Left atrial appendage closure: a new strategy for cardioembolic events despite oral anticoagulation.

BACKGROUND: Patients with non-valvular atrial fibrillation (nvAF) who experienced a cardioembolic (CE) event despite adequate oral anticoagulation (OAC) are at high risk of recurrence, and further prevention strategies are deemed necessary. The present study aimed to evaluate the safety and efficacy of off-label use of left atrial appendage closure (LAAC) in this subset of patients. METHODS: Seventy-five consecutive patients with nvAF who experienced a CE event despite adequate OAC therapy were retrospectively enrolled from two Italian centers. Patients were divided according to the treatment strategy following the index event: DOAC group (49 patients who continued OAC therapy with DOACs) and LAAC group (26 patients who underwent LAAC procedure). 1:1 propensity-score matching between the two groups was performed. LAAC group was made up of two subgroups according to the post-procedural pharmacological regimen: 1) dual antiplatelet therapy (DAPT) for 3 months followed by indefinite single antiplatelet therapy (LAAC+SAPT); or 2) aspirin plus DOAC for 3 months followed by indefinite DOAC therapy (LAAC+DOAC). The primary endpoint was a composite of CE event, major bleeding, or procedure-related major complication. RESULTS: During a median follow-up of 3.4 years (IQR: 2.0-5.3), LAAC was a predictor of primary endpoint-free survival (HR=0.28, 95% CI: 0.08-0.97; P=0.044); within LAAC group, no procedure-related major complication occurred. Moreover, a trend toward a lower rate of both CE events and major bleedings was observed in LAAC group, particularly in the subgroup LAAC+DOAC. CONCLUSIONS: LAAC is a reasonable therapeutic option in nvAF patients who suffered a CE event despite adequate OAC therapy.

Step by Step through the Years-High vs. Low Energy Lead Extraction Using Advanced Extraction Techniques.

Background: Limited data is available about the outcome of TLE in patients with vs. without high energy leads in the last decade. Methods: This is an analysis of consecutive patients undergoing TLE at a high-volume TLE centre from 2001 to 2021 using the stepwise approach. Baseline characteristics, procedural details and outcome of patients with high energy lead (ICD group) vs. without high energy lead (non-ICD group) were compared. Results: Out of 667 extractions, 991 leads were extracted in 405 procedures (60.7%) in the ICD group and 439 leads in 262 procedures (39.3%) in the non-ICD group. ICD patients were significantly younger (median 67 vs. 74 years) and were significantly less often female (18.1% vs. 27.7%, p < 0.005 for both). Advanced extraction tools were used significantly more often in the ICD group (73.2% vs. 37.5%, p < 0.001), but there were no significant differences in the successful removal (98.8% vs. 99.2%) or complications (4.7% vs. 3.1%) between the groups (p > 0.2 for both). Discussion: Using the stepwise approach, overall procedural success was high and complication rate was low in a high-volume centre. In patients with a high energy lead, the TLE procedure was more complex, but outcome was similar to comparator patients.

Working on the dirty side-the ipsilateral subclavian access for temporary pacing after lead extraction.

Background: Temporary pacing is necessary in pacemaker-dependent patients after transvenous lead extraction (TLE) for cardiac implantable electronic device infection. In case of unavailability of other accesses, we propose to use the ipsilateral subclavian access (ISA) combined with a standard permanent active fixation lead for the temporary pacemaker and present preliminary data. Methods: We consecutively enrolled patients undergoing TLE who received a temporary pacemaker using the ISA between August 2016 and April 2020 at our centre. Results: During the observation period, 36 patients undergoing TLE for pocket infection (72.2%), endocarditis (25.0%) or other causes received a temporary pacemaker over the ISA. Their mean age was 77.0 ± 10.7 years, and 13.9% were female. Complete TLE was achieved in 94.4%. There were no major periprocedural complications. Intra-hospital mortality was 11.1%. Pocket revision was performed in 19.4%. During long-term follow-up (23 ± 13 months), 8.3% had a relapse of local pocket infection and 2.8% needed rehospitalization for reintervention. Conclusions: Temporary pacing using a standard permanent active fixation lead using the ISA is a convenient alternative to conventional venous accesses. However, risks of implanting a lead into a previously infected area have to be taken into account.

Prognostic implications of different clinical profiles in hypertrophic cardiomyopathy.

Hypertrophic cardiomyopathy (HCM) is a myocardial genetic disease relatively common in the general population with heterogenous clinical presentation, natural history and prognosis. About 60% of HCM patients have a stable clinical course, while others may experience a variety of HCM-related complications which follows relatively independent pathways, and that can be distinguished in different subgroups. These subgroups are represented by patients with left ventricular outflow tract obstruction; patients with end-stage disease and reduced or preserved systolic function; patients with apical hypertrophy; patients with apical aneurysm; patients with atrial fibrillation, patients at high risk of sudden death and patients with preclinical HCM. The purpose of this review was to describe each of these clinical profiles with its prognostic implications.

The predictive role of renal function and systemic inflammation on the onset of de novo atrial fibrillation after cardiac surgery.

BACKGROUND: The association between postoperative atrial fibrillation (POAF) and renal function was previously grounded in patients undergoing coronary artery bypass grafting through unknown mechanisms. We aim to investigate the association between renal function and POAF in a cohort composed mostly of patients undergoing valve surgery and to explore the role of inflammation as a pathogenic mechanism linking renal dysfunction and arrhythmogenesis. METHODS: Altogether 444 patients who underwent cardiac surgery without previous history of atrial fibrillation were analysed. Serum creatinine and high sensitivity C-reactive protein (hs-CRP) concentrations were obtained at baseline and on the 3rd, 8th and 15th postoperative day; estimated glomerular filtration rate (eGFR) was calculated by the Modified Diet Renal Disease (MDRD) formula. Patients were divided into three groups on the basis of baseline eGFR. RESULTS: Overall, 173 (39%) patients developed POAF, 29.5% in the group with normal eGFR (≥90 ml/min/1.73 m(2)), 43.3% among patients with eGFR 60-90 ml/min/1.73 m(2) and 55.6% in the group with eGFR ≤60 ml/min/1.73 m(2). Patients developing POAF had lower eGFR on all the samples. At baseline preoperatively hs-CRP levels did not differ in the two groups.On multivariate analysis, age and eGFR were identified as independent predictors of POAF. The risk of POAF progressively increased from mild impairment (odds ratio (OR) 1.59, 95% confidence interval (CI) 1.01-2.50) to severe reduction of renal function (OR 2.35, 95% CI 1.25-4.48). CONCLUSIONS: Age and eGFR were identified as the strongest predictors of POAF in a population largely composed of valve surgery patients. Renal function, even from early stage, is independently associated with the increasing risk of developing POAF.