. 46 (4.0%), p < 0.001), with an absolute but not statistically significant difference between patients aged 65-74 and ≥ 75 years (47 (7.3%) vs. 16 (8.8%), p = 0.528). In patients aged ≥ 65 years, there was no difference in the prevalence of LAA thrombus between patients treated with VKA and NOAC, in contrast to patients aged < 65 years, in whom such a difference was observed (27 (6.5%) vs. 16 (2.5%), p = 0.002). In multivariate logistic regression, predictors of LAA thrombus in both age groups were older age, non-paroxysmal AF, and heart failure, whereas only in patients aged < 65 years - VKA use, and in those aged ≥ 65 years - lower glomerular filtration rate and platelet count. Conclusions: Despite OAC use, older patients with AF remain at high risk of LAA thrombus formation. Older age, non-paroxysmal AF, and heart failure are predictors of LAA thrombus, irrespective of age.

Safety and efficacy of percutaneous atrial appendage closure followed by antiplatelet therapy in a high-risk population: single-center experience with a WATCHMAN device.

Introduction: In our everyday practice we encounter many patients with non-valvular atrial fibrillation with either a contraindication to oral anticoagulation or with its inefficiency. Aim: To investigate whether left atrial appendage closure (LAAC) followed by post-procedure antiplatelet therapy is safe and efficient in a high-risk population. Material and methods: Ninety-one (48 males) consecutive patients with non-valvular atrial fibrillation (NVAF) underwent an LAAC procedure using a first-generation WATCHMAN 2.5 device followed by antiplatelet therapy. Clinical and transesophageal echocardiography data were collected at baseline and at the follow-up visit. Results: The median (IQR) CHA2DS2-VASc score was 5 (4.0-6.0) and the HAS-BLED score was 3 (3.0-4.0); the mean (SD) age was 74.4 (8.4). A bleeding history was observed in 89% of patients and 24.2% of patients had a history of stroke or transient ischemic attack (TIA). The procedure was successful in 98.9%. Post-procedure therapy was dual antiplatelet therapy in 85 patients; 3 patients received single antiplatelet therapy and the therapy was maintained until the follow-up visit. Peri-procedural complications were tamponade (3.3%), pericardial effusion (2.2%) and two deaths (2.2%) with no bleeding or vascular complications. The median follow-up was 67 (52.75-84.75) days. Primary safety endpoint (bleeding BARC type 3 or more, tamponade, pericardial effusion, and device embolization) and primary efficacy endpoint (stroke or TIA, hemorrhagic stroke, peripheral embolism, cardiovascular (CV) and non-CV death) were observed in 2 and 4 patients, respectively. Conclusions: The LAAC procedure followed by antiplatelet therapy seems to be safe and efficient in the high-risk population. Further studies in this field are required.

Impact of previous coronary artery revascularization on outcomes in patients undergoing transcatheter aortic valve implantation.

Introduction: Coexistence of coronary artery disease (CAD) in patients with severe aortic stenosis (AS) referred for transcatheter aortic valve implantation (TAVI) raises questions regarding the safety and efficacy of TAVI in this subset of patients. Aim: To evaluate the impact of previous coronary revascularization in terms of percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) on clinical outcomes after TAVI. Material and methods: A total of 507 consecutive patients who underwent TAVI were divided into: non-revascularization (NR), post-PCI and post-CABG groups. The endpoints were established according to VARC-2 definitions. Results: Patients with previous coronary revascularization (36.7% of the population) were younger, more often male and their EuroSCORE II risk evaluation was significantly higher (NR 7.9% vs. post-PCI 8.0% vs. post-CABG 20.5%, p < 0.0001). Patients after PCI or CABG prior to TAVI had similar 30-day all-cause mortality rates as those without coronary revascularization at baseline (NR vs. post-PCI vs. post-CABG: 8.1% vs. 5.5% vs. 6.8%, respectively; p = 0.6). There were no differences in 12-month all-cause mortality rates between groups (NR vs. post-PCI vs. post-CABG: 15.3% vs. 14.2% vs. 16.9%, respectively; log-rank p = 0.67). In the Cox proportional-hazards regression model, acute kidney injury stage 2-3 (HR = 3.7, 95% CI: 2.14-6.33; p < 0.001) and post-TAVI stroke (HR = 3.5, 95% CI: 1.57-7.8; p = 0.002) were independently correlated with 1-year mortality. Conclusions: TAVI seems to be a safe and effective procedure for the treatment of severe AS in patients with previous coronary revascularization.

Valve-in-valve transcatheter transfemoral mitral valve implantation (ViV-TMVI): Characteristics and early results from nationwide registry.

BACKGROUND: Valve-in-valve transcatheter transfemoral mitral valve implantation (ViV-TMVI) is an emerging treatment alternative to reoperation in high surgical risk patients with a failed mitral bioprostheses. AIM: To describe characteristics and evaluate 30-day outcomes of ViV-TMVI in the Polish population. METHODS: Nationwide registry was initiated to collect data of all patients with failed mitral bioprosthesis undergoing ViV-TMVI in Poland. This study presents 30-days clinical and echocardiographic follow-up. RESULTS: Overall, 27 ViV-TMVI were performed in 8 centers until May 2022 (85% since 2020). Mean (standard deviation [SD]) age was 73 (11.6) years with the median (interquartile range [IQR]) STS score of 5.3% (4.3%-14.3%). Mean (SD) time between surgical implantation and ViV-TMVI was 8.2 (3.2) years. Failed Hancock II (29%) and Perimount Magna (22%) were most frequently treated. Mechanisms of failure were equally often pure mitral regurgitation or stenosis (both 37%) with mixed etiology in 26%. Balloon-expandable Sapien 3/Ultra were used in all but 1 patient. Technical success was 96.3% (1 patient required additional prosthesis). Mean (SD) transvalvular mitral gradient reached 6.7 (2.2) mm Hg and mitral valve area was 1.8 (0.4) cm². None of the patients had moderate or severe mitral regurgitation with only 14.8% graded as mild. In 92.6% device success (2 patients had mean gradient ≥10 mm Hg) and in 85.6% procedural success was present. There were no deaths, cerebrovascular events or need for mitral valve surgery during 30-day follow-up. CONCLUSIONS: In short-term observation ViV-TMVI is safe and effective alternative for patients with failed mitral bioprosthesis at high surgical risk of re-operation. Longer observations on larger sample are warranted.

Impact of Enterococci vs. Staphylococci Induced Infective Endocarditis after Transcatheter Aortic Valve Implantation.

BACKGROUND: The two most common organisms found in infective endocarditis following transcatheter aortic valve implantation (TAVI-IE) are enterococci (EC-IE) and staphylococci (SC-IE). We aimed to compare clinical characteristics and outcomes of patients with EC-IE and SC-IE. METHODS: TAVI-IE patients from 2007 to 2021 were included in this analysis. The 1-year mortality was the primary outcome measure of this retrospective multi-center analysis. RESULTS: Out of 163 patients, 53 (32.5%) EC-IE and 69 (42.3%) SC-IE patients were included. Subjects were comparable with regard to age, sex, and clinically relevant baseline comorbidities. Symptoms at admission were not significantly different between groups, except for a lower risk for presenting with septic shock in EC-IE than SC-IE. Treatment was performed in 78% by antibiotics alone and in 22% of patients by surgery and antibiotics, with no significant differences between groups. The rate of any complication, in particular heart failure, renal failure, and septic shock during treatment for IE, was lower in EC-IE compared with SC-IE (p < 0.05). In-hospital (EC-IE: 36% vs. SC-IE: 56%, p = 0.035) and 1-year mortality (EC-IE: 51% vs. SC-IE: 70%, p = 0.009) were significantly lower in EC-IE compared with SC-IE. CONCLUSIONS: EC-IE, compared with SC-IE, was associated with a lower morbidity and mortality. However, absolute numbers are high, a finding that should trigger further research in appropriate perioperative antibiotic management and improvement of early IE diagnosis in the case of clinical suspicion.

Assessment of knowledge and beliefs concerning mental disorders among medical students - preliminary report. / Ocena postaw wobec osób z zaburzeniami psychicznymi wsród studentów medycyny - doniesienie wstepne.

OBJECTIVES: The aim of the study was to assess attitudes towards people with mental disorders. METHODS: The survey was carried out in a group of 93 students of the fifth year of medical studies (medical faculty) including 59 women and 34 men, aged 24.34 ± 1.28 years. RESULTS: In the conducted research, personal contact with a psychiatrist due to problems with their own mental health was declared by 23% of respondents. The choice of psychiatry as a field of specialization was declared by 19% of students. In the analysis of the questionnaire on beliefs, as many as 83% of respondents considered that mental illness is a cause for shame. Analyzing the attitude of the respondents to treatment, it was shown that as many as 80% of people believed that compulsory hospitalization is a right procedure. It should be emphasized that only 31% of the surveyed students believed that people with mental disorders should decide to have offspring, and 36% of people thought that mentally disturbed people would not be good as parents. As many as 30% of respondents believed that people with mental disorders more often commit crimes than healthy people, and 42% of students showed a lack of determination in this aspect. CONCLUSIONS: The results of the research suggest the necessity of expanding knowledge and shaping appropriate attitudes towards people with mental disorders among future doctors.

Differences in the predictors of left atrial appendage thrombus between men and women treated with dabigatran or rivaroxaban.

INTRODUCTION: Some patients with atrial fibrillation (AF) develop left atrial appendage thrombus (LAAT) despite receiving anticoagulant treatment. Different scores were proposed to evaluate thromboembolic risk in patients with AF. Risk stratification according to sex is common in clinical practice. OBJECTIVE: We aimed to identify predictors of LAAT separately in men and women treated with dabigatran or rivaroxaban. PATIENTS AND METHODS: This retrospective study included 1256 patients (479 women [38.1%]) with AF who underwent transesophageal echocardiography before electrical cardioversion or catheter ablation, between January 2013 and December 2019, and received dabigatran or rivaroxaban for at least 3 weeks. RESULTS: Multivariable logistic regression analysis revealed nonparoxysmal AF to predict LAAT in women (odds ratio [OR], 9.70; P = 0.002). In men, the predictors were heart failure (OR, 4.14; P = 0.001), diabetes (OR, 2.64; P = 0.002), nonparoxysmal AF (OR, 5.61; P = 0.02), and estimated glomerular filtration rate below 60 ml/min/1.73 m2 (OR, 2.77; P = 0.01). In the receiver operating characteristic curve analysis, the CHA2DS2­VASc-RAF score had the highest value for predicting LAAT in women (area under the curve [AUC] = 0.786). In men, CHA2DS2­VASc-RAF, CHA2DS2, CHA2DS2­VASc, and R2CHADS2 had sufficient predictive value (AUC = 0.786, 0.726, 0.734, and 0.780, respectively). CONCLUSIONS: The predictors of LAAT differ between men and women treated with dabigatran or rivaroxaban. In women, the CHA2DS2­VASc­RAF score had the highest predictive value, while in men all the scores had equally sufficient predictive value.

Long-Term Mortality After TAVI for Bicuspid vs. Tricuspid Aortic Stenosis: A Propensity-Matched Multicentre Cohort Study.

Objectives: Patients with bicuspid aortic valve (BAV) stenosis were excluded from the pivotal trials of transcatheter aortic valve implantation (TAVI). We compared the in-hospital and long-term outcomes between patients undergoing TAVI for bicuspid and tricuspid aortic valve (TAV) stenosis. Methods: We performed a retrospective registry-based analysis on patients who underwent TAVI for BAV and TAV at five different centers between January 2009 and August 2017. The primary outcome was long-term all-cause mortality. Secondary outcomes were in-hospital mortality, procedural complications, and valve performance. Results: Of 1,451 consecutive patients who underwent TAVI, two propensity-matched cohorts consisting of 130 patients with BAV and 390 patients with TAV were analyzed. All-cause mortality was comparable in both groups up to 10 years following TAVI (HR 1.09, 95% CI: 0.77-1.51). Device success and in-hospital mortality were comparable between the groups (96 vs. 95%, p = 0.554 and 2.3 vs. 2.1%, p = 0.863, respectively). Incidence of procedural complications was similar in both groups, with a trend toward a higher rate of stroke in patients with BAV (5 vs. 2%, p = 0.078). Incidence of moderate or severe paravalvular leak (PVL) at discharge was comparable in both groups (2 vs. 2%, p = 0.846). Among patients with BAV, all-cause mortality was similar in self-expanding and balloon-expandable prostheses (HR 1.02, 95% CI: 0.52-1.99) and lower in new-generation devices compared to old-generation valves (HR 0.27, 95% CI 0.12-0.62). Conclusion: Patients who had undergone TAVI for BAV had comparable mortality to patients with TAV up to 10 years after the procedure. The device success, in-hospital mortality, procedural complications, and PVL rate were comparable between the groups. The high rate of neurological complications (5%) in patients with BAV warrants further investigation.

Sex Differences in Infective Endocarditis After Transcatheter Aortic Valve Replacement.

BACKGROUND: Outcomes after transcatheter aortic valve replacement (TAVR) and infectious diseases may vary according to sex. METHODS: This multicentre study aimed to determine the sex differences in clinical characteristics, management, and outcomes of infective endocarditis (IE) after TAVR. A total of 579 patients (217 women, 37.5%) who had the diagnosis of definite IE following TAVR were included retrospectively from the Infectious Endocarditis After TAVR International Registry. RESULTS: Women were older (80 ± 8 vs 78 ± 8 years; P = 0.001) and exhibited a lower comorbidity burden. Clinical characteristics and microbiological profiles were similar between men and women, but culture-negative IE was more frequent in women (9.9% vs 4.3%; P = 0.009). A high proportion of patients had a clinical indication for surgery (54.4% in both groups; P = 0.99), but a surgical intervention was performed in a minority of patients (women 15.2%, men 20.3%; P = 0.13). The mortality rate at index IE hospitalisation was similar in both groups (women 35.4%, men 31.7%; P = 0.37), but women exhibited a higher mortality rate at 2-year follow-up (63% vs 52.1%; P = 0.021). Female sex remained an independent risk factor for cumulative mortality in the multivariable analysis (adjusted HR 1.28, 95% CI 1.02-1.62; P = 0.035). After adjustment for in-hospital events, surgery was not associated with better outcomes in women. CONCLUSIONS: There were no significant sex-related differences in the clinical characteristics and management of IE after TAVR. However, female sex was associated with increased 2-year mortality risk.

Left Atrial Thrombus in Atrial Fibrillation/Flutter Patients in Relation to Anticoagulation Strategy: LATTEE Registry.

Background: Atrial fibrillation (AF) and flutter (AFl) increase the risk of thromboembolism. The aim of the study was to assess the prevalence of left atrial thrombus (LAT) in AF/AFl in relation to oral anticoagulation (OAC). Methods: LATTEE (NCT03591627) was a multicenter, prospective, observational study enrolling consecutive patients with AF/AFl referred for transesophageal echocardiography before cardioversion or ablation. Results: Of 3109 patients enrolled, 88% were on chronic, 1.5% on transient OAC and 10% without OAC. Of patients on chronic OAC, 39% received rivaroxaban, 30% dabigatran, 14% apixaban and 18% vitamin K antagonists (VKA). Patients on apixaban were oldest, had the worst renal function and were highest in both bleeding and thromboembolic risk, and more often received reduced doses. Prevalence of LAT was 8.0% (7.3% on chronic OAC vs. 15% without OAC; p < 0.01). In patients on VKA, prevalence of LAT was doubled compared to patients on non-VKA-OACs (NOACs) (13% vs. 6.0%; p < 0.01), even after propensity score weighting (13% vs. 7.5%; p < 0.01). Prevalence of LAT in patients on apixaban was higher (9.8%) than in those on rivaroxaban (5.7%) and dabigatran (4.7%; p < 0.01 for both comparisons), however, not after propensity score weighting. Conclusions: The prevalence of LAT in AF is non-negligible even on chronic OAC. The risk of LAT seems higher on VKA compared to NOAC, and similar between different NOACs.

Mitral Valve Infective Endocarditis after Trans-Catheter Aortic Valve Implantation.

Scarce data exist on mitral valve (MV) infective endocarditis (IE) after transcatheter aortic valve implantation (TAVI). This multicenter study included a total of 579 patients with a diagnosis of definite IE after TAVI from the IE after TAVI International Registry and aimed to evaluate the incidence, characteristics, management, and outcomes of MV-IE after TAVI. A total of 86 patients (14.9%) had MV-IE. These patients were compared with 284 patients (49.1%) with involvement of the transcatheter heart valve (THV) only. Two factors were found to be associated with MV-IE: the use of self-expanding valves (adjusted odds ratio 2.49, 95% confidence interval [CI] 1.23 to 5.07, p = 0.012), and the presence of an aortic regurgitation ≥2 at discharge (adjusted odds ratio 3.33; 95% CI 1.43 to 7.73, p <0.01). There were no differences in IE timing and causative microorganisms between groups, but surgical management was significantly lower in patients with MV-IE (6.0%, vs 21.6% in patients with THV-IE, p = 0.001). All-cause mortality rates at 2-year follow-up were high and similar between patients with MV-IE (51.4%, 95% CI 39.8 to 64.1) and patients with THV-IE (51.5%, 95% CI 45.4 to 58.0) (log-rank p = 0.295). The factors independently associated with increased mortality risk in patients with MV-IE were the occurrence of heart failure (adjusted p <0.001) and septic shock (adjusted p <0.01) during the index hospitalization. One of 6 IE episodes after TAVI is localized on the MV. The implantation of a self-expanding THV and the presence of an aortic regurgitation ≥2 at discharge were associated with MV-IE. Patients with MV-IE were rarely operated on and had a poor prognosis at 2-year follow-up.