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.

[Does intracoronary abciximab improve the outcome of percutaneous coronary interventions? A randomized controlled trial]. / 'Mejora el uso de abciximab intracoronario el resultado del intervencionismo percutáneo? Estudio prospectivo y aleatorizado.

INTRODUCTION AND OBJECTIVES: It has been clearly demonstrated that abciximab is useful in percutaneous coronary interventions. However, it is not known if intracoronary administration of the initial abciximab bolus improves outcome. Moreover, there may be safety concerns. METHODS: The study was a single-center prospective randomized trial that included all patients undergoing coronary angioplasty involving the use of abciximab. Patients were randomized to either intracoronary or intravenous administration of the abciximab bolus. The primary endpoint was the incidence of major adverse cardiac events (i.e., death, myocardial infarction, or the need for revascularization); secondary endpoints were hemorrhagic complications and the troponin-I level. RESULTS: The study included 137 patients; 72 received an intracoronary abciximab bolus and 65, an intravenous bolus. Clinical characteristics and baseline angiographic findings were similar in the two groups. All patients underwent coronary stent implantation. No difference was observed between the intracoronary bolus group and the intravenous bolus group in type of stent used (drug eluting stent 47.2% vs 50.8%, respectively), total stent length, or final TIMI flow grade (3 vs 2.97, respectively). The intervention success rates were also similar (98.5% vs. 99%, respectively). No complication associated with the administration route was reported. However, the level of the myocardial injury marker troponin I increased significantly in the intravenous bolus group. Clinical follow-up at 1 year did not reveal any difference in the incidence of major adverse cardiac events: 8.5% in the intracoronary bolus group versus 6.2% in the intravenous bolus group. CONCLUSIONS: Intracoronary administration of an abciximab bolus did not appear to be less safe or effective than intravenous administration. Less post-procedural myocardial damage was observed in the intracoronary bolus group.

[Safety and effectiveness of single-lead VDD pacing]. / Seguridad y eficacia de los sistemas de estimulación VDD monosonda.

INTRODUCTION AND OBJECTIVES: Single-lead VDD pacing provides the physiological benefits of atrioventricular synchrony with the convenience of a single-lead system. However, concern remains about the method's safety and effectiveness. METHOD: In total, 700 patients with single-lead VDD pacemakers were evaluated retrospectively. The following parameters were recorded: age, sex, etiology, the symptoms and electrocardiographic diagnosis that justified pacemaker implantation, the venous access route used for implantation, atrial sensing at implantation, atrial undersensing at follow-up, the occurrence of supraventricular tachyarrhythmias, and final pacing mode. RESULTS: Third-degree atrioventricular block was the main indication for pacemaker implantation (66.4%). The most commonly used venous access route was via the right cephalic vein (49.1%). At implantation, the mean atrial signal was 1.8 (4 1.15) mV. During follow-up, significant atrial undersensing occurred in 7.7% of patients; in 1.9%, it could not be corrected by device reprogramming. Uncontrollable supraventricular arrhythmias were observed in 6.4% of patients. Symptomatic sinus node disease was rare. By the end of follow-up, 91.4% of patients were still on VDD pacing, while, in 8.3%, the pacemaker had to be reprogrammed to the VVI mode. Only 0.3% required atrial lead implantation for DDD pacing. Left-side venous access during implantation was a independent predictora of atrial undersensing at follow-up. Low values of atrial detection at implant did not reach statistical signification although it showed a remarkable trend. CONCLUSIONS: Single-lead VDD pacing seems to be safe and effective when appropriately indicated. Our findings are consistent with those of previously published studies.

[Conservative management of a post infarction intramyocardial dissecting hematoma]. / Tratamiento conservador de un hematoma disecante intramiocárdico postinfarto.

Intramyocardial dissecting hematoma is an infrequent complication of subacute myocardial infarction. Pathological findings consist of a cavity filled with blood, the outer wall of which is the myocardium and pericardium and the inner wall, which faces the ventricular cavity, is part of the myocardium and endocardium. There is scarce information on the subject and the management of these patients continues to be debated. However, there is a certain preference for surgical repair of the defect. Cases in which conservative treatment is a therapeutic option have been reported. We report the case of a patient with an intramyocardial dissecting hematoma after acute anterolateral myocardial infarction who was treated conservatively and achieved a satisfactory outcome in the intermediate-to-long term period.

Hidroneumopericardio iatrogénico tras pericardiocentesis / Iatrogenic Hidropneumopericardium after Pericardiocentesis

El hidroneumopericardio se define por la presencia de líquido y aire en la cavidad pericárdica. Se trata de una afección infrecuente en los adultos, habitualmente asociada a buen pronóstico, pero que puede resultar potencialmente grave. Presentamos el caso de un paciente trasplantado renal que debutó con taponamiento cardíaco y que precisó pericardiocentesis; varios días después, presentó un cuadro de dolor torácico debido a un hidroneumopericardio iatrogénico. Las pruebas de imagen son claves en la obtención de este diagnóstico.

Hydropneumopericardium is defined by the accumulation of serous fluid and gas in the pericardial sac. It is uncommon in adults, usually associated with favorable outcomes; yet, it may be severe occasionally. We present the case of a kidney transplant patient who developed cardiac tamponade requiring pericardiocentesis. Several days after the procedure, the patient presented chest pain due to iatrogenic hydropneumopericardium. Image tests are essential to make this diagnosis.

Vasoespasmo coronario asintomático y arritmias ventriculares graves / Asymptomatic Coronary Artery Spasm and Severe Ventricular Arrhythmias

El vasoespasmo coronario generalmente evoluciona con episodios de dolor torácico y elevación del ST. No obstante, existen casos de vasoespasmo sin dolor torácico con taquiarritmias ventriculares documentadas. Su incidencia se desconoce y debe incluirse en el diagnóstico diferencial de taquicardia o fibrilación ventricular idiopática. En esta presentación se describe el caso de un paciente con historia de dos cuadros sincopales sin cardiopatía estructural aparente. La monitorización electrocardiográfica continua objetivó episodios de elevación del ST que conducían a taquicardia ventricular polimorfa. Con el diagnóstico de vasoespasmo coronario asintomático se inició tratamiento con calcioantagonistas y se implantó un cardiodesfibrilador automático.

Coronary artery spasm usually results in episodes of chest pain and ST-segment elevation. However, it may occasionally occur in the absence of angina with documented severe ventricular arrhythmias. The incidence of this condition is unknown and should be included in the differential diagnosis of idiopathic ventricular tachycardia or fibrillation. We describe the case of a patient with a history of two episodes of syncope without apparent structural heart disease. Continuous ECG monitoring revealed the presence of episodes of ST-segment elevation leading to polymorphic ventricular tachycardia. Asymptomatic coronary artery spasm was diagnosed and treatment with calcium channel blockers was initiated; an implantable cardioverter defibrillator device was implanted.

Muerte súbita, taponamiento y síndrome coronario agudo como manifestación clínica de un aneurisma coronario gigante / Sudden death, tamponade and acute coronaey syndrome as the clinical presentation of a giant coronary aneurysm

Los aneurismas coronarios son una patología infrecuente (0,5-3 por ciento de incidencia). Suelen asociarse con estenosis coronarias y la aterosclerosis es la etiología más frecuente. Nuestro paciente debutó con muerte súbita. Posteriormente presentó taponamiento cardíaco y a las 24 horas desarrolló un IAM inferior. La coronariografía mostró una gran dilatación esferoidal (4,5 × 5 cm) en la coronaria derecha proximal. Se trató con resección del aneurisma y puente aortocoronario. La evolución suele ser asintomática. La rotura o la muerte súbita son formas raras de presentación. La actitud conservadora es el tratamiento más comúnmente aplicado. La indicación quirúrgica dependerá de la presencia de estenosis coronarias asociadas o de la existencia de complicaciones.