Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 75
Filtrar
1.
JACC Clin Electrophysiol ; 6(8): 989-996, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32819535

RESUMO

OBJECTIVES: This study sought to define the association between conduction recovery across the cavotricuspid isthmus (CTI) and typical atrial flutter (AFL) recurrence when CTI ablation is performed with pulmonary vein isolation (PVI) compared with a stand-alone procedure. BACKGROUND: CTI ablation is commonly performed at the same time as PVI to treat AFL or as an empiric therapy. Conduction recovery is a recognized problem after linear ablation in the left atrium (e.g., mitral isthmus ablation) and is proarrhythmic. Less is known about conduction recovery after CTI ablation and possible differences in outcomes when performed at the time of PVI compared with at the time of a stand-alone procedure. METHODS: Eligible participants who underwent stand-alone CTI ablation were compared with those who underwent a combined (CTI+PVI) procedure. CTI conduction recovery was assessed at the time of a second ablation. Conduction recovery across the CTI (primary outcome) and recurrence of typical AFL (secondary outcome) were studied using multivariable logistic regression. RESULTS: Among 295 eligible participants (median age: 64 years [interquartile range: 55 to 69 years]; 33% women), recovery was assessed in 232 and was more common after combined versus stand-alone CTI ablation (52% [72 of 139] vs. 13% [12 of 93]; p < 0.001). In multivariable analysis, CTI ablation performed as a combined procedure increased odds of CTI conduction recovery 7.8-fold (odds ratio: 7.8; 95% confidence interval: 3.3 to 18.3; p < 0.001) and clinical AFL recurrence 4.1-fold (odds ratio: 4.1; 95% confidence interval: 1.0 to 16.9; p = 0.049). CONCLUSIONS: CTI ablation performed at the time of atrial fibrillation ablation is associated with higher rates of conduction recovery and typical flutter recurrence.

2.
Transl Stroke Res ; 2020 Aug 07.
Artigo em Inglês | MEDLINE | ID: mdl-32770310

RESUMO

Anticoagulation increases the risk of intracerebral hemorrhage (ICH) in patients with cerebral amyloid angiopathy (CAA), so the management of stroke-risk in patients with both atrial fibrillation (AF) and CAA is controversial. Advances in left atrial appendage closure (LAAC) techniques provide a stroke-risk-reduction option which avoids long-term oral anticoagulation (OAC). We aimed to evaluate the safety of this intervention in patients with CAA. This is an observational cohort study of patients with severe CAA (with or without ICH) and AF who were treated with LAA closure. The Watchman™ and Amulet® LAAC devices and Lariat procedure or open surgical closure of the LAA were all considered acceptable means of closure. Patients with symptomatic ICH and those naïve to anticoagulation were placed on clopidogrel and/or aspirin for 6 weeks after the procedure; patients who previously tolerated anticoagulation remained on warfarin or a DOAC for 6 weeks post-procedure. All anticoagulation therapy was discontinued after confirmation of LAAC. All patients had aggressively optimized blood pressure and fall precautions in addition to surgical intervention. Safety, tolerability, stroke, and hemorrhage rates were documented. Twenty-six patients with a mean CHA2DS2-VASc score of 4.6 were treated, 13 with a history of symptomatic lobar hemorrhage and 13 without. All patients who completed LAAC tolerated the device implantation. There were no documented ischemic strokes or symptomatic ICH during the 30 days after device implantation. Patients were followed for an average of 25 months. One patient who underwent Lariat LAAC had an ischemic stroke in follow-up, but recovered well; there were no other thromboemboli in this cohort. This cohort study provides evidence that LAAC appears to be a safe and tolerable treatment to reduce stroke risk in patients with CAA. Because of the small size of the cohort and relatively short follow-up, the efficacy for stroke and ICH prevention is not conclusive, but the preliminary results are encouraging. LAA closure may be a good alternative to anticoagulation in patients with CAA and atrial fibrillation.

4.
Heart Rhythm ; 17(9): 1545-1553, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32464184

RESUMO

BACKGROUND: Experience with retrieval of a Watchman left atrial (LA) appendage (LAA) closure device (WD) is limited. An embolized or grossly malpositioned WD warrants retrieval to minimize the risk of thromboembolic complications and vascular occlusion. OBJECTIVE: The purpose of this study was to report approaches for percutaneous retrieval of a WD from multicenter experience. METHODS: Data on successful WD retrievals were obtained from high-volume operators. Data included clinical characteristics; structural characteristics of the LA and LAA; and procedural details of the deployment and retrieval procedure, type of retrieval (immediate: during the same procedure; delayed: during a separate procedure after the successful deployment), equipment used, complications, and postretrieval management. RESULTS: Ten successful percutaneous and 1 surgical retrievals comprised this study. Seven patients had immediate retrieval, while 4 had delayed retrieval. The median duration before delayed retrieval was 45 days (range 1-45 days). The median LAA diameter and size of a successfully deployed WD was 16 mm (range 14-24 mm) and 21 mm (range 21-30 mm), respectively. A WD was retrieved from the LA (n = 1), LAA (n = 2), left ventricle (n = 2), and aorta (n = 6). The reason for retrieval from the LAA was inadequate deployment, resulting in a significant peri-device leak. Retrieval from the LA or LAA was successfully performed using snares (n = 2) and a Raptor grasping device (n = 1). Retrieval from the left ventricle was achieved with a snare (n = 1) and surgery (n = 1). Retrieval from the aorta required snares (n = 5) and retrieval forceps (n = 1). Five patients were successfully reimplanted with a larger size WD. The only complication during percutaneous retrieval was a pseudoaneurysm. CONCLUSION: Retrieval of an embolized or malpositioned WD is feasible, and familiarity with snares and grasping tools can facilitate a successful removal.

5.
PLoS One ; 15(3): e0229646, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32126112

RESUMO

Kratom is a botanical substance that is marketed and promoted in the US for pharmaceutical opioid indications despite having no US Food and Drug Administration approved uses. Kratom contains over forty alkaloids including two partial agonists at the mu opioid receptor, mitragynine and 7-hydroxymitragynine, that have been subjected to the FDA's scientific and medical evaluation. However, pharmacological and toxicological data for the remaining alkaloids are limited. Therefore, we applied the Public Health Assessment via Structural Evaluation (PHASE) protocol to generate in silico binding profiles for 25 kratom alkaloids to facilitate the risk evaluation of kratom. PHASE demonstrates that kratom alkaloids share structural features with controlled opioids, indicates that several alkaloids bind to the opioid, adrenergic, and serotonin receptors, and suggests that mitragynine and 7-hydroxymitragynine are the strongest binders at the mu opioid receptor. Subsequently, the in silico binding profiles of a subset of the alkaloids were experimentally verified at the opioid, adrenergic, and serotonin receptors using radioligand binding assays. The verified binding profiles demonstrate the ability of PHASE to identify potential safety signals and provide a tool for prioritizing experimental evaluation of high-risk compounds.


Assuntos
Mitragyna/química , Plantas Medicinais/química , Alcaloides de Triptamina e Secologanina/química , Animais , Sítios de Ligação , Células HEK293 , Humanos , Técnicas In Vitro , Simulação de Acoplamento Molecular , Ensaio Radioligante , Receptores Adrenérgicos/efeitos dos fármacos , Receptores Adrenérgicos/metabolismo , Receptores Opioides/efeitos dos fármacos , Receptores Opioides/metabolismo , Receptores Opioides mu/efeitos dos fármacos , Receptores Opioides mu/metabolismo , Receptores de Serotonina/efeitos dos fármacos , Receptores de Serotonina/metabolismo , Alcaloides de Triptamina e Secologanina/farmacocinética , Alcaloides de Triptamina e Secologanina/farmacologia , Relação Estrutura-Atividade
6.
Artigo em Inglês | MEDLINE | ID: mdl-32048116

RESUMO

PURPOSE: Current guidelines recommend complete extraction of cardiovascular implantable electronic devices (CIEDs) in the case of persistent or recurrent fungemia without other identifiable sources, though supporting evidence is lacking. We sought to evaluate the prognosis of patients with candidemia and CIEDs. METHODS: Twelve consecutive patients (54 ± 12 years, 8 male) with CIED and concurrent candidemia were reviewed. RESULTS: At the time of diagnosis with candidemia, seven patients were immunocompromised, six were on long-term antibacterial therapy, two were intravenous drug users, four were on chronic hemodialysis, and six had a central venous catheter. Four patients were confirmed as definite CIED infection as vegetation was visible on lead by echocardiogram. The other 8 patients were considered possible CIED infection with candidemia of unknown focus. All patients with visible vegetation underwent CIED removal without complications, and other patients were initially managed non-operatively. After 1 year of follow-up, 7 patients had died and at extended follow-up, all patients without lead removal died while 3 of 4 patients with lead extraction survived. Of note, 50% of deaths in the patients without lead removal were associated with fungal sepsis. CONCLUSIONS: Candida fungemia is associated with a high mortality. CIED removal should be an early consideration in these patients even if lead vegetations are not seen.

7.
Card Electrophysiol Clin ; 12(1): 29-37, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32067645

RESUMO

Referring patients with nonvalvular atrial fibrillation (NVAF) for left atrial appendage closure (LAAC) device should be based on bleeding risks, poor anticoagulation compliance, and patient goals. Patient selection should consider overall prognosis and risk of implant procedure. We detail specific clinical scenarios where LAAC could be considered, based on FDA-approved indications. The indications for LAAC are different in Europe. High-risk scenarios in which LAA occlusion may be preferred alone, or in addition to oral anticoagulation use, are reviewed. Ongoing clinical trials and newer device designs will help change the appropriate post-implant drug regimen which will affect patient and device selection.

8.
J Cardiovasc Electrophysiol ; 31(3): 718-722, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32003095

RESUMO

INTRODUCTION: The optimal approach to the extraction of leads with large vegetations remains uncertain. METHODS: High-risk patients with lead associated vegetations undergoing device extraction at Vanderbilt Hospital with concomitant use of the Penumbra Aspiration System (Penumbra Inc, Alameda, CA) are described. An 8.5 Fr Agilis NXT (Abbott Inc, St. Paul, MN) was advanced to the right atrium, through which a Penumbra Indigo Cat-8 catheter was advanced. Using intracardiac echocardiography, the Penumbra was positioned directly on the vegetation, suction was applied until adherent, and the Indigo catheter and Agilis sheath were then removed en-bloc and aspirated debris flushed out. This was repeated until debulking was considered successful. RESULTS: Eight cases were performed. The median vegetation size was 2 cm. Pathogens were Enterococcus, Staphylococcus, Candida, Cutibacterium, and Enterobacter. In seven of eight cases, aspiration successfully reduced vegetations to less than 1 cm before successful percutaneous cardiac implantable electronic device removal. One patient underwent surgical removal via thoracotomy. There were no acute complications related to the Penumbra catheter. Three patients had CT evidence of small pulmonary emboli postprocedure. The length of stay was 3 to 27 days. One patient died on POD 1 of refractory ventricular tachycardia unrelated to the procedure. One patient died of ongoing sepsis 2 weeks postextraction. CONCLUSIONS: The Penumbra Indigo Aspiration system can be useful for vegetation debulking before transvenous lead extraction.

10.
J Cardiovasc Electrophysiol ; 30(11): 2501-2507, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31515883

RESUMO

INTRODUCTION: Hyponatremia commonly follows percutaneous exclusion of the left atrial appendage (LAA) with the LARIAT suture delivery device. The aim of this study was to evaluate for clinical predictors hyponatremia following ligation of the appendage with the LARIAT device. METHODS AND RESULTS: A retrospective analysis was conducted on 61 consecutive patients (average age 69.7 ± 9.8 years, 55.7% male) who underwent successful appendage ligation with the LARIAT device. Acute hyponatremia (AH) was defined as a drop in serum sodium (Na) by greater than or equal to 4 mmol/L within 48 hours of ligation while exaggerated acute hyponatremia (EAH) was defined as a drop greater than or equal to 10 mmol/L. Among all patients, there was a significant decrease in [Na] at 24 hours (3.26 ± 2.77 mmol/L) and 48 hours (4.98 ± 3.74 mmol/L). Thirty-two patients (52.4%) had AH while six patients (9.8%) experienced EAH. A body mass index (BMI) of less than 28.4 kg/m2 was associated with AH (P = .037) while a BMI < 25 kg/m2 was associated with EAH (P = .021). A linear regression analysis comparing the maximum sodium decrease to the indexed left atrial (LA) diameter found that for every 1 cm/m2 increase in indexed LA diameter, there was a 2.5 mEq/L decrease in serum sodium (P = .04). CONCLUSIONS: Hyponatremia frequently occurs following LAA ligation with the LARIAT device. A low BMI < 25 kg/m2 is associated with a drop in serum sodium of greater than 10 mmol/L while increasing indexed LA diameter predicts any AH. AH is also associated with a significantly lower systolic blood pressure 48 to 72 hours post LAA exclusion with the LARIAT device.

11.
Heart Rhythm ; 16(12): 1855-1861, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31125674

RESUMO

BACKGROUND: A high rate of malfunction, predominantly intermittent high-frequency artifacts (HFAs), has been recently reported in Abbott Medical Tendril pacing leads. OBJECTIVE: To investigate the factors associated with the occurrence of HFAs on Tendril leads using a commonly used comparator lead for a control. METHODS: We reviewed institutional data for Medtronic CapSureFix 5076 and Abbott Medical Tendril pace-sense leads retrospectively. Recordings deemed to be due to electromagnetic interference and far-field oversensing were not included in the classification of HFAs. RESULTS: A total of 7673 leads were analyzed: 1628 Optim-insulated Tendril leads, 825 non-Optim Tendril leads, and 5220 CapSureFix 5076. HFAs were seen in 212 leads and were more frequently observed in Tendril compared to CapSureFix leads during a mean follow-up of 4.1 ± 3.6 years. Lower age at implant, defibrillator systems, atrial position, and connection to an Abbott Medical generator were associated with increased HFA. In multivariable analysis, only connection to Abbott Medical generators (odds ratio 7.686, P < .001) and age (odds ratio 0.988 per year, P = .016) were independently associated with HFAs on pace-sense leads. In an Abbott-generator-only analysis, Optim-insulated Tendril leads were more likely to display HFAs than non-Optim Tendril leads but not Medtronic CapSureFix 5076 leads. CONCLUSION: Abbott Medical pulse generators independently predict HFA in Tendril and CapSureFix 5076 leads, likely the result of displaying short or low-amplitude noise episodes that other devices do not record. When restricted to Abbott generators only, Optim-insulated Tendril leads show an increased incidence of HFAs when compared to non-Optim Tendril leads but not CapSureFix 5076 leads.

12.
Pacing Clin Electrophysiol ; 42(7): 965-969, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31045260

RESUMO

BACKGROUND: Boston Scientific (Marlborough, MA, USA) implantable cardioverter-defibrillators (ICDs) and cardiac resynchronization therapy defibrillators (CRT-Ds) manufactured between 2008 and 2014 are potentially subject to premature battery depletion through a low-voltage capacitor malfunction occurring as a result of hydrogen buildup within the device. Although some of these devices are currently under advisory, other devices manufactured during this timeframe carry a lower risk of the same malfunction. These same devices are known to have superior longevity in general, and the overall mean lifespan of the devices remains long. METHODS: All patients implanted or followed at our two centers who experienced premature battery depletion and had a Boston Scientific ICD or CRT-D potentially at risk for low-voltage capacitor malfunction were studied retrospectively. RESULTS: Nineteen out of 838 patients (2.3%) with devices potentially at risk have had premature battery depletion: 5.7% of those under advisory and 1.1% of those not under advisory. None of our patients had compromised therapy, and all had >27 days of projected battery longevity remaining. CONCLUSIONS: Undetected premature battery depletion in this population of ICDs has the potential to expose a patient to an interval of time where the device is unable to provide therapy. However, with enrollment in remote monitoring, regular follow-up, and attention to audible alerts, the risk of therapy loss due to low-voltage state can be effectively mitigated. For these reasons, prophylactic generator replacement is not recommended.

13.
Circulation ; 139(20): e967-e989, 2019 05 14.
Artigo em Inglês | MEDLINE | ID: mdl-30943783

RESUMO

Left ventricular assist devices (LVADs) are an increasingly used strategy for the management of patients with advanced heart failure with reduced ejection fraction. Although these devices effectively improve survival, atrial and ventricular arrhythmias are common, predispose these patients to additional risk, and complicate patient management. However, there is no consensus on best practices for the medical management of these arrhythmias or on the optimal timing for procedural interventions in patients with refractory arrhythmias. Although the vast majority of these patients have preexisting cardiovascular implantable electronic devices or cardiac resynchronization therapy, given the natural history of heart failure, it is common practice to maintain cardiovascular implantable electronic device detection and therapies after LVAD implantation. Available data, however, are conflicting on the efficacy of and optimal device programming after LVAD implantation. Therefore, the primary objective of this scientific statement is to review the available evidence and to provide guidance on the management of atrial and ventricular arrhythmias in this unique patient population, as well as procedural interventions and cardiovascular implantable electronic device and cardiac resynchronization therapy programming strategies, on the basis of a comprehensive literature review by electrophysiologists, heart failure cardiologists, cardiac surgeons, and cardiovascular nurse specialists with expertise in managing these patients. The structure and design of commercially available LVADs are briefly reviewed, as well as clinical indications for device implantation. The relevant physiological effects of long-term exposure to continuous-flow circulatory support are highlighted, as well as the mechanisms and clinical significance of arrhythmias in the setting of LVAD support.


Assuntos
Arritmias Cardíacas/terapia , Baixo Débito Cardíaco/terapia , Insuficiência Cardíaca/terapia , Coração Auxiliar , Arritmias Cardíacas/epidemiologia , Arritmias Cardíacas/etiologia , Baixo Débito Cardíaco/etiologia , Terapia de Ressincronização Cardíaca , Ablação por Cateter , Desfibriladores Implantáveis , Desenho de Equipamento , Falha de Equipamento , Átrios do Coração/fisiopatologia , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/fisiopatologia , Ventrículos do Coração/fisiopatologia , Coração Auxiliar/efeitos adversos , Humanos , Comunicação Interdisciplinar , Relações Profissional-Família , Análise de Sobrevida
14.
Clin Pharmacol Ther ; 106(1): 116-122, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30957872

RESUMO

The US Food and Drug Administration's Center for Drug Evaluation and Research (CDER) developed an investigational Public Health Assessment via Structural Evaluation (PHASE) methodology to provide a structure-based evaluation of a newly identified opioid's risk to public safety. PHASE utilizes molecular structure to predict biological function. First, a similarity metric quantifies the structural similarity of a new drug relative to drugs currently controlled in the Controlled Substances Act (CSA). Next, software predictions provide the primary and secondary biological targets of the new drug. Finally, molecular docking estimates the binding affinity at the identified biological targets. The multicomponent computational approach coupled with expert review provides a rapid, systematic evaluation of a new drug in the absence of in vitro or in vivo data. The information provided by PHASE has the potential to inform law enforcement agencies with vital information regarding newly emerging illicit opioids.


Assuntos
Analgésicos Opioides/química , Substâncias Controladas/química , Controle de Medicamentos e Entorpecentes/organização & administração , Simulação de Acoplamento Molecular/métodos , United States Food and Drug Administration/organização & administração , Simulação por Computador , Desenho de Fármacos , Fentanila/química , Humanos , Saúde Pública , Relação Estrutura-Atividade , Estados Unidos
15.
Cardiol Clin ; 37(2): 241-249, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30926025

RESUMO

Atrial fibrillation is common in patients with congestive heart failure (CHF). Due to reduced left atrial appendage (LAA) emptying velocities and increased sludge formation, a higher rate of stroke and embolism are seen with CHF. Up to 50% of CHF patients are inadequately covered for stroke protection with anticoagulation, and, even while on therapy, CHF patients are at risk for failure to clear LAA or left ventricular (LV) thrombus. Device-based LAA closure (LAAC) alternatives exist. Following intracardiac device closure, an increased rate of device-related thrombus is seen in heart failure patients, which warrants further study to optimize LAAC benefits.


Assuntos
Anticoagulantes/uso terapêutico , Apêndice Atrial/diagnóstico por imagem , Fibrilação Atrial/terapia , Ecocardiografia Transesofagiana/métodos , Insuficiência Cardíaca/terapia , Trombose/prevenção & controle , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/epidemiologia , Comorbidade , Saúde Global , Cardiopatias/diagnóstico , Cardiopatias/etiologia , Cardiopatias/prevenção & controle , Insuficiência Cardíaca/epidemiologia , Humanos , Incidência , Prognóstico , Trombose/diagnóstico , Trombose/etiologia
16.
Heart Rhythm ; 16(1): 12-17, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30012348

RESUMO

BACKGROUND: Incomplete surgical left atrial appendage occlusion (S-LAAO) with a narrow neck has been shown to predict an increased rate of embolic stroke. Patients with a previously attempted S-LAAO were systematically excluded from all clinical trials of LAA closure devices. OBJECTIVE: The purpose of this study was to evaluate the feasibility of Watchman LAA device closure for patients referred with chronically incomplete S-LAAO. METHODS: A prospective single-arm feasibility cohort evaluated only subjects undergoing Watchman LAA closure following incomplete S-LAAO. Patients referred and implanted were followed in the Vanderbilt LAA Registry. Preprocedure computed tomographic angiography and transesophageal echocardiography (TEE) were performed to evaluate suitability for closure, with 45-day follow-up TEE postimplant. RESULTS: All attempted LAA closures after incomplete S-LAAO were successful (n = 6). Mean age was 76.3 ± 7 years. Mean CHADS2Vasc score was 3.8 ± 0.8, and HAS-BLED score was 3.5 ± 0.5. At 45-day follow up, all subjects had complete device seal with no thrombus on device and had transitioned to clopidogrel plus aspirin. Three subjects had narrow ostial necks with a maximum diameter ≤9 mm. In all cases, the 4.7-mm Watchman access sheath was able to cross the ostial stricture. Mean occluder size implanted was 28 ± 4 mm. Mean LAA dimension by TEE in the 45° and 135° views for depth was 31 mm and ostial diameter was 11 × 16 mm, below the minimum Watchman indication for use of 17 mm. No major intraoperative complications occurred. CONCLUSION: Watchman LAA closure seems to be feasible in patients with chronically incomplete S-LAAO, including subjects with a narrow neck ≤9 mm in width.

17.
Semin Cardiothorac Vasc Anesth ; 23(1): 70-87, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30020024

RESUMO

Atrial fibrillation is a very common arrhythmia whose prevalence is expected to increase significantly as the population ages. The associated stroke risk is a major cause of morbidity and mortality. Stroke prevention by anticoagulation carries its own risks, leading to the search for alternative strategies. Multiple techniques have been developed to exclude the left atrial appendage (the main source of thromboembolism in atrial fibrillation) from the circulation. Such techniques offer the hope of stroke prevention without the risks of anticoagulation. This article describes the percutaneous approaches being currently performed in the United States. Particular emphasis is placed on the use of transesophageal echocardiography to guide these procedures.


Assuntos
Apêndice Atrial/fisiopatologia , Fibrilação Atrial/terapia , Cateterismo Cardíaco/instrumentação , Acidente Vascular Cerebral/prevenção & controle , Apêndice Atrial/diagnóstico por imagem , Ecocardiografia Transesofagiana/métodos , Desenho de Equipamento , Humanos , Fatores de Risco , Resultado do Tratamento
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA