Left Atrial Appendage Occlusion: British Cardiovascular Intervention Society and British Heart Rhythm Society Position Statement.

Percutaneous left atrial appendage occlusion aims to reduce the risk of stroke in patients with AF, particularly those who are not good candidates for systemic anticoagulation. The procedure has been studied in large international randomised trials and registries and was approved by the National Institute for Health and Care Excellence in 2014 and by NHS England in 2018. This position statement summarises the evidence for left atrial appendage occlusion and presents the current indications. The options and consensus on best practice for pre-procedure planning, undertaking a safe and effective implant and appropriate post-procedure management and follow-up are described. Standards regarding procedure volume for implant centres and physicians, the role of multidisciplinary teams and audits are highlighted.

Left Atrial Appendage Occlusion: British Cardiovascular Intervention Society and British Heart Rhythm Society Position Statement.

Percutaneous left atrial appendage occlusion aims to reduce the risk of stroke in patients with AF, particularly those who are not good candidates for systemic anticoagulation. The procedure has been studied in large international randomised trials and registries and was approved by the National Institute for Health and Care Excellence in 2014 and by NHS England in 2018. This position statement summarises the evidence for left atrial appendage occlusion and presents the current indications. The options and consensus on best practice for pre-procedure planning, undertaking a safe and effective implant and appropriate post-procedure management and follow-up are described. Standards regarding procedure volume for implant centres and physicians, the role of multidisciplinary teams and audits are highlighted.

Improving antimicrobial use through better diagnosis: The relationship between diagnostic stewardship and antimicrobial stewardship.

Antimicrobial stewardship programs (ASPs) exist to optimize antibiotic use, reduce selection for antimicrobial-resistant microorganisms, and improve patient outcomes. Rapid and accurate diagnosis is essential to optimal antibiotic use. Because diagnostic testing plays a significant role in diagnosing patients, it has one of the strongest influences on clinician antibiotic prescribing behaviors. Diagnostic stewardship, consequently, has emerged to improve clinician diagnostic testing and test result interpretation. Antimicrobial stewardship and diagnostic stewardship share common goals and are synergistic when used together. Although ASP requires a relationship with clinicians and focuses on person-to-person communication, diagnostic stewardship centers on a relationship with the laboratory and hardwiring testing changes into laboratory processes and the electronic health record. Here, we discuss how diagnostic stewardship can optimize the "Four Moments of Antibiotic Decision Making" created by the Agency for Healthcare Research and Quality and work synergistically with ASPs.

Utilizing procalcitonin in a clinical setting to help differentiate between aspiration pneumonia and aspiration pneumonitis.

OBJECTIVE: Aspiration can lead to complications such as aspiration pneumonia (ASPNA) or aspiration pneumonitis. Use of procalcitonin (PCT) assays has been supported to help differentiate between bacterial and nonbacterial etiologies for infection. We hypothesize PCT levels will differ significantly in patients with ASPNA versus aspiration pneumonitis. METHODS: This study retrospectively analyzed patients with an ICD-10 diagnosis of ASPNA or aspiration pneumonitis from September 2017 to September 2019. 228 patients met criteria and were divided into two cohorts: aspiration pneumonitis (45 patients) or ASPNA (183 patients). Initial and 48-hour PCTs were assessed. RESULTS: The aspiration pneumonitis cohort had a higher percentage of patients with normal initial PCT levels than the ASPNA cohort (86.7% vs 38.8%; P < 0.0001). CONCLUSION: This study suggests PCT could be a useful tool to help differentiate between ASPNA and aspiration pneumonitis. We postulate utilizing PCT levels alongside current diagnostic criteria would allow for more appropriate treatment and improved antibiotic stewardship.

Passengers' self-protective intentions while using ride-hailing services during the COVID-19 pandemic.

In the transport context, there has been limited research examining passengers' health-protective behaviour while travelling during a health-related crisis such as COVID-19. This study develops a conceptual model aiming to explore determinants associated with passengers' self-protective intentions using the context of ride-hailing services in Vietnam. Ride-hailing services are popular in countries where public transport is underdeveloped. The conceptual model is based on perceived risk and self-efficacy as the main predictor of self-protective intentions when using ride-hailing services. In addition, the proposed conceptual model explores the direct and indirect impact of subjective knowledge and the perceived effectiveness of preventive measures on self-protective intentions. The proposed conceptual model was tested on a large sample of ride-hailing users in Vietnam (n = 527). The structural equation modelling (SEM) analysis results indicate that self-efficacy has the highest total impact on self-protective behaviour, followed by subject knowledge and perceived effectiveness of preventive measures. Self-efficacy also plays a fully mediating role in the linkage between the perceived effectiveness of preventive measures implemented by ride-hailing organisations and the intention to engage in self-protective behaviour. The results of this study expand the current understanding of ride-hailing passengers' health-protective behaviour and contribute to the transport and public health literature.

Noninferiority of Subcutaneous Versus Intravenous Casirivimab/Imdevimab for Outpatient Treatment of SARS-CoV-2 in a Real-World Setting.

Monoclonal antibody (mAb) therapy has emerged as one of the mainstay treatment options for SARS-CoV-2. To improve speed of delivery and decrease bedside nursing needs, subcutaneous (SC) delivery of mAbs has been explored as an alternative to standard intravenous (IV) administration. To date, data regarding the effectiveness of SC compared with IV mAb are lacking. This retrospective cohort analysis conducted between April 2021 and August 2021 compared hospitalization rates among patients receiving IV versus SC administration of casirivimab/imdevimab (Regen-COV) at a single institution in Arkansas. Casirivimab/imdevimab was a promising mAb therapy utilized during the height of the Delta variant surge of the SARS-CoV-2 pandemic. Before resistance developed by the Omicron variant, casirivimab/imdevimab was utilized for outpatient treatment of SARS-CoV-2 patients at risk of deterioration. Primary outcomes of this investigation were the 30-day post-treatment rate of hospitalization and intensive care unit (ICU) care during hospitalization. There was no increased risk of hospitalization or ICU care with SC administration compared with IV administration. As SARS-CoV-2 continues to mutate into variants such as Omicron and develop resistance to existing mAbs, these preliminary findings of noninferiority of SC versus IV warrant ongoing investigation into SC administration of other mAbs.

Performer Roles and Behaviors in Dyadic Sexually Explicit Media Featuring Men Who Have Sex with Men.

Heterosexual gender roles are not directly relevant to gay romantic relationships, but gay men often take on different relationship roles depending on their sexual roles. In the present paper, we argue that gay men might draw on sexually explicit media (SEM) featuring men who have sex with men (MSM) to get information about how insertive sexual partners ("tops") and receptive sexual partners ("bottoms") typically behave. For this to be the case, however, we would have to reliably observe different behavior in SEM performers acting as tops vs. bottoms. We examined 220 of the most viewed online dyadic MSM SEM videos to determine whether performed verbal and physical intimacy, victimization, and sexual behaviors depended on the sexual role taken. We found that tops and bottoms engaged in similar amounts of intimacy behaviors, but that bottoms were depicted as initiating sexual activity more than tops. Tops enacted physical and psychological victimization more than bottoms, although these behaviors were rare. Tops were shown taking the insertive role across all sexual acts and versatile performers (i.e., those taking both insertive and receptive roles) were rarely depicted. The present study adds to the literature about the complexity of sexual-self-labels, and suggests that MSM SEM depictions of intimacy and sexual decision-making depend on the sexual role taken.

Understanding sexual activity while driving as a form of distracted driving.

Sexual activity while driving has been reported in emerging research. Sexual activity while driving is a form of distracted driving because it includes an individual (the driver) who deviates resources from the primary task (driving) towards a secondary task (sexual activity). However, most of our current knowledge about the range of sexual activities while driving is based on self-reported data or media reports. Thus, an in-depth understanding of sexual activities while driving and their interactions with non-sexual driving behaviours and vehicle control is missing. Additionally, there is limited information on the context of where sexual activities while driving occurs and the influence of factors such as the environment, the vehicle, interactions with other road users, and other in-vehicle distractions. To cover this gap, a content analysis of sexually explicit media (SEM) was conducted on a sample of 270 videos depicting real driving. We conducted descriptive analyses and used decision tree analysis to explore the association between sexual activities while driving and their interactions with non-sexual driving behaviours and vehicle control. The videos portrayed a naturalistic driving situation of a driver of a moving vehicle engaging in sexual activity. The results show that when engaging in sexual activity, drivers do not present safe vehicle control. Sexual activity imposes additional cognitive, physical, and visual demands on the driver, thereby decreasing safety. Similar to other distractions, drivers engaging in sexual activity while driving appear to mitigate risks. Concerning the potential for legal sanctions, it appears that drivers may attempt to conceal sexual activity by reducing their visible nudity and minimising interactions with other road users. Finally, mobile phones and cameras appear to interact with sexual activities while driving, by imposing potential restrictions on the range of sexual activities. Implications for policymakers and practitioners are discussed.

Impact of afterload and infiltration on coexisting aortic stenosis and transthyretin amyloidosis.

OBJECTIVE: The coexistence of wild-type transthyretin cardiac amyloidosis (ATTR) is common in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI). However, the impact of ATTR and AS on the resultant AS-ATTR is unclear and poses diagnostic and management challenges. We therefore used a multicohort approach to evaluate myocardial structure, function, stress and damage by assessing age-related, afterload-related and amyloid-related remodelling on the resultant AS-ATTR phenotype. METHODS: We compared four samples (n=583): 359 patients with AS, 107 with ATTR (97% Perugini grade 2), 36 with AS-ATTR (92% Perugini grade 2) and 81 age-matched and ethnicity-matched controls. 99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) scintigraphy was used to diagnose amyloidosis (Perugini grade 1 was excluded). The primary end-point was NT-pro Brain Natriuretic Peptide (BNP) and secondary end-points related to myocardial structure, function and damage. RESULTS: Compared with older age controls, the three disease cohorts had greater cardiac remodelling, worse function and elevated NT-proBNP/high-sensitivity Troponin-T (hsTnT). NT-proBNP was higher in AS-ATTR (2844 (1745, 4635) ng/dL) compared with AS (1294 (1077, 1554)ng/dL; p=0.002) and not significantly different to ATTR (3272 (2552, 4197) ng/dL; p=0.63). Diastology, hsTnT and prevalence of carpal tunnel syndrome were statistically similar between AS-ATTR and ATTR and higher than AS. The left ventricular mass indexed in AS-ATTR was lower than ATTR (139 (112, 167) vs 180 (167, 194) g; p=0.013) and non-significantly different to AS (120 (109, 130) g; p=0.179). CONCLUSIONS: The AS-ATTR phenotype likely reflects an early stage of amyloid infiltration, but the combined insult resembles ATTR. Even after treatment of AS, ATTR-specific therapy is therefore likely to be beneficial.

Cardiovascular magnetic resonance facilitates entirely contrast-free transcatheter aortic valve implantation: case report.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is usually planned using contrast-enhanced computed tomography (CT) to determine the suitability of cardiovascular anatomy. Computed tomography for TAVI planning requires the administration of intravenous contrast, which may not be desirable in patients with severely reduced renal function. CASE SUMMARY: We present an unusual case of an 89-year-old patient with an urgent need for treatment of critical, symptomatic aortic stenosis who also had severe chronic kidney disease. We judged that this posed a relative contraindication to the use of intravenous contrast. We designed and implemented a novel, contrast-free cardiovascular magnetic resonance (CMR) protocol and used this to plan all aspects of the procedure. Transcatheter aortic valve implantation was conducted successfully with zero contrast medium administration leading to an excellent clinical result and recovery of renal function. CONCLUSION: Contrast-free CMR appears to be a viable alternative to CT for planning structural aortic valve intervention in the rare cases where intravenous contrast is relatively contraindicated.

Procedural Mortality With Transcatheter Aortic Valve Replacement - Balloon Inflation is Associated With Increased Risk.

OBJECTIVES: To assess the impact of balloon use for predilation, valve implantation, or postdilation on in-hospital mortality among patients undergoing transcatheter aortic valve replacement (TAVR). BACKGROUND: TAVR utilizes self-expanding, mechanically expanding, or balloon-expandable valves. Balloon inflation is inherent to deployment of balloon-expandable valves. Balloons may additionally be used with all valve types for pre- and postdilation. The relationships between valve mechanism, balloon use, and in-hospital mortality are not fully characterized. METHODS: Prospective data were collected on 4063 patients undergoing TAVR for aortic stenosis at 4 high-volume centers in the United Kingdom. In-hospital mortality was analyzed according to valve expansion mechanism, use of balloons for pre- and postdilation, and specific cause of death. RESULTS: Mean patient age was 83 ± 8 years. Implanted valves were self expanding (n = 2241; 55%), mechanically expanding (n = 1092; 27%), or balloon expandable (n = 727; 18%). In-hospital death occurred in 66 cases (1.6%). Thirty-six deaths (54.5%) were classified as implantation-related mortalities, with rates of 0.8%, 0.5%, and 1.7% (P=.04) among self-expanding, mechanically expanding, and balloon-expandable technologies, respectively. Patients who underwent balloon inflation at any stage of their procedure (n = 2556; 63%) had significantly higher implantation-related mortality than those who did not (1.3% vs 0.3%, respectively; P<.01). Balloon-expandable valve procedures were associated with significantly higher all-cause mortality (2.6% vs 1.4%; P=.02) and implantation-related mortality (1.7% vs 0.7%; P=.02) than non-balloon-expandable valve procedures. Balloon-related complications accounted for 18 cases (26%) of total in-hospital mortality, including all 12 cases (17.4%) of annular rupture and 5 cases (7.2%) of coronary occlusion. CONCLUSIONS: Balloon use for predilation, valve implantation, or postdilation was associated with an increased mortality risk. Balloon-related complications were the largest contributor to in-hospital mortality, comprising all cases of annular rupture and the majority of coronary occlusion cases.

Long-term outcomes and periprocedural safety and efficacy of percutaneous left atrial appendage closure in a United Kingdom tertiary center: An 11-year experience.

BACKGROUND: Left atrial appendage occlusion (LAAO) has been widely adopted as a strategy for stroke prevention in patients with atrial fibrillation ineligible for oral anticoagulation. OBJECTIVE: The purpose of this study was to explore longer-term "real-world" safety and efficacy outcomes in patients undergoing LAAO given varied practices in antithrombotic regimens and adoption of same-day discharge. METHODS: Analysis of acute procedural and long-term outcome data was performed for all patients undergoing LAAO implant in a United Kingdom tertiary center over an 11-year period. Rates of adverse events were calculated and compared to predicted rates in historical cohorts according to CHA2DS2-VASc and HAS-BLED scores. RESULTS: Device implantation was attempted in 229 patients, with an acute procedural success rate of 98.2% and low rate of major procedural complications of 2.6% at 30 days, including 1.3% procedure-related mortality. In the last year of enrollment, 75% of patients were discharged on the same day of the procedure. A strategy of early cessation of antithrombotic therapy was adopted, with a low rate of device-related thrombus. Over total follow-up of 889 patient-years, there were low rates of thromboembolic events (2.2/100 patient-years) and of significant bleeding events (intracranial bleed 0.6/100 patient-years; nonprocedural major bleeding 2.3/100 patient-years). CONCLUSION: LAAO with a same-day discharge strategy and early cessation of antiplatelet therapy seems to be safe and effective in reducing the risk of stroke and major bleeding over mean follow-up approaching 4 years. Although these data are reassuring, results from randomized trials with strict shorter periods of postprocedural antithrombotic therapy are eagerly awaited.

Caged-in: Successful percutaneous closure of left atrial appendage with Watchman-FLX in the presence of proximal thrombus.

Percutaneous mechanical closure of the left atrial appendage (LAA) is a valuable stroke prevention strategy in patients with atrial fibrillation and contraindication to oral anticoagulation. LAA thrombus is a common finding in patients with atrial fibrillation and frequently fails to resolve despite therapeutic anticoagulation. In this scenario, LAA occlusion device implant is generally discouraged due to the high risk of thrombus dislodgement and embolization; however, alternative management options are limited. We report the first case of a successful LAA occlusion device (Watchman-FLX) implant in the presence of a proximal thrombus.

Community prevalence, mechanisms and outcome of mitral or tricuspid regurgitation.

OBJECTIVE: The study aims were (1) to identify the community prevalence of moderate or greater mitral or tricuspid regurgitation (MR/TR), (2) to compare subjects identified by population screening with those with known valvular heart disease (VHD), (3) to understand the mechanisms of MR/TR and (4) to assess the rate of valve intervention and long-term outcome. METHODS: Adults aged ≥65 years registered at seven family medicine practices in Oxfordshire, UK were screened for inclusion (n=9504). Subjects with known VHD were identified from hospital records and those without VHD invited to undergo transthoracic echocardiography (TTE) within the Oxford Valvular Heart Disease Population Study (OxVALVE). The study population ultimately comprised 4755 subjects. The severity and aetiology of MR and TR were assessed by integrated comprehensive TTE assessment. RESULTS: The prevalence of moderate or greater MR and TR was 3.5% (95% CI 3.1 to 3.8) and 2.6% (95% CI 2.3 to 2.9), respectively. Primary MR was the most common aetiology (124/203, 61.1%). Almost half of cases were newly diagnosed by screening: MR 98/203 (48.3%), TR 69/155 (44.5%). Subjects diagnosed by screening were less symptomatic, more likely to have primary MR and had a lower incidence of aortic valve disease. Surgical intervention was undertaken in six subjects (2.4%) over a median follow-up of 64 months. Five-year survival was 79.8% in subjects with isolated MR, 84.8% in those with isolated TR, and 59.4% in those with combined MR and TR (p=0.0005). CONCLUSIONS: Moderate or greater MR/TR is common, age-dependent and is underdiagnosed. Current rates of valve intervention are extremely low.

Intimacy in Dyadic Sexually Explicit Media Featuring Men Who Have Sex with Men.

Sexually explicit material (SEM) featuring men who have sex with men (MSM) may be a source of information about intimacy in same-sex male relationships for MSM. However, little is known about how MSM SEM depicts intimacy between male performers. The current study examined the 220 most viewed dyadic scenes of MSM SEM videos for the presence of verbal intimacy (compliments, personal disclosure, and expressions of care) and physical intimacy (kissing, cuddling, affectionate touch, and genital touch before and after sex) between performers. At least one example of physical and verbal intimacy was present in the majority of videos (91% and 68% of videos, respectively). Most forms of physical and verbal intimacy occurred before or during sex, with intimacy being least evident post-sex. We also tested if the presence of intimacy was associated with viewer interactions with videos (likes and dislikes) and number of views. Only one of seven forms of intimacy, care (verbal), was associated with more interactions (i.e., likes and dislikes per 100,000 views), and there was no association with the number of views. Potential implications for MSM's understandings of intimacy are recognized and discussed with reference to sexual script theory.

Prevalence and Outcomes of Concomitant Aortic Stenosis and Cardiac Amyloidosis.

BACKGROUND: Older patients with severe aortic stenosis (AS) are increasingly identified as having cardiac amyloidosis (CA). It is unknown whether concomitant AS-CA has worse outcomes or results in futility of transcatheter aortic valve replacement (TAVR). OBJECTIVES: This study identified clinical characteristics and outcomes of AS-CA compared with lone AS. METHODS: Patients who were referred for TAVR at 3 international sites underwent blinded research core laboratory 99mtechnetium-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) bone scintigraphy (Perugini grade 0: negative; grades 1 to 3: increasingly positive) before intervention. Transthyretin-CA (ATTR) was diagnosed by DPD and absence of a clonal immunoglobulin, and light-chain CA (AL) was diagnosed via tissue biopsy. National registries captured all-cause mortality. RESULTS: A total of 407 patients (age 83.4 ± 6.5 years; 49.8% men) were recruited. DPD was positive in 48 patients (11.8%; grade 1: 3.9% [n = 16]; grade 2/3: 7.9% [n = 32]). AL was diagnosed in 1 patient with grade 1. Patients with grade 2/3 had worse functional capacity, biomarkers (N-terminal pro-brain natriuretic peptide and/or high-sensitivity troponin T), and biventricular remodeling. A clinical score (RAISE) that used left ventricular remodeling (hypertrophy/diastolic dysfunction), age, injury (high-sensitivity troponin T), systemic involvement, and electrical abnormalities (right bundle branch block/low voltages) was developed to predict the presence of AS-CA (area under the curve: 0.86; 95% confidence interval: 0.78 to 0.94; p < 0.001). Decisions by the heart team (DPD-blinded) resulted in TAVR (333 [81.6%]), surgical AVR (10 [2.5%]), or medical management (65 [15.9%]). After a median of 1.7 years, 23% of patients died. One-year mortality was worse in all patients with AS-CA (grade: 1 to 3) than those with lone AS (24.5% vs. 13.9%; p = 0.05). TAVR improved survival versus medical management; AS-CA survival post-TAVR did not differ from lone AS (p = 0.36). CONCLUSIONS: Concomitant pathology of AS-CA is common in older patients with AS and can be predicted clinically. AS-CA has worse clinical presentation and a trend toward worse prognosis, unless treated. Therefore, TAVR should not be withheld in AS-CA.

Safety and Operational Efficiency of Restructuring and Redeploying a Transcatheter Aortic Valve Replacement Service During the COVID-19 Pandemic: The Oxford Experience.

BACKGROUND: The risk of nosocomial COVID-19 infection for vulnerable aortic stenosis patients and intensive care resource utilization has led to cardiac surgery deferral. Untreated severe symptomatic aortic stenosis has a dismal prognosis. TAVR offers an attractive alternative to surgery as it is not reliant on intensive care resources. We set out to explore the safety and operational efficiency of restructuring a TAVR service and redeploying it to a new non-surgical site during the COVID-19 pandemic. METHODS: The institutional prospective service database was retrospectively interrogated for the first 50 consecutive elective TAVR cases prior to and after our institution's operational adaptations for the COVID-19 pandemic. Our endpoints were VARC-2 defined procedural complications, 30-day mortality or re-admission and service efficiency metrics. RESULTS: The profile of patients undergoing TAVR during the pandemic was similar to patients undergoing TAVR prior to the pandemic with the exception of a lower mean age (79 vs 82 years, p < 0.01) and median EuroScore II (3.1% vs 4.6%, p = 0.01). The service restructuring and redeployment contributed to the pandemic-mandated operational efficiency with a reduction in the distribution of pre-admission hospital visits (3 vs 3 visits, p < 0.001) and the time taken from TAVR clinic to procedure (26 vs 77 days, p < 0.0001) when compared to the pre-COVID-19 service. No statistically significant difference was noted in peri-procedural complications and 30-day outcomes, while post-operative length of stay was significantly reduced (2 vs 3 days, p < 0.0001) when compared to pre-COVID-19 practice. CONCLUSIONS: TAVR service restructuring and redeployment to align with pandemic-mandated healthcare resource rationalization is safe and feasible.