Embolization of percutaneous left atrial appendage closure devices: Timing, management and clinical outcomes.

BACKGROUND: Left atrial appendage (LAA) occluder embolization is an infrequent but serious complication. OBJECTIVES: We aim to describe timing, management and clinical outcomes of device embolization in a multi-center registry. METHODS: Patient characteristics, imaging findings and procedure and follow-up data were collected retrospectively. Device embolizations were categorized according to 1) timing 2) management and 3) clinical outcomes. RESULTS: Sixty-seven centers contributed data. Device embolization occurred in 108 patients. In 70.4 % of cases, it happened within the first 24 h of the procedure. The device was purposefully left in the LA and the aorta in two (1.9 %) patients, an initial percutaneous retrieval was attempted in 81 (75.0 %) and surgery without prior percutaneous retrieval attempt was performed in 23 (21.3 %) patients. Two patients died before a retrieval attempt could be made. In 28/81 (34.6 %) patients with an initial percutaneous retrieval attempt a second, additional attempt was performed, which was associated with a high mortality (death in patients with one attempt: 2.9 % vs. second attempt: 21.4 %, p < 0.001). The primary outcome (bailout surgery, cardiogenic shock, stroke, TIA, and/or death) occurred in 47 (43.5 %) patients. Other major complications related to device embolization occurred in 21 (19.4 %) patients. CONCLUSIONS: The majority of device embolizations after LAA closure occurs early. A percutaneous approach is often the preferred method for a first rescue attempt. Major adverse event rates, including death, are high particularly if the first retrieval attempt was unsuccessful. CONDENSED ABSTRACT: This dedicated multicenter registry examined timing, management, and clinical outcome of device embolization. Early embolization (70.4 %) was most frequent. As a first rescue attempt, percutaneous retrieval was preferred in 75.0 %, followed by surgical removal (21.3 %). In patients with a second retrieval attempt a higher mortality (death first attempt: 2.9 % vs. death second attempt: 24.1 %, p < 0.001) was observed. Mortality (10.2 %) and the major complication rate after device embolization were high.

Coronary Embolism Among Patients With ST-Segment-Elevation Myocardial Infarction and Atrial Fibrillation: An Underrecognized But Deadly Association.

BACKGROUND: The prevalence and impact of coronary emboli (CE) in patients with ST-segment-elevation myocardial infarction (STEMI) and atrial fibrillation (AF) have not been specifically studied. The objective was to describe the clinical characteristics and outcomes of patients with AF and CE in a large series of patients with STEMI. METHODS AND RESULTS: We investigated 2292 consecutive patients with STEMI and among them 225 patients with AF: 46 patients with a STEMI related to CE (group A) and 179 patients with a STEMI related to an atherosclerotic cause (group B). Compared with the 2067 patients without AF and CE (group C), patients with AF and CE were older (73 versus 59 years, P<0.05), more likely to be female (43% versus 22%, P<0.05), and presented more frequently with cardiogenic shock at admission (26% versus 9%, P<0.05). The baseline characteristics of patients with AF (group A versus B) did not differ significantly according to STEMI pathogenesis. In the unadjusted analysis, the 45-day mortality was higher in patients with CE and AF (group A versus group C: 20% versus 4%; P<0.05 and group A versus group B: 20% versus 8%, P=not significant); this trend persisted at 2-year follow-up (group A versus group C: 24% versus 6%; P<0.05 and group A versus group B: 24% versus 17%, P=not significant). After stabilized inverse exposure probability weighting adjustment, a higher 45-day mortality rate was confirmed in patients with CE and AF (group A versus group C: 18% versus 5%, P<0.05). CONCLUSIONS: In patients presenting with STEMI and AF, CE was associated with excess early mortality. REGISTRATION: URL: clinicaltrials.gov. Identifier: NCT05679843.

Causes of death in growing-finishing pigs in two technified farms in southern Brazil / Causas de morte em suínos de crescimento e terminação em duas granjas tecnificadas no Sul do Brasil

The aim of this study was to investigate the main causes of death in growing-finishing pigs in southern Brazil. During a one-year period (from 2018 to 2019), two industrial pig herds (18 and 20 thousand pigs each farm) in southern Brazil were monitored along the four seasons of the year (12 days per season on each farm), in order to perform necropsies of all pigs that died in that period. The two farms had an average monthly mortality rate ranging from 0.94 to 3.93% in the evaluated months. At necropsy, tissues were collected, fixed in 10% formalin solution and processed routinely for histopathological examination. When necessary, samples were sent for bacterial culture and PCR to identify etiologic agents. A total of 601 necropsies were performed, with 94.9% of conclusive diagnoses. Infectious diseases corresponded to 64.4% of conclusive diagnosis and non-infectious diseases to 35.6%. The most prevalent causes of death were: pneumonia (33%), gastric ulcers (15.4%), circovirosis (9.9%), systemic bacterial embolism (5.4%), polyserositis (4.4%), dilated cardiomyopathy and torsion of abdominal organs (4.3% each), and bacterial pericarditis (3.4%). Regarding pneumonias (199/601), the main agents identified in these cases were Pasteurella multocida, Influenza A virus and Mycoplasma hyopneumoniae, mainly in associations.(AU)

O objetivo do presente trabalho foi investigar as principais causas de morte de suínos em fase de crescimento e terminação no Sul do Brasil. Durante o período de um ano (entre 2018 e 2019), duas granjas tecnificadas de suínos no Sul do Brasil foram acompanhadas nas quatro estações (12 dias por estação em cada granja), para realização de necropsias dos suínos que morreram nesse período. As duas propriedades apresentavam mortalidade mensal média entre 0,94 e 3,93% nos meses avaliados. Na necropsia, amostras de órgãos foram colhidas, fixadas em formol 10% e processadas rotineiramente para o exame histopatológico. Quando necessário, amostras foram enviadas para o cultivo bacteriano e PCR para identificação de agentes etiológicos. Foram realizadas um total de 601 necropsias, com 94,9% de diagnósticos conclusivos. As doenças infecciosas corresponderam a 64,4% dos diagnósticos conclusivos e as não infecciosas a 35,6%. As principais causas de morte foram: pneumonias (33%), úlcera gástrica (15,4%), circovirose (9,9%), embolia bacteriana sistêmica (5,4%), polisserosite (4,4%), cardiomiopatia dilatada e torção de órgãos abdominais (4,3% cada) e pericardite bacteriana (3,4%). Com relação às pneumonias (199/601), os principais agentes associadas as lesões foram Pasteurella multocida, vírus da Influenza A e Mycoplasma hyopneumoniae, principalmente associados entre si.(AU)

Asymptomatic and symptomatic embolic events in infective endocarditis: associated factors and clinical impact

ABSTRACT Background: Embolic complications of infective endocarditis are common. The impact of asymptomatic embolism is uncertain. Objectives: To determine the frequency of emboli due to IE and to identify events associated with embolism. Methods: Retrospective analysis of an endocarditis database, prospectively implemented, with a post hoc study driven by analysis of data on embolic events. Data was obtained from the International Collaboration Endocarditis case report forms and additional information on embolic events and imaging reports were obtained from the medical records. Variables associated with embolism were analyzed by the statistical software R version 3.1.0. Results: In the study period, 2006-2011, 136 episodes of definite infective endocarditis were included. The most common complication was heart failure (55.1%), followed by embolism (50%). Among the 100 medical records analyzed for emboli in left-sided infective endocarditis, 36 (36%) were found to have had asymptomatic events, 11 (11%) to the central nervous system and 28 (28%) to the spleen. Cardiac surgery was performed in 98/136 (72%). In the multivariate analysis, splenomegaly was the only associated factor for embolism to any site (p < 0.01, OR 4.7, 95% CI 2.04-11). Factors associated with embolism to the spleen were positive blood cultures (p = 0.05, OR 8.9, 95% CI 1.45-177) and splenomegaly (p < 0.01, OR 9.28, 95% CI 3.32-29); those associated to the central nervous system were infective endocarditis of the mitral valve (p < 0.05, OR 3.5, 95% CI 1.23-10) and male gender (p < 0.05, OR 3.2, 95% CI 1.04-10). Splenectomy and cardiac surgery did not impact on in-hospital mortality. Conclusions: Asymptomatic embolism to the central nervous system and to the spleen were frequent. Splenomegaly was consistently associated with embolic events.

The Clinical Impacts of Apparent Embolic Event and the Predictors of In-Hospital Mortality in Patients with Infective Endocarditis

Embolic event is a common and important complication of infective endocarditis (IE). The objective of this study was to investigate the clinical impacts of embolic event in patients with IE and the predictors of in-hospital mortality. Data was collected in Pusan National University Hospital and Pusan National University Yangsan Hospital between January 2009 and December 2010. One hundred ten patients were included. Embolic events occur in 39 of 110 patients (35.5%). Brain (n = 18, 38.5%) was the main site of embolic infarction. Patients with embolism showed higher in-hospital mortality (46.2% vs. 8.5%, respectively, P = 0.03), more frequent ICU admission (53.8% vs. 35.2%, respectively, P = 0.045) and more accompanying other cardiac complication (43.6% vs. 21.1%, respectively, P = 0.017). The in-hospital mortality rate was 18.2%. On the logistic regression analysis of the predictors for in-hospital mortality, age (RR, 1.079; 95% CI, 1.036-1.123, P = 0.001), embolic event (RR, 3.510; 95% CI, 1.271-9.69, P = 0.015) and staphylococcal infection (RR, 5.098; 95% CI, 1.308-18.508, P = 0.023) were independently associated with in-hospital mortality. Embolic events in IE are associated with poor in-hospital outcome; and these data about embolic events and the predictors of in-hospital mortality may improve the management of this disease in hospitals.

Infarto cerebral hemorrágico por embolización de un trombo mural cardíaco / Hemorrhagic cerebral infarction due to embolization of a mural thrombus within the right ventricle

Las enfermedades cerebrovasculares son consecuenciade una alteración en la circulación cerebral. Suforma más distintiva de presentación es el ictus, entendidocomo un déficit neurológico focal de instauraciónbrusca y evolución rápida.Un infarto cerebral de origen oclusivo puede debersebien a una trombosis in situ o bien a una embolia procedentede un foco distante. En las embolias cerebrales lacausa principal son los trombos murales cardiacos y elárea encefálica afectada con mayor frecuencia es el territorioirrigado por la arteria cerebral media.Presentamos el caso de una mujer de 81 años, conantecedentes de Hepatitis C, cardiopatía hipertensiva yfibrilación auricular crónica, que sufrió una fractura decadera consecutiva a una caída accidental. Durante elingreso hospitalario comenzó un cuadro de deterioroneurológico progresivo que no llegó a ser filiado, falleciendo9 días después. En la autopsia médico-forense seencontró un infarto cerebral hemorrágico en el territoriode la arteria cerebral media izquierda. Dado que las arteriasdel Polígono de Willis eran permeables y ante la presenciade trombos vitales adheridos a la pared del ventrículoderecho, se estimó como causa más probable delaccidente vasculocerebral la embolización de uno dedichos trombos

Cerebrovascular diseases are due to a disturbance incerebral blood flow. The most frequent way ofpresentation is stroke, defined as a sudden and focalneurological impairment with rapid evolution.Cerebral infarction of occlusive origin can besecondary to in situ thrombosis or to embolism from adistal focus. Mural thrombi are the main cause of brainembolism and the middle cerebral artery territory is themost likely affected brain area.We report the case of an 81 year-old woman, withantecedents of Hepatitis C, hypertensive cardiopathy andchronic atrial fibrillation, who suffered a hip fracture due toan accidental fall. A progressive neurological impairment ofunknown aetiology appeared during her hospitalization,and she died 9 days after her admission. Forensic autopsyfound a hemorrhagic cerebral infarction in the territory ofthe left middle cerebral artery. As the arteries of thepolygon of Willis were patent and there were vital thrombiadhered to the free wall of the right ventricle,thromboembolism was considered the most probablecause of the cerebrovascular event

Variables predictoras de embolias en endocarditis infecciosa / Embolism predictors of infective endocarditis

El evento embólico (EE) aumenta la morbi-mortalidad de la endocarditis infecciosa (EI). La prevalencia de EE oscila entre 22% y 50%, pudiendo ocasionar hasta el 25% de las muertes de los pacientes que lo presentan. El EE puede ocurrir previamente al diagnóstico, durante el tratamiento o bien posteriormente al mismo. Nuestro objetivo fue analizar las características demográficas, clínicas, microbiológicas, ecocardiográficas y terapeúticas, de pacientes con EI (con y sin embolias) para tratar de establecer variables predictoras del EE. Se realizó en el Hospital Italiano de La Plata, desde marzo de 1996 hasta diciembre de 2004, un estudio descriptivo observacional de una cohorte de pacientes con diagnóstico de EI. Se analizaron en forma retrospectiva 53 pacientes con EI (35 sin EE y 18 con EE). La presencia de vegetación (en el ecocardiograma transtorácico (ETT) y/o en el transesofágico (ETE) al momento del diagnóstico, el tamaño ³ 10 mm y el compromiso de la válvula mitral nativa, fueron las variables en las que existió una asociación estadísticamente significativa con el EE para ser consideradas como predictoras. El tamaño ³ 10 mm fue la única variable asociada a EE en el análisis de regresión logística. Durante el tratamiento antibiótico electivo hubo una reducción de EE, no observándose a partir de la segunda semana.

The embolic event (EE) increases the morbidity and mortality of infective endocarditis (IE). Prevalence of EE ranges between 22% and 50%, death rates being up to 25% of patients. EE may occur prior to diagnosis, during treatment or afterwards. The objective of this study was to evaluate the demographic, clinical, microbiological, echocardiographic and therapeutic characteristics in patients suffering from IE (with or without emboli) in order to determine predictors for EE. A descriptive study based on observations of patient population diagnosed with IE was conducted at the Hospital Italiano of La Plata during the period March 1996 - December 2004. Fifty-three patients with IE were analyzed (35 without EE and 18 with EE) in retrospect. We found that the presence of vegetations in the transthoracic (TTE) and/or transesophagic (TEE) echocardiographies at the time of diagnosis, the size ³ 10 mm and the compromise of the native mitral valve were the variables that showed significant statistical association with EE to be considered as predictors. The size ³ 10 mm was the only variable associated with EE in the logistic regression analysis. During the elective antibiotic treatment, there was a reduction in EE, without their being present from the second week onwards.

Variables predictoras de embolias en endocarditis infecciosa / Embolism predictors of infective endocarditis

El evento embólico (EE) aumenta la morbi-mortalidad de la endocarditis infecciosa (EI). La prevalencia de EE oscila entre 22% y 50%, pudiendo ocasionar hasta el 25% de las muertes de los pacientes que lo presentan. El EE puede ocurrir previamente al diagnóstico, durante el tratamiento o bien posteriormente al mismo. Nuestro objetivo fue analizar las características demográficas, clínicas, microbiológicas, ecocardiográficas y terapeúticas, de pacientes con EI (con y sin embolias) para tratar de establecer variables predictoras del EE. Se realizó en el Hospital Italiano de La Plata, desde marzo de 1996 hasta diciembre de 2004, un estudio descriptivo observacional de una cohorte de pacientes con diagnóstico de EI. Se analizaron en forma retrospectiva 53 pacientes con EI (35 sin EE y 18 con EE). La presencia de vegetación (en el ecocardiograma transtorácico (ETT) y/o en el transesofágico (ETE) al momento del diagnóstico, el tamaño ³ 10 mm y el compromiso de la válvula mitral nativa, fueron las variables en las que existió una asociación estadísticamente significativa con el EE para ser consideradas como predictoras. El tamaño ³ 10 mm fue la única variable asociada a EE en el análisis de regresión logística. Durante el tratamiento antibiótico electivo hubo una reducción de EE, no observándose a partir de la segunda semana. (AU)

The embolic event (EE) increases the morbidity and mortality of infective endocarditis (IE). Prevalence of EE ranges between 22% and 50%, death rates being up to 25% of patients. EE may occur prior to diagnosis, during treatment or afterwards. The objective of this study was to evaluate the demographic, clinical, microbiological, echocardiographic and therapeutic characteristics in patients suffering from IE (with or without emboli) in order to determine predictors for EE. A descriptive study based on observations of patient population diagnosed with IE was conducted at the Hospital Italiano of La Plata during the period March 1996 - December 2004. Fifty-three patients with IE were analyzed (35 without EE and 18 with EE) in retrospect. We found that the presence of vegetations in the transthoracic (TTE) and/or transesophagic (TEE) echocardiographies at the time of diagnosis, the size ³ 10 mm and the compromise of the native mitral valve were the variables that showed significant statistical association with EE to be considered as predictors. The size ³ 10 mm was the only variable associated with EE in the logistic regression analysis. During the elective antibiotic treatment, there was a reduction in EE, without their being present from the second week onwards.(AU)

Arterial embolectomy in lower limbs

Arterial embolisms in the lower limbs occur frequently, and are of great interest to the vascular surgeon. The authors studied 159 cases of arterial embolisms in lower limbs from January 1991 to July 1993. Ages varied from 12 to 98, with a mean of 58. Eighty patients were male and 78 were female. In most cases, etiology of the embolus was well-established, and mainly caused (78 percent) by atrial fibrillation. Oclusion was most frequent in the femoral artery (53.4 percent). All patients presented severe lower limb ischemia, but not gangrene, on admission. The duration of ischemia, between of onset of symptoms and the liberation of arterial flow, was in most patients (67.9 percent) less than 24 hours. All patients were submitted to lower limb embolectomy with the Fogartyy catheter, of which 70.9 percent were done through the femoral artery. Fasciotomy was performed on 48 patients due to a compartimental syndrome. Nineteen patients died immediately after operation; 68.4 percent due to heart failure. Twenty-three (16.4 percent) of the 140 surviving patients (150 operated limbs) were submitted to amputations after the occlusion of artery branches, which had undergone embolectomies. One hundred and twenty-seven limbs (84.6 percent) were preserved in 117 patients (83.5 percent). Eleven cases (7.3 percent) required repeated surgery with the Fogarty catheter. The patients wich muscle tenderness, paralysis, or ischemia lasting longer than 24 hours had worse results in relation to the preservation of the limb (p<0.05). We conclude that patients who present lower limb embolisms, are in good clnical condition, and who do not have any necrosis in the limbs, have good outcomes as to limb preservation, along with low complication rates, after embolectomy with the Fogarty catheter. Limb preservation was significantly higher in patients who did not present muscle tenderness, and who had normal motor activity and a ischemia duration of less than 24 hours.

Diagnóstico y pronóstico de la enfermedad ateroembólica / Diagnosis and prognosis of atheroembolic disease

La enfermedad ateroembólica suele desencadenarse a partir de técnicas diagnósticasy terapéuticas vasculares invasivas, o a partir del tratamiento con anticoagulanteso fibrinolíticos. Se caracteriza por la oclusión de arteriolas desde placasateromatosas, con componente de colesterol, liberadas en general desde la aorta.El riñón es probablemente el órgano que más se afecta por su localización próximaa la aorta abdominal, y por la cantidad de flujo sanguíneo que recibe.Describimos los factores epidemiológicos de 19 casos diagnosticados por criterioshistológicos en 18 de ellos, resaltando la eosinofilia y la insuficiencia renalprogresiva como datos clínicos orientativos de la enfermedad, en pacientes connefropatía isquémica y arteriosclerosis generalizada. Un 53% de los pacientes sepresentan con el antecedente de cateterismo o maniobra quirúrgica vascular; un26% de manera totalmente espontánea.Resaltamos la importancia de la biopsia renal en el diagnóstico de la enfermedadateroembólica, y su mal pronóstico general con una mortalidad del 63% enun seguimiento medio de 18 meses. Resaltamos el fallo multiorgánico como causade fallecimiento en los pacientes que se presentan con formas similares a una vasculitissistémica. Y resaltamos la insuficiencia renal con requerimiento de diálisis,como índice de mal pronóstico en los enfermos que se presentan de forma subaguda.El conocimiento de la enfermedad y su prevención resultan las terapéuticasmás eficaces

Atheroembolic disease is recognized as an iatrogenic complication from an invasivevascular procedure, such as manipulation of the aorta during angiographyor vascular surgery, and after anticoagulant and fibrinolytic therapy. Cholesterolcrystal embolism is caused by showers of cholesterol crystals from an atheroscleroticaorta that occlude small arteries. The kidney is a frequent target organ for cholesterol emboli because of proximity of the renal arteries to abdominal aortaand it receive an enormous amount of blood flows.We describe the epidemiologic agents of 19 cases that were diagnosed by histologicsections of the affected tissues; the eosinophilia and the renal failure arethe clinical features that guide to the diagnosis, in patients with ischemic nephropathyand general atherosclerosis. 53% among patients had a previous invasiveprocedure and 26% occurred spontaneously.We remark the importance of the kidney’s biopsy in diagnosis of the atheroembolicdisease and their bad prognosis with 63% of death rate in 18 months ofaverage follow-up. We report patients with the multiple cholesterol emboli syndromemimicking systemic vasculitis: they died by multivisceral acute failure. Thesubacute presentation of atheroembolic disease with progressive renal failure treatedwith hemodialysis is a sign of bad prognosis. The knowledge of the diseaseand their prevention are the better treatment

Resultados y oportunidad del tratamiento quirúrgico de las embolias de las extremidades / Results of the surgical treatment of embolic occlusion of limb arteries

La oclusión embólica de una extremidad representa una emergencia médica. Nuestro objetivo es analizar la oportunidad del diagnóstico y tratamiento de las embolias de las extremidades y sus resultados. Fueron revisadas retrospectivamente las fichas clínicas de los pacientes sometidos a Embolectomía de las extremidades, entre Enero de 1995 y Diciembre del 2002. El grupo esta compuesto por 26 hombres y 42 mujeres, en los que se realizaron 75 embolectomías. Un 28 por ciento de los pacientes presentó la embolia estando hospitalizado, y en el resto, está fue su motivo de ingreso. En el grupo de pacientes hospitalizados, el tiempo previo al diagnóstico fue 1.6 días (media) y en los otros de 8.2 días (media). Todos los pacientes con embolias en Clase II b y estadios iniciales de Clase III (clasificación de la SVS/ISCVS), fueron intervenidos dentro de las 6 horas siguientes al diagnóstico. De las 75 embolectomías; se logró revascularizar el 88 por ciento de las extremidades diagnosticadas dentro de las primeras 24 hora de evolución, y sólo un 48.8 por ciento de aquellas que presentaban mas de 24 horas, lo que representa una diferencia estadísticamente significativa (p=0.000). Fueron realizadas 18 amputaciones mayores (24 por ciento). La mortalidad post operatoria fue de 31 por ciento. No hubo diferencia en cuanto a mortalidad en el grupo con diagnóstico en las primeras 24 horas, comparado con aquellos en que el diagnóstico fue mas tardío. Existió mayor mortalidad entre los pacientes que presentaron el episodio embólico estando hospitalizados por otra patología (52.6 por ciento) con respecto a aquellos en que la embolia motivo el ingreso (22,4 por ciento), p = 0.016. Lo anterior mostraría que la alta mortalidad esta asociada a la gravedad de las patologías subyacentes.

Embolia arterial: tratamiento quirúrgico en 105 pacientes: análisis de factores de riesgo y morbimortalidad / Arterial embolism: surgical treatment in 105 patients: analysis and risk factors and morbidity and mortality

Se analizó la experiencia en el tratamiento quirúrgico de 105 pacientes (60 hombres y 45 mujeres). La embolia se localizó en las extremidades inferiores en el 82,2%, superiores 8,9%, mesentérica 6,7% y renal 2,4%. El 93,3% tienen patologías asociadas. En el 87,6% se objetivó la fuente embólica. Cinco pacientes (4,8%) requieren de amputación mayor (3 en forma primaria), todos ellos con más de 24 hr de evolución y con compromiso isquémico avanzado. Fallecen 8 pacientes (7,2%), seis son mayores de 70 años y tienen 2 o más patologías asosciadas. El 28,6%, 9,1% y 33,4% de las embolias aórticas, ilíacas y femorales fallecen; los 3 pacientes con fibrilación auricular asociada a valvulopatía aórtica no reumática, 1 de los 2 con mixoma y 1 de los 5 con endocarditis bacteriana, fallecen. No hubo diferencia en la mortalidad cuando la embolia fué única o múltiple. El tratamiento de elección de la embolia arterial es, en la actualidad, la asociación de anticoagución con cirugía precoz, lo que ha permitido reducir su morbimortalidad. El riesgo es mayor en los mayores de 70 años con múltiples patologías, y en la embolia de la bifurcación aórtica, la incidencia de amputación mayor aumenta cuando el paciente consulta con más de 24 hr de evolución, si hay evidencias de compromiso isquémico severo y cuando afecta las arterias poplítea o femoral