This is Your Brain, and This is Your Brain on Atrial Fibrillation: The Roles of Cardiac Malperfusion Events and Vascular Dysfunction in Cognitive Impairment.

AF is an independent and strong predictor of long-term cognitive decline. However, the mechanism for this cognitive decline is difficult to define and likely multifactorial, leading to many different hypotheses. Examples include macro- or microvascular stroke events, biochemical changes to the blood-brain barrier related to anticoagulation, or hypo-hyperperfusion events. This review explores and discusses the hypothesis that AF contributes to cognitive decline and dementia through hypo-hyperperfusion events occurring during cardiac arrhythmias. We briefly explain several brain perfusion imaging techniques and further examine the novel findings associated with changes in brain perfusion in patients with AF. Finally, we discuss the implications and areas requiring more research to further understand and treat patients with cognitive decline related to AF.

Ejection Fraction Improvement Does Not Reflect Changes in Quality of Life Following Cardiac Resynchronization Therapy.

OBJECTIVE: To determine if health-related quality of life (HRQoL) improvement after cardiac resynchronization therapy (CRT) correlates with improved left-ventricular ejection fraction (EF). BACKGROUND: CRT was reported to improve EF and HRQoL in clinical trials of heart failure with reduced EF (HFrEF). It is unknown if improvements in HRQoL reflect EF response to CRT. METHODS: We included HFrEF patients who underwent CRT and had both pre- and post-CRT HRQoL assessment. EF response was categorized as absent (0% change or decrease), modest (0%-19% increase), or significant ( > 20% increase). We examined the associations between EF response and generic (PROMIS) and HF-specific (KCCQ-12) HRQoL. RESULTS: The group included 115 patients with mean age of 65 years and baseline EF of 31%; 39% were female (n = 45). Nineteen percent (n = 22) had significant, 57% (n = 66) modest, and 23% (n = 27) absent EF responses. AF burden across significant (8.9%), modest (4.8%), and absent EF responders (1.4%) was similar ( P = 0.20). Significant improvements in KCCQ-12 (43.4-57.5, P = 0.003), current health visual analog scale (49.1-55.9, P = 0.042), PROMIS fatigue (58.9-55.1, P = 0.026), and PROMIS satisfaction (42.7-46.4, P = 0.020) resulted following CRT across all groups. There was no association between significant EF improvement and HRQoL by KCCQ-12 (nonresponse, 44.4%; modest response, 33.3%; and significant response, 22.2%) at 1 year ( P = 0.52 across all groups). CONCLUSION: CRT was associated with a modest to significant EF response in a majority of patients. However, EF response did not significantly correlate with generic or HF-specific HRQoL measures. Further investigations are warranted into determinants of improved HRQoL following CRT.

Depression as a Driving Force for Low Time in Therapeutic Range and Dementia in Patients With and Without Atrial Fibrillation.

Both time in therapeutic range (TTR) for anticoagulation and depression are associated with dementia risk. The purposes of this study were to examine the impact of depression on TTR and to describe the partitioned contribution of depression and TTR on long-term dementia risk. We studied 14,953 patients anticoagulated with warfarin (target INR 2-3) for atrial fibrillation (AF), venous thromboembolism (VTE), or a mechanical heart valve from 2003 to 2015. We excluded patients with a diagnosis of dementia before or within 6 months of warfarin initiation. We examined the association of depression with TTR using finite mixture modeling and logistic regression and utilized multivariable Cox hazard regression to determine the association of TTR and depression with incident dementia at 3 and 13 years. Forty % (n = 6055) of patients were diagnosed with depression before or while on warfarin. Patients with depression had significantly lower TTR and were 1.37 times more likely to have TTR <50% than non-depressed patients (p <0.0001). During follow-up, 4.2% of patients received the diagnosis of dementia within 3 years as compared to 12% during all-time follow up. The 3-year risk of dementia was highest for patients with a ≤50% TTR regardless of depression status. The 3-year dementia risk was associated with TTR (p <0.0001) but not depression. However, for all-time dementia both TTR (p <0.0001) and depression (p <0.0001) as well as their interaction (p = 0.049) were associated with dementia. Depression increased the risk of long-term dementia by 1.69 fold (95% CI: 1.33, 2.15) for patients with the lowest TTR. Depression is prevalent in patients managed with warfarin and is associated with significant decreases in TTR. In conclusion, decreased TTR appears to increase 3-year dementia risk and both low TTR and depression interact to increase risk for all-time dementia in patients taking warfarin.

Coronary Artery Bypass: Review of Surgical Techniques and Impact on Long-Term Revascularization Outcomes.

Coronary revascularization for multivessel disease remains a common and costly source of hospitalizations in the United States. Surgical techniques influence outcomes for coronary bypass and also affect the need for percutaneous coronary intervention in the future. As more radial access has been used for coronary angiography, consideration for use of the radial artery as a surgical conduit remains unclear. Saphenous vein grafts are commonly used for coronary bypass, however long-term patency remains suboptimal, and is also associated with a higher risk of adverse events with percutaneous coronary intervention. Thus, understanding the interplay between coronary bypass techniques and percutaneous coronary intervention has become increasingly important.

Shoulder arthroplasty in solid organ transplant patients: a retrospective, match paired analysis.

BACKGROUND: Several studies have evaluated total hip and knee arthroplasty in solid organ transplant (SOT) patients; however, there are limited studies evaluating shoulder arthroplasty in SOT patients. This study compares the complications and functional outcomes of SOT patients undergoing shoulder arthroplasty with a matched control group. METHODS: The institution's database was retrospectively reviewed for patients with a history of SOT undergoing primary shoulder arthroplasty (with minimum 2-year follow-up) and compared with a control group matched for age, sex, preoperative diagnosis, and surgical procedure. Preoperative and postoperative range of motion and outcome scores, perioperative surgical and medical complications, hospital length of stay, and mortality were compared. RESULTS: Fifteen patients with previous SOT underwent 19 shoulder arthroplasties. Thirty-four underwent 35 shoulder arthroplasties in the control group. At last follow-up, the SOT group had a significantly worse UCLA score. The SOT group had a significantly worse improvement in UCLA, active elevation, and passive elevation scores in pre- to postoperative scores. There was no difference in length of stay, infection, or surgical complications. Ninety-day readmissions, medically related complications, and required blood transfusion were significantly higher in the SOT group. There was increased mortality in the SOT compared with the control group (death occurred on average 1577 days after arthroplasty). CONCLUSION: Shoulder arthroplasty in patients with previous SOT appears safe and effective for degenerative shoulder disorders. Patients should be counseled preoperatively that their range of motion and function may not improve as much as their nontransplant cohorts. SOT patients may have increased incidence of postoperative blood transfusions and medically related complications.

Myocardial Infarction Secondary to Left Internal Mammary Artery Graft Occlusion After Left Subclavian Bypass.

Cardiogenic shock is a severe, often fatal presentation of acute myocardial infarction. This report presents an unusual case of ST-segment elevation myocardial infarction with left internal mammary artery occlusion occurring after instrumentation of the left subclavian artery as part of planned repair of a complex aortic aneurysm. (Level of Difficulty: Advanced.).