ABSTRACT
BACKGROUND: The prevalence and impact of coronary emboli (CE) in patients with ST-segment-elevation myocardial infarction (STEMI) and atrial fibrillation (AF) have not been specifically studied. The objective was to describe the clinical characteristics and outcomes of patients with AF and CE in a large series of patients with STEMI. METHODS AND RESULTS: We investigated 2292 consecutive patients with STEMI and among them 225 patients with AF: 46 patients with a STEMI related to CE (group A) and 179 patients with a STEMI related to an atherosclerotic cause (group B). Compared with the 2067 patients without AF and CE (group C), patients with AF and CE were older (73 versus 59 years, P<0.05), more likely to be female (43% versus 22%, P<0.05), and presented more frequently with cardiogenic shock at admission (26% versus 9%, P<0.05). The baseline characteristics of patients with AF (group A versus B) did not differ significantly according to STEMI pathogenesis. In the unadjusted analysis, the 45-day mortality was higher in patients with CE and AF (group A versus group C: 20% versus 4%; P<0.05 and group A versus group B: 20% versus 8%, P=not significant); this trend persisted at 2-year follow-up (group A versus group C: 24% versus 6%; P<0.05 and group A versus group B: 24% versus 17%, P=not significant). After stabilized inverse exposure probability weighting adjustment, a higher 45-day mortality rate was confirmed in patients with CE and AF (group A versus group C: 18% versus 5%, P<0.05). CONCLUSIONS: In patients presenting with STEMI and AF, CE was associated with excess early mortality. REGISTRATION: URL: clinicaltrials.gov. Identifier: NCT05679843.
Subject(s)
Atrial Fibrillation , Embolism , ST Elevation Myocardial Infarction , Humans , Atrial Fibrillation/complications , Atrial Fibrillation/diagnosis , Atrial Fibrillation/mortality , Atrial Fibrillation/epidemiology , Female , Male , ST Elevation Myocardial Infarction/mortality , ST Elevation Myocardial Infarction/complications , ST Elevation Myocardial Infarction/diagnosis , ST Elevation Myocardial Infarction/therapy , ST Elevation Myocardial Infarction/epidemiology , Middle Aged , Aged , Embolism/mortality , Embolism/epidemiology , Embolism/diagnosis , Embolism/etiology , Prevalence , Risk Factors , Aged, 80 and over , Time FactorsABSTRACT
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.
Subject(s)
Atrial Appendage , Atrial Fibrillation , Cardiac Catheterization , Device Removal , Registries , Humans , Male , Atrial Appendage/diagnostic imaging , Atrial Appendage/physiopathology , Female , Aged , Retrospective Studies , Treatment Outcome , Time Factors , Aged, 80 and over , Risk Factors , Cardiac Catheterization/adverse effects , Cardiac Catheterization/instrumentation , Cardiac Catheterization/mortality , Atrial Fibrillation/therapy , Atrial Fibrillation/mortality , Device Removal/adverse effects , Embolism/etiology , Embolism/mortality , Middle Aged , Septal Occluder Device , Left Atrial Appendage ClosureABSTRACT
BACKGROUND: Increased D-dimer levels have been shown to correlate with adverse outcomes in various clinical conditions. However, few studies with a large sample size have been performed thus far to evaluate the prognostic value of D-dimer in patients with infective endocarditis (IE). METHODS: 613 patients with IE were included in the study and categorized into two groups according to the cut-off of D-dimer determined by receiver operating characteristic (ROC) curve analysis for in-hospital death: > 3.5 mg/L (n = 89) and ≤ 3.5 mg/L (n = 524). Multivariable regression analysis was used to determine the association of D-dimer with in-hospital adverse events and six-month death. RESULTS: In-hospital death (22.5% vs. 7.3%), embolism (33.7% vs 18.2%), and stroke (29.2% vs 15.8%) were significantly higher in patients with D-dimer > 3.5 mg/L than in those with D-dimer ≤ 3.5 mg/L. Multivariable analysis showed that D-dimer was an independent risk factor for in-hospital adverse events (odds ratio = 1.11, 95% CI 1.03-1.19, P = 0.005). In addition, the Kaplan-Meier curve showed that the cumulative 6-month mortality was significantly higher in patients with D-dimer > 3.5 mg/L than in those with D-dimer ≤ 3.5 mg/L (log-rank test = 39.19, P < 0.0001). Multivariable Cox regression analysis showed that D-dimer remained a significant predictor for six-month death (HR 1.11, 95% CI 1.05-1.18, P < 0.001). CONCLUSIONS: D-dimer is a reliable prognostic biomarker that independently associated with in-hospital adverse events and six-month mortality in patients with IE.
Subject(s)
Endocarditis/blood , Fibrin Fibrinogen Degradation Products/analysis , Adult , Aged , Biomarkers/blood , Embolism/etiology , Embolism/mortality , Endocarditis/complications , Endocarditis/diagnosis , Endocarditis/mortality , Female , Hospital Mortality , Humans , Male , Middle Aged , Predictive Value of Tests , Prognosis , Reproducibility of Results , Retrospective Studies , Risk Assessment , Risk Factors , Stroke/etiology , Stroke/mortality , Time Factors , Up-RegulationABSTRACT
INTRODUCTION: Charlson Comorbidity Index (CCI) is commonly used in outcome studies to adjust for patient comorbid conditions but has not been specifically validated for use in acute embolic lower limb ischaemia (AELLI). OBJECTIVES: The aim of this study was to access whether a high CCI score unadjusted (CCIu) and adjusted (CCIa) by age relates to major amputation and mortality after a first episode of AELLI. METHODS: The last 100 patients presenting with the first event of AELLI submitted to embolectomy at our Vascular Surgery Department were retrospectively evaluated. Patient characteristics, pre- and post-operative period variables were collected and CCIu and CCIa calculated. Survival predictors were analyzed using Cox regression. The area under the curve of the receiver operating characteristic curves was calculated to validate and determine the discriminating ability of CCIu and CCIa in predicting amputation rate and 30-day mortality. Youden index was used to determine the critical value. Survival analysis was performed with Kaplan-Meier method and differences between survival curves were tested with Log-Rank test. A P value of <0.05 was considered statistically significant. RESULTS: The mean age was 80.03±10.776 years and the mean follow-up 19.28±7.929 months. Amputation rate was 16%, 30-day mortality 21% and long-term mortality 42%. Patients with CCIu≥3 compared with patients with CCIu<3 had higher amputation rate (37.5% vs. 1.7%; OR:35.400), 30-day mortality (47.5% vs. 3.3%; OR:35.400) and global mortality (P=0.00). Also, patients with CCIa≥6 compared with patients with CCIa<6 had higher amputation rate (34.1% vs. 1.8%; OR:28.488), 30-day mortality (47.7% vs. 0.0%) and global mortality (P=0.00). Multivariate analysis showed that both CCIu and CCIa were independent predictors of amputation rate and 30-day mortality. CONCLUSION: CCIu and CCIa have proven to be good predictors of amputation rate and survival, thus being a valuable prognostic factor in patients presenting with the first event of AELLI.
Subject(s)
Decision Support Techniques , Embolism/diagnosis , Ischemia/diagnosis , Lower Extremity/blood supply , Aged , Aged, 80 and over , Amputation, Surgical , Clinical Decision-Making , Comorbidity , Embolectomy , Embolism/mortality , Embolism/surgery , Female , Humans , Ischemia/mortality , Ischemia/surgery , Limb Salvage , Male , Portugal , Predictive Value of Tests , Retrospective Studies , Risk Assessment , Risk Factors , Time Factors , Treatment OutcomeABSTRACT
BACKGROUND: Acute aortic occlusion (AAO) represents potentially fatal acute vascular emergency that requires prompt diagnosis and intervention. Clinical condition of patients with AAO is frequently severely devastated when surgical intervention is questionable. Our objective was to retrospectively review our institutional experience with AAO and assess predictors of intrahospital mortality and morbidity. METHODS: This is a retrospective single-center cohort study with prospectively collected data between January 1, 2005 and January 1, 2018. The total number of 28 consecutive patients with AAO were included in our analysis. Patients with acute aortic thrombosis manifested by bilateral acute limb ischemia were divided in two groups based on potential caues of AAO (embolism or in-situ thrombosis) differentiated according to condition of aortoilical segment. RESULTS: We identified 28 patients with AAO. All of them underwent either aortobifemoral bypass (N.=20, 71%) or bilateral trans-femoral thrombectomy (N.=8, 29%). The overall in-hospital mortality was 36%. Factors that influenced in-hospital mortality were: paralysis (OR=4.41, 95% CI: 1.88-21.78) and higher lactate values on admission (OR=1.23, 95% CI: 1.09-1.83), postoperative development of severe acute kidney injury (OR=3.08, 95% CI: 1.42-14.66), hemodialysis (OR=10.74, 95% CI: 1.64-109.78) and bowel ischemia (OR=5.19, 95% CI: 1.58-55.63). CONCLUSIONS: Paralysis, higher lactate values, development of acute kidney injury, hemodialysis and bowel ischemia are predictors of worse outcome and may be used for risk stratification of patients with acute aortic occlusion and improve counseling patients and their families about expected postoperative outcomes. Patients with embolism and malignant disease have worse outcome; however, this should be tested in future studies on larger sample.
Subject(s)
Aortic Diseases/mortality , Arterial Occlusive Diseases/mortality , Embolism/mortality , Hospital Mortality , Ischemia/mortality , Postoperative Complications/mortality , Thrombosis/mortality , Aged , Aortic Diseases/surgery , Arterial Occlusive Diseases/surgery , Embolism/surgery , Female , Humans , Ischemia/surgery , Leg/blood supply , Male , Retrospective Studies , Risk Factors , Thrombosis/surgeryABSTRACT
AIM: The mortality of patients with infective endocarditis (IE) is high. The management of patients with large vegetations is controversial. This study sought to investigate the association of vegetation size on outcomes including valve destruction, embolism and mortality. METHODS AND RESULTS: One hundred and forty-two (142) patients with definite IE and transoesophageal echocardiography (TEE) imaging available for analysis were identified and data retrospectively reviewed. Vegetation length, width and area were measured. Severe valve destruction was defined as the composite of one or more of severe valve regurgitation, abscess, pseudoaneurysm, perforation or fistula. Associations with 6-month mortality were identified by Cox regression analysis. Eighty (80) (56.3%) patients had evidence of valve destruction on TEE. Vegetation length ≥10 mm and vegetation area ≥50 mm2 were significantly associated with increased risk of valve destruction, (both odds ratio OR 1.21, p=0.03 and p=0.02 respectively). Thirty-nine (39) (72.2%) patients who had an embolic event, did so prior initiation of antibiotics. Six (6)-month mortality was 18.3%. In the surgically managed group, vegetation size was not associated with mortality. In the medically managed group, vegetation area (mm2) was associated with increased mortality (HR 1.01, p<0.01) along with age (HR 1.06, p=0.03). CONCLUSION: Vegetation length ≥10 mm or area ≥50 mm2 are associated with increased risk of valve destruction. Vegetation size may also predict mortality in medically managed but not surgically managed patients with IE. Further studies to evaluate whether surgery in patients with large vegetation size improves outcomes is warranted.
Subject(s)
Embolism , Endocarditis, Bacterial , Endocarditis , Heart Valve Diseases , Embolism/diagnostic imaging , Embolism/mortality , Endocarditis/diagnostic imaging , Endocarditis, Bacterial/complications , Endocarditis, Bacterial/mortality , Heart Valve Diseases/diagnostic imaging , Humans , Retrospective StudiesABSTRACT
The aim of this study was to investigate the main causes of death in growing-finishing pigs in southern Brazil. During a one-year period (from 2018 to 2019), two industrial pig herds (18 and 20 thousand pigs each farm) in southern Brazil were monitored along the four seasons of the year (12 days per season on each farm), in order to perform necropsies of all pigs that died in that period. The two farms had an average monthly mortality rate ranging from 0.94 to 3.93% in the evaluated months. At necropsy, tissues were collected, fixed in 10% formalin solution and processed routinely for histopathological examination. When necessary, samples were sent for bacterial culture and PCR to identify etiologic agents. A total of 601 necropsies were performed, with 94.9% of conclusive diagnoses. Infectious diseases corresponded to 64.4% of conclusive diagnosis and non-infectious diseases to 35.6%. The most prevalent causes of death were: pneumonia (33%), gastric ulcers (15.4%), circovirosis (9.9%), systemic bacterial embolism (5.4%), polyserositis (4.4%), dilated cardiomyopathy and torsion of abdominal organs (4.3% each), and bacterial pericarditis (3.4%). Regarding pneumonias (199/601), the main agents identified in these cases were Pasteurella multocida, Influenza A virus and Mycoplasma hyopneumoniae, mainly in associations.(AU)
O objetivo do presente trabalho foi investigar as principais causas de morte de suínos em fase de crescimento e terminação no Sul do Brasil. Durante o período de um ano (entre 2018 e 2019), duas granjas tecnificadas de suínos no Sul do Brasil foram acompanhadas nas quatro estações (12 dias por estação em cada granja), para realização de necropsias dos suínos que morreram nesse período. As duas propriedades apresentavam mortalidade mensal média entre 0,94 e 3,93% nos meses avaliados. Na necropsia, amostras de órgãos foram colhidas, fixadas em formol 10% e processadas rotineiramente para o exame histopatológico. Quando necessário, amostras foram enviadas para o cultivo bacteriano e PCR para identificação de agentes etiológicos. Foram realizadas um total de 601 necropsias, com 94,9% de diagnósticos conclusivos. As doenças infecciosas corresponderam a 64,4% dos diagnósticos conclusivos e as não infecciosas a 35,6%. As principais causas de morte foram: pneumonias (33%), úlcera gástrica (15,4%), circovirose (9,9%), embolia bacteriana sistêmica (5,4%), polisserosite (4,4%), cardiomiopatia dilatada e torção de órgãos abdominais (4,3% cada) e pericardite bacteriana (3,4%). Com relação às pneumonias (199/601), os principais agentes associadas as lesões foram Pasteurella multocida, vírus da Influenza A e Mycoplasma hyopneumoniae, principalmente associados entre si.(AU)
Subject(s)
Animals , Pneumonia/mortality , Stomach Ulcer/mortality , Swine Diseases/mortality , Circoviridae Infections/mortality , Sus scrofa , Pasteurella multocida , Mycoplasma hyopneumoniae , Embolism/mortalityABSTRACT
BACKGROUND: The benefit of combining aspirin and direct oral anticoagulants on the reduction of cardiovascular events in atrial fibrillation or flutter is not well studied. We aimed to assess whether concurrent aspirin and direct oral anticoagulant therapy for atrial fibrillation or flutter will result in less coronary, cerebrovascular and systemic ischemic events compared to direct oral anticoagulant therapy alone. METHODS: Retrospective study of adult patients between 18 and 100 years old who have nonvalvular atrial fibrillation or flutter and were started on a direct oral anticoagulant (apixaban, rivaroxaban, or dabigatran), between January 1, 2010 and September 1, 2015 within the Beaumont Health System. Exclusions were history of venous thromboembolic disease and use of other antiplatelet therapies such as P2Y12 inhibitors. Patients were classified into two groups based on concurrent aspirin use and observed for a minimum of 2 years. Primary outcome was major adverse cardiac events, defined as acute coronary syndromes, ischemic strokes, and embolic events. Secondary outcomes were bleeding and death. RESULTS: Six thousand four patients were in the final analysis, 57% males and 80% Caucasians, median age 71, interquartile range (63-80). The group exposed to aspirin contained 2908 subjects, and the group unexposed to aspirin contained 3096 subjects. After using propensity scores to balance the baseline characteristics in both groups, the analysis revealed higher rate of major adverse cardiac events in the exposed group compared to the unexposed group, (HR 2.11, 95% CI (1.74-2.56)) with a number needed to harm of 11 (95% CI [9-11]). The rate of bleeding was also higher in the exposed group, (HR 1.30, 95% CI (1.11-1.52)). The rate of death was not statistically different between the groups, (HR 0.87, 95% CI (0.61-1.25)). CONCLUSIONS: In this observational analysis of patients with atrial fibrillation and flutter, the concomitant use of direct oral anticoagulants and aspirin was associated with an increased risk of both major adverse cardiac and bleeding events when compared to the use of direct oral anticoagulants alone. These findings underscore the potential harm of this combination therapy when used without a clear indication.
Subject(s)
Acute Coronary Syndrome/prevention & control , Aspirin/administration & dosage , Atrial Fibrillation/drug therapy , Atrial Flutter/drug therapy , Embolism/prevention & control , Factor Xa Inhibitors/administration & dosage , Ischemic Stroke/prevention & control , Platelet Aggregation Inhibitors/administration & dosage , Acute Coronary Syndrome/diagnosis , Acute Coronary Syndrome/mortality , Administration, Oral , Adolescent , Adult , Aged , Aged, 80 and over , Aspirin/adverse effects , Atrial Fibrillation/diagnosis , Atrial Fibrillation/mortality , Atrial Flutter/diagnosis , Atrial Flutter/mortality , Embolism/diagnosis , Embolism/mortality , Factor Xa Inhibitors/adverse effects , Female , Hemorrhage/chemically induced , Humans , Ischemic Stroke/diagnosis , Ischemic Stroke/mortality , Male , Middle Aged , Platelet Aggregation Inhibitors/adverse effects , Retrospective Studies , Risk Assessment , Risk Factors , Time Factors , Treatment Outcome , Young AdultABSTRACT
Background Dose adjustment of non-vitamin K antagonist oral anticoagulants (NOACs) is indicated in some patients with atrial fibrillation (AF), based on selected patient factors or concomitant medications. We assessed the frequency of label adherence of NOAC dosing among AF patients and the associations between off-label NOAC dosing and clinical outcomes. Methods and Results We evaluated 53 649 AF patients treated with an NOAC using Korean National Health Insurance Service database during the period from 2013 to 2016. NOAC doses were classified as either underdosed or overdosed, consistent with Korea Food and Drug Administration labeling. Cox proportional hazards regression was performed to investigate the effectiveness and safety outcomes including stroke or systemic embolism, major bleeding, and all-cause mortality. Overall, 16 757 NOAC-treated patients (31.2%) were underdosed, 4492 were overdosed (8.4%), and 32 400 (60.4%) were dosed appropriately according to drug labeling. Compared with patients with label adherence, those who were underdosed or overdosed were older (aged 71±8 and 75±7 years versus 70±9 years, respectively; P<0.001) and had higher CHA2DS2-VASc scores (4.6±1.7 and 5.3±1.7 versus 4.5±1.8, respectively; P<0.001). NOAC overdosing was associated with increased risk for stroke or systemic embolism (5.76 versus 4.03 events/100 patient-years, P<0.001), major bleeding (4.77 versus 2.94 events/100 patient-years, P<0.001), and all-cause mortality (5.43 versus 3.05 events/100 patient-years, P<0.001) compared with label-adherent use. Conclusions In real-world practice, a significant proportion (almost 2 in 5) of AF patients received NOAC doses inconsistent with drug labeling. NOAC overdosing is associated with worse clinical outcomes in Asian AF patients.
Subject(s)
Atrial Fibrillation/drug therapy , Drug Labeling , Embolism/prevention & control , Factor Xa Inhibitors/administration & dosage , Off-Label Use , Stroke/prevention & control , Administration, Oral , Aged , Aged, 80 and over , Atrial Fibrillation/complications , Atrial Fibrillation/mortality , Databases, Factual , Drug Overdose , Embolism/etiology , Embolism/mortality , Factor Xa Inhibitors/adverse effects , Female , Hemorrhage/chemically induced , Humans , Male , Middle Aged , Practice Patterns, Physicians' , Republic of Korea , Risk Assessment , Risk Factors , Stroke/etiology , Stroke/mortality , Treatment OutcomeABSTRACT
Background It is still controversial whether catheter ablation for atrial fibrillation (AF) improves survival and other outcomes in patients with AF. This study evaluated whether ablation reduces death and other events in nationwide real-world Asian patients with AF. Methods and Results From the Korean National Health Insurance Service database, 194 928 adult patients (aged ≥18 years) with newly diagnosed AF were treated with ablation or medical therapy (antiarrhythmic or rate control drugs) between January 1, 2005, and December 1, 2015. Among these patients, this study included 9185 with ablation and 18 770 with medical therapy. The time at risk was counted from the first medical therapy, and ablation was analyzed as a time-varying covariate. Inverse probability of treatment weighting was used to correct for differences between the groups. After weighting, the 2 cohorts had similar background characteristics. During a median (25th, 75th percentiles) follow-up of 43 (19, 81) months, ablation of AF was associated with lower incidence and risk of composite outcome, including death, heart failure admission, and stroke/systemic embolism (2.5 and 6.4 per 100 person-years, respectively; hazard ratio [HR], 0.47; 95% CI, 0.43-0.52; P<0.001), all-cause death (1.0 and 3.6 per 100 person-years; HR, 0.41; 95% CI, 0.36-0.47; P<0.001), heart failure admission (0.7 and 1.9 per 100 person-years; HR, 0.43; 95% CI, 0.37-0.50), and ischemic stroke/systemic embolism (1.1 and 2.8 per 100 person-years; HR, 0.39; 95% CI, 0.34-0.44) than medical therapy. Conclusions Ablation may be associated with lower risk of death, heart failure admission, and ischemic stroke/systemic embolism in real-world Asian patients with AF.
Subject(s)
Anti-Arrhythmia Agents/therapeutic use , Atrial Fibrillation/therapy , Catheter Ablation , Embolism/prevention & control , Heart Rate/drug effects , Stroke/prevention & control , Aged , Anti-Arrhythmia Agents/adverse effects , Atrial Fibrillation/diagnosis , Atrial Fibrillation/mortality , Atrial Fibrillation/physiopathology , Catheter Ablation/adverse effects , Catheter Ablation/mortality , Databases, Factual , Embolism/diagnosis , Embolism/mortality , Female , Heart Failure/mortality , Heart Failure/prevention & control , Humans , Incidence , Male , Middle Aged , Patient Admission , Recovery of Function , Registries , Republic of Korea , Retrospective Studies , Risk Assessment , Risk Factors , Stroke/diagnosis , Stroke/mortality , Time Factors , Treatment OutcomeABSTRACT
BACKGROUND: Several studies have indicated that acute myocardial infarction (AMI) secondary to coronary artery embolism (CE) has a poor prognosis. However, in the latter studies, CE of tumor origin accounts for a considerable proportion of cases and the clinical features and contribution to overall prognosis of non-tumor CE are unknown and therefore the subject of this study. METHODS: We retrospectively studied 2006 consecutive patients with AMI at our medical center from January 2014 to October 2018. Non-tumor CE was diagnosed based on angiographic, biochemical, and imaging criteria. Patients were divided into two groups: patients without CE (control) and patients with non-tumor CE. RESULTS: Atrial fibrillation was the most frequent etiology (n = 32, 69.6%) in the non-tumor CE group (n = 46). Compared with the control group, the non-tumor CE group had (all p < 0.05): higher incidence of atrial fibrillation; larger left atrial diameter, left ventricular end-diastolic diameter and left ventricular end-systolic diameter; lower left ventricular ejection fraction, ST-segment-elevation myocardial infarction incidence and low density lipoprotein cholesterol level; lower incidence of multivessel coronary stenosis, level of culprit lesion stenosis and proportion of angioplasty; higher ratio of manual thrombectomy and antithrombotic drugs alone therapy; lower thrombolysis in myocardial infarction (TIMI) grade and higher corrected TIMI frame counts (CTFC) after reperfusion; and statistically similar overall survival at median 864 (interquartile range, 413-1272) days. CONCLUSIONS: The overall incidence of non-tumor CE was 2.3%, with atrial fibrillation as its most common etiology. Midterm overall survival was similar between AMI patients secondary to non-tumor CE and those without CE.
Subject(s)
Embolism/complications , Myocardial Infarction/etiology , Prognosis , Aged , Atrial Fibrillation/complications , Atrial Fibrillation/physiopathology , Chi-Square Distribution , Coronary Vessels/diagnostic imaging , Coronary Vessels/physiopathology , Electrocardiography/methods , Embolism/epidemiology , Embolism/mortality , Female , Humans , Kaplan-Meier Estimate , Male , Middle Aged , Myocardial Infarction/mortality , Myocardial Infarction/physiopathology , Retrospective StudiesABSTRACT
The purpose of this study is to provide detailed data on treatment persistence and clinical outcomes in Chinese patients with nonvalvular atrial fibrillation (NVAF). A single-center retrospective observational study was conducted. A total of 26,663 NVAF patients were enrolled from January 1, 2014 to December 31, 2017, clinical information of whom were from inpatient and outpatients data system was collected. The 1-year treatment persistence rates of 11,350 dabigatran users were 24.5% in 2014, 36.6% in 2015, 37.7% in 2016 and 51.8% in 2017. The predominant reason of non-persistence patients was the cost of treatment. Incidence rates of all-cause death, ischemic stroke and embolism were 1.99/100 person-years, 2.56/100 person-years and 0.77/100 person-years, respectively. Incidence rates of minor bleeding events, intracranial hemorrhage and gastrointestinal hemorrhage were 10.05/100 person-years, 0.51/100 person-years and 0.85/100 person-years, respectively. In conclusion, it is of importance for Chinese clinicians to know about these information because dabigatran is a relatively new drug in China. Compared with other reported data, patients of this study have (1) lower dabigatran persistence and lower incident rates of all-cause death, systemic embolism, minor bleeding events and gastrointestinal hemorrhage and (2) higher incident rates of ischemic stroke and intracranial hemorrhage.
Subject(s)
Antithrombins/administration & dosage , Atrial Fibrillation/drug therapy , Brain Ischemia/mortality , Dabigatran/administration & dosage , Embolism/prevention & control , Stroke/prevention & control , Administration, Oral , Aged , Antithrombins/adverse effects , Atrial Fibrillation/diagnosis , Atrial Fibrillation/mortality , Brain Ischemia/diagnosis , Brain Ischemia/prevention & control , China/epidemiology , Dabigatran/adverse effects , Embolism/diagnosis , Embolism/mortality , Female , Hemorrhage/chemically induced , Hemorrhage/mortality , Humans , Incidence , Male , Middle Aged , Retrospective Studies , Stroke/diagnosis , Stroke/mortality , Time Factors , Treatment OutcomeABSTRACT
BACKGROUND: This study was performed to summarize our experience in treating acute superior mesenteric artery embolism (SMAE) by percutaneous mechanical thrombectomy (PMT). METHODS: The clinical data of five patients with acute SMAE treated by PMT in our center from October 2015 to May 2018 were retrospectively analyzed. PMT was performed under local anesthesia. Access was established via the femoral artery or brachial artery. Thrombectomy was performed on the superior mesenteric artery using a 6F Rotarex catheter (Straub Medical, Wangs, Switzerland). RESULTS: Technical success of PMT was achieved in all five patients; emboli were completely removed in three patients and partially removed in two patients. No PMT-related complications were noted after surgery. Four patients were smoothly discharged from the hospital after their symptoms were relieved. One patient still had symptoms of intestinal ischemia after the operation, and massive small intestinal necrosis was found by exploratory laparotomy. Intestinal resection was performed, and the patient died 4 months later. CONCLUSIONS: PMT by the Rotarex system is a minimally invasive, safe, and effective technique in removing SMAE. Early application of PMT can avoid intestinal necrosis.
Subject(s)
Brachial Artery , Catheterization, Peripheral , Embolism/therapy , Femoral Artery , Mesenteric Artery, Superior , Mesenteric Ischemia/therapy , Thrombectomy , Acute Disease , Aged , Catheterization, Peripheral/adverse effects , Catheterization, Peripheral/mortality , Embolism/diagnostic imaging , Embolism/mortality , Embolism/physiopathology , Female , Humans , Male , Mesenteric Artery, Superior/diagnostic imaging , Mesenteric Artery, Superior/physiopathology , Mesenteric Ischemia/diagnostic imaging , Mesenteric Ischemia/mortality , Mesenteric Ischemia/physiopathology , Middle Aged , Punctures , Retrospective Studies , Risk Factors , Splanchnic Circulation , Thrombectomy/adverse effects , Thrombectomy/mortality , Treatment OutcomeABSTRACT
BACKGROUND: A global, randomized clinical trial indicated the efficacy and safety of apixaban in stroke prevention in patients with nonvalvular atrial fibrillation (NVAF). However, data in the elderly NVAF patients ≥75 years, especially those on reduced dose, are limited. HYPOTHESIS: To confirm the current dose reduction criteria of apixaban in elderly NVAF patients. METHOD: With a large-scale, multicenter prospective observational study, one-year outcomes after administration of on-label doses of apixaban were analyzed in Japanese NVAF patients aged ≥75 years. Endpoints were stroke or systemic embolism, bleeding requiring hospitalization, total death, and cardiovascular death. RESULTS: A total of 3031 patients (average age, 81.7 years; female, 48.2%) taking standard (5 mg bid) or reduced dose (2.5 mg bid) of apixaban were enrolled from 110 facilities. Standard and reduced apixaban doses were administered in 1284 (42.4%) and 1747 (57.6%) patients, respectively. Event rates (/100 person-years) in standard and reduced dose groups were 1.67 and 1.56, respectively, for stroke or systemic embolism, 1.42 and 2.25 for bleeding requiring hospitalization, 1.41 and 4.46 for total death, and 0.41 and 1.36 for cardiovascular death. Reduced apixaban dose was not significantly associated with stroke or systemic embolism and bleeding requiring hospitalization, but was independently associated with total and cardiovascular death. CONCLUSIONS: Incidences of stroke or systemic embolism and bleeding requiring hospitalization were similar between standard and reduced apixaban doses in the elderly NVAF patients. The incidences of total and cardiovascular death were significantly higher in the reduced dose group due to the coexisting higher risks in this group.
Subject(s)
Atrial Fibrillation/drug therapy , Embolism/prevention & control , Factor Xa Inhibitors/administration & dosage , Pyrazoles/administration & dosage , Pyridones/administration & dosage , Stroke/prevention & control , Age Factors , Aged , Aged, 80 and over , Atrial Fibrillation/diagnosis , Atrial Fibrillation/mortality , Embolism/diagnosis , Embolism/mortality , Factor Xa Inhibitors/adverse effects , Female , Hemorrhage/chemically induced , Hemorrhage/therapy , Hospitalization , Humans , Incidence , Japan/epidemiology , Male , Prospective Studies , Pyrazoles/adverse effects , Pyridones/adverse effects , Registries , Risk Assessment , Risk Factors , Stroke/diagnosis , Stroke/mortality , Time Factors , Treatment OutcomeABSTRACT
AIMS: Peri-procedural transcatheter valve embolization and migration (TVEM) is a rare but potentially devastating complication of transcatheter aortic valve implantation (TAVI). We sought to assess the incidence, causes, and outcome of TVEM in a large multicentre cohort. METHODS AND RESULTS: We recorded cases of peri-procedural TVEM in patients undergoing TAVI between January 2010 and December 2017 from 26 international sites. Peri-procedural TVEM occurred in 273/29 636 (0.92%) TAVI cases (age 80.8 ± 7.3 years; 53.8% female), of which 217 were to the ascending aorta and 56 to the left ventricle. The use of self-expanding or first-generation prostheses and presence of a bicuspid aortic valve were independent predictors of TVEM. Bail-out measures included repositioning attempts using snares or miscellaneous tools (41.0%), multiple valve implantations (83.2%), and conversion to surgery (19.0%). Using 1:4-propensity matching, we identified a cohort of 235 patients with TVEM (TVEMPS) and 932 patients without TVEM (non-TVEMPS). In the matched cohort, all-cause mortality was higher in TVEMPS than in non-TVEMPS at 30 days (18.6% vs. 4.9%; P < 0.001) and after 1 year (30.5% vs. 16.6%; P < 0.001). Major stroke was more frequent in TVEMPS at 30 days (10.6% vs. 2.8%; P < 0.001), but not at 1 year (4.6% vs. 1.9%; P = 0.17). The need for emergent cardiopulmonary support, major stroke at 30 days, and acute kidney injury Stages 2 and 3 increased the risk of 1-year mortality, whereas a better renal function at baseline was protective. CONCLUSION: Transcatheter valve embolization and migration occurred in approximately 1% and was associated with increased morbidity and mortality.
Subject(s)
Embolism , Heart Valve Prosthesis/adverse effects , Postoperative Complications , Prosthesis Failure , Transcatheter Aortic Valve Replacement/adverse effects , Aged , Aged, 80 and over , Embolism/epidemiology , Embolism/etiology , Embolism/mortality , Female , Humans , Incidence , Male , Postoperative Complications/epidemiology , Postoperative Complications/etiology , Postoperative Complications/mortality , Prosthesis Failure/adverse effects , Prosthesis Failure/etiology , Registries , Retrospective Studies , Risk Factors , Stroke/epidemiology , Treatment OutcomeABSTRACT
Aims: Non-vitamin K antagonist oral anticoagulants (NOACs) and vitamin K antagonists (VKAs) are used to prevent stroke in patients with atrial fibrillation (AF). This paper aimed to evaluate the clinical efficacy and safety of NOACs when compared to VKAs by calculating the number needed to treat (NNT) at 2 years using incidence rates and hazard ratios (HRs) derived from a meta-analysis of studies conducted in real-world settings. Materials and methods: HRs were sourced from a published systematic literature review and a meta-analysis of real-world evidence on the use of NOACs vs VKAs. Rivaroxaban, dabigatran, and apixaban vs VKAs were investigated. The efficacy outcomes included: a composite of ischaemic stroke and systemic embolism (IS/SE), ischaemic stroke (IS), and all-cause mortality. The safety analysis assessed major bleeding and intracranial haemorrhage (ICH). Results: Superiority of NOACs vs VKAs was observed in 10/15 comparisons. Treating patients with rivaroxaban and dabigatran was associated with a reduced risk of IS and all-cause mortality compared to VKAs, with one death prevented every 22 and 32 patients, respectively, and one IS prevented every 206 and 166 patients, respectively. Rivaroxaban was significantly associated with a reduced risk of IS/SE compared to VKA (NNT: 107). No significant differences were observed between apixaban and VKAs. Dabigatran and apixaban were associated with a reduced risk of major bleeding compared to VKA (NNT: 59 and 38, respectively). No significant difference was observed between rivaroxaban and VKAs regarding major bleeding. Rivaroxaban, dabigatran, and apixaban were significantly associated with a reduced risk of ICH (NNT: 205, 115, and 108, respectively). Limitations: Heterogeneity in definitions of major bleeding across studies. Conclusions: The NNT calculation, when approached and interpreted properly, is a practical measure of the effectiveness of a treatment. The calculation based on HRs showed that NOACs are safe and effective alternatives to VKAs in real life.
Subject(s)
Anticoagulants/administration & dosage , Anticoagulants/classification , Atrial Fibrillation/drug therapy , Stroke/prevention & control , Administration, Oral , Anticoagulants/therapeutic use , Antithrombins/therapeutic use , Embolism/mortality , Embolism/prevention & control , Factor Xa Inhibitors/therapeutic use , Humans , Sample Size , Stroke/mortality , Vitamin K/antagonists & inhibitors , Warfarin/therapeutic useABSTRACT
BACKGROUND: Fenestrated/branched endografts for aortic repair (FB-EVAR) are valid options to treat thoracoabdominal aortic aneurysms (TAAAs). Successful repair requires manipulation of target visceral vessels (TVVs) with possible splanchnic ischemia. The aim of the study was to evaluate the clinical impact of splanchnic ischemia occurring in FB-EVAR for TAAA. METHODS: Between 2010 and 2015, patients with TAAAs undergoing FB-EVAR were prospectively enrolled. Clinical, morphological, procedural, and 30-day data were evaluated. Splanchnic ischemia was defined as the presence of splanchnic ischemic lesions (SILs) visible at perioperative computed tomography angiography. Preoperative, postoperative, and 30-day hepatic/pancreatic/renal laboratory functions were analyzed. End points were incidence of SILs, laboratory splanchnic functions worsening (≥25% of baseline), and presence of related clinical/morphological and procedural risk factors. RESULTS: Thirty-six patients (male: 78%; age: 73 ± 7 years) with 27 (75%) type I-III and 9 (25%) type IV TAAA who underwent FB-EVAR for a total of 127 TVV (branches: 47-60%; fenestrations: 53-67%). Fourteen SILs occurred in 12 (33%) patients: 4 (29%) in pancreas, 3 (21%) in spleen, 2 (14%) in bowel, 5 (36%) in kidney. The cause was embolic in 79% and thrombotic in 21%. No preoperative clinical/morphological data or procedural data were correlated with SIL. Pancreatic, hepatic, or renal function worsening occurred at 24 hr in 16 (44%), 16 (44%), and 9 (25%) cases, respectively. Overall, SILs were associated with increased values of C-reactive protein (CRP) (17.9 ± 0.4 vs. 9.9 ± 9.0 mg/dL; P = 0.03) and bilirubin (1.2 ± 2.3 vs. 1.0 ± 0.5 mg/dL; P = 0.02) at 24 hr. Specifically, SIL of the celiac trunk and superior mesenteric and renal arteries' parenchyma were associated with the significant laboratory function changes 24 hr. SIL of the superior mesenteric artery was associated with increased 30-day mortality (50% vs. 7 %; P = 0.002). Pancreatic, hepatic, or renal function worsening occurred at 30 days in 2 (6%), 0 (0%), and 4 (12%) cases, with similar laboratory tests in patients with and without SIL. CONCLUSIONS: SIL can be frequently detected after FB-EVAR for TAAA and appears mainly of embolic origin. No clinical, morphological, or procedural predictors could be identified in our series. Postoperative laboratory changes of CRP, bilirubin, activated partial thromboplastin time, and amylases are associated with SIL but disappear without clinical consequences within 30 days. However, SIL occurring in the superior mesenteric artery are associated with an increased 30-day mortality.
Subject(s)
Aortic Aneurysm, Thoracic/surgery , Blood Vessel Prosthesis Implantation/adverse effects , Blood Vessel Prosthesis Implantation/instrumentation , Blood Vessel Prosthesis , Embolism/etiology , Endovascular Procedures/adverse effects , Endovascular Procedures/instrumentation , Mesenteric Artery, Superior/physiopathology , Mesenteric Ischemia/etiology , Mesenteric Vascular Occlusion/etiology , Splanchnic Circulation , Aged , Aged, 80 and over , Aortic Aneurysm, Thoracic/mortality , Aortic Aneurysm, Thoracic/physiopathology , Blood Vessel Prosthesis Implantation/mortality , Computed Tomography Angiography , Databases, Factual , Embolism/diagnostic imaging , Embolism/mortality , Embolism/physiopathology , Endovascular Procedures/mortality , Female , Humans , Male , Mesenteric Artery, Superior/diagnostic imaging , Mesenteric Ischemia/diagnostic imaging , Mesenteric Ischemia/mortality , Mesenteric Ischemia/physiopathology , Mesenteric Vascular Occlusion/diagnostic imaging , Mesenteric Vascular Occlusion/mortality , Mesenteric Vascular Occlusion/physiopathology , Prospective Studies , Prosthesis Design , Risk Factors , Thrombosis/etiology , Thrombosis/physiopathology , Time Factors , Treatment OutcomeABSTRACT
INTRODUCTION: Iatrogenic embolization following cardiac investigative procedures may result from hydrophilic polymer emboli (HPE) from catheter valve and vessel wall calcifications, and air embolism from open heart surgery. This retrospective clinical pathologic analysis was undertaken to ascertain the frequency and extent of these potentially fatal complications. METHODS: This retrospective clinical pathologic autopsy analysis with premortem diagnostic imaging correlation identified 110 individuals who had undergone endovascular procedures between 2010 and 2016 within 90â¯days of death and followed by hospital autopsy. Clinical outcomes, radiologic studies, and autopsy materials were reviewed. RESULTS: Iatrogenic emboli were assessed as causing death in 9/110 autopsy cases (8.2%) and 9/34 (26.5%) cases with proven iatrogenic emboli. Iatrogenic emboli caused strokes in 10/110 (9.1%) autopsy cases including calcified emboli (CE, n=6), HPE (n=2), cardiac valvular tissue (n=1), and air embolism (n=1). Seven cases of calcified emboli complicating endovascular procedures were identified: four of the CE were thought to be the cause of death due to fatal strokes (n=2) and fatal myocardial (n=1) and colonic infarction (n=1). The CE likely originated from calcified aortic valves and atherosclerotic aortic plaques. Histologic evidence of HPE was found in 23% (25/110) of cases; 54% (26/48) showed evidence of infarction in postprocedural imaging, with radiologic evidence of infarction in 32% (8/25) of cases with HPE histology. Endovascular aortic repair was associated with the greatest density/distribution of HPE. HPE material showed degradation with time and was often associated with an inflammatory response. HPE directly contributed to death in three cases. One fatal air embolism followed open heart surgery, and one cardiac tissue embolus resulted in a major stroke. CONCLUSIONS: We advocate for greater awareness of these underrecognized and occasionally fatal complications of endovascular procedures. Targeted postprocedural imaging has a role in the identification of iatrogenic embolic infarcts.
Subject(s)
Cardiac Catheterization/adverse effects , Embolism/etiology , Endovascular Procedures/adverse effects , Foreign-Body Migration/etiology , Iatrogenic Disease , Polymers/adverse effects , Adult , Aged , Aged, 80 and over , Atherosclerosis/complications , Autopsy , Calcinosis/complications , Cardiac Catheterization/instrumentation , Cardiac Catheterization/mortality , Cause of Death , Cerebral Angiography/methods , Computed Tomography Angiography , Embolism/diagnostic imaging , Embolism/mortality , Embolism/pathology , Embolism, Air/etiology , Endovascular Procedures/instrumentation , Endovascular Procedures/mortality , Female , Foreign-Body Migration/diagnostic imaging , Foreign-Body Migration/mortality , Foreign-Body Migration/pathology , Humans , Male , Middle Aged , Retrospective Studies , Risk Factors , Time Factors , Young AdultABSTRACT
OBJECTIVE: The primary objective was to evaluate the safety of transfer, type of procedure, and factors associated with limb salvage in patients with acute limb ischemia (ALI) treated at a quaternary referral center. METHODS: A retrospective review of all patients with ALI secondary to thrombotic or embolic occlusion at a quaternary referral hospital from 2013 to 2016 was conducted. Patients were transferred from throughout Washington and Alaska by ambulance, helicopter, or fixed-wing modes of transportation. Demographics, transport and operative timing, Rutherford classification, level of occlusion, procedural information, and fasciotomy characteristics were reviewed. Outcomes measured included limb salvage rates, discharge disposition, and mortality. RESULTS: One hundred twelve patients with ALI were identified, with 82% due to thrombosis and 18% due to arterial embolization. Fifty-seven percent of patients were transferred from a referring hospital with low mean transfer times (1.9 hours for embolic, 2.7 hours for thrombotic). Although the initial operative strategy varied according to the etiology, with 50% of thrombotic occlusions treated with endovascular therapies and 80% of embolic occlusions treated with open thrombectomy, the rates of limb salvage did not vary based on operative approach (92% endovascular first, 90% open first). Further, limb salvage rates were identical between transferred and nontransferred patients (77%). Limb salvage was successful in 91% of patients with Rutherford class 1 and 2 disease, but only 8% in patients with Rutherford class 3 disease. In-hospital and 30-day mortality rates were not different based on ischemic etiology (5%), although patients with Rutherford class 3 disease had significantly higher mortality rates (15%) compared with patients with class 1 (6%), class 2a (6%), and class 2b (2%) disease. Fasciotomy was performed in 29% of patients, with 59% of fasciotomy wounds closed primarily. Predictors of amputation include multiple attempts at limb salvage, higher Rutherford class, multilevel occlusion, more proximal levels of occlusion, and nonviable muscle seen after fasciotomy, with ischemic times trending toward higher amputation rates without statistical significance. There was no difference in discharge disposition based on ischemic etiology. CONCLUSIONS: The modern treatment of patients with ALI is effective, with high rates of limb salvage and low mortality regardless of transfer status, etiology, or initial operation performed. In situations where compartment syndrome is unclear, fasciotomy should not be withheld because it provides valuable predictive information regarding limb salvage.