Short- and Long-Term Outcomes of Patients with Postoperative Arrhythmia after Liver Surgery.

BACKGROUND: New-onset postoperative arrhythmia (PA) has previously been described as a pivotal risk factor for postoperative morbidity and mortality after visceral surgery. However, there is a lack of data concerning liver surgery. The incidence and impact of new-onset postoperative arrhythmia after liver surgery was, therefore, analyzed in a monocentric study. METHODS: In total, n = 460 patients (221 female, 239 male) who underwent liver surgery between January 2012 and April 2020 without any prior arrhythmia in their medical history were included in this retrospective analysis. Clinical monitoring started with the induction of anesthesia and was terminated with discharge from the intensive care unit (ICU) or intermediate care unit (IMC). Follow-up included documentation of complications during the hospital stay, as well as long-term survival analysis. RESULTS: Postoperative arrhythmia after liver surgery was observed in 25 patients, corresponding to an incidence of 5.4%. The occurrence of arrhythmia was significantly associated with intraoperative complications (p < 0.05), liver fibrosis/cirrhosis (p < 0.05), bile fistula/bile leakage/bilioma (p < 0.05), and organ failure (p < 0.01). Survival analysis showed a significantly poorer overall survival of patients who developed postoperative arrhythmia after liver surgery (p < 0.001). CONCLUSIONS: New-onset postoperative arrhythmia after liver surgery has an incidence of only 5.4% but is significantly associated with higher postoperative morbidity and poorer overall survival.

Comparison of transcatheter leaflet-approximation and direct annuloplasty in tricuspid regurgitation.

BACKGROUND: Transcatheter repair emerges as a treatment option in patients with tricuspid regurgitation (TR) and high surgical risk. AIMS: This study aimed to compare leaflet-based and annuloplasty-based transcatheter repair in patients with TR. METHODS: In a retrospective analysis consecutive patients undergoing either transcatheter edge-to-edge repair (TEER) or direct annuloplasty (AP) for relevant TR at 2 centers were compared with respect to baseline characteristics, procedural efficacy and safety (death, myocardial infarction, procedure or device-related cardiothoracic surgery, or stroke at 30 days). RESULTS: 161 patients (57% female, median age 79 [75-82] years) with comparable clinical baseline characteristics in the TEER (n = 87) and AP (n = 74) group were examined. Baseline TR grade was significantly less severe in the TEER compared to the AP group (torrential 9.2 vs. 31.1%, p = 0.001). Technical success and improvement of TR grades were not significantly different across groups. In analysis matched for baseline TR severity, reduction of TR grade to less than moderate was significantly more common in the AP group (47.8 vs. 26.1%, p = 0.031). Major or more severe bleeding occurred in 9.2% of TEER and 20.3% of AP patients (p = 0.049) without any fatal bleedings. Major adverse events (MAE) were similar across groups with four patients (4.7%) in the TEER group and five patients (6.9%) in the AP group (p = 0.733) and 6-month survival did not differ significantly. CONCLUSIONS: Differences observed between patients treated with TEER and AP provide first evidence for tailoring distinct transcatheter treatment techniques to individual patient characteristics.

[Pulmonary hypertension associated with left heart disease (group 2)]. / Pulmonale Hypertonie im Zusammenhang mit Linksherzerkrankungen (Gruppe 2).

Patients with left heart disease (LHD) often display pulmonary hypertension (PH), which impacts morbidity and mortality. The pathophysiology of PH is complex and entails pulmonary congestion due to elevated left-sided filling pressures, pulmonary vasoconstriction as well as vascular remodeling. The recent ESC/ERS Guidelines on pulmonary hypertension updated the hemodynamic definitions of pulmonary hypertension in general, and the subclassification of post-capillary PH. This review summarizes recent advances in the diagnostic work-up and management strategies of PH associated with LHD. Specifically, we summarize revisited hemodynamic definitions and the characteristics of isolated post-capillary PH (IpcPH) and combined post- and pre-capillary PH (CpcPH). Furthermore, we review the current knowledge on the pathogenesis of PH-LHD, the prognostic relevance of hemodynamic parameters, and the management strategies, differentiating between treatment of the underlying left heart disease and therapies targeting the pulmonary circulation. The article emphasises the need for precise diagnostic work-up and individualized treatment strategies in patients with PH-LHD.

[Preclinical loading in patients with acute chest pain and acute coronary syndrome - PRELOAD survey]. / Präklinisches Loading bei Patienten mit akutem Thoraxschmerz und akutem Koronarsyndrom ­ PRELOAD-Umfrage.

BACKGROUND: Guidelines on myocardial infarction (MI) recommend antithrombotic and anticoagulatory treatment at time of diagnosis. MI with ST segment elevation (STEMI) is mostly a certain diagnosis. Acute coronary syndrome without ST segment elevation (NSTE-ACS) has diagnostic uncertainty and remains a working diagnosis in the prehospital setting. OBJECTIVE: Assessment of prehospital loading with aspirin and heparin depending on ACS subtype and pretreatment with oral anticoagulants. METHODS: The PRELOAD survey was a nationwide German study. STEMI/NSTE-ACS scenarios were designed and varied in pretreatment: I) no pretreatment, II) new oral anticoagulants (NOAC), III) vitamin K antagonist (VKA). Loading strategy was assessed and included: a) aspirin (ASA), b) unfractionated heparin (UFH), c) ASA + UFH, d) no loading. RESULTS: A total of 708 emergency physicians were included. In NSTE-ACS without pretreatment, 79% chose loading (p < 0.001). ASA + UFH (71.4%) was the preferred option. In corresponding STEMI scenario, 100% chose loading and 98.6% preferred ASA + UFH (p < 0.001). In NSTE-ACS with NOAC pretreatment, 69.8% favored loading (p < 0.001); in VKA pretreatment the corresponding rate was 72.3% (p < 0.001). In each scenario, ASA was the preferred option. In STEMI with NOAC pretreatment, 97.5% chose loading (p < 0.001); analogous rate was 96.8% in STEMI with VKA pretreatment (p < 0.001). ASA was the preferred option again. CONCLUSIONS: Prehospital loading was the preferred treatment strategy despite the diagnostic uncertainty in NSTE-ACS and guidelines recommending loading at time of diagnosis. Pretreatment with oral anticoagulants resulted in a strategy shift to loading with only aspirin. In STEMI patients, this indicates potential undertreatment.

A nationwide analysis of reperfusion therapies for pulmonary embolism in older patients with frailty.

BACKGROUND: Reperfusion therapy is challenging in the elderly. Catheter-directed therapies are an alternative for higher-risk pulmonary embolism (PE) patients if systemic thrombolysis (ST) is contraindicated or has failed. Their safety has not been evaluated in specific vulnerable populations. AIMS: We aimed to assess the safety of reperfusion therapies in elderly and frail patients in the real world. METHODS: In the US Nationwide Inpatient Sample from 2016 to 2020, we identified hospitalisations of patients ≥65 years with PE and defined a frailty subgroup using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator. We investigated reperfusion therapies (ST, catheter-directed thrombolysis [CDT], catheter-based thrombectomy [CBT], surgical embolectomy [SE]) and their associated safety outcomes (overall and major bleeding). RESULTS: Among 980,245 hospitalisations of patients ≥65 years with PE (28.0% frail), reperfusion therapies were used in 4.9% (17.6% among high-risk PE). ST utilisation remained stable, while the use of catheter-directed therapies increased from 1.7% in 2016 to 3.2% in 2020. Among all hospitalisations with reperfusion, CDT, compared to ST, was associated with reduced major bleeding (5.8% vs 12.2%, odds ratio [OR] 0.58, 95% confidence interval [CI]: 0.49-0.70); these results also applied to frail patients. CBT, compared to SE, was also associated with reduced major bleeding (11.0% vs 22.4%, OR 0.63, 95% CI: 0.43-0.91), but not among frail patients. These differences were particularly significant in patients with non-high-risk PE. Differences persisted for overall bleeding as well. CONCLUSIONS: Catheter-directed therapies may be a safer alternative to classical reperfusion therapies for elderly and frail patients with PE requiring reperfusion treatment.

Pulmonary hypertension associated with left heart disease.

Pulmonary hypertension (PH) is a common condition in patients with left heart disease (LHD) that is highly relevant for morbidity and mortality. While post-capillary in nature, the pathophysiology of PH in patients with LHD (heart failure/cardiomyopathy, valvular heart disease; other: congenital/acquired) is complex, and decisions about management strategies are challenging. Recently, the updated European Society of Cardiology/European Respiratory Society guidelines on the diagnosis and treatment of PH revisited hemodynamic definitions and the sub-classification of post-capillary PH, and provided numerous new recommendations on the diagnosis and management of PH associated with various types of LHD. Here, we review several novel aspects that focus on: (a) updated hemodynamic definitions, including the distinction between isolated post-capillary PH (IpcPH) and combined post- and pre-capillary PH (CpcPH); (b) the pathogenesis of PH-LHD, considering various components contributing to PH, such as pulmonary congestion, vasoconstriction, and vascular remodeling; (c) the prognostic relevance of PH and hemodynamic markers; (d) the diagnostic approach to PH-LHD; (e) management strategies in PH-LHD, distinguishing between targeting the underlying left heart condition, the pulmonary circulation, and/or impaired right ventricular function. In conclusion, precise clinical and hemodynamic characterization and detailed phenotyping are essential for prognostication and the management of patients with PH-LHD.

Unexpected paradoxical embolization following catheter-directed thrombectomy with the FlowTriever™ system in a patient with pulmonary embolism: a case report.

Background: The optimal therapy for patients suffering from acute pulmonary embolism (PE) classified as intermediate-high risk still needs to be identified. Catheter-directed thrombectomy (CDTE) is a safe procedure to reduce thrombus burden immediately. The lack of randomized trials is one reason: catheter-directed thrombolysis (CDT) has not yet received a clear recommendation in our guidelines. Herein, we report an unexpected event in the course of a patient with PE treated with CDTE using the FlowTriever™ system, the only FDA-approved catheter system for percutaneous mechanical thrombectomy regarding this indication. Case Summary: A 57-year-old male presented with dyspnoea at the emergency department of our university hospital. The computed tomography (CT) scan showed bilateral PE, and ultrasound of the left lower limb revealed deep venous thrombosis. According to the current ESC guidelines, he was classified intermediate-high risk. We performed bilateral CDTE. On the first and third day post-intervention, our patient presented neurological deficits. Whereas the first CT scan of the cerebrum remained normal, the CT scan at Day 3 showed demarcated embolic stroke. Further imaging diagnostic gave evidence to an ischemic lesion in the left kidney. Transesophageal echocardiography revealed a patent foramen ovale (PFO) as the origin of paradoxical embolism and thus mechanism of both ischemic lesions. Compliant to the current recommendations, percutaneous PFO closure was performed. Our patient recovered properly without any sequelae. Discussion: Whether the deep venous thrombosis is the source of embolization or the catheter-directed retrieval of clots may have transported clot material to the right atrium which further on embolized systemically will remain unclear. Yet, we have to consider it as a potential complication in catheter-directed treatment of PE in patients with a PFO.

Acute Chest Pain­Diagnostic Accuracy and Pre-Hospital Use of Anticoagulants and Platelet Aggregation Inhibitors

BACKGROUND: Acute chest pain (aCP) can be a symptom of life-threatening diseases such as acute coronary or aortic syndrome, but often has a non-cardiac cause. The recommendations regarding pre-hospital drug treatment of patients with aCP are ambiguous. METHODS: A retrospective cohort study was conducted of 822 patients with aCP who were attended by emergency physicians. The cause of aCP was classified as follows: acute coronary syndrome without ST-segment elevation (NSTE-ACS), acute aortic syndrome, hypertensive crisis, cardiac arrhythmias, musculoskeletal, or other. The suspected and discharge diagnoses were compared, and the pre-hospital administration of acetylsalicylic acid (ASA) and unfractionated heparin (UFH) was analyzed. Furthermore, the parameters that improved diagnostic accuracy were investigated. RESULTS: The positive predictive value of the diagnosis assigned by the emergency physician (EP diagnosis) was 39.7%. NSTEACS was the most commonly suspected cause of aCP (74.7%), but was confirmed after hospital admission in only 26.3% of patients. ASA was administered in 51%, UFH in 55%, and both substances in 46.4% of cases. A large proportion of patients received anticoagulants in the pre-hospital setting although the discharge diagnosis was not NSTE-ACS: ASA 62.9%, UFH 66.0%, both substances 56.5%. CONCLUSION: ASA and UFH are often given to EP-accompanied patients with aCP despite the low accuracy of diagnosis in the pre-hospital setting. Pre-hospital measurement of high-sensitivity troponin T (hs Trop-T) might improve discrimination between NSTE-ACS and other causes of aCP. This is important, as the current guidelines contain no clear recommendations for prehospital drug treatment in NSTE-ACS.

Incidence and impact of new-onset postoperative arrhythmia after surgery of the lower gastrointestinal tract.

Postoperative arrhythmias (PAs) are common events and have been widely investigated in cardiothoracic surgery. Within visceral surgery, a recent study revealed a significant occurrence of PA in esophageal resections. In contrast, PA in lower gastrointestinal surgery is rarely investigated and has been rudimentary described in the medical literature. The present work is a retrospective cohort study of 1171 patients who underwent surgery of lower gastrointestinal tract between 2012 and 2018. All included patients were treated and monitored in the intensive care unit (ICU) or intermediate care unit (IMC) after surgery. Follow-up, performed between January and May 2021, was obtained for the patients with PA investigating the possible persistence of PA and complications such as permanent arrhythmia or thromboembolic events after discharge. In total, n = 1171 patients (559 female, 612 male) without any history of prior arrhythmia were analyzed. Overall, PA occurred in n = 56 (4.8%) patients after surgery of the lower GI. The highest incidence of PA was seen in patients undergoing bowel surgery after mesenteric ischaemia (26.92%), followed by cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC; 16.67%). PA was significantly associated with higher age (72 years (IQR 63-78 years) vs. 64 years (IQR 55-73.5 years), p < 0.001) and longer length of stay in the ICU (median 15 days (IQR 5-25 days) vs. median 2 days (IQR 1-5 days), p < 0.001). PA was independently associated with organ failure (OR = 4.62, 95% CI 2.11-10.11, p < 0.001) and higher in-house mortality (OR = 3.37, 95% CI 1.23-9.28, p < 0.001). In median, PA occurred 66.5 h after surgery. In follow-up, 31% of all the patients with PA showed development of permanent arrhythmia. The incidence of PA after lower GI surgery is comparatively low. Its occurrence, however, seems to have severe implications since it is significantly associated with higher rates of organ failure and in-house mortality. Also, compared to the general population, the development of permanent arrhythmia is significantly higher in patients who developed new-onset PA.

Coronary angiography after cardiac arrest without ST-elevation myocardial infarction: a network meta-analysis.

AIMS: This network meta-analysis aimed to assess the effect of early coronary angiography (CAG) compared with selective CAG (late and no CAG) for patients after out-of-hospital cardiac arrest without ST-elevation myocardial infarction (NSTE-OHCA). METHODS AND RESULTS: A systematic literature search was performed using the EMBASE, MEDLINE and Web of Science databases without restrictions on publication date. The last search was performed on 15 July 2022. Randomized controlled trials (RCTs) and non-randomized studies (NRS) comparing the effect of early CAG to selective CAG after NSTE-OHCA on survival and/or neurological outcomes were included. Meta-analyses were performed based on a DerSimonian-Laird random effects model. A total of 18 studies were identified by the literature search. After the exclusion of two studies due to high risk of bias, 16 studies (six RCTs, ten NRS) were included in the final analyses. Meta-analyses showed a statistically significant increase in survival after early CAG compared with selective CAG in the overall analysis [OR: 1.40, 95% confidence interval (CI): (1.12-1.76), P < 0.01, I2 = 68%]. This effect was lost in the subgroup analysis of RCTs [OR: 0.89, 95% CI: (0.73-1.10), P = 0.29, I2 = 0%]. Random effects model network meta-analysis of NRS based on a Bayesian method showed statistically significant increased survival after late compared with early CAG [OR: 4.20, 95% CI: (1.22, 20.91)]. CONCLUSION: The previously reported superiority of early CAG after NSTE-OHCA is based on NRS at high risk of selection and survivorship bias. The meta-analysis of RCTs does not support routinely performing early CAG after NSTE-OHCA.

Incidence, Associated Risk Factors, and Outcomes of Postoperative Arrhythmia After Upper Gastrointestinal Surgery.

Importance: New-onset postoperative arrhythmia, which most often presents as postoperative atrial fibrillation (AF), is a frequent complication in patients undergoing visceral surgery of the upper gastrointestinal tract. Its relevance for patients' outcomes is unknown. Objective: To assess the incidence of arrhythmia after upper gastrointestinal surgery, its risk factors, and its short- and long-term implications for patient outcomes. Design, Setting, and Participants: This cohort study included 1210 patients who underwent surgery of the upper gastrointestinal tract (esophagus, stomach, or pancreas) at the University Medical Center Göttingen in Germany between January 2012 and December 2018. Follow-up was performed between February and May 2020. Patients were excluded if they had a preexisting cardiac arrhythmia or pacemaker. Main Outcomes and Measures: The incidence of atrial fibrillation (AF) was recorded in most cases of postoperative arrhythmia; therefore, the analysis focused on postoperative AF. A multivariable logistic regression model was used to assess associations between surgical complications and postoperative AF occurrence, with odds ratios and 95% CIs reported. Results: A total of 1210 patients (median [IQR] age, 62 [19-90] years; 704 [58.2%] men) were enrolled in this study. Postoperative arrhythmia was recorded in 100 patients (8.3%). Among the different procedures, esophagectomy was associated with the highest incidence of postoperative AF (45.5% in complex esophageal resections and 17.1% in elective thoracoabdominal esophagectomies). The incidence of postoperative AF was associated with prolonged length of stay in the intensive care unit (23.4 days for patients with postoperative AF vs 5.9 days for those without; P < .001). Four factors were associated with the occurrence of postoperative AF: patients' age (OR, 1.06; 95% CI, 1.03-1.08; P < .001), intraoperative surgical complications (OR, 2.47; 95% CI, 1.29-4.74; P = .006), infections (OR, 2.23; 95% CI, 1.31-3.80; P = .003), and organ failure (OR, 4.01; 95% CI, 2.31-6.99; P < .001). In the multivariable analysis, postoperative AF (OR, 7.08; 95% CI, 2.75-18.23; P < .001) and sepsis (OR, 10.98; 95% CI, 3.91-30.81; P < .001) were associated with in-hospital mortality. At a median 19-month follow-up, 20 of 74 patients (27.0%) with postoperative AF developed recurring episodes of arrhythmia after discharge. Conclusions and Relevance: This cohort study found that the postoperative AF was associated with an increased length of stay in the intensive care unit and in-hospital mortality in patients after upper gastrointestinal tract surgery. In addition, postoperative AF was associated with development of permanent or paroxysmal arrhythmia after discharge.

Prevalence of left ventricular thrombus formation after mitral valve edge-to-edge repair.

The prevalence of left ventricular (LV) thrombus formation following percutaneous mitral valve edge-to-edge repair (TMVR) with the MitraClip system is unclear. Decreased total stroke volume and perfusion of the LV apex after mitral valve repair may facilitate thrombus formation especially in the context of reduced LV function. LV thrombus may cause disabling stroke or other thromboembolic events in this elderly and multimorbid patient cohort. Analyses of the prevalence of and risk factors for left ventricular thrombus formation in patients treated with the MitraClip system due to severe mitral valve regurgitation. All discharge and follow-up transthoracic echocardiographic examinations up to 6 months of 453 consecutive patients treated with the MitraClip system were screened for the presence of LV thrombus. Prevalence of LV thrombus formation was 1.1% (5/453). Importantly, LV thrombi were exclusively found in patients with severely depressed left ventricular systolic function (LV-EF < 30%), comprising a prevalence of 4.4% in this subgroup (5/113). Importantly, two of these patients were under active DOAC therapy with Rivaroxaban and Apixaban, respectively. Apart from LV-EF, we did not identify other factors that might have facilitated LV thrombus formation. LV thrombus formation following percutaneous mitral valve repair occurred exclusively in patients with severely depressed LV-EF. As two patients developed LV thrombus despite of DOAC therapy, anticoagulation with a Vitamin K antagonist should be considered in patients with an indication for oral anticoagulation following TMVR.

Meta-analysis of extracorporeal membrane oxygenation in combination with intra-aortic balloon pump vs. extracorporeal membrane oxygenation only in patients with cardiogenic shock due to acute myocardial infarction.

Background: Incidence and mortality of cardiogenic shock (CS) in patients with acute myocardial infarction (AMI) remain high despite substantial therapy improvements in acute percutaneous coronary intervention over the last decades. Unloading the left ventricle in patients with Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) can be performed by using an intra-aortic balloon pumps' (IABP) afterload reduction, which might be especially beneficial in AMI patients with CS. Objective: The objective of this meta-analysis was to assess the effect of VA-ECMO + IABP vs. VA-ECMO treatment on the mortality of patients with CS due to AMI. Methods: A systematic literature search was performed using EMBASE, COCHRANE, and MEDLINE databases. Studies comparing the effect of VA-ECMO + IABP vs. VA-ECMO on mortality of patients with AMI were included. Meta-analyses were performed to analyze the effect of the chosen treatment on 30-day/in-hospital mortality. Results: Twelve studies were identified by the literature search, including a total of 5,063 patients, 81.5% were male and the mean age was 65.9 years. One thousand one hundred and thirty-six patients received treatment with VA-ECMO in combination with IABP and 2,964 patients received VA-ECMO treatment only. The performed meta-analysis showed decreased mortality at 30-days/in-hospital after VA-ECMO + IABP compared to VA-ECMO only for patients with cardiogenic shock after AMI (OR 0.36, 95% CI 0.30-0.44, P≤0.001). Combination of VA-ECMO + IABP was associated with higher rates of weaning success (OR 0.29, 95% CI 0.16-0.53, P < 0.001) without an increase of vascular access complications (OR 0.85, 95% CI 0.35-2.08, P = 0.72). Conclusion: In this meta-analysis, combination therapy of VA-ECMO + IABP was superior to VA-ECMO only therapy in patients with CS due to AMI. In the absence of randomized data, these results are hypothesis generating only.

Midterm outcomes of LAA occlusion with the AMPLATZER Cardiac Plug and AMPLATZER Amulet devices in a high-risk cohort.

LAA occlusion has become a favourable option in patients with atrial fibrillation not eligible for oral anticoagulation therapy. Proof of effectiveness of LAA closure devices in a midterm follow-up period. This retrospective single-center cohort study analysed outcome in patients treated with AMPLATZER Cardiac Plug or AMPLATZER Amulet device. A standardized follow-up by phone call focusing on data of death, stroke and bleeding events was performed. Routine antiplatelet strategy was DAPT for 3 months post procedural. 212 patients (mean age 77 ± 6 years) were included. Follow up was performed in 197 (93%) patients. Patients were at high risk for thromboembolic or bleeding events (prior stroke/TIA 29%; prior bleeding 54%. Overall, there was a mean follow-up period of 1244.2 days (± 756.7) and a total of 674 patient years. We observed 25 events later than day 8 post procedure. We were able to demonstrate a high effectiveness of the AMPLATZER Cardiac Plug/AMPLATZER Amulet devices regarding the prevention of stroke and bleedings in a high-risk real-world cohort during a midterm follow-up period. Overall, we observed remarkably lower rates of stroke and bleedings as predicted with CHA2DS2-VASc and HASBLED scores.

How long is long enough? Good neurologic outcome in out-of-hospital cardiac arrest survivors despite prolonged resuscitation: a retrospective cohort study.

BACKGROUND: Despite all efforts, mortality of out of hospital cardiac arrest (OHCA) remains high. Patients with OHCA due to a primary shockable rhythm typically have a better prognosis. However, outcome worsens if return of spontaneous circulation (ROSC) cannot be achieved quickly. There is insufficient evidence for maximum duration of resuscitation in these patients and it is unclear, which patients profit from transport under ongoing CPR. OBJECTIVE: Investigate predictors for favourable neurologic outcome in OHCA patients with presumed cardiac cause due to refractory shockable rhythm (rSR). METHODS: Retrospective analysis of OHCA patients that presented to a tertiary hospital due to a rSR. RESULTS: One hundred seventy-five OHCA patients with presumed cardiac cause due to rSR were included. Overall hospital mortality was 50% and 83% of initial survivors were discharged with a good neurologic outcome [cerebral performance category (CPC) 1-2]. In patients with a time from cardiac arrest to ROSC of > 45 min, 18% survived to CPC 1-2. Independent predictors for good neurologic outcome were age, lower no-flow time and lower serum lactate levels at hospital arrival. CONCLUSION: In an urban setting, a significant proportion of OHCA patients with rSR can survive to a good neurologic outcome, despite very long time to ROSC.

Left atrial appendage occlusion for stroke despite oral anticoagulation (resistant stroke). Results from the Amplatzer Cardiac Plug registry.

INTRODUCTION AND OBJECTIVES: Despite the efficacy of oral anticoagulant (OAC) therapy, some patients continue to have a high residual risk and develop a stroke on OAC therapy (resistant stroke [RS]), and there is a lack of evidence on the management of these patients. The aim of this study was to analyze the safety and efficacy of left atrial appendage occlusion (LAAO) as secondary prevention in patients with nonvalvular atrial fibrillation who have experienced a stroke/transient ischemic attack despite OAC treatment. METHODS: We analyzed data from the Amplatzer Cardiac Plug multicenter registry on 1047 consecutive patients with nonvalvular atrial fibrillation undergoing LAAO. Patientes with previous stroke on OAC therapy as indication for LAAO were identified and compared with patients with other indications. RESULTS: A total of 115 patients (11%) with RS were identified. The CHA2DS2-VASc and the HAS-BLED score were significantly higher in the RS group (respectively 5.5±1.5 vs 4.3±1.6; P <.001; 3.9±1.3 vs 3.1±1.2; P <.001). No significant differences were observed in periprocedural major safety events (7.8 vs 4.5%; P=.1). With a mean clinical follow-up of 16.2±12.2 months, the observed annual stroke/transient ischemic attack rate for the RS group was 2.6% (65% risk reduction) and the observed annual major bleeding rate was 0% (100% risk reduction). CONCLUSIONS: Patients with RS undergoing LAAO showed similar safety outcomes to patients without RS, with a significant reduction in stroke/transient ischemic attack and major bleeding events during follow-up. Adequately powered controlled trials are needed to further investigate the use of LAAO in RS patients.

Insights into permanent pacemaker implantation following TAVR in a real-world cohort.

BACKGROUND: Permanent pacemaker implantation (PPI) following TAVR is a frequent post interventional complication and its management remains controversial. OBJECTIVE: We sought to elucidate the electrophysiological, procedural, and clinical baseline parameters that are associated with and perhaps predict the need for PPI after TAVR in a heterogeneous-valve-type real-world cohort. METHODS: Overall, 494 patients receiving TAVR at our center from April 2009 to August 2015 were screened. ECG analyses and clinical parameters were collected prospectively. RESULTS: Overall, 401 patients in this all-comers real-world TAVR cohort with a PPI rate of 16% were included. The mean age was 82 years, and the mean duration to PPI was 5.5 days. A large proportion of Edwards SAPIEN valves (81%), DirectFlow, CoreValve, and Portico were implanted. The main indications for PPI were atrioventricular (AV) block III, AV-block Mobitz type II, bradycardic atrial fibrillation and persistent sinus bradycardia. Between groups with and without PPI, significant differences were noted in the prevalence of post TAVR balloon dilatation, resting heart rate, QRS interval, PR interval with a cut-off of >178 ms, left anterior fascicular block and RBBB in univariate analyses. In the subsequent multiple regression analysis, post TAVR balloon dilatation and a PR interval with a cut-off of >178 ms were significant predictors of PPI. CONCLUSION: This real-world cohort differs from others in its size and heterogeneous valve selection, and indicates for the first time that patients with post balloon dilatation or prolonged PR interval are at a higher risk for pacemaker dependency after TAVR.

Hemodiafiltration Treatment for Severe Valproic Acid Intoxication: Case Report and Updated Systematic Literature Review.

Background: Valproic acid (VPA) has been approved for the treatment of seizure disorders. It is also commonly used in psychiatric disorders, such as schizophrenia spectrum disorders. With increasing administration, reports of intoxications are more frequently reported. The most common findings of VPA intoxication are central nervous system depression, respiratory depression, hypotension, metabolic acidosis, and elevated lactate, among others. Methods: We describe a case report of VPA intoxication with hemodiafiltration (HDF) as extracorporeal treatment (ECTR) for removal of VPA. This treatment modality has only rarely been reported in the current literature. In addition, we performed an updated systematic literature review (SLR) of additional cases on the topic ranging from December 1st, 2014 to April 20th, 2018. We searched MEDLINE and Web of Science for relevant references. Results: In the presented case, VPA intoxication occurred in a 46-year-old female patient after oral ingestion of 56 g of VPA. In addition to vasopressors and endotracheal intubation, we administered L-Carnitine (L-Car) and performed hemodiafiltration treatment. After intravenous therapy with L-Car and simultaneous HDF sessions, we observed full recovery without neurological sequelae. The SLR identified 8 additional articles reporting favorable outcomes with extracorporeal treatments in most cases. Conclusion: HDF and other extracorporeal procedures are safe and effective therapeutic options in patients with VPA intoxication. The choice of ECTR modality mainly depends on local experience and the setting. In the present case, ingestion of 56 g was successfully treated with HDF. These findings are in line with several other case reports describing positive outcomes. Extracorporeal treatment, including HDF, should be considered early in the management of VPA intoxication. Supporting evidence is emerging, but it is of limited quality.

Predictors of mortality and ICD shock therapy in primary prophylactic ICD patients-A systematic review and meta-analysis.

BACKGROUND: There is evidence that the benefit of a primary prophylactic ICD therapy is not equal in all patients. PURPOSE: To evaluate risk factors of appropriate shocks and all- cause mortality in patients with a primary prophylactic ICD regarding contemporary studies. DATA SOURCE: PubMed, LIVIVO, Cochrane CENTRAL between 2010 and 2016. STUDY SELECTION: Studies were eligible if at least one of the endpoints of interest were reported. DATA EXTRACTION: All abstracts were independently reviewed by at least two authors. The full text of all selected studies was then analysed in detail. DATA SYNTHESIS: Our search strategy retrieved 608 abstracts. After exclusion of unsuitable studies, 36 papers with a total patient number of 47282 were included in our analysis. All-cause mortality was significantly associated with increasing age (HR 1.41, CI 1.29-1.53), left ventricular function (LVEF; HR 1.21, CI 1.14-1.29), ischemic cardiomyopathy (ICM; HR 1.37, CI 1.14-1.66) and co-morbidities such as impaired renal function (HR 2.30, CI 1.97-2.69). Although, younger age (HR 0.96, CI 0.85-1.09), impaired LVEF (HR 1.26, CI 0.89-1.78) and ischemic cardiomyopathy (HR 2.22, CI 0.83-5.93) were associated with a higher risk of appropriate shocks, none of these factors reached statistical significance. LIMITATIONS: Individual patient data were not available for most studies. CONCLUSION: In this meta-analysis of contemporary clinical studies, all-cause mortality is predicted by a variety of clinical characteristics including LVEF. On the other hand, the risk of appropriate shocks might be associated with impaired LVEF and ischemic cardiomyopathy. Further prospective studies are required to verify risk factors for appropriate shocks other than LVEF to help select appropriate patients for primary prophylactic ICD-therapy.