Transaxillary Stenting of LVAD Outflow Graft Obstruction.

An 82-year-old man with a HeartMate II left ventricular assist device presented with low-flow alarms and cardiogenic shock secondary to left ventricular assist device outflow graft obstruction. Given high risk for redo sternotomy, the heart team decided on percutaneous intervention with peripheral stents, a procedure that is currently limited to case reports. (Level of Difficulty: Advanced.).

Use of non-warfarin oral anticoagulants instead of warfarin during left atrial appendage closure with the Watchman device.

BACKGROUND: In the stroke prevention trials of left atrial appendage closure with the Watchman device (Boston Scientific), a postimplantation antithrombotic regimen of 6 weeks of warfarin was used. OBJECTIVE: Given the clinical complexity of warfarin use, the purpose of this study was to study the relative feasibility and safety of using non-warfarin oral anticoagulants (NOACs) instead of warfarin during the peri- and initial postimplantation periods after Watchman implantation. METHODS: This was a retrospective multicenter study of consecutive patients undergoing Watchman implantation and receiving peri- and postprocedural NOACs or warfarin. Transesophageal echocardiography or chest computed tomography was performed between 6 weeks and 4 months postimplant to assess for device-related thrombosis. Bleeding and thromboembolic events also were evaluated at the time of follow-up. RESULTS: In 5 centers, 214 patients received NOACs (46% apixaban, 46% rivaroxaban, 7% dabigatran, and 1% edoxaban) in either an uninterrupted (82%) or a single-held-dose (16%) fashion. Compared to a control group receiving uninterrupted warfarin (n = 212), the rates of periprocedural complications, including bleeding events, were similar (2.8% vs 2.4%, P = 1). At follow-up, the rates of device-related thrombosis (0.9% vs 0.5%, P = 1), composite of thromboembolism or device-related thrombosis (1.4% vs 0.9%, P = 1), and postprocedure bleeding events (0.5% vs 0.9%, P = .6) also were comparable between the NOAC and warfarin groups. CONCLUSION: NOACs proved to be a feasible peri- and postprocedural alternative regimen to warfarin for preventing device-related thrombosis and thromboembolic complications expected early after appendage closure with the Watchman device, without increasing the risk of bleeding.

Superior vena cava echocardiography as a screening tool to predict cardiovascular implantable electronic device lead fibrosis.

BACKGROUND: Currently there is no noninvasive imaging modality used to risk stratify patients requiring lead extractions. We report the novel use of superior vena cava (SVC) echocardiography to identify lead fibrosis and complex cardiac implantable electronic device (CIED) lead extraction. With an aging population and expanding indications for cardiac device implantation, the ability to deal with the complications associated with chronically implanted device has also increased. METHODS: This was a retrospective analysis of Doppler echocardiography recorded in our outpatient Electrophysiology/Device Clinic office over 6 months. Images from 109 consecutive patients were reviewed. RESULTS: 62% (68/109) did not have a CIED and 38% (41/109) had a CIED. In patients without a CIED, 6% (4/68) displayed turbulent color flow by Doppler in the SVC, while 22% (9/41) of patients with a CIED displayed turbulent flow. Fisher's exact test found a statistically significant difference between the two groups (p value < 0.05). The CIED group was subdivided into 2 groups based on device implant duration (< 2 years vs. ≥ 2 years). Of the CIED implanted for ≥ 2 years, 27% (9/33) had turbulent flow in the SVC by Doppler, while no patients (0/8) with implant durations < 2 years demonstrated turbulent flow. Nine patients underwent subsequent lead extraction. A turbulent color pattern successfully identified all 3 patients that had significant fibrosis in the SVC found during extraction. CONCLUSION: Our data suggests that assessing turbulent flow using color Doppler in the SVC may be a valuable noninvasive screening tool prior to lead extraction in predicting complex procedures.

The influence of anemia after percutaneous coronary intervention on clinical outcomes.

BACKGROUND: Although the consequences of bleeding after percutaneous coronary intervention (PCI) are well documented, there are no data on the impact of post-PCI anemia (PPA) on clinical outcomes. METHODS: We evaluated the incidence, predictors, and prognostic implications of PPA on clinical outcomes in 1415 PCI procedures. We compared clinical outcomes of patients with PPA (ie, nadir post-PCI hemoglobin < 10 gm/dL) vs without PPA. In patients with PPA, we assessed the influence of thrombolysis in myocardial infarction (TIMI; major or minor) bleeding, drop in hemoglobin by > or = 3 gm/dL, and use of blood transfusions on outcomes. RESULTS: Post-PCI anemia developed in 124 (8.8%) patients. Of these, 50 (40%) suffered TIMI (major or minor) bleeding, 68 (55%) had a hemoglobin drop of > or = 3 gm/dL, and 39 (32%) patients received blood transfusions. Compared to patients without PPA, those with PPA had greater incidence of 6 month death (6.5% vs 1.7 %, p = 0.003), 6 month major adverse cardiovascular event (MACE; death, reinfarction, or target vessel revascularization; 27.3% vs 14.5%, p = 0.0006), and long-term mortality (25.8% vs 8.7 %, p or = 3 gm/dL, and use of blood transfusions did not impact outcomes. CONCLUSION: We found that PPA is common, occurs frequently in the absence of bleeding or significant drop in hemoglobin, and connotes poor long-term outcomes.