Intentional vomiting as a rare cause of hypercalcemia and consequent acute renal failure: a case report.

Two most common causes of elevated serum calcium levels, which together account for nearly 90% of all cases, are primary hyperparathyroidism and malignancy. Thus, it is necessary to consider other disorders in the diagnostic evaluation of patients with hypercalcemia. We report the case of a 40-year-old female patient with an intellectual disability who was admitted to the Emergency Department with severe symptomatic hypercalcemia and acute renal failure, caused by recurrent intentional vomiting. The aim of this report is to help clinicians make an accurate diagnosis by considering recurrent vomiting habits as a potential cause of hypercalcemia and acute renal failure. Our case provides a comprehensive diagnostic work-up and multidisciplinary treatment strategies for patients with symptomatic hypercalcemia.

COVID-19 pandemic: Impact on the cardiac implantable electronic devices' implantation rates in Croatia.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) pandemic has influenced health-care organization worldwide, including management of non-communicable diseases. The aim of this study was to determine the impact of COVID-19 pandemic on cardiac implantable electronic devices' (CIEDs) implantation rates in Croatia. METHODS: A retrospective, observational, national study was conducted. The data on CIEDs' implantation rates from 20 Croatian implantation centres, between January 2018 and June 2021, were extracted from the national Health Insurance Fund registry. Implantation rates before and after COVID-19 pandemic started, were compared. RESULTS: The overall numbers of CIED implantations in Croatia during COVID-19 pandemic were not different in comparison to 2 years pre-COVID-19 time (2618 vs. 2807, p = .081). The pacemaker implantation rates decreased significantly (by 45%) during April (122 vs. 223, p < .001) and May 2020 (135 vs. 244, p = .001), as well as during November 2020 (177 vs. 264, p = .003), but significantly increased during summer months 2020 comparing to 2018 and 2019 (737 vs. 497, p<0.001). The ICD implantation rates decreased significantly by 59% in April 2020 (26 vs. 64, p = .048). CONCLUSION: To the authors best knowledge this is a first study including complete national data on CIED implantation rates and COVID-19 pandemic impact. A significant reduction in number of both pacemaker and ICD implants during specific months of the COVID-19 pandemic was determined. However, afterwards compensation in implants resulted in similar total number when the complete year was evaluated.

Ba6Ge2Se12 and Ba7Ge2Se17: Two Centrosymmetric Barium Seleno-Germanates with Polyatomic Anion Disorder.

Herein, the crystal structures and physical properties of two previously unreported barium seleno-germanates, Ba6Ge2Se12 and Ba7Ge2Se17, are presented. Ba6Ge2Se12 adopts the P21/c space group with a = 10.0903(2) Å, b = 9.3640(2) Å, c = 25.7643(5) Å, and ß = 90.303(1)°, whereas Ba7Ge2Se17 crystallizes in the Pnma space group with a = 12.652(1) Å, b = 20.069(2) Å, c = 12.3067(9) Å. Both structures feature polyatomic anion disorder: [Se2]2- in the case of Ba6Ge2Se12 and [GeSe5]4- in the case of Ba7Ge2Se17. The anion disorder is verified by comparing pair distribution functions of ordered and disordered models of the structures. These anions are split unevenly across two possible sets of atomic coordinates. The optical band gaps obtained from the powdered samples are found to be 1.75 and 1.51 eV for Ba6Ge2Se12 and Ba7Ge2Se17, respectively. Differential scanning calorimetry experiments indicate that the compounds are stable under the exclusion of air up to at least 673 K. The thermal diffusivity measurements revealed thermal conductivities reaching values as low as 0.33 W m-1 K-1 in both compounds at 573 K.

Role of empirical isolation of the superior vena cava in patients with recurrence of atrial fibrillation after pulmonary vein isolation-a multi-center analysis.

BACKGROUND: Non-pulmonary vein (PV) triggers play a role in the initiation of atrial fibrillation (AF), with the superior vena cava (SVC) being a common location. The aim of the current study was to investigate a strategy of empirical SVC isolation (SVCI) in addition to re-isolation of PV in patients with recurrence of AF after index PV isolation (PVI). METHODS: We retrospectively analyzed consecutive patients from two centers with recurrence of AF after index PVI, undergoing a repeat ablation. Whereas only a re-isolation of the PV was intended in patients with reconnections of equal or more than two PV (PVI group), an additional SVCI was aimed for in patients with < 2 isolated PV in addition to the re-isolation of the PV (PVI + group). Analysis was performed as-treated and per-protocol. RESULTS: Of the 344 patients included in the study (age 60 ± 10 years, 73% male, 66% paroxysmal AF), PVI only was performed in 269 patients (77%) and PVI plus SVCI (PVI +) in 75 patients (23%). Overall, freedom from AF/AT after repeat PVI was 80% (196 patients) in the PVI group and 73% in the PVI + group (p = 0.151). In multivariable Cox regression analysis, presence of persistent AF (HR 2.067 (95% CI 1.389-3.078), p < 0.001) and hypertension (HR 1.905 (95% CI 1.218-2.980), p = 0.005) were identified as only significant predictors of AF/AT recurrence. The per-protocol results did not differ from this observation. CONCLUSIONS: A strategy of an empirical additional SVCI at repeat PVI ablation for recurrence of AF/AT does not improve outcome compared to a PVI only approach.

Management of conduction disorders after transcatheter aortic valve implantation: results of the EHRA survey.

Conduction disorders such as left bundle branch block (LBBB) are common after transcatheter aortic valve implantation (TAVI). Consensus regarding a reasonable strategy to manage conduction disturbances after TAVI has been elusive. The European Heart Rhythm Association (EHRA) conducted a survey to capture contemporary clinical practice for conduction disorders after TAVI. A 25-item online questionnaire was developed and distributed among the EHRA electrophysiology (EP) research network centres. Of 117 respondents, 44% were affiliated with university hospitals. A standardized management protocol for advanced conduction disorders such as LBBB or atrioventricular block (AVB) after TAVI was available in 63% of participating centres. Telemetry after TAVI was chosen as the most frequent management strategy for patients with new-onset or pre-existing LBBB (79% and 70%, respectively). Duration of telemetry in patients with new-onset LBBB varied, with a 48-h period being the most frequently chosen, but almost half monitoring continued for at least 72 h. Similarly, in patients undergoing EP study due to new-onset LBBB, the HV interval cut-off point leading to pacemaker implantation was heterogeneous among European centres, although an HV >75 ms threshold was the most common. Conduction system pacing was chosen as a preferred approach by 3.7% of respondents for patients with LBBB and normal left ventricular ejection fraction (LVEF), and by 5.6% for patients with LBBB and reduced LVEF. This survey suggests some heterogenity in the management of conduction disorders after TAVI across European centres. The risk stratification strategies vary substantially. Conduction system pacing in patients with LBBB after TAVI is still underused.

Case Report: Optical Coherence Tomography Usage for Treatment of the Chronically Lost Stent in the Left Main Coronary Artery.

Acute adverse outcomes of a stent loss during percutaneous coronary intervention (PCI) are well described, however, data on long-term consequences are scarce, especially with intravascular imaging. We report a case of a coronary stent loss in the left main and ostial left circumflex artery (LCx) bifurcation and its migration into the LCx ostium during PCI procedures. This rare complication, which was not immediately noticed, was verified and successfully resolved 5 months after using optical coherence tomography and right trans-radial access. Considering the infrequency of this complication, few cases have been reported, however, our case has several distinct specificities. We aim to encourage the crushing technique in cases of chronic stent loss when the retrieval is not an option and highlight the optical coherence tomography (OCT) value in imaging and evaluation of similar complex settings.

Acute Occlusion of the Infarct-Related Artery as a Predictor of Very Long-Term Mortality in Patients with Acute Myocardial Infarction.

AIM: The survey's aim was to examine the significance of infarct-related artery (IRA) occlusion (verified angiographically) on very long-term outcomes of patients with acute myocardial infarction, within the STEMI and NSTEMI diagnosis. METHODS: A single-center, nonrandomized, registry-based study on patients treated for acute coronary syndrome with percutaneous coronary intervention between June 2011 and December 2016 was conducted. Patients with angiographically proven IRA occlusion (100% stenosis with TIMI flow 0 distal to occlusion) were categorized as occlusive myocardial infarction (OMI) and patients with patent IRA (50-99% stenosis with TIMI 1-3 flow) were categorized as nonocclusive myocardial infarction (NOMI) and very long-term outcomes were analyzed. Data were collected prospectively from the hospital's PCI registry and the database of the Croatian Institute of Public Health. RESULTS: A total of 2450 patients were included in the study. 796 (32.5%) patients had NOMI and 1654 patients (67.5%) had OMI. According to ECG changes, 1534 patients presented with STEMI (62,6%) and 916 with NSTEMI (37,8%). 88% of STEMI patients presented with OMI and 12% with NOMI, while patients with NSTEMI in 33,8% presented with OMI and in 66,81% with NOMI. A median follow-up was 4.7 years. There was no significant difference in cardiovascular mortality between the groups (14.8% vs 13.1%; OMI vs NOMI, respectively; p=0.374) neither in all-cause mortality (19% vs 21.5%; OMI vs NOMI, respectively; p=0.374). Patients with NSTEMI had a significantly higher very long-term mortality (21.6% vs 18.1%; NSTEMI vs STEMI, respectively; p=0.029). CONCLUSION: The main findings of the study are as follows: (1) total IRA occlusion was not associated with higher long-term mortality; (2) NSTEMI was associated with a higher mortality rate compared with STEMI, independent of angiographic presentation (OMI/NOMI); (3) IRA occlusion was not associated with significantly higher mortality rates in patients with STEMI and NSTEMI, respectively.

THE ROLE OF ANTHROPOMETRIC PARAMETERS AND PHYSICAL ACTIVITY LEVEL IN PATIENTS WITH ACUTE CORONARY SYNDROME ADMITTED TO THE INTENSIVE CARDIAC CARE UNIT.

Anthropometric parameters have a role in diagnosing obesity, which increases the risk of acute coronary syndrome (ACS). The aim of the study was to assess the impact of obesity and physical activity level on the severity and long-term prognosis of ACS. A total of 116 patients with ACS were analyzed according to baseline (demography, medical history, anthropometry), severity (clinical presentation, in-hospital complications, laboratory, echocardiography, coronary angiography) and prognostic parameters (major adverse cardiovascular events during a six-year period). The levels of obesity and physical activity (Baecke/Lipid Research Clinics physical activity questionnaires) were compared with a sample of the Croatian general population. Study results showed the subjects with a higher number of narrowed coronary arteries (CAs) to have higher body mass index (BMI) and waist circumference (WC); those with stenosed left anterior descending artery and anterior myocardial infarction (MI) had higher BMI; waist-to-hip ratio (WHR) positively correlated with creatine kinase and negatively with left ventricle ejection fraction (p<0.05). Inactive patients more often had multi-vessel coronary disease and anterior MI; patients with a higher leisure physical activity index had a lower number of affected CAs, lower rate of stent implantations and lower stent length, while those with a higher work physical activity index had a lower rate of anterior MI (p<0.05). During the follow-up, inactive patients had more strokes and deaths (p<0.05). Our patients had higher body weight, WC and WHR, as well as lower leisure time and total physical activity indices than the general population (p<0.05). In conclusion, ACS is less severe and has better long-term prognosis in less obese patients with a higher level of physical activity. Patients with ACS are more obese and have lower total, as well as leisure time physical activity indices than the general population.

Prospective Evaluation of a Standardized Screening for Atrial Fibrillation after Ablation of Cavotricuspid Isthmus Dependent Atrial Flutter.

AIMS: We aimed to prospectively investigate the effectiveness of a standardized follow-up for AF-detection after common atrial flutter (cAFL) ablation. METHODS: A total of 309 patients after cAFL ablation without known AF, from 5 centers, and at least one completed, standardized follow-up at 3, 6 and 12 months, including a 24 h Holter-electrocardiogram (ECG), were included. The primary outcome was incident atrial fibrillation (AF), or atrial tachycardia (AT). Predictors were investigated by Cox proportional-hazards models. RESULTS: The mean age was 67.9 years; 15.2% were female and the mean CHA2DS2-VASc (Congestive heart failure, Hypertension, Age, Diabetes, Stroke, Vascular disease, Sex category) score was 2.4 points. The great majority of patients (90.3%) were anticoagulated. Over a mean follow-up of 12.2 months with a standardized approach, AF/AT was detected in 73 patients, corresponding to 11.7% at 3 months, 18.4% at 6 months and 28.2% at 12 months of follow-up. AF was found in 64 patients, AT in 9 and both in 2 patients. Occurrence of AF was recorded in 40 (60.6%) patients by Holter-ECG and in the remaining 26 (39.4%) by clinical follow-up only. There was no difference in male versus female (p = 0.08), or in younger versus older patients (p = 0.96) for AF/AT detection. Only coronary artery disease (hazard ratio [95% confidence intervals] 1.03 [1.01-1.05], p = 0.01) was associated with the primary outcome. CONCLUSIONS: AF or AT was detected in a large proportion of cAFL patients after cavotricuspid-isthmus (CTI) ablation, using a standardized follow-up over 1 year. This standardized screening can be easily implemented with high patient acceptance. The high proportion of post-ablation AF needs to be taken into consideration when deciding on long-term oral anticoagulation.

Differences in activated clotting time and total unfractionated heparin dose during pulmonary vein isolation in patients on different anticoagulation therapy.

BACKGROUND: Periprocedural pulmonary vein isolation (PVI) anticoagulation requires balancing between bleeding and thromboembolic risk. Intraprocedural anticoagulation is monitored by activated clotting time (ACT) with target value >300 s, and there are no guidelines specifying an initial unfractionated heparin (UFH) dose. METHODS: We aimed to assess differences in ACT values and UFH dosage during PVI in patients on different oral anticoagulants. We conducted an international, multi-center, registry-based study. Consecutive patients with atrial fibrillation (AF) undergoing PVI, on uninterrupted anticoagulation therapy, were analyzed. Before transseptal puncture, UFH bolus of 100 IU/kg was administered regardless of the anticoagulation drug. RESULTS: Total of 873 patients were included (median age 61 years, IQR 53-66; female 30%). There were 248, 248, 189, 188 patients on warfarin, dabigatran, rivaroxaban, and apixaban, respectively. Mean initial ACT was 257 ± 50 s, mean overall ACT 295 ± 45 s and total UFH dose 158 ± 60 IU/kg. Patients who were receiving warfarin and dabigatran compared to patients receiving rivaroxaban and apixaban had: (i) significantly higher initial ACT values (262 ± 57 and 270 ± 48 vs. 248 ± 42 and 241 ± 44 s, p < .001), (ii) significantly higher ACT throughout PVI (309 ± 46 and 306 ± 44 vs. 282 ± 37 and 272 ± 42 s, p < .001), and (iii) needed lower UFH dose during PVI (140 ± 39 and 157 ± 71 vs. 171 ± 52 and 172 ± 70 IU/kg). CONCLUSION: There are significant differences in ACT values and UFH dose during PVI in patients receiving different anticoagulants. Patients on warfarin and dabigatran had higher initial and overall ACT values and needed lower UFH dose to achieve adequate anticoagulation during PVI than patients on rivaroxaban and apixaban.

Delayed radiofrequency ablation efficacy in slow pathway ablation: a case report.

BACKGROUND: The delayed effect of radiofrequency (RF) ablation was described in cases of accessory pathway and premature ventricular contraction ablation, as well as delayed atrioventricular (AV) block after slow pathway ablation. CASE SUMMARY: We report a case of a female patient with AV nodal re-entry tachycardia (AVNRT), in whom the first electrophysiology study ended with acute failure of slow pathway ablation, despite using long steerable sheath, both right and left-sided ablation with >15 min of RF energy application and repeatedly achieving junctional rhythm. Six weeks afterwards, during scheduled three-dimensional electroanatomical mapping procedure, there was no proof of dual AV nodal conduction nor could the tachycardia be induced. Also, the patient did not have palpitations between the two procedures nor during the 12-month follow-up period. DISCUSSION: This case illustrates that watchful waiting for delayed RF ablation efficacy in some cases of AVNRT ablation could be reasonable, in order to reduce the risk of complications associated with slow pathway ablation.

First-degree atrioventricular block in patients with atrial fibrillation and atrial flutter: the prevalence of intra-atrial conduction delay.

PURPOSE: PR interval prolongation > 200 ms resulting in the diagnosis of first-degree atrioventricular block (AVB1) is caused by a delay in the AV nodal/His conduction and/or the right intra-atrial conduction (RIAC). The aim of the study was to assess the prevalence of AVB1 due to RIAC delay (AVB1 with normal AH and HV) in patients with atrial fibrillation (AF) and atrial flutter (AFlu). METHODS: We included 1067 consecutive patients (33% female, age 63 ± 13 years) referred for catheter ablation of AF (AF-group) (453 patients), AF and AFlu (136 patients), AFlu (292 patients), and AVNRT/AVRT (186 patients). AH-, HV-, PR-interval, and P-wave duration were measured on the 12-lead ECG and the intracardiac electrograms in sinus rhythm. RIAC delay was defined as a prolonged PR interval > 200 ms with normal AH and HV intervals. RESULTS: The prevalence of AVB1 is higher in patients with AFlu (41%) and AF (21%) and patients with both arrhythmias (30%) as compared with a reference group (8%) of patients with AVNRT/AVRT. AVB1 was due to RIAC delay in 42 of 67 patients (63%) in the AF-group, in 37 of 96 patients (39%) in the AFlu-group, and in 17 of 36 patients (47%) in the AF/AFlu group, respectively. AV nodal conduction delay was more common in AFlu patients compared with AF patients. CONCLUSION: RIAC delay is a common underlying cause of AVB1 in patients with AF and AFlu. These findings may impact the prescription of antiarrhythmic and AV-nodal blocking drugs.

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).

MANAGEMENT OF PATIENTS WITH CARDIAC IMPLANTABLE ELECTRONIC DEVICES UNDERGOING MAGNETIC RESONANCE IMAGING - PROPOSAL FOR UNIFIED HOSPITAL PROTOCOL: CROATIAN WORKING GROUP ON ARRHYTHMIAS AND CARDIAC PACING.

For many years, magnetic resonance imaging (MRI) was contraindicated in patients with cardiac implantable electronic devices (CIED). Today, there is a growing amount of evidence that MRI can be performed safely in the majority of patients with CIEDs. Firstly, there are devices considered MRI conditional by manufacturers that are available on the market and secondly, there is clear evidence that even patients with MRI non-conditional devices can also undergo MRI safely. Protocols have been developed and recommendations from different cardiac and radiologic societies have been published in recent years. However, the majority of physicians are still reluctant to refer these patients to MRI. Therefore, this document is published as a joint statement of the Croatian Working Group on Arrhythmias and Cardiac Pacing and Department of Radiology, Sestre milosrdnice University Hospital Centre to guide and ease the management of patients with CIED undergoing MRI. Also, we propose a unified protocol and checklist that could be used in Croatian hospitals.

Paroxysmal atrial fibrillation recurrence after redo procedure-ablation modality impact.

BACKGROUND: Atrial fibrillation recurrence (AFR) is common after pulmonary vein isolation (PVI), and the rate does not differ between radiofrequency (RF) and cryoballoon (CB) ablation. The aim of this study was to assess the impact of the ablation modality used at the index PVI on the outcome after redo PVI in patients with paroxysmal AF. METHODS: In this prospective, single-center, non-randomized study, consecutive patients with paroxysmal AF who have undergone the index PVI with either RF ablation (RF group) or 2nd-generation CB (CB group) were included. The primary endpoint was freedom from recurrence of atrial arrhythmia lasting > 30 s. RESULTS: A total of 105 patients undergoing redo PVI for paroxysmal AF were included (median age 61 years; 24% female; left ventricular ejection fraction (LVEF) 57 ± 8%; left atrial volume index (LAVI) 34 ± 11 mm). Index PVI was done either with focal RF (n = 81) or with CB (n = 24) and redo PVI only with focal RF. Total procedure time (139 vs. 113 min, p = 0.10) and RF delivery time (1017 vs. 870 s, p = 0.33) of the redo PVI were not significantly different. After a median follow-up of 371 (185-470) days, there were no differences between the RF and CB groups regarding the AFR rate after the second PVI (24 vs. 23%, p = 0.89). The Kaplan-Meier analysis showed no difference between the groups regarding AFR freedom time (p = 0.81). In multivariable logistic regression, only coronary artery disease was identified as an independent long-term predictor of AFR (OR 4.15, 95% CI 1.17-14.71, p = 0.027). CONCLUSIONS: The ablation modality used at the index PVI has no impact on long-term outcome after redo PVI in patients with paroxysmal AF.

Man vs machine: Performance of manual vs automated electrocardiogram analysis for predicting the chamber of origin of idiopathic ventricular arrhythmia.

BACKGROUND: Radiofrequency catheter ablation of idiopathic ventricular arrhythmias (VAs) is performed to eliminate symptoms and to prevent or reverse arrhythmia-induced cardiomyopathy. Preprocedural prediction of the chamber of VA origin is critical for patient counseling, procedure planning, and guidance of invasive mapping. OBJECTIVE: We aimed to assess the performance of manual expert versus automated 12-lead electrocardiogram (ECG) analysis in the prediction of VA origin. METHODS: Patients with ablation of idiopathic VA and sustained success were included. The VA origin was defined as the site where ablation caused arrhythmia suppression. Standard baseline 12-lead ECGs with documentation of the VA were analyzed manually in a blinded fashion by three electrophysiologists and three electrophysiology (EP) fellows. In addition, the same standard 12-lead ECG was analyzed by an automated computer algorithm using a vectorcardiographic approach. RESULTS: Thirty-eight patients (median age, 47 [interquartile range, 37-58]; 68% female) were enrolled. The VA originated from the right ventricle in 24 (63%) and the left ventricle in 14 (37%) patients. The electrophysiologists and EP fellows identified the VA chamber of origin with a similar accuracy of 73% and 72% (P = .72). The automated algorithm showed a higher accuracy of 89% (P = .03 compared with electrophysiologists and EP fellows). This resulted in a sensitivity of 95% and specificity of 86%. CONCLUSION: While the manual ECG analysis of the standard 12-lead ECG by both electrophysiologists and EP fellows correctly identified the chamber of VA origin in around 75% of cases, an automated vectorcardiographic computer algorithm achieved an accuracy of 89% with clinically acceptable diagnostic parameters.

Prevalence and Management of Atrial Thrombi in Patients With Atrial Fibrillation Before Pulmonary Vein Isolation.

OBJECTIVES: This study aimed to investigate the prevalence and management of left atrial (LA) thrombi detected by transesophageal echocardiography (TEE) in patients with atrial fibrillation undergoing pulmonary vein isolation (PVI). BACKGROUND: Little data are available on LA thrombi before PVI. METHODS: All patients scheduled for PVI between April 2010 and April 2018 undergoing pre-procedural TEE were analyzed. Management of LA thrombus was at the discretion of the treating physician. RESULTS: In this study, 1,753 pre-procedural TEE from 1,358 patients (mean age 61 ± 10 years, 28% female) were included. Anticoagulation was used in 86% of all TEE (51% with direct oral anticoagulants [DOAC], 35% with vitamin K antagonists [VKA]). Thrombi were found in 11 TEE (0.6%), all in the LA appendage. Of the 11 patients with a thrombus, 5 (46%) had paroxysmal atrial fibrillation, 2 (18%) had a CHA2DS2-VASc (Congestive Heart Failure, Hypertension, Age ≥75 Years, Diabetes Mellitus, Prior Stroke or Transient Ischemic Attack or Thromboembolism, Vascular Disease, Age 65 to 74 Years, Sex) score of 1, and 5 (46%) were in sinus rhythm at the time of TEE. Of the 8 patients (72%) on anticoagulation therapy, 5 were treated with DOAC and 3 with VKA. Starting anticoagulation (n = 3), switching to VKA with a target international normalized ratio of 2.5 to 3 (n = 3), or switching to a DOAC (n = 1) or a different DOAC (n = 4) resulted in thrombus resolution in 9 of 11 patients (82%). CONCLUSIONS: In patients with atrial fibrillation scheduled for PVI, LA thrombi are rare and present in <1%. Thrombi were found in patients on VKA and DOAC, in low-risk patients, and despite sinus rhythm. Thrombus resolution was achieved in the majority of patients by changing the anticoagulation regimen.

Impact of intracoronary contrast injection pressure on reperfusion during primary percutaneous coronary intervention in acute ST-segment elevation myocardial infarction: A prospective randomized pilot study.

BACKGROUND: Distal embolization of plaque and thrombotic debris in the infarct-related artery (IRA) may lead to microvascular obstruction resulting in impaired myocardial reperfusion.The aim of the study was to assess the impact of contrast injection pressure in IRA, during primary percutaneous coronary intervention (PCI), on myocardial reperfusion in patients with acute ST-segment elevation myocardial infarction (STEMI). METHODS: This prospective, randomized, open label, pilot trial evaluated acute STEMI patients who underwent primary PCI, with blinded evaluation of end points. Patients were assigned to higher injection pressure group A (550 pound/inch2) or lower injection pressure group B (200 pound/inch2). Primary endpoint was the postprocedural incidence of restored myocardial perfusion defined as myocardial blush grade (MBG) 3. RESULTS: Study included 100 consecutive acute STEMI patients, with median age of 63 (56-72) years (77% men) who were randomized to higher and lower injection pressure group. Baseline demographic, clinical and angiographic characteristics did not differ significantly between the groups. There were no significant differences between the study groups regarding difference in achieved MBG 3 (33 vs 36 patients, p = 0.247) nor regarding the ST-segment deviation score neither immediately after (3 vs 4 mm, p > 0.3) nor 24 h after primary PCI (2 vs 3 mm, p > 0.3). CONCLUSION: There was no impact of lower intracoronary contrast injection pressure in comparison to higher injection pressure, during primary PCI in patients with acute STEMI, on myocardial reperfusion as assessed by MBG or ST segment changes in the ECG.The study was registered at registry ClinicalTrials.gov with the registration number: NCT03445364, on February 26th 2018.