Not to Rush-Laboratory Parameters and Procedural Complications in Patients Undergoing Left Atrial Appendage Closure.

Background: As a preventive procedure, minimizing periprocedural risk is crucially important during left atrial appendage closure (LAAC). Methods: We included consecutive patients receiving LAAC at nine centres and assessed the relationship between baseline characteristics and the acute procedural outcome. Major procedural complications were defined as all complications requiring immediate invasive intervention or causing irreversible damage. Logistic regression was performed and included age and left-ventricular function. Furthermore, the association between acute complications and long-term outcomes was evaluated. Results: A total of 405 consecutive patients with a median age of 75 years (37% female) were included. 47% had a history of stroke. Median CHA2DS2-VASc score was 4 (interquartile range, 3−5) and the median HAS-BLED score was 3 (2−4). Major procedural complications occurred in 7% of cases. Low haemoglobin (OR 0.8, 95% CI 0.65−0.99 per g/dL, p = 0.040) and end-stage kidney disease (OR 13.0, CI 2.5−68.5, p = 0.002) remained significant in multivariate analysis. Anaemia (haemoglobin < 12 and < 13 g/dL in female and male patients) increased the risk of complications 2.2-fold. Conclusions: The major complication rate was low in this high-risk patient population undergoing LAAC. End-stage kidney disease and low baseline haemoglobin were independently associated with a higher major complication rate.

Indications and Outcome in Patients Undergoing Left Atrial Appendage Closure-The Austrian LAAC Registry.

BACKGROUND: Complete real-world data on the indications and outcomes of left atrial appendage closure (LAAC) outside of clinical trials are rare. In this study, we stratified patients undergoing LAAC by indication groups. METHODS: This analysis of the national multicentre Austrian LAAC Registry comprised all patients that underwent LAAC up until 2018 at the currently active centres in Austria. The baseline characteristics, procedural details and outcomes between the following indication groups were compared: bleeding as an indication for LAAC ("bleeding" group) vs. thromboembolism despite oral anticoagulation (OAC; "thromboembolism" group) vs. an intolerance to OAC for reasons other than the above ("other" group). RESULTS: The analysis included 186 patients, with 59.7% in the "bleeding" group, 8.1% in the "thromboembolism" group and 32.2% in the "other" group. The CHADS2 score was the highest in the "thromboembolism" group and the HAS-BLED score was the highest in the "bleeding" group. The procedural outcomes were similar between groups (implantation success, 97.3%), with major complications occurring in 7.0% of patients. One-year survival free from stroke, bleeding or LAAC-associated hospitalisation was 83.9%, 90.0% and 81.4% in the "bleeding", "thromboembolism" and "other" groups, respectively (p = 0.891). CONCLUSIONS: In routine clinical practice, LAAC was used in a heterogeneous patient population with atrial fibrillation (AF) and contraindication, inefficacy or intolerance to OAC. The long-term outcome was favourable in all groups.

Impact of On-Site Cardiac Surgery on Clinical Outcomes After Transfemoral Transcatheter Aortic Valve Replacement.

OBJECTIVES: This study sought to investigate the outcome of high-risk and inoperable patients with severe symptomatic aortic stenosis undergoing transfemoral transcatheter aortic valve replacement (TAVR) in hospitals with (iOSCS) versus without institutional on-site cardiac surgery (no-iOSCS). BACKGROUND: Current guidelines recommend the use of TAVR only in institutions with a department for cardiac surgery on site. METHODS: In this analysis of the prospective multicenter Austrian TAVI registry, 1,822 consecutive high-risk patients with severe symptomatic aortic stenosis undergoing transfemoral TAVR were evaluated. A total of 290 (15.9%) underwent TAVR at no-iOSCS centers (no-iOSCS group), whereas the remaining 1,532 patients (84.1%) were treated in iOSCS centers (iOSCS group). RESULTS: Patients of the no-iOSCS group had a higher perioperative risk defined by the logistic EuroSCORE (20.9% vs. 14.2%; p < 0.001) compared with patients treated in hospitals with iOSCS. Procedural survival was 96.9% in no-iOSCS centers and 98.6% in iOSCS centers (p = 0.034), whereas 30-day survival was 93.1% versus 96.0% (p = 0.039) and 1-year survival was 80.9% versus 86.1% (p = 0.017), respectively. After propensity score matching for confounders procedural survival was 96.9% versus 98.6% (p = 0.162), 93.1% versus 93.8% (p = 0.719) at 30 days, and 80.9% versus 83.4% (p = 0.402) at 1 year. CONCLUSIONS: Patients undergoing transfemoral TAVR in hospitals without iOSCS had a significantly higher baseline risk profile. After propensity score matching short- and long-term mortality was similar between centers with and without iOSCS.

Quantitation of right ventricular volumes and ejection fraction by three-dimensional echocardiography in patients: comparison with magnetic resonance imaging and radionuclide ventriculography.

Three-dimensional echocardiography (3DE) provides volumetric measurements without geometric assumptions. Volume-rendered 3DE has been shown to be accurate for the measurement of right ventricular (RV) volumes in vitro and in animal studies; however, few data are available regarding its accuracy in patients. This study examined the accuracy of 3DE for quantitation of RV volumes and ejection fraction (EF) in patients, compared to magnetic resonance imaging (MRI) and radionuclide ventriculography (RNV). Twenty patients underwent MRI, gated equilibrium RNV, and 3DE using rotational acquisition from both the transesophageal and transthoracic approaches. RV volumes and EF were calculated from the 3DE data using multislice analysis (true Simpson's rule). RV volumes calculated by MRI (end-diastolic volume (EDV) 109.4 +/- 34.3 mls, end-systolic volume (ESV) 59.6 +/- 31.0 mls, and EF 47.7 +/- 17.1%) agreed closely with 3DE. For transesophageal echocardiography, EDV was 108.1 +/- 29.7 mls (r = 0.86, mean difference 1.3 +/- 17.8 mls); ESV was 62.5 +/- 23.8 mls (r = 0.85, mean difference 2.8 +/- 15.1 mls); and EF was 43.2 +/- 11.7% (r = 0.84, mean difference 4.5 +/- 9.7%). For transthoracic echocardiography, EDV was 107.7 +/- 27.5 mls (r = 0.85, mean difference 1.6 +/- 18.2 mls); ESV was 59.7 +/- 22.1 mls (r = 0.93, mean difference 3.2 +/- 19.6 mls); and EF was 45.2 +/- 11.5% (r = 0.86, mean difference 2.0 +/- 9.4%). There were close correlations, small mean differences and narrow limits of agreement between RNV-derived EF (43.4 +/- 12.1%) and both transesophageal (r = 0.95 mean difference 0.2 +/- 3.7%) and transthoracic 3DE (r = 0.95, mean difference 1.8 +/- 5.4%). Three-dimensional echocardiography is a promising new method of calculating RV volumes and EF, comparing well with MRI and RNV. The accuracy of transthoracic 3DE was comparable to that of the transesophageal approach. Three-dimensional echocardiography has the potential to be useful in the clinical assessment of RV disorders.

A head-to-head comparison of infusion and bolus doses of adenosine for stress myocardial contrast echocardiography.

BACKGROUND: This study was a head-to-head, intraindividual comparison of the diagnostic accuracy and side effect profile of bolus and infusion administration of adenosine for stress myocardial contrast echocardiography (MCE). METHODS: Adenosine MCE was performed in 64 subjects, referred for stress thallium-201 single-photon emission computed tomography (SPECT) for known or suspected CAD. Each patient received adenosine by multiple boluses (6-12 mg/bolus) and infusion (140 mug/kg per min for 6 min) forms in random order, given at least 20 minutes apart. RESULTS: No prolonged or serious adverse events occurred during either adenosine bolus or infusion. Compared to SPECT imaging, the sensitivity, specificity, and concordance for the diagnosis of CAD were 77%, 87%, and 82% for adenosine infusion MCE and 81%, 90%, and 86% for adenosine bolus MCE, respectively. CONCLUSIONS: Both adenosine infusion and adenosine bolus protocols are safe for MCE in humans and can be used for the diagnosis of CAD.

Therapeutic ultrasound in cardiology.

Ultrasound can be exploited to derive therapeutic results by using its bioeffects such as creation of mechanical vibrations, localized cavitations, microstream formation, physicochemical changes and thermal energy. Extensive in vitro and animal investigations during the last 2 decades have laid a foundation for ultrasound energy to be used for treatment purposes in various medical specialties. In the area of cardiovascular diseases, ultrasound could be used for thrombolysis, adjunct to coronary interventions, drug delivery, local gene transfer, and creating therapeutic lesions. The dispensation approaches to therapeutic ultrasound are varied, from the use of low- to medium-range frequency, low to focused high intensity, and catheter-based to external devices. Catheter-based ultrasound could be useful for intracoronary thrombolysis, and external ultrasound instrument with transcutaneous delivery could be of use in applications such as creation of myocardial lesions, peripheral vessel thrombolysis, and drug and gene delivery. Adjunct administration of microbubbles has been found to enhance thrombolysis, and drug and gene therapy. Ongoing studies strongly suggest that therapeutic ultrasound could have an important role in cardiovascular disorders associated with thrombosis, inflammation, atherosclerotic disease, and arrhythmias.