A case report of postcardioversion device-related thrombus in a patient with left atrial appendage occlusion device on apixaban.

Background: Current guidelines recommend proceeding with cardioversion, without the explicit need for preprocedural transesophageal echocardiography (TEE), in patients compliant with oral anticoagulation for at least 3 weeks. The relevance of these guidelines remains unclear in those undergoing repeat cardioversion. Case summary: A 66-year-old male with a history of atrial fibrillation (AF) and a left atrial appendage occlusion (LAAO) device, compliant with apixaban, presented with dyspnea and lightheadedness. He was cardioverted into sinus rhythm, 10 days before symptom onset, with TEE unremarkable at the time. An ECG revealed that the patient converted back into AF and a repeat cardioversion was scheduled. At the patient's request, a TEE was obtained, revealing a new 2 cm×1 cm thrombus in the left atrium above the WATCHMAN device. Cardioversion was canceled and the patient was hospitalized for AF management. Discussion: Cardioverted patients are at risk for thrombus formation due to atrial stunning, a transitory dysfunction of the atrial appendage and atrium, which occurs immediately after cardioversion and can persist for several weeks. The likelihood of a thrombus is further propagated by individual risk factors for stroke. Conclusion: Anticoagulation does not eliminate the risk of thrombus formation in those with increased risk factors for stroke. Further studies are warranted to assess the need for routine TEE, after cardioversion, in those with stroke risk factors on anticoagulation or who have LAAO.

Dietary Supplement Use in Patients with Cardiovascular Disease.

IMPORTANCE AND OBJECTIVE: Dietary supplements and herbs (called naturoceuticals) are commonly used by Americans, but little is known about their use in cardiovascular disease patient populations. The objective was to evaluate naturoceutical use in a sample population of cardiovascular disease patients in the U.S. DESIGN, SETTING AND PARTICIPANTS: A non-blinded, single medical center clinic open questionnaire was delivered to cardiovascular clinic patients with known cardiovascular diseases. MAIN OUTCOMES AND MEASURES, AND RESULTS: Estimation of naturoceutical usage prevalence and frequency in the sample population of cardiovascular disease patients. A total of 163 patients (n = 99 males, 64 females) participated (mean age: males, 66 years; females, 64 years). Overall, 76.7 percent of participants reported using naturoceuticals. Of them, about 63.2 percent took more than one type, and 90.3 percent reported daily usage. Of the naturoceuticals reportedly being taken, multivitamins containing vitamin K were the most commonly consumed (32.3 percent male, 29.7 percent female), followed by vitamin D (23.2 percent male, 31.3 percent female) and fish oil (24.2 percent male, 15.6 percent female). CONCLUSIONS AND RELEVANCE: The present study revealed that naturoceutical use was very popular in cardiovascular disease patients, largely due to the belief that they could reduce and/or prevent symptoms and disease in general. The benefits and hazards of those naturoceuticals being used concurrent with other prescription medications were discussed.

Outcomes and Safety of Transcatheter Aortic Valve Implantation With and Without Routine Use of Transesophageal Echocardiography.

Transesophageal echocardiography (TEE) has been extensively used historically for Transcatheter aortic valve implantation (TAVI) but focus is shifting from routine use of TEE and general anesthesia to "as needed" use. We evaluated patients who had TAVI in our institution from September 2012 to February 2017. Decision for implantation and use of TEE during procedure was made by the structural heart team on a case-to-case basis, based on FDA approved indications. Data including procedural details, length of stay and rehospitalizations were obtained from all patients. TAVI was performed on 178 patients during the study period of which 104 of 178 had TEE during TAVI. Baseline characteristics were fairly comparable in both groups. Similar proportion of self-expanding and balloon expanding valves were deployed. Patients in TEE group had longer overall procedure time (107 minute vs 83 minute, p = 0.0002) and longer length of stay (5.01days vs 2.49days, p < 0.0001). Echocardiographic study postprocedure showed similar incidence of paravalvular leak and similar gradients and velocities across aortic valve. Rates of 30-day readmissions were similar in both groups. In conclusion, in this single-center retrospective analysis-TAVI without the 'routine use' of TEE was comparable with those done with TEE guidance in terms of periprocedural complications and 30-day readmissions. Overall procedure length and length of stay was predictably higher in the TEE group.

Clinical factors associated with physician choice of femoral versus radial access: A real-world experience from a single academic center.

OBJECTIVES: To analyze clinical factors associated with operator's preference in selection of femoral versus radial access for angiography and percutaneous intervention (PCI) procedures. BACKGROUND: There has been an increase in radial access in cardiac catheterization and PCI in the last few decades. METHODS: Data from 11 226 consecutive cardiac catheterization procedures were collected from Sanford University Medical Center (University of South Dakota, Sanford School of Medicine) from 2011 to 2015. RESULTS: In the overall cases, clinical factors that favored upfront femoral access include patients presenting as ST-elevation myocardial infarction (STEMI) or emergent, coronary artery bypass graft, body mass index (BMI) <30 kg/m2 and age ≥70 years, whereas morbidly obese patients (BMI ≥35) and age <70 favored upfront radial access. Radial access in the overall group had lower fluoroscopy time (6.5 vs 8.4 min, P < 0.0001) and lower contrast use (68.8 vs 80.6 cc, P < 0.0001). In the PCI group, efficacy of upfront radial access is less evident with radial fluoroscopy time (10.1 vs 11.0 min, P < 0.0028) and contrast use being higher in radial group (113.8 vs 108.2 cc, P < 0.037). Interventional cardiologists were more efficient in diagnostic cases than non-interventional cardiologists. CONCLUSION: STEMI or emergent cases and elderly patients favor upfront femoral access. As BMI increases and age decreases, radial access is progressively favored. In diagnostic cases, radial access appears to be superior to femoral access in efficacy, but the distinction is less obvious in PCI and STEMI or emergent cases.

Rural United States Experience of Incorporation of a Technologically Advanced and Procedurally Complex Cardiovascular Program - the Sanford Trans-Catheter Aortic Valve Replacement Experience.

Trans-catheter aortic valve replacement (TAVR) was approved by the U.S. Food and Drug Administration in 2012 for treatment of severe symptomatic aortic stenosis in non-surgical and high risk patients. Implementation of this complex procedure requires a comprehensive heart team approach. Rural demographics in the Midwest pose many challenges related to low volumes of operations both at institutional and individual levels, leading to serious concerns about the quality of care delivered in such a setting. We compared the TAVR data at the University of South Dakota Sanford Medical Center to the national registry with the aim of looking at differences in outcomes of this procedure in a rural setting.