Left Ventricular Ejection Fraction Can Predict Atrial Thrombosis Even in Non-High-Risk Individuals with Atrial Fibrillation.

Background­Current guidelines do not recommend routine use of transesophageal echocardiography (TOE) in anticoagulated patients with atrial fibrillation (AF). The aim of our study was to identify predictors for left atrial thrombosis (LAT) in patients with AF that would require TOE despite anticoagulation therapy, using clinical, laboratory and echocardiographic data which are usually obtained in those patients in a real-world setting. Methods­We analyzed data from electronic medical records (EMR) of consecutive AF patients referred to two university hospitals between January 2014 and December 2017 for pulmonary vein isolation (PVI) or direct current cardioversion. The primary endpoint was the presence of left atrial thrombus on TOE. Multivariable and univariable logistic regression models were computed using variables that were significantly different between the LAT and the control groups. Results­A total of 838 patients were included, of whom 132 (15.8%) had LAT. After controlling for other variables, only the left ventricle ejection fraction (LVEF) remained statistically significant with an OR of 0.956 (95% CI 0.934−0.979), p < 0.01. Regression models including LVEF had significantly higher areas under the receiver operating characteristic (ROC) curves, including in subgroups with non-high thromboembolic risk (CHA2DS2-Vasc = 0 or 1), with an area under the curve (AUC) of 0.76 (95% CI 0.71−0.81), p < 0.0001. Conclusions­The LVEF is an independent predictor of LAT, and it might improve thromboembolic risk stratification in future models. LVEF significantly increased the predictive value of the CHA2DS2-Vasc model and was able to identify LAT in non-high-risk patients.

NOMOGRAM CONTAINING SIMPLE ROUTINE CLINICAL AND BIOCHEMICAL PARAMETERS CAN PREDICT PATHOLOGIC VENTRICULAR REMODELING IN STEMI PATIENTS.

Heart failure is the leading cause of morbidity and mortality worldwide, with ischemic heart disease being one of the most important etiologic factors. Heart failure develops due to ventricular remodeling, which leads to increases in left ventricular end-systolic and end-diastolic volumes. In this prospective observational study, we included 101 patients with first episode of ST-segment elevation myocardial infarction in whom percutaneous coronary intervention was conducted within 12 h and Thrombolysis in Myocardial Infarction III flow was achieved. The aim was to determine which clinical and biochemical parameters can help predict pathologic ventricular remodeling 1 year after myocardial infarction. We created a nomogram based on routinely used blood tests and vital parameters which showed highest correlation with pathologic ventricular remodeling. The nomogram included NTproBNP value 12 h after reperfusion, aspartate transaminase value 12 h after reperfusion, systolic blood pressure value on admission, and culprit coronary artery. We performed ROC analysis which yielded great predictive value of the nomogram. The area under curve was 0.907 (95% CI 0.842-0.973). The nomogram value of -3.54 had 91.4% sensitivity and 74.0% specificity. We believe that this nomogram, once validated, could offer a widely available, low-cost option that would help identify patients at risk of developing pathologic left ventricular remodeling and achieve this at a very early stage of myocardial infarction (12 h after reperfusion has been achieved).

Atrial appendages' mechanics assessed by 3D transoesophageal echocardiography as predictors of atrial fibrillation recurrence after pulmonary vein isolation.

BACKGROUND: Although there are numerous studies reflecting predictors of atrial fibrillation (AF) recurrence (AFR) after pulmonary vein isolation (PVI), data on atrial appendages' mechanics is scarce. This study aimed to assess atrial appendages' mechanics by 2-dimensional (2D) and 3-dimenssional (3D) transoesphageal echocardiography (TEE) and to explore its value to predict AFR after PVI. METHODS: Consecutive patients with paroxysmal AF undergoing first PVIwere analysed. 3D and 2D-TEE with tissue Doppler imaging (TDI) and strain analysis was obtained prior to the PVI, including: left atrial appendage (LAA) TDI and strain analysis, LAA ostium surface area, right atrial appendage's TDI velocity and superior vena cava (SVC) ostium surface area. The primary end-point was freedom from any documented recurrence of atrial arrhythmia lasting > 30 s. RESULTS: This single-centre, prospective study included 74 patients with paroxysmal AF (median age 59 years; 36% female; BMI 27.4 ±â€¯4.1 kg/m2, LA volume index 32 ±â€¯11 mL/m2). After a median follow-up of 14 (IQR 10-22) months, 21 (28%) patients had AFR. In a univariate and multivariate Cox-regression analysis LAA TDI velocity (HR 1.48, 95%CI 1.28-1.62, p < 0.001) and LAA ostium surface area(HR 1.58, 95%CI 1.06-1.81, p = 0.033) both independently predicted AFR after single PVI. RAA TDI velocity and SVC ostium surface area were not correlated to AFR. CONCLUSION: Paroxysmal AF patients with lower LAA TDI tissue velocity and LAA ostium surface area have higher risk of developing AFR after PVI. To our knowledge, this is the first study assessing atrial appendages' mechanics in predicting AFR after PVI.Clinical trial registration: www.drks.de(Identifier: DRKS00010495).

Noninvasive Recanalization of a Coronary Chronic Total Occlusion.

BACKGROUND: Spontaneous recanalization of a chronically occluded artery is rare and reported anecdotally. CASE SUMMARY: We report a case of a patient with a chronically occluded right coronary artery, found on a coronary angiography performed due to acute ST elevation myocardial infarction with an occluded circumflex artery as a culprit lesion. Three months later, a follow-up angiography was performed and a recanalization of the occluded right coronary artery was detected. DISCUSSION: There is a possibility that intrinsic fibrinolytic mechanisms with the additional effect of standard antithrombotic drugs administrated after the acute coronary event led to the recanalization.

Plasminogen activator inhibitor-1 activity and long-term outcome in patients with ST-elevation myocardial infarction treated with primary percutaneous coronary intervention: a prospective cohort study.

AIM: To determine the relationship between plasminogen activator inhibitor-1 (PAI-1) activity rise during the first 24 hours of ST-elevation myocardial infarction (STEMI) treatment and death after 5 years. METHODS: From May 1, 2009 to March 23, 2010, 87 STEMI patients treated with primary percutaneous coronary intervention (PCI) at the Sestre Milosrdnice University Hospital Center were consecutively enrolled in prospective single-center cohort study. PAI-1 activity was determined on admission and 24 hours later. The primary end-point was death after 5 years. The predictive value of PAI-1 activity variables as biomarkers of death was assessed using receiver operating characteristic (ROC) curve, independent predictors of death were assessed using multivariate Cox regression, and covariates independently related to higher PAI-1 activity rise were assessed using linear regression. RESULTS: Two patients died during the hospital treatment and 11 during the follow-up. PAI-1 activity rise had the largest area under curve (0.748) for predicting death rate (optimal cut-off point 3.7 U/mL, sensitivity 53.8%, specificity 90.5%). Patients with PAI-1 activity rise higher than 3.7 U/mL had significantly higher mortality (P<0.001). Kaplan-Meier survival curve diverged within the first year after STEMI. Independent predictors of death were PAI-1 rise and final Thrombolysis in Myocardial Infarction flow. PAI-1 activity rise was independently related to heart failure, thrombus aspiration, and body weight. CONCLUSION: PAI-1 activity rise higher than 3.7 U/mL is associated with higher 5-year death rate in STEMI patients treated with primary PCI.

Left anterior descending coronary artery dissection during ventricular tachycardia ablation - case report.

Fascicular left ventricular tachycardia (VT) is the second most frequent idiopathic left VT in the setting of a structurally normal heart. Catheter ablation is curative in most patients with low complication rates. We report a case of ostial left anterior descending coronary artery (LAD) occlusion during fascicular ventricular tachycardia ablation. Dissection was the most likely cause of LAD obstruction. To the authors' best knowledge, this is the first case reporting selective LAD dissection during electrophysiology study with no left main coronary artery (LMCA) affection.

Analysis of blood pressure changes in patients undergoing total hip or knee replacement in spinal and general anesthesia.

The aim of this study was to analyze hemodynamic changes in hypertensive and normotensive patients undergoing total hip or knee replacement in spinal and general anesthesia. Eighty patients who underwent total hip or knee replacement surgery in the period between July 2010 and February 2011 at Sveti Duh University Hospital were retrospectively evaluated. Seventeen patients underwent the operation in general anesthesia and 63 patients in regional anesthesia. They were allocated into groups of normotensive (n=24) or hypertensive patients (n=56). The anthropologic and hematologic parameters of normotensive and hypertensive patients were compared, as well as their blood pressures immediately before and during the operation. Blood pressure immediately before anesthesia induction, the highest and the lowest intraoperative blood pressures were recorded. Blood pressure immediately before anesthesia induction was significantly higher in hypertensive patients who underwent the operation in regional anesthesia compared to normotensive patients (158.48 mm Hg vs. 144.71 mm Hg, P<0.01). The highest intraoperative systolic blood pressure was also significantly higher in hypertensive patients operated on in regional anesthesia compared to normotensive patients (161.20 mm Hg vs. 146.76 mm Hg, P<0.01). The difference between the highest and the lowest intraoperative systolic blood pressure was significantly greater in hypertensive patients undergoing the operation in regional anesthesia compared to normotensive patients (46.41 mm Hg vs. 35.88 mm Hg, P<0.05). The results presented in this paper indicate that the fluctuations of intraoperative blood pressure were greater and the highest intraoperative systolic blood pressure was higher in hypertensive compared to normotensive patients undergoing the operation in regional anesthesia. In our study, there were no significant differences in intraoperative blood pressure between hypertensive and normotensive patients who underwent the operation in general anesthesia.