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1.
J Vasc Access ; 21(1): 55-59, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31188045

RESUMO

OBJECTIVE: The aim of this study was to compare two complex vascular access techniques that utilize the axillary artery as inflow and accesses were created with early cannulation grafts: the axillary-atrial arteriovenous graft versus axillary-iliac arteriovenous graft. METHODS: This is a retrospective study of end-stage renal disease patients with occluded intrathoracic central veins that underwent complex hemodialysis access creation in our institution after failed endovascular recanalization attempts. Patients' demographics, comorbidities, number and types of previous accesses, intraoperative variables, and clinical outcomes were collected and compared. RESULTS: Four patients underwent axillary-atrial arteriovenous graft creation with Flixene™ (Atrium™, Hudson, NH, USA) grafts, through a midline sternotomy to expose the right atrium; all were successfully implanted and used for hemodialysis within the first 72 h; one patient developed a pseudoaneurysm in the mid-graft portion, requiring surgical repair, and it is currently functional. Eight axillary-iliac arteriovenous grafts were created; all grafts were patent and were utilized within 96 h after placement. At 6 months of follow-up period, five (62 %) of our patients underwent graft thrombectomy, one (12 %) balloon angioplasty at the vein anastomosis secondary to stenosis, and two (25 %) grafts were removed due to infectious complications. Axillary-atrial arteriovenous graft and axillary-iliac arteriovenous graft primary patency rates at 6 months were 75% and 48%, respectively; 6-month secondary patency of the axillary-atrial arteriovenous graft compares favorably against that of axillary-iliac arteriovenous graft (100% vs 75%, respectively). CONCLUSION: Despite the invasiveness, direct atrial outflow procedures remain a valid alternative in carefully selected patients with adequate cardiopulmonary reserve.


Assuntos
Derivação Arteriovenosa Cirúrgica , Apêndice Atrial/cirurgia , Artéria Axilar/cirurgia , Implante de Prótese Vascular , Veia Ilíaca/cirurgia , Falência Renal Crônica/terapia , Diálise Renal , Adulto , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Derivação Arteriovenosa Cirúrgica/instrumentação , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Feminino , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/fisiopatologia , Oclusão de Enxerto Vascular/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução Vascular
2.
Rev Esp Cardiol (Engl Ed) ; 73(1): 21-27, 2020 Jan.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-30956034

RESUMO

INTRODUCTION AND OBJECTIVES: Elderly patients with atrial fibrillation are at greater risk of both cardioembolic events and major bleeding than younger patients. Left atrial appendage occlusion (LAAO) could be an attractive alternative for these patients, but there are limited data on outcomes with LAAO in patients ≥ 85 years old. The aim of the present study was to assess the safety and efficacy of LAAO in patients ≥ 85 years old. METHODS: A total of 1025 patients included in the EWOLUTION registry who underwent LAAO were analyzed and 84 patients ≥ 85 years old were identified and compared with the younger cohort. RESULTS: Patients ≥ 85 years old had higher estimated stroke and hemorrhagic risks than younger patients (CHA2DS2-VASc: 5.2±1.2 vs 4.4±1.6, P <.0001; HAS-BLED: 2.7±1.1 vs 2.3±1.2; P=.003; ≥ 85 years vs <85 years). Procedural success was high and similar in both groups (98.8% vs 98.5%; P=.99). There were no differences in 7-day device- or procedure-related adverse event rates (2.6% in ≥ 85 years vs 3.1% in <85 years; P=.80). Despite the higher baseline stroke risk, there was no difference at follow-up between the groups in the annualized stroke rate (0.8/100 patient-years in ≥ 85 years vs 1.3/100 patient-years in <85 years; P=.649). CONCLUSIONS: LAAO in patients ≥ 85 years is safe and effective even though these patients are at high risk for embolic and hemorrhagic events. LAAO may be a reasonable alternative to oral anticoagulation in these patients.


Assuntos
Apêndice Atrial/cirurgia , Fibrilação Atrial/cirurgia , Cateterismo Cardíaco/métodos , Sistema de Registros , Dispositivo para Oclusão Septal , Acidente Vascular Cerebral/prevenção & controle , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/complicações , Europa (Continente)/epidemiologia , Feminino , Seguimentos , Humanos , Incidência , Masculino , Estudos Prospectivos , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia , Taxa de Sobrevida/tendências , Fatores de Tempo , Resultado do Tratamento
3.
J Interv Cardiol ; 2019: 6704031, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31772541

RESUMO

Objectives: The aim of this study was to investigate the outcomes of left atrial appendage occlusion (LAAO) in high bleeding risk patients suffering atrial fibrillation (AF) and to analyze the different antithrombotic therapies following the intervention. Background Methods: This monocentric study included 68 patients with nonvalvular AF with an absolute contraindication to OAT or at high bleeding risk. Follow-up was done with a clinical visit at 3-6-12 months. Results: Successful LAAO was achieved in 67/68 patients. At discharge, 32/68 patients were on dual antiplatelet therapy (APT), 34/68 were without any antithrombotic therapy or with a single antiplatelet drug, and 2/68 were on anticoagulant therapy. At three-month follow-up visit, 73.6% of the patients did not receive dual APT, of whom 14.7% had no thrombotic therapy and 58.9% were on single antiplatelet therapy. During a follow-up of 1.4 ± 0.9 years, 3/62 patients had late adverse effects (2 device-related thrombus without clinical consequences and 1 extracranial bleeding). The device-related thrombosis was not related to the antithrombotic therapy. Conclusions: LAAO is feasible and safe and prevents stroke in patients with AF with contraindication to oral anticoagulant therapy. After LAAO, single antiplatelet therapy seems to be a safe alternative to dual antiplatelet therapy, especially in patients at high bleeding risk. No benefit has been observed with dual APT.


Assuntos
Apêndice Atrial/cirurgia , Fibrilação Atrial , Fibrinolíticos/efeitos adversos , Hemorragia/prevenção & controle , Implantação de Prótese , Dispositivo para Oclusão Septal , Acidente Vascular Cerebral , Idoso , Fibrilação Atrial/complicações , Fibrilação Atrial/epidemiologia , Fibrilação Atrial/cirurgia , Contraindicações de Medicamentos , Feminino , Fibrinolíticos/uso terapêutico , Seguimentos , Hemorragia/induzido quimicamente , Humanos , Itália/epidemiologia , Masculino , Implantação de Prótese/efeitos adversos , Implantação de Prótese/instrumentação , Implantação de Prótese/métodos , Risco Ajustado/métodos , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , Resultado do Tratamento
4.
J Cardiovasc Med (Hagerstown) ; 20(11): 752-761, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31567634

RESUMO

BACKGROUND: Atrial fibrillation is the most common cardiac arrhythmia, posing a heavy burden on patients' wellbeing and healthcare budgets. Patients undergoing cardiac surgery are at risk of developing postoperative atrial fibrillation (POAF), new-onset atrial fibrillation and subsequent atrial fibrillation-related complications, including stroke. Sufficient clinical identification of patients at risk fails while the pathological substrate changes that precede atrial fibrillation remain unknown. Here, we describe the PREDICT AF study design, which will be the first study to associate tissue pathophysiology and blood biomarkers with clinical profiling and follow-up of cardiothoracic surgery patients for the prediction of future atrial fibrillation. METHODS: PREDICT AF will include 150 patients without atrial fibrillation and a CHA2DS2-VASc score of at least 2 undergoing cardiac surgery. The left atrial appendage will be excised during surgery and blood samples will be collected before surgery and at 6 and 12 months' follow-up. Tissue and blood analysis will be used for the discovery of biomarkers including microRNAs and protein biomarkers. The primary study endpoint is atrial fibrillation, which will be objectified by 24 h Holters and ECGs after 30 days for POAF and after 6, 12 and 24 months for new-onset atrial fibrillation. Secondary endpoints include the dynamic changes of blood biomarkers over time and other atrial arrhythmias. PREDICT AF participants may benefit from extensive postoperative care with clinical phenotyping, rhythm monitoring and primary prevention of stroke. CONCLUSION: We here describe the PREDICT AF trial design, which will enable the discovery of biomarkers that truly predict POAF and new-onset atrial fibrillation by combining tissue and plasma-derived biomarkers with comprehensive clinical follow-up data. TRIAL REGISTRATION: Retrospectively registered NCT03130985 27 April 2017.


Assuntos
Apêndice Atrial/metabolismo , Fibrilação Atrial/etiologia , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Apêndice Atrial/cirurgia , Fibrilação Atrial/sangue , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/fisiopatologia , Biomarcadores/sangue , Eletrocardiografia , Feminino , Frequência Cardíaca , Humanos , Masculino , Pessoa de Meia-Idade , Países Baixos , Valor Preditivo dos Testes , Estudos Prospectivos , Fatores de Proteção , Projetos de Pesquisa , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
5.
Wiad Lek ; 72(9 cz 2): 1829-1833, 2019.
Artigo em Polonês | MEDLINE | ID: mdl-31622274

RESUMO

Atrial fibrillation (AF) is the most common cardiac arrhythmia in the adult population. Thromboembolic events are one of the reson of increased mortality in this group of patients. Oral anticoagulation therapy significantly reduces the risk of complications, however every tenth patient has contraindications to this treatment. Percutaneous left atrial appendage occlusion (LAAO) is effective, non-pharmacological method of treatment through elimination the source of thromi. This procedure is dedicated to patients with high risk of thromboembolism events and contraindications to anticoagulation.


Assuntos
Apêndice Atrial/cirurgia , Fibrilação Atrial/terapia , Tromboembolia/prevenção & controle , Anticoagulantes , Fibrilação Atrial/complicações , Humanos , Terapia Trombolítica
7.
BMJ Case Rep ; 12(9)2019 Sep 05.
Artigo em Inglês | MEDLINE | ID: mdl-31492729

RESUMO

Primary cardiac tumours are relatively rare in the paediatric population, with benign tumours accounting for >90% of cases. Cardiac fibromas are rare primary tumours that typically reside in the ventricles. Symptoms are usually the result of blood outflow obstruction or disruption of the cardiac conduction system. They do not typically regress and usually require surgical intervention. In this case, we report a rare finding of a right atrial fibroma in an 18-month-old female who presented with lethargy and vomiting. Chest X-ray revealed an enlarged cardiac silhouette, and follow-up CT showed a 3.7×3.2×3.7 cm hypodense lesion in the right atrium. Cardiac MRI revealed the diagnosis, which was confirmed on pathology.


Assuntos
Fibroma/diagnóstico por imagem , Neoplasias Cardíacas/diagnóstico por imagem , Apêndice Atrial/diagnóstico por imagem , Apêndice Atrial/cirurgia , Tamponamento Cardíaco/etiologia , Tamponamento Cardíaco/terapia , Ecocardiografia , Feminino , Fibroma/complicações , Fibroma/cirurgia , Átrios do Coração/diagnóstico por imagem , Átrios do Coração/cirurgia , Neoplasias Cardíacas/cirurgia , Humanos , Imagem Tridimensional , Lactente , Imagem por Ressonância Magnética , Derrame Pericárdico/etiologia , Derrame Pericárdico/terapia , Pericardiocentese , Síndrome do Desconforto Respiratório do Adulto/etiologia , Tomografia Computadorizada por Raios X , Vômito/etiologia
8.
Braz J Cardiovasc Surg ; 34(4): 495-498, 2019 08 27.
Artigo em Inglês | MEDLINE | ID: mdl-31454207

RESUMO

Management of symptomatic atrial tachycardia (AT) during pregnancy seems challenging, especially those originating from left atrial appendage (LAA), which easily tend to be incessant and mediate cardiomyopathy. It's contradictory between therapy and pregnancy. In this study, we report a case of a woman who presented with persistent AT, which lead to heart failure, during early pregnancy. She underwent successful catheter ablation using CartoSound and electroanatomic mapping without fluoroscopy. An electrophysiology (EP) study confirmed a focal LAA tachycardia. Soon after, left ventricular function of her heart normalized, and the patient successfully delivered a healthy child.


Assuntos
Apêndice Atrial/cirurgia , Fibrilação Atrial/cirurgia , Ablação por Cateter/métodos , Complicações Cardiovasculares na Gravidez/cirurgia , Adulto , Apêndice Atrial/diagnóstico por imagem , Fibrilação Atrial/diagnóstico por imagem , Eletrocardiografia , Eletrofisiologia , Feminino , Humanos , Gravidez , Complicações Cardiovasculares na Gravidez/diagnóstico por imagem
9.
Curr Cardiol Rep ; 21(7): 66, 2019 06 10.
Artigo em Inglês | MEDLINE | ID: mdl-31183616

RESUMO

PURPOSE OF REVIEW: Atrial fibrillation is the most common arrhythmia worldwide and is a major risk factor for embolic stroke. For patients with atrial fibrillation who are unable to tolerate systemic anticoagulation, left atrial appendage (LAA) occlusion has been shown to mitigate stroke risk. In this article, we describe the vital role of the echocardiographer in intraprocedural guidance of percutaneous LAA occlusion procedures as well as in the pre- and post-procedure assessment of these patients. RECENT FINDINGS: A few percutaneously delivered devices for LAA exclusion from the systemic circulation are available in contemporary practice. These devices employ an either exclusive endocardial LAA occlusion approach, such as the Watchman (Boston Scientific, Maple Grove, MN) and Amulet (St. Jude Medical, Minneapolis, MN), or both an endocardial and pericardial (epicardial) approach such as the Lariat procedure (SentreHEART, Palo Alto, CA). Two- and three-dimension transesophageal echocardiography is critical for patient selection, procedure planning, procedural guidance, and ensuring satisfactory immediate as well as long-term LAA occlusion/exclusion efficacy. This review will provide an overview of the role of the echocardiographer in all aspects of LAA occlusion/exclusion procedures for the most commonly used commercially available devices in current practice.


Assuntos
Apêndice Atrial/cirurgia , Fibrilação Atrial/cirurgia , Cateterismo Cardíaco/métodos , Ecocardiografia Transesofagiana/métodos , Cirurgia Assistida por Computador/métodos , Apêndice Atrial/diagnóstico por imagem , Fibrilação Atrial/diagnóstico , Átrios do Coração , Humanos , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , Resultado do Tratamento
10.
EuroIntervention ; 15(8): 663-670, 2019 Oct 20.
Artigo em Inglês | MEDLINE | ID: mdl-31217149

RESUMO

AIMS: Device surveillance after left atrial appendage (LAA) closure (LAAC) is important to assess device positioning, peri-device leak (PDL) and device-related thrombus (DRT). There are limited data on the role of cardiac CT angiography (CCTA) after LAAC. We therefore sought to compare CCTA to transoesophageal echocardiography (TEE) in patients who successfully underwent LAAC. METHODS AND RESULTS: We report our consecutive series of non-valvular atrial fibrillation patients who underwent LAAC and had CCTA and TEE post LAAC. Prospective cardiac-gated CCTA was performed with the Toshiba 320-detector or Siemens second-generation 128-slice dual-source scanner, and post-processing was performed with IMPAX 3D reformats. Glomerular filtration rate <30 mL/min/1.73 m² was an exclusion for CCTA. Device positioning, PDL or fabric leak, ratio of left atrial (LA) to LAA linear attenuation coefficient, and DRT were analysed. One hundred and two patients underwent LAAC (79 WATCHMAN, 17 Amulet, 6 ACP). Mean age was 76.4±7.5 years, CHADS2 score 3.0±1.3, and CHADS-VASc score 4.6±1.6. CCTA was performed at a mean of 105.2±54.8 days, and TEE at a mean of 124.9±100.3 days post LAAC. LAA patency was observed in 52/100 (52%), with 45 (86.5%) via PDL and seven (13.5%) through fabric leak. Linear attenuation coefficient <100 HU and LA:LAA ratio <0.25 were seen in occluded devices. PDL was only observed in 35/102 (34.3%) on TEE. Mean device compression was greater with sealed devices (11.3±4.3% versus 8.2±4.0%, p<0.001). There was only one DRT, which was observed on both TEE and CCTA. CONCLUSIONS: CCTA is a suitable alternative to TEE for device surveillance post LAAC. CCTA was more sensitive than TEE for assessing PDL and can delineate the cause of residual LAA contrast patency.


Assuntos
Apêndice Atrial/diagnóstico por imagem , Apêndice Atrial/cirurgia , Fibrilação Atrial/cirurgia , Angiografia por Tomografia Computadorizada/métodos , Ecocardiografia Transesofagiana/métodos , Complicações Pós-Operatórias/diagnóstico por imagem , Dispositivo para Oclusão Septal , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/diagnóstico por imagem , Procedimentos Endovasculares , Humanos , Estudos Prospectivos
11.
Pediatr Cardiol ; 40(6): 1144-1150, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31152184

RESUMO

Congenital right atrial appendage aneurysm (RAAA) is an extremely rare malformation that can coexist with atrial tachyarrhythmia. There is no consensus on treatment for this condition. This research aimed to investigate the clinical characteristics and efficacy of surgical resection to treat atrial tachyarrhythmia originating from RAAA in children. Four RAAA children diagnosed with atrial tachyarrhythmia at the age of 1-5.25 years weighing 8.3-17.1 kg were discussed in this retrospective study. Patients underwent various treatments, included electrocardiogram (ECG) and echocardiography, antiarrhythmic medication therapy, radiofrequency catheter ablation (RFCA), surgical resection of RAAA and pathological examinations. The results from these treatments along with clinical features of patients were analyzed. The incidence of RAAA in patients with atrial tachycardia originating from the right or left atrial appendages (RAA or LAA) was 7.3% (4/55). The prevalence of RAAA in the RAA was 12.5% (4/32). Atrial tachyarrhythmia was identified both prenatally (26 and 36 weeks of gestational age) and postnatally (1 and 4 months after birth), with two patients per group, respectively. The RAAAs condition in two patients with atrial tachycardia (AT), concomitant atrial flutter (AF) and atrial fibrillation (Af) was identified using echocardiogram. Although, RAAA in two patients with mono AT was unidentified in echocardiogram and failed to be identified in the procedure of RFCA, RAAA was confirmed during surgical resection of the RAA. Multiple pre-surgical antiarrhythmic medications combined therapy used to treat all four patients showed either no effect at all or was only partially effective. The original atrial tachyarrhythmia was successfully abolished after RAAA surgical resection in four patients. AT originating from new foci was established in two patients post-surgically. The conditions of these two patients were successfully reverted and normal sinus rhythm maintained in the application of antiarrhythmic medications. These results confirmed the efficacy of RAAA surgical resection. The pathology study showed cystic dilation in parts of the atrial cavity, fibrosis of the cyst wall, generalized fibrosis of atrial myocardium with myocardium atrophy and cystic dilation. RAAA is prone to misdiagnosis by echocardiogram. Atrial tachyarrhythmia in patients with RAAA is usually resistant to antiarrhythmic medication therapy and RFCA. Surgical resection of RAAA is a safe and effective option that is minimally invasive.


Assuntos
Apêndice Atrial/cirurgia , Aneurisma Cardíaco/cirurgia , Taquicardia/cirurgia , Antiarrítmicos/uso terapêutico , Apêndice Atrial/anormalidades , Ablação por Cateter/métodos , Pré-Escolar , Ecocardiografia , Feminino , Aneurisma Cardíaco/complicações , Aneurisma Cardíaco/epidemiologia , Humanos , Incidência , Lactente , Masculino , Estudos Retrospectivos , Taquicardia/complicações , Taquicardia/diagnóstico , Taquicardia/tratamento farmacológico , Resultado do Tratamento
12.
J Vet Cardiol ; 23: 15-20, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31174725

RESUMO

Aneurysmal dilation of the atrial appendage (auricle) is rare in humans and dogs. Congenital and acquired etiologies are hypothesized. Although right auricular aneurysm has been described in dogs, this is the first case report of an aneurysm of the left auricle of a dog with an intact pericardium. In humans, because complications of arrhythmia and thromboembolic disease have been reported, surgical resection of left auricular aneurysm is recommended. This report describes the successful surgical resection of a left auricular aneurysm in a dog, including a one-year follow up. Surgical resection can be considered in dogs with auricular aneurysm.


Assuntos
Apêndice Atrial/cirurgia , Doenças do Cão/cirurgia , Aneurisma Cardíaco/veterinária , Animais , Apêndice Atrial/diagnóstico por imagem , Doenças do Cão/diagnóstico por imagem , Cães , Ecocardiografia/veterinária , Aneurisma Cardíaco/diagnóstico por imagem , Aneurisma Cardíaco/cirurgia , Masculino , Resultado do Tratamento
14.
Gen Thorac Cardiovasc Surg ; 67(8): 726-727, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31102137

RESUMO

A 70-year-old man underwent cardiac surgery including left atrial appendage closure. A pigtail catheter was inserted into the pericardial sac because of delayed tamponade. Removal of the catheter was planned for 2 days after drain insertion. However, the resistance was high and pulsatile. The patient was transferred to the catheterization laboratory and a guide wire was inserted through the catheter, revealing the catheter route around the left atrial appendage. The wire was exchanged for a stiff wire to uncurl the catheter as much as possible, then the catheter was removed. The left atrial appendage does not usually represent an obstacle to catheter removal because it is soft and shrinkable. However, once the left atrial appendage becomes closed off, it can become hard, unshrinkable and an obstacle that might be caught by the drainage catheter.


Assuntos
Apêndice Atrial/cirurgia , Cateteres Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos , Drenagem/instrumentação , Derrame Pericárdico/cirurgia , Idoso , Apêndice Atrial/diagnóstico por imagem , Fibrilação Atrial/cirurgia , Ecocardiografia Transesofagiana , Humanos , Masculino , Valva Mitral/cirurgia , Resultado do Tratamento
15.
J Thromb Thrombolysis ; 48(2): 209-214, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31102161

RESUMO

The left atrial appendage (LAA) is a major source of thromboembolism, particularly in patients with atrial fibrillation (AF). LAA exclusion has arisen as a method of stroke prophylaxis in high-risk patients who have failed medical management, in whom medical management is contraindicated, and in those undergoing concomitant cardiac surgery. Percutaneous LAA exclusion with devices such as the Watchman has been described extensively in the cardiology literature, but surgical exclusion is less often discussed. Several techniques exist for surgical LAA exclusion, including appendage excision (removal), internal ligation from within the left atrium (LA), and external occlusion without opening the LA. The decision of which surgical technique to employ is dependent upon individual patient characteristics including risk factors, surgical history, and appendage anatomy. This paper discusses patient selection for surgical LAA exclusion and methods of surgical exclusion for the non-cardiac surgery medical practitioner.


Assuntos
Apêndice Atrial/cirurgia , Seleção de Pacientes , Tromboembolia/prevenção & controle , Procedimentos Cirúrgicos Cardíacos/métodos , Humanos , Acidente Vascular Cerebral/prevenção & controle
16.
Cerebrovasc Dis ; 47(3-4): 188-195, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31121584

RESUMO

BACKGROUND: Patients surviving an initial stroke present a significantly increased risk for further strokes. Left atrial appendage closure (LAAC) became an alternative treatment to pharmacological therapy for stroke prevention in atrial fibrillation (AF) patients. OBJECTIVE: To evaluate the long-term efficacy of LAAC in primary and secondary stroke prevention in patients with AF. METHODS: This retrospective study enrolled 139 patients following LAAC who were divided into 2 groups: 37 patients with prior stroke (Stroke Group) and 102 patients without stroke (Control Group). Overall, cumulative follow-up was 530.1 patient-years. RESULTS: Mean CHADS2, CHA2DS2-VASc scores, and HAS-BLED score were higher in patients with prior stroke compared to patients without stroke (3.0 vs. 1.4, p < 0.0001 and 4.6 vs. 2.3, p < 0.0001, 4.0 vs. 2.8, p < 0.0001, respectively). There were no significant differences between other patient factors (sex, heart failure, hypertension, previous stroke/transient ischemic attack, peripheral vascular disease), which may increase the risk of thromboembolism based on the CHA2DS2-VASc score. Average follow-up was 51.3 months in patients with previous stroke and 50 months in patients without previous stroke. Thromboembolic event rate was 0.8 vs. 0.5 (p = 0.72), bleeding event rate was 0 years vs. 1.4 (p = 0.25), and mortality rates were 0.8 vs. 2.1 (p = 0.38) between the Stroke Group and the Control Group. The estimated reductions in thromboembolic and bleeding risks were 89 and 100%, respectively, in Stroke Group, and 91 and 81%, respectively, in Control Group. CONCLUSION: Patients with prior stroke may be the preferred group for LAAC regardless of the presence or absence of contraindications for anticoagulant therapy.


Assuntos
Apêndice Atrial/cirurgia , Fibrilação Atrial/cirurgia , Procedimentos Cirúrgicos Cardíacos , Prevenção Secundária/métodos , Acidente Vascular Cerebral/prevenção & controle , Adulto , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/uso terapêutico , Apêndice Atrial/fisiopatologia , Fibrilação Atrial/complicações , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/fisiopatologia , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
17.
Am J Cardiol ; 124(2): 233-238, 2019 07 15.
Artigo em Inglês | MEDLINE | ID: mdl-31109635

RESUMO

Catheter ablation is nowadays the core treatment of atrial fibrillation (AF). Propofol infusion sedation is an accepted safety strategy; however, respiratory depression with respiratory variations is frequent. Noninvasive mechanical ventilation (NIV) added to deep sedation could improve procedural safety and success. We sought to assess the predictive factors and safety of NIV in combination to propofol deep sedation in left atrial ablation procedures. Procedural data from 252 consecutive patients who underwent left atrial ablation (166 [66%] persistent, 86 [34%] for paroxysmal AF) were analyzed. Sedation with 1% propofol was used in all procedures and controlled by electrophysiologists. Arterial blood gas analysis was performed regularly during the procedure. NIV was indicated for respiratory depression with pH <7.25 and pCO2 >50 mm Hg or agitated patient with the need for more profound sedation. No patient needed endotracheal intubation, and no procedure was abandoned due to adverse effects of sedation. NIV was used in 25 patients (10%). Predictive factors for the use of NIV were high-dose propofol sedation (p = 0.010), persistent AF (p = 0.029), prolonged procedure time (p = 0.006), increased body mass index (p = 0.008) and presence of obstructive sleep apnea (OSA; p <0.001). In a Cox regression analysis, OSA was an independent factor for NIV use (p = 0.016). In conclusion, propofol deep sedation for patients who underwent left atrial ablation is safe. Adding NIV in high-risk patients (i.e., OSA, high body mass index, and lengthy procedure duration) provides better respiratory homeostasis and could impact long-term procedure results.


Assuntos
Apêndice Atrial/cirurgia , Fibrilação Atrial/cirurgia , Ablação por Cateter/métodos , Sedação Profunda/métodos , Propofol/farmacologia , Respiração Artificial/métodos , Anestésicos Intravenosos/farmacologia , Fibrilação Atrial/fisiopatologia , Feminino , Seguimentos , Frequência Cardíaca/fisiologia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento
18.
J Invasive Cardiol ; 31(8): 212-216, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31088992

RESUMO

BACKGROUND: Stroke recurrence despite optimal oral anticoagulation (OAC) might represent a novel indication for left atrial appendage occlusion (LAAO). The heterogeneity of these patients is generally high, as the presence of valvular atrial fibrillation (VAF) is common. The aim of this study was to explore the role of LAAO as an adjunctive therapy to OAC in patients with recurrent stroke despite optimal OAC. METHODS: The study screened consecutive patients who underwent percutaneous LAAO at nine centers between 2009 and 2017. Patients with recurrent stroke despite optimal OAC were selected and those with an absolute or relative contraindication to OAC were not included in the study. RESULTS: Among 837 patients who underwent LAAO between the study period, a total of 22 (2.6%) met the inclusion criteria. There was a high percentage of VAF (38%) and 59% presented more than one cardioembolic event before LAAO. All patients underwent successful implantation of the device and no procedural major adverse events were reported. In all but 3 patients, anticoagulation was continued after LAAO. With a median clinical follow-up of 1.8 years (range, 0.7-2.8 years), only 1 stroke and 1 transient ischemic attack were reported, translating into a significant reduction of cerebrovascular events before and after LAAO (2.0 ± 1.0 events vs 0.1 ± 0.3 events; P<.01). Imaging follow-up revealed only 1 case of device thrombosis. CONCLUSIONS: LAAO as an adjunctive therapy to OAC seems to be feasible and safe in patients with previous cardioembolic events despite optimal OAC. In our series, this strategy was associated with a low rate of cerebrovascular events after LAAO.


Assuntos
Anticoagulantes/administração & dosagem , Apêndice Atrial/cirurgia , Fibrilação Atrial/terapia , Dispositivo para Oclusão Septal , Acidente Vascular Cerebral/prevenção & controle , Administração Oral , Idoso , Fibrilação Atrial/complicações , Feminino , Seguimentos , Humanos , Masculino , Estudos Retrospectivos , Acidente Vascular Cerebral/etiologia , Fatores de Tempo , Resultado do Tratamento
19.
Herz ; 44(4): 310-314, 2019 Jun.
Artigo em Alemão | MEDLINE | ID: mdl-31076823

RESUMO

Atrial fibrillation is the most frequent cardiac arrhythmia worldwide, causing approximately 20% of all ischemic strokes. Therefore, oral anticoagulation is recommended in patients with atrial fibrillation with at least a moderate risk of stroke; however, there is a significant proportion of patients who cannot undergo long-term oral anticoagulation. As the left atrial appendage is of major relevance for atrial fibrillation-induced thrombus formation, catheter-based or surgical closure of the left atrial appendage appears to be a promising therapeutic option. Large registry studies including patients with catheter-based left atrial appendage closure have proven its effectiveness and a decreasing procedure-related complication rate. This review article summarizes the current knowledge and introduces major ongoing randomized studies, which will investigate the impact of left atrial appendage closure on stroke prevention. The authors hope that the results of the randomized CLOSURE AF trial, which is funded by the German Center for Cardiovascular Research e. V. and is now recruiting patients in Germany, will help to solve many of the currently prevalent clinical questions.


Assuntos
Apêndice Atrial , Fibrilação Atrial , Acidente Vascular Cerebral , Anticoagulantes , Apêndice Atrial/cirurgia , Fibrilação Atrial/complicações , Fibrilação Atrial/cirurgia , Alemanha , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , Resultado do Tratamento
20.
Heart Vessels ; 34(11): 1858-1865, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31144099

RESUMO

Percutaneous left atrial appendage closure (LAAC) may decrease risks of stroke and bleeding in elderly patients with non-valvular atrial fibrillation (NVAF), but it is still lacking of evidence. The present study aimed at evaluating the efficacy and safety of LAAC in patients with NVAF over 75 years. 351 patients with NVAF who underwent LAAC were retrospectively analyzed on the LAAC procedure characteristics and the clinical follow-up according to age (age ≥ 75 years or < 75 years). Out of the 351 patients, LAA were successfully closed in 347 patients (98.9%), including 341 with Watchman (WM) device and 6 with Amplatzer cardiac plug (ACP) device because of the WM device-incompatible anatomy. There were no significant differences in total LAAC success rate and procedure-related major complications within 7 days between the groups aged ≥ 75 years and aged < 75 years. After a nearly 2-year follow-up, there was an increased trend of major bleedings and all bleedings in the group aged ≥ 75 years, but there were no significant differences between both groups in all-cause death, cardiovascular death, stroke/TIA/system embolism, device thrombus and device gap (> 5 mm). Kaplan-Meier analysis revealed that the relative risk of annual thromboembolic events between the observed values and the expected ones based on CHA2DS2-VASc score in the group aged ≥ 75 years decreased more obviously (61.9% vs. 54.3%); however, the relative risk of bleedings between the observed values and the expected ones based on HAS-BLED score in the younger group aged < 75 years decreased more significantly (59.6% vs. 29.2%). LAAC in patients with advanced age (age ≥ 75 years), has the same level of efficacy, safety and feasibility as in the younger patients aged < 75 years. Thus, LAAC may be an ideal choice to prevent stroke in NVAF patients with advanced age.


Assuntos
Apêndice Atrial/cirurgia , Fibrilação Atrial/cirurgia , Cateterismo Cardíaco/métodos , Procedimentos Cirúrgicos Cardíacos/métodos , Dispositivo para Oclusão Septal , Acidente Vascular Cerebral/prevenção & controle , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Apêndice Atrial/diagnóstico por imagem , Fibrilação Atrial/complicações , Causas de Morte/tendências , Ecocardiografia , Feminino , Alemanha/epidemiologia , Humanos , Incidência , Masculino , Estudos Retrospectivos , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia , Taxa de Sobrevida/tendências , Fatores de Tempo
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