Effectiveness and safety of same day discharge after left atrial appendage closure under moderate conscious sedation.

BACKGROUND: Left atrial appendage occlusion (LAAO) using Watchman device has become a world-wide, well-established therapeutic alternative to chronic systemic oral anticoagulation in patient who are at high-risk of bleeding with paroxysmal (PAF) or chronic atrial fibrillation (Afib). Currently, LAAO procedures are performed under general anesthesia (GA) and patients stay overnight post procedure in the United States. We aimed to present the effectiveness and safety of same day discharge following LAAO under moderate conscious sedation (MCS) in patients without procedural complications. METHODS: A total of 112 patients between August 2019 and May 2020 with elevated CHA2 DS2 VASc (median score of 3) underwent transesophageal echocardiography (TEE)-guided LAAO with FDA approved Watchman (Boston Scientific, MN) under MCS and discharged home on the same day 6 hr following their post procedural transthoracic echocardiogram (TTE) evaluations. All patients had next day TTE and follow up at the cardiology clinic. We prospectively evaluated clinical and procedural outcomes using medical records of these patients. RESULTS: Among all the patients, the mean age was 83.5 ± 8.5 years, 45 (40%) were women. Procedural duration, device implant time and fluoroscopic times were 45 ± 8.6, 14.5 ± 7.8 and 10.2 ± 1.2 min, respectively. The median required dosage of propofol was 105 ± 2.8 mg. No complications arose from MCS. There was no need for conversion to GA in any of the patients during the procedure. All patients were able to be discharged 6 hr following their TTE evaluation post procedure. There were no procedural complications. CONCLUSIONS: Same day discharge following LAAO closure seems to be safe and effective in patients without procedural complications. LAAO can also be performed safely and effectively under moderate conscious sedation. Applying moderate conscious sedation may simplify the LAAO procedure, reduce procedural time, procedural costs and hospital stay while increasing overall patient satisfaction.

Feasibility of Same-Day Discharge Approach After Transcatheter Mitral Valve Repair Procedures.

INTRODUCTION: Early discharge strategies are increasingly adopted after percutaneous cardiac interventions. However, there is a paucity of data on early discharge after transcatheter mitral valve repair (TMVRep) procedures. In this report, we aimed to present our data on same-day discharge after MitraClip (Abbott Structural) procedures. METHODS: A total of 82 patients who underwent TMVRep and were discharged the same day were included in the study. Patients who underwent the procedure with moderate conscious anesthesia, and without periprocedural complications and a stable early course post procedure, were considered candidates for same-day discharge. A next-day follow-up exam at the cardiology clinic was scheduled for all patients for removal of the groin access figure-of-eight subcutaneous sutures and for echocardiographic examination. RESULTS: Thirty-nine patients had primary mitral regurgitation (MR), while 43 patients had secondary MR. A mean of 1.4 ± 0.4 clips were implanted per patient (range, 1 to 2 clips). Postprocedural MR grade was 1+ or lower in 64 patients (63.6%) and 2+ in 38 patients (36.4%). All patients were evaluated in the office clinic the next day, and had no major complications. CONCLUSION: Same-day discharge approach can be safely performed in selected patients after TMVRep procedures. However, further studies with larger sample sizes are needed.

Evaluation of Effectiveness and Safety of Left Atrial Appendage Closure Under Moderate Conscious Sedation.

BACKGROUND: Left atrial appendage closure (LAAC) using the Watchman device has become a well-established, world-wide therapeutic alternative to oral anticoagulation in high-risk patients for bleeding with paroxysmal, persistent atrial fibrillation (Afib) or permanent Afib. Currently, in the United States, LAAC procedures are performed under general anesthesia (GA). We present the feasibility, effectiveness, and safety of LAAC under moderate conscious sedation (MCS). METHODS: A total of 112 patients with elevated CHA2DS22VASc (median score of 3) between November 2018 and November 2019 underwent transesophageal echocardiography (TEE)-guided LAAC with the FDA-approved Watchman LAAC device (Boston Scientific) under MCS. We prospectively evaluated clinical and procedural outcomes using medical records of these patients. RESULTS: Mean patient age was 73.5 ± 4.5 years and 45 (40%) were women. Procedural duration, device implant time, and fluoroscopic times were 45 ± 8.6 minutes, 14.5 ± 2.8 minutes, and 10.2 ± 1.2 minutes, respectively. The median required dosage of propofol was 101 ± 2.8 mg. No complications were observed from MCS. There was no need for conversion to GA in any of the patients during the procedure. CONCLUSIONS: LAAC is safe and effective when performed under MCS. Thus, applying MCS may simplify the LAAC procedure, as well as reduce procedural time and procedural costs, while increasing overall patient satisfaction.

Successful WATCHMAN Device Implantation in a Patient with IVC Filter Thrombosis and Iliac Vein Occlusions.

Percutaneous left atrial appendage occlusion has been shown to be a safe and cost-effective treatment for stroke prevention in patients with nonvalvular atrial fibrillation with increased stroke and bleeding risk. Venous system might be occluded from prior procedures or have structural abnormalities. Herein, we present a successful WATCHMAN device implantation in a patient with inferior vena cava filter thrombosis and iliac vein occlusions.

Evaluation of Effectiveness and Safety of Transcatheter Mitral Valve Repair Under Moderate Conscious Sedation.

BACKGROUND: Transcatheter mitral valve repair (TMVR) using the MitraClip system (Abbott Vascular) has become a world-wide, well-established therapeutic alternative to symptomatic patients with severe mitral regurgitation (MR) and prohibitive surgical risk. Currently, TMVRs are performed under general anesthesia. Herein, we aimed to present the effectiveness and safety of TMVR under moderate conscious sedation (MCS). METHODS: A total of 102 patients with severe MR (49 primary MRs and 53 secondary MRs) who underwent TMVR with MCS between December 2018 and December 2019 were included. We prospectively evaluated clinical and procedural outcomes using medical records of these patients. RESULTS: Among all the patients, the mean age was 81.6 ± 3.5 years, 60 (59%) were women, and 72.7% had coronary artery disease. The mean left ventricular ejection fraction was 47.9 ± 12.7%, while the MR grade was 3+ in 18.2% of the patients and 4+ in 81.8%. A mean of 1.2 ± 0.4 clips (range, 1-2 clips) were implanted per patient. Postprocedural MR grade was 1+ or lower in 64 patients (63.6%) and 2+ in 38 patients (36.4%). Procedural duration, clip implant time, and fluoroscopy times were 60 ± 10.5 minutes, 19.5 ± 8.0 minutes, and 10.1 ± 2.1 minutes, respectively. The median required dosage of propofol was 140 mg (interquartile range, 84-156 mg). No complications arose from MCS. There was no need for conversion to general anesthesia in any of these patients during the procedure. CONCLUSIONS: TMVR can be performed safely and effectively under moderate conscious sedation. Applying moderate conscious sedation may simplify the TMVR procedure and reduce procedural time and costs, while increasing overall patient satisfaction.

Assessment of Vascular Patency and Inflammation with Intravascular Optical Coherence Tomography in Patients with Superficial Femoral Artery Disease Treated with Zilver PTX Stents.

PURPOSE: Zilver PTX nitinol self-expanding drug-eluting stent with paclitaxel coating is effective for treatment of superficial femoral artery (SFA) disease. However, as with any stent, it induces a measure of vascular inflammatory response. The current clinical trial (NCT02734836) aimed to assess vascular patency, remodeling, and inflammatory markers with intravascular optical coherence tomography (OCT) in patients with SFA disease treated with Zilver PTX stents. METHODS: Serial OCT examinations were performed in 13 patients at baseline and 12-month follow-up. Variables evaluated included neointimal area, luminal narrowing, thrombus area, stent expansion as well as measures of inflammation including, peri-strut low-intensity area (PLIA), macrophage arc, neovascularization, stent strut apposition and coverage. RESULTS: Percentage of malapposed struts decreased from 10.3 ±â€¯7.9% post-intervention to 1.1 ±â€¯2.2% at 12-month follow-up, but one patient showed late-acquired stent malapposition (LASM). The percent of uncovered struts at follow-up was 3.0 ±â€¯4.5%. Average expansion of stent cross-sectional area from baseline to follow-up was 35 ±â€¯19%. The average neointimal area was 7.8 ±â€¯3.8 mm2. Maximal luminal narrowing was 61.1 ±â€¯25.0%, and average luminal narrowing was 35.4 ±â€¯18.2%. Average peri-strut low-intensity area (PLIA) per strut was 0.017 ±â€¯0.018 mm2. Average number of neovessels per mm of stent was 0.138 ±â€¯0.181. Average macrophage angle per frame at follow-up was 7 ±â€¯11°. Average thrombus area at follow-up was 0.0093 ±â€¯0.0184 mm2. CONCLUSION: At 12-month follow-up, OCT analysis of Zilver PTX stent shows outward remodeling and minimal neointimal growth, but evidence of inflammation including PLIA, neovessels, thrombus and macrophages. SUMMARY: Thirteen patients with PAD had paclitaxel-coated stents implanted in their SFAs and were then imaged with OCT at baseline and 12-month follow-up. OCT proxy metrics of inflammation were quantified.

Evaluation of the relationship between mandibular condyle cortication and chronologic age with cone beam computed tomography.

PURPOSE: The aim of the present study is to evaluate the relationship between mandibular condyle cortication and chronologic age and gender via cone-beam computed tomography (CBCT) and to investigate the effectiveness of using the condylar cortication as a new method of age estimation. METHODS: CBCT images from 433 subjects aged 8 to 31 years were included in this study. The right and left condyle cortication were assessed on the sagittal plane separately for each individual by the same investigator via a new method that describes the cortication of the condyle. Type I: There is no cortication on the condyle. Type II: The bone that is on the superior surface of the condyle is seen less density than the structures around the condyle. Type III: The surface of the condyle is seen similar or higher density than the surrounding cortical areas. RESULTS: The type of the condyle cortication in the right and left mandible was similar for almost each subject and there was no statistically significant different between them (p = 0.375). When we evaluated the results without including these patients for male, Type I cortication of the condyle was seen at 14.14 ±â€¯2.3 years, Type II cortication of the condyle was seen at 16.11 ±â€¯3.18 years and Type III cortication of the condyle was seen at 19.39 ±â€¯3.96 years. For the female, Type I cortication of the condyle was seen at 13.01 ±â€¯2.16 years, Type II cortication of the condyle was seen at 15.52 ±â€¯2.71 years and Type III cortication of the condyle was seen at 17.95 ±â€¯3.13 years. The minimum age of Type III cortication was 11 and 15 years old for male and female, respectively. However, there are subjects, who are 30 year old man and 31 year old female, have no cortication as much as similar or higher than the surrounding the cortical areas. CONCLUSION: This study is the first investigation of the relationship between condyle cortication and chronologic age with CBCT in the Turkish population. The type of cortication in the right and left condyle may be different for the same individual. Chronologic age increased as the stages of the cortication process from Type I to Type III in male and female individuals, and all the stages of the cortication in the mandibular condyle of male occur later time according to female.