"I Tripped and Broke My Heart": A Case Report of Right Atrial Rupture.

A 66-year-old woman tripped and fell onto outstretched hands. She did not hit her chest. She developed chest pain and presented to the emergency department in shock. Transthoracic echocardiography demonstrated a large pericardial effusion with cardiac tamponade. Despite recurrent pericardiocentesis, the fluid did not decrease on echocardiography, and she continued to be in profound shock. Emergent surgical exploration identified rupture of the right atrium at its insertion into the superior vena cava. This case demonstrates atrial rupture despite no obvious direct chest impact and emphasizes the need for emergent surgical exploration in patients with hemopericardium and persistent tamponade despite pericardiocentesis.

Après avoir trébuché, une femme âgée de 66 ans est tombée sur ses mains étendues. Son thorax n'a pas touché le sol. Elle a par la suite éprouvé une douleur thoracique et s'est présentée au service des urgences en état de choc. Une échocardiographie transthoracique a révélé un important épanchement péricardique et une tamponnade cardiaque. Malgré des péricardiocentèses répétées, le volume de liquide observé à l'échocardiographie ne diminuait pas et la patiente était toujours en état de choc profond. Une exploration chirurgicale d'urgence a permis de détecter une rupture de l'oreillette droite au lieu de son insertion dans la veine cave supérieure. Le cas de cette patiente démontre qu'une rupture auriculaire est possible même sans impact direct au thorax et fait ressortir l'importance d'une exploration chirurgicale d'urgence chez les patients hémopéricardiques présentant une tamponnade qui persiste malgré une péricardiocentèse.

Aortic Arch Reconstructive Surgery With Conventional Techniques vs Frozen Elephant Trunk: A Systematic Review and Meta-Analysis.

BACKGROUND: Frozen elephant trunk (FET) surgery offers a new alternative in the management of complex thoracic aortic aneurysms and dissections. We performed a systematic review and meta-analysis of comparator observational studies evaluating the efficacy of FET compared with conventional aortic arch surgery, primarily focusing on mortality and stroke as well as the secondary outcomes of spinal cord ischemia, major bleeding, and operative time. METHODS: We searched MEDLINE, EMBASE, PubMed, and the Cochrane Library for trials and studies comparing the FET technique with conventional surgery in patients with aortic aneurysms or dissections, or both. The overall quality of evidence was low, as assessed by Grading of Recommendations, Assessment, Development, and Evaluation, based primarily on the risk of bias secondary to study design, plausible confounding, and imprecision. RESULTS: Meta-analysis revealed a significant reduction in mortality (12 studies, 1803 patients: odds ratio [OR], 0.55; 95% CI, 0.39-0.78) and a nonsignificant reduction in stroke (12 studies, 1803 patients: OR, 0.78; 95% CI, 0.52-1.15) favouring FET; however, FET was associated with a significant increase in spinal cord ischemia (9 studies, 1476 patients: OR, 2.20; 95% CI, 1.10-4.37). No significant differences between groups were observed regarding major bleeding, cardiopulmonary bypass time, or cross-clamp time. CONCLUSIONS: Current evidence suggests that FET surgery is associated with lower mortality in patients with thoracic aneurysmal disease and dissections, without a significant increase in stroke, bleeding, or operative times. However, the risk of spinal cord ischemia is increased in patients who undergo FET. A well-powered randomized trial is needed to evaluate this evolving field.

Left atrial appendage occlusion for stroke prevention in patients with atrial fibrillation: a systematic review and network meta-analysis of randomized controlled trials.

INTRODUCTION: Atrial fibrillation (AF) is one of the leading causes of stroke. Risks associated with oral anticoagulation (OAC) limit adherence to recommended therapy. Left atrial appendage (LAA) occlusion is a treatment alternative in patients with AF. We performed a network meta-analysis (NMA) of randomized trials evaluating the efficacy of LAA occlusion compared with oral anticoagulant, antiplatelet, and placebo for stroke prevention. We also assessed the impact of LAA occlusion on mortality, major bleeding, and operative time. EVIDENCE ACQUISITION: We searched MEDLINE, EMBASE, PubMed, and Cochrane Library for randomized trials comparing percutaneous or surgical LAA occlusion with standard of care in AF patients. EVIDENCE SYNTHESIS: Conventional meta-analysis found no difference between groups for stroke (5 trials, 1285 patients;RR 0.78, 95% CI 0.47-1.29), and a significant reduction in mortality (5 trials, 1285 patients; RR 0.71, 95% CI 0.51-0.99) favouring LAA occlusion. NMA demonstrated a trend towards reduction in stroke (OR 0.84, 95% CrI 0.47-1.55) and mortality (OR 0.69, 95% CrI 0.44-1.10) for LAA occlusion versus warfarin, but no statistically significant effect. Statistical ranking curves placed LAA occlusion as the most efficacious treatment on the outcomes of stroke and mortality when compared to warfarin, aspirin, or placebo. No significant differences between groups were seen in major bleeding or operative time for surgical trials. The overall quality of the evidence was low as assessed by GRADE. CONCLUSIONS: LAA occlusion appears to preserve the benefits of OAC therapy for stroke prevention in patients with AF, but the current evidence is of low quality.

Genotype-guided versus standard vitamin K antagonist dosing algorithms in patients initiating anticoagulation. A systematic review and meta-analysis.

Variability in vitamin K antagonist (VKA) dosing is partially explained by genetic polymorphisms. We performed a meta-analysis to determine whether genotype-guided VKA dosing algorithms decrease a composite of death, thromboembolic events and major bleeding (primary outcome) and improve time in therapeutic range (TTR). We searched MEDLINE, EMBASE, CENTRAL, trial registries and conference proceedings for randomised trials comparing genotype-guided and standard (non genotype-guided) VKA dosing algorithms in adults initiating anticoagulation. Data were pooled using a random effects model. Of the 12 included studies (3,217 patients), six reported all components of the primary outcome of mortality, thromboembolic events and major bleeding (2,223 patients, 87 events). Our meta-analysis found no significant difference between groups for the primary outcome (relative risk 0.85, 95% confidence interval [CI] 0.54-1.34; heterogeneity Χ(²)=4.46, p=0.35, I(²)=10%). Based on 10 studies (2,767 patients), TTR was significantly higher in the genotype-guided group (mean difference (MD) 4.31%; 95% CI 0.35, 8.26; heterogeneity Χ(²)=43.31, p<0.001, I(²)=79%). Pre-specified exploratory analyses demonstrated that TTR was significantly higher when genotype-guided dosing was compared with fixed VKA dosing (6 trials, 997 patients: MD 8.41%; 95% CI 3.50,13.31; heterogeneity Χ(²)=15.18, p=0.01, I(²)=67%) but not when compared with clinical algorithm-guided dosing (4 trials, 1,770 patients: MD -0.29%; 95% CI -2.48,1.90; heterogeneity Χ(²)=1.53, p=0.68, I(²)=0%; p for interaction=0.002). In conclusion, genotype-guided compared with standard VKA dosing algorithms were not found to decrease a composite of death, thromboembolism and major bleeding, but did result in improved TTR. An improvement in TTR was observed in comparison with fixed VKA dosing algorithms, but not with clinical algorithms.

Nonpharmacologic approaches to stroke prevention in atrial fibrillation.

The greatest priority in treating atrial fibrillation (AF) is stroke prevention. There are now 3 main approaches to prevention: (1) oral anticoagulation (OAC), (2) eradication of AF, and (3) exclusion of the left atrial appendage (LAA) from the systemic circulation. The goal of this article is to review these approaches, with particular emphasis on nonpharmacologic methods and their role in light of current evidence. OAC is effective but is limited by major bleeding, physician and patient reluctance to use anticoagulants, and patient noncompliance. Eradication of AF with antiarrhythmic drugs has not been effective, and suppression with ablation has not yet been properly tested for stroke prevention. Finally, occlusion of the LAA is promising, but definitive evidence of efficacy for stroke prevention is lacking. Trials such as WATCHMAN LAA System for Embolic Protection in Patients With Atrial Fibrillation (PROTECT AF) and Prospective Randomized Evaluation of the WATCHMAN LAA Closure Device in Patients With Atrial Fibrillation vs Long-Term Warfarin Therapy (PREVAIL) provide the best quality evidence for LAA device closure, with results suggesting noninferiority to OAC. Surgical trials have yet to show the efficacy of LAA occlusion for stroke prevention. This review highlights the evidence behind each of these approaches and concludes that to date OAC remains the standard for stroke prevention in AF. Future trials will need to address novel OAC therapy when comparing them with LAA exclusion, and large randomized trials will be required to ascertain indications for nonpharmacologic therapy in current practice.