Embolization of Patent Foramen Ovale Closure Device-Rare Complication and Unique Management Approach.

Percutaneous closure of the patent foramen ovale (PFO) is generally regarded as a safe and effective procedure, indicated in patients with a prior PFO-associated stroke. While it is highly safe, rarely, it could be accompanied by a migration of the device, mainly caused by the interplay of a specific PFO morphology and inappropriate device sizing. Herein, we outline a seldom-observed complication of an unintentional detachment of the PFO closure device during implantation, leading to its migration into the abdominal aorta, and a unique management approach. Due to the inability to recapture the occluder with a snare, which is considered to be a mainstay of endovascular retrieval methods, two coronary guidewires were maneuvered through the mesh of the occluder and then captured with a snare proximally to the occluder. This innovative dual-wire-snare system was carefully pulled to the common femoral artery, a position deemed suitable for surgical extraction via arteriotomy, which was achieved successfully.

Intrathecal drug delivery for cancer pain at the end of life: a case study.

Two-thirds of patients with advanced cancer have pain and, of these, approximately 10-20% do not respond to conventional pain management approaches. This case study concerns a hospice patient who received intrathecal drug delivery for intractable cancer pain at the end of life. This involved working in partnership with a hospital-based interventional pain team. Despite side-effects and complications associated with intrathecal drug delivery and the requirement for inpatient nursing care, intrathecal drug delivery was the best option for the patient. The case identifies the importance of a patient-centred approach to decision-making, effective partnerships between hospice and acute hospital teams, and nurse education as key factors contributing to the provision of safe and effective intrathecal drug delivery.

[Surgical and interventional management of benign prostatic obstruction: Guidelines from the Committee for Male Voiding Disorders of the French Urology Association]. / Traitement chirurgical et interventionnel de l'obstruction sous-vésicale liée à une hyperplasie bénigne de prostate : revue systématique de la littérature et recommandations de bonne pratique clinique du Comité des Troubles Mictionnels de l'Homme.

OBJECTIVE: The aim of the Male Lower Urinary Tract Symptoms Committee (CTMH) of the French Urology Association was to propose an update of the guidelines for surgical and interventional management of benign prostatic obstruction (BPO). METHODS: All available data published on PubMed® between 2018 and 2020 were systematically searched and reviewed. All papers assessing surgical and interventional management of adult patients with benign prostatic obstruction (BPO) were included for analysis. After studies critical analysis, conclusions with level of evidence and French guidelines were elaborated in order to answer the predefined clinical questions. RESULTS/GUIDELINES: Offer a trans-uretral incision of the prostate to treat patients with moderate to severe lower urinary tract symptoms (LUTS) with a prostate volume<30cm3, without a middle lobe. TUIP increases the chances of preserving ejaculation. Propose mono- or bipolar trans-urethral resection of the prostate (TURP) to treat patients with moderate to severe LUTS with a prostate volume between 30 and 80cm3. Vaporization by Greenlight™ or by bipolar energy can be offered as an alternative to TURP. Offer a Greenlight™ laser vaporization to patients at risk of bleeding. Offer endoscopic prostate enucleation to surgically treat patients with moderate to severe LUTS as an alternative to TURP and open prostatectomy (OP). Minimally invasive prostatectomy is an alternative to OP in centers without access to adequate endoscopic procedures. Embolization of the prostatic arteries may be offered in the event of a contraindication or refusal of surgery for prostates with a volume>80cm3. Prostatic uretral lift is an alternative in patients interested in preserving their ejaculatory function and with a prostate volume<70cm3 without a middle lobe. Aquablation and Rezum™ are under evaluation and should be offered in research protocols. CONCLUSION: Major changes in surgical management of BPO have occurred and aim at reducing morbidity and improving quality of life of patients.

Potentially malignant disorders-The case for intervention.

Potentially malignant disorders (PMD) are recognisable mucosal conditions preceding invasive squamous carcinoma development. Established oral cancer remains a lethal and deforming disease, with a rising incidence. Management techniques for identifiable oral precursor lesions have traditionally been polarised between observational and interventional surgical techniques. By defining salient management goals for treating potentially malignant disease, and examining the evidence supporting the efficacy of treatment intervention, this paper presents the case for interventional laser surgery as a definitive diagnostic and treatment modality.

Percutaneous interventional management of biliary complications after pediatric liver transplantation: A 16-year single-institution experience.

The aim of the study was to investigate the BiCx after the pediatric OLT and to assess the efficacy of the fluoroscopic-guided PBI in the patients with BiCx as compared to the SR. A total of 340 OLTs were performed in 302 patients over the last 16 years. The inclusion criteria were the presence of BS or BL as a complication after OLT. The management of the BiCx was studied. Graft revision, graft loss, and survival were evaluated following PBI and SR. BiCx occurred in 17.1% (58/339) of the transplants; 6.2% (21/339) of transplants demonstrated BL and 12.7% (43/339) of the transplants had BS. Overall graft survival rates at 1 and 3 years in OLT with BL treated with PBI were 75.0% and 68.8% as compared with 75% and 66.7% in OLT treated with SR (P>.05). Overall graft survival rates at 1 and 3 years in OLT with BS treated with PBI were 70.6% and 54.5% as compared with 71.4% and 50% in OLT with SR or ERCP, respectively (P>.05). Based on the results, we conclude that PBI is as effective as SR in patients with the BL and BS after OLT.

Interventional therapies in acute myocardial infarction complicated by cardiogenic shock.

Cardiogenic shock remains the most common cause of death in patients with acute myocardial infarction. Early revascularization of the infarct-related artery has been shown to reduce mortality and is the therapeutic cornerstone. The optimal revascularization strategy of additional non-culprit lesions remains yet to be determined. Further, uncertainties exist with respect to access site choice, antiplatelet regimen as well as mechanical support devices. This review outlines current evidence on the interventional management of cardiogenic shock complicating acute myocardial infarction.

Circulatory and Respiratory Parameters during Acute Endovascular Stroke Therapy in Conscious Sedation or General Anesthesia.

BACKGROUND: Whether patients suffering from acute ischemic stroke and undergoing endovascular recanalization should be treated under general anesthesia (GA) or conscious sedation (CS) is a matter of debate. According to retrospective studies, GA appears to be associated with a worse outcome than CS. The underlying mechanisms are unknown, but hypotension and hypocapnia during GA have been suggested. There are no prospective data on this question. METHODS: We prospectively analyzed consecutive patients who were treated with endovascular recanalization from 11, 2013 to 03, 2014 regarding blood pressure, end-tidal carbon dioxide (etCO2), cerebral oximetry (by near-infrared spectroscopy), ventilation parameters, response to commands, basic parameters (age, gender, percentage of posterior circulation stroke, National Institutes of Health Stroke Scale score [NIHSSS] on admission, NIHSSS at discharge, rate of successful recanalization [thrombolysis in cerebral infarction scale >2a], duration of intervention, symptom-to-recanalization time, and door-to-needle time), and medication used. RESULTS: Forty-four patients (29 under GA and 15 in CS) were included. Significant differences between the groups (GA versus CS) were found in the median dose of norepinephrine (.4 mg/hour versus .1 mg/hour, P = .003), mean systolic blood pressure (139.67 mm Hg versus 155.00 mm Hg, P = .003), mean duration of relative hypotension (systolic blood pressure <140 mm Hg; 42.75 versus 15 minutes, P = .004), and mean etCO2 values (37.29 mm Hg versus 27.33 mm Hg, P = .004). CONCLUSIONS: In this small prospective study, patients under CS required less vasopressor medication and had a higher mean blood pressure than those under GA, but they also showed signs of hyperventilation. The impact of these physiological differences on outcome needs to be studied in randomized trials.

[Peri-interventional management of acute endovascular stroke treatment]. / Periinterventionelles Management der akuten endovaskulären Schlaganfallbehandlung.

Due to the ground breaking consistent evidence that supports the effect of endovascular stroke treatment (EST), many acute care hospitals and stroke centers will have to be prepared to provide this treatment in an optimal way within the coming years. In addition to the intervention itself, patient preparation, stabilization and monitoring during the treatment as well as the aftercare represent significant challenges and have mostly not yet been sufficiently investigated. Under these aspects, the questions of optimal sedation and airway management have received the highest attention. Based on retrospective study results it already seems to be justified, respecting certain criteria, to prefer EST with the patient under conscious sedation (CS) in comparison to general anesthesia (GA) and to only switch to GA in cases of emergency until this question has been clarified by prospective studies. This and other aspects of peri-interventional management, such as logistics, monitoring, blood pressure, ventilation settings, postprocedural steps of intensive or stroke unit care and imaging follow-up are summarized in this overview. The clinical and radiological selection of patients and thus the decision for intervention or technical aspects of the intervention itself will not be part of this article.

Imaging and Interventional Management of Lymphatic Disorders.

Lymphatic flow disorders are reviewed, and a classification based on magnetic resonance lymphography findings outlined. Examples of successful interventional management based on this classification are provided. Presented at the 2023 ISL International Congress of Lymphology, Genoa, Italy in a special symposium on central and regional lymphatic system in health and disease.

Economic evaluation of management strategies for complex regional pain syndrome (CRPS).

Background: The economic impact of Complex Regional Pain Syndrome (CRPS) on both patients and the global healthcare system continues to escalate. However, the economic implications associated with management interventions for CRPS have received limited attention. Therefore, our objective is to perform a thorough examination of published economic assessments of the various management strategies utilized for CRPS. Methods: A thorough search spanning four general medical databases and three health economic databases to identify full economic evaluations on CRPS management strategies from January 1994 to June 2023 were conducted. The quality of these studies were evaluated by employing the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement. To enable cross-study comparisons conducted in different countries, we adjusted the costs reported in the selected studies for inflation and converted them into 2023 US dollars. Results: A total of nine economic evaluations, consisting of eight high-quality and one medium-quality, were identified across five nations during a span of 29 years. The findings suggest that the most economically efficient intervention for CRPS are interventional approaches of Spinal Cord Stimulation (SCS) in comparison to conventional management for long periods of time. Furthermore, in situations where there is a limited time period of less than 1 year, rehabilitation therapies, particularly physical therapy, have been demonstrated to be more effective in terms of both cost and clinical outcomes. Conclusion: The interventional management strategies, particularly for severe and persistent CRPS over long periods, may offer the greatest cost efficiency. In conditions with limited timelines, rehabilitation measures, such as rehabilitation therapies, can be cost-effective. However, insufficient data for other common interventions prevents the formation of a definitive conclusion. Similarly, it is crucial to recognize that the results of these interventions might be affected by the selection of comparator and the threshold for willingness to pay.

Unveiling the Rarity: An Anomaly of the Left Circumflex Artery Supplying Left Ventricular Apex and Presenting With Myocardial Infarction.

Coronary arteries are typically identified based on the myocardial territory they supply. In rare cases of coronary artery anomalies, the apex of the heart may be supplied by arteries other than the left anterior descending artery. While it is more common for the posterior descending artery from the right coronary artery to supply the apex, there are rare instances where the left circumflex (LCX) artery performs this function. This case report describes an unusual occurrence where the left ventricular apex is supplied by an obtuse marginal branch of the LCX artery. We present this case due to its rarity, unique presentation, and the challenges it poses for both medical and surgical management.

Efficacy of peripheral interventional radiologists performing endovascular stroke therapy guided by CT perfusion triage of patients.

PURPOSE: To assess safety and efficacy of intraarterial mechanical thrombectomy for treatment of ischemic stroke in a community hospital by peripheral interventional radiologists employing computed tomography (CT) perfusion imaging for patient selection. MATERIALS AND METHODS: Forty patients, 11 men (27.5%) and 29 women (72.5%), were treated between February 2008 and October 2011. Eligible patients had a National Institutes of Health Stroke Scale (NIHSS) score greater than 8 and diagnosis of large-vessel ischemic stroke by head CT angiogram, and met previously reported CT perfusion imaging triage criteria. RESULTS: The baseline NIHSS score was 18.0 ± 7.9 (range, 8-35). Sixteen patients (40%) had a baseline NIHSS score greater than 20. Symptom onset was unknown in five patients. Symptom onset to device time in the remaining 35 patients was 254.8 minutes ± 150.9 (range, 75-775 min). A total of 65% of patients showed thrombolysis in cerebral infarction (TICI) 2a, 2b, or 3 flow following the procedure. Symptomatic intracranial hemorrhage was seen in four patients (10.0%). At 90 days, 32 patients (80%) were alive and eight (20%) had died. The modified Rankin scale (mRS) score at 90 days was no more than 2 in 20 patients (50.0%). The mean mRS score at 90 days was 2.9 ± 2.0 (range, 0-6). NIHSS score at 90 days was 5.1 ± 6.1 (range, 0-24). In patients with successful recanalization (ie, TICI 2 or 3 flow), a good clinical outcome (ie, mRS score ≤ 2) was achieved in 65.3% of patients (mean, 2.4 ± 1.9; range, 0-6), and 90-day mortality rate was 15.4%, compared with 28.6% in patients with TICI 0/1 flow. CONCLUSIONS: Peripheral interventional radiologists who use CT perfusion imaging for patient triage can have good neurologic outcomes and provide sustainable, safe, and complete around-the-clock coverage for endovascular stroke treatment.

Acute combined revascularization in acute ischemic stroke with intracranial arterial occlusion: self-expanding solitaire stent during intravenous thrombolysis.

PURPOSE: To investigate the safety and efficacy of the self-expanding Solitaire stent used during intravenous thrombolysis (IVT) for intracranial arterial occlusion (IAO) in acute ischemic stroke (AIS). MATERIALS AND METHODS: Consecutive nonselected patients with AIS with IAO documented on computed tomographic angiography or magnetic resonance angiography and treated with IVT were included in this prospective study. Stent intervention was initiated and performed during administration of IVT without waiting for any clinical or radiologic signs of potential recanalization. Stroke severity was assessed by National Institutes of Health Stroke Scale (NIHSS), and 90-day clinical outcome was assessed by modified Rankin scale (mRS), with a good outcome defined as an mRS score of 0-2. Recanalization was rated by thrombolysis in cerebral infarction (TICI) scale. RESULTS: Fifty patients (mean age, 66.8 y ± 14.6) had a baseline median NIHSS score of 18.0. Overall recanalization was achieved in 94% of patients, and complete recanalization (ie, TICI 3 flow) was achieved in 72% of patients. The mean time from stroke onset to maximal recanalization was 244.2 minutes ± 87.9, with a median of 232.5 minutes. The average number of device passes was 1.5, with a mean procedure time to maximal recanalization of 49.5 minutes ± 13.0. Symptomatic intracerebral hemorrhage occurred in 6% of patients. The median mRS score at 90 days was 1, and 60% of patients had a good outcome (ie, mRS score 0-2). The overall 3-month mortality rate was 14%. CONCLUSIONS: Combined revascularization with the Solitaire stent during IVT appears to be safe and effective in the treatment of acute IAO.

Multimodal Analgesia in Pediatric Cancer Pain Management: A Retrospective Single-Center Study.

Objectives A multimodal approach to pain management, including potential interventional techniques, is suggested to achieve adequate pain control. This study discusses the techniques and medications employed to manage pain in pediatric oncology patients. Methodology This study included 90 patients under 18 years of age who underwent pain management in the algology clinic between 2002 and 2020. From the algology follow-up records, the following data were recorded: demographic information, follow-up time, cancer diagnosis and stage, cause and location of pain, systems involved, duration and intensity of pain, analgesic and adjuvant drugs prescribed, routes and duration of drug administration, complications, interventional procedures if performed, "pain intensity" scores prior to and following treatment, and daily and total analgesic consumption of the patients. Results The mean age was 11.4±4.1 years (min-max: 2-17). Leukemia and lymphoma were the most frequently diagnosed (30%). Of the 31 features identified in the staging, 27 (87.1%) were stage 4 at admission. The causes of pain in children were neoplasms in 81.2% (n = 73). At admission, 72.3% (n = 65) had severe pain for at least a month. It was determined that 90% (n = 81) of the patients were using opioids and 28.9% (n = 26) were using dual opioids. The mean tramadol dose was 129.0±97.9 mg/day (12-380 mg/day), and the mean morphine dose was 14.8±11.3 mg/day (1-52 mg/day). The mean transdermal fentanyl dose was 33.2±21.6 µgr/h (12-75 µgr/h). Adjuvant therapy was administered in 25.6% (n = 24) of the patients. Epidural catheterization was performed on 6.6% (n = 6) of the patients. The mean initial pain scores were 5.2±1.7, which decreased to 1.5±0.7 with a significant difference (p < 0.001). In the study, 93% (n = 84) of the patients had no pain management complications noted. Conclusions The pain level that pediatric cancer patients endure critically influences their and their family's quality of life. The fact that opioid-related adverse effects associated with pediatric pain management occur far less frequently than previously thought may help prevent opiophobia. Effective and safe analgesia can be provided with multimodal analgesia to manage pediatric cancer pain.

Telemedical management in patients waiting for transcatheter aortic valve implantation: the ResKriVer-TAVI study design.

Aims: The majority of patients with severe aortic stenosis (AS) planned for transcatheter aortic valve implantation (TAVI) are elective outpatients. During the COVID-19 pandemic, the time between the heart team's decision and TAVI increased due to limited healthcare resources. We therefore implemented telemedical approaches to identify AS patients at risk for clinical deterioration during the waiting time. The purpose of the prospective, randomized, controlled ResKriVer-TAVI study (DRKS00027842) is to investigate whether a digital concept of telemedical interventional management (TIM) in AS patients waiting for TAVI improves the clinical outcomes. In the present article, we report the study protocol of the ResKriVer-TAVI trial. Methods: ResKriVer-TAVI will enroll AS patients planned for elective TAVI. Randomization to the TIM group or standard care will be made on the day of the heart team's decision. TIM will include a daily assessment of weight, blood pressure, a 2-channel electrocardiogram, peripheral capillary oxygen saturation, and a self-rated health status until admission for TAVI. TIM will allow optimization of medical therapy or an earlier admission for TAVI if needed. Standard care will not include any additional support for patients with AS. All patients of the TIM group will receive a rule-based TIM including standard operating procedures when a patient is crossing prespecified values of a vital sign. Results: The primary endpoint consists of days lost due to cardiovascular hospitalization and death of any cause within 180 days after the heart team's decision. Major secondary endpoints include all-cause mortality within 365 days, the number of telemedical interventions, and adherence to TIM. Follow-up visits will be conducted at admission for TAVI as well as 6 and 12 months after the heart team's decision. Conclusions: ResKriVer-TAVI will be the first randomized, controlled trial investigating a telemedical approach before TAVI in patients with AS. We hypothesize that primary and secondary endpoints of AS patients with TIM will be superior to standard care. The study will serve to establish TIM in the clinical routine and to increase the resilience of TAVI centers in situations with limited healthcare resources.

Stroke risk management in carotid atherosclerotic disease: A Clinical Consensus Statement of the ESC Council on Stroke and the ESC Working Group on Aorta and Peripheral Vascular Diseases.

Carotid atherosclerotic disease continues to be an important cause of stroke, often disabling or fatal. Such strokes could be largely prevented through optimal medical therapy and carotid revascularization. Advancements in discovery research and imaging along with evidence from recent pharmacology and interventional clinical trials and registries and the progress in acute stroke management have markedly expanded knowledge base for clinical decisions in carotid stenosis. Nevertheless, there is variability in carotid-related stroke prevention and management strategies across medical specialities. Optimal patient care can be achieved by (1) establishing a unified knowledge foundation and (2) fostering multi-specialty collaborative guidelines. The emergent Neuro-Vascular Team concept, mirroring the multi-disciplinary Heart Team, embraces diverse specializations, tailores personalized, stratified medicine approaches to individual patient needs, and integrates innovative imaging and risk-assessment biomarkers. Proposed approach integrates collaboration of multiple specialists central to carotid artery stenosis management such as neurology, stroke medicine, cardiology, angiology, ophthalmology, vascular surgery, endovascular interventions, neuroradiology and neurosurgery. Moreover, patient education regarding current treatment options, their risks and advantages, is pivotal, promting patient's active role in clinical care decisions. This enables optimization of interventions ranging from lifestyle modification, carotid revascularization by stenting or endarterectomy, as well as pharmacological management encompassing statins, novel lipid-lowering and antithrombotic strategies and targeting inflammation and vascular dysfunction. This consensus document provides a harmonized multi-specialty approach to multimorbidity prevention in carotid stenosis patients, based on comprehensive knowledge review, pinpointing research gaps in an evidence-based medicine approach. It aims to be a foundational tool for interdisciplinary collaboration and prioritized patient-centric decision-making.

Pharmacological and interventional management of pulmonary embolism: where do we stand?

As the third most common cardiovascular disease, pulmonary embolism (PE) has an uptrending incidence and mortality, resulting in significant healthcare expenditure. Risk stratification of acute PE guides management. Although anticoagulation remains the cornerstone management, systemic fibrinolysis and targeted therapeutic approaches, catheter-directed thrombolysis and catheter-based embolectomy are available for high-risk patients. Life-threatening bleeding complications associated with systemic fibrinolysis have restricted its widespread implementation. Catheter-based techniques for intermediate high-risk categories were devised to reduce bleeding complications and improve outcomes. Catheter-directed thrombolysis helps minimize bleeding by way of direct drug delivery. Catheter-based embolectomy mechanically retrieves thrombi without using fibrinolytics. This focused review of medical and interventional management of acute PE provides a highlight of ongoing trials expected to add value to current practice.

As the third most common disease affecting the heart and blood circulation, clot(s) in a blood vessel in the lungs lead to an increased likelihood of death. Using medication that prevents the blood from clotting is the cornerstone treatment. Medications that break the clot are also available but life-threatening bleeding can occur. Treatment approaches such as using a flexible tube to break the clot or retrieving it are used in severe disease. These approaches were developed to reduce bleeding and improve outcomes by delivering clot-breaking medication directly at the site of the clot. This is a review of managing clots in the blood vessel in the lungs that also provides a highlight of ongoing studies expected to improve current practice.

Perfect outcome of kidney recipients with ureteral stenosis after treatment with open surgery under magnetic resonance urography localization.

BACKGROUND: To evaluate the outcome of kidney recipients with ureteral stenosis after treatment with open surgery under magnetic resonance urography (MRU) localization. METHODS: We assessed 2,256 consecutive kidney transplant recipients between October 2010 and December 2018. Ureteral stenosis was detected by ultrasound, confirmed and positioned by Magnetic Resonance Urography. All patients underwent open ureteral reconstruction. The ureteral stenosis was located according to the location on the MRU during the operation. Surgical complications and recurrence rate were recorded in the stenosis group. Outcomes were compared with those of a matched control group of transplant recipients with no history of ureteric stenosis. RESULTS: The incidence of ureteral stenosis in our center was 3.1% (70/2,256). Sixty-four cases (91.4%) were confirmed to have distal stenosis and were reconstructed with ureterovesical re-implantation; six cases (8.6%) were confirmed to have mid-distal stenosis and were subjected to ureteroureterostomy with the use of native ureter. The overall success rate was 100% and the graft function was salvaged in all cases. There was no recurrence of stenosis after a mean follow-up of 38.9±26.3 months. The complication rate was 5.7%. The 110-month graft survival and patient survival were not significantly different between the stenosis and control groups.Conclusions: MRU is an effective method for non-invasive and accurate diagnosis of ureteral stenosis in kidney transplant recipients. Open ureteral reconstruction surgery under MRU localization for treatment of ureter stenosis after kidney transplantation had a high success rate, low recurrence rate and high safety.

Management of acute cholecystitis in elderly patients: A propensity score-matched analysis of surgical vs. medical treatment.

BACKGROUND: Acute cholecystitis (AC) is a life-threatening emergency in elderly patients. AIMS: To compare the commonly used management strategies for elderly patients with AC as well as resulting morbidity, mortality and length of hospital stay (LOS). METHODS: All patients ≥ 65 years admitted to our emergency department for AC between January 1st, 2014 and December 31st, 2018 were included in the study. We compared patients that received medical treatment to patients who received operative procedures. In order to correct for baseline covariates and factors associated to clinical management, we used a 1:1 propensity score matching (PSM) analysis. The primary outcome was the overall in-hospital mortality. Secondary outcomes included occurrence of major complications and LOS. RESULTS: A total of 1075 patients were enrolled: 483 patients received a medical treatment and 592 patients underwent interventional procedures. After PSM, 770 patients (385 for each treatment group) were included in the analysis. The analysis revealed that both mortality and cumulative major complications were similar in medical and interventional group. We found that among comorbidities, Charlson comorbidity index and congestive heart failure were significantly higher in the medical treatment group (5 [4-6] vs. 4 [3-6] and 11.7% vs. 4.7%, respectively; p<0.001). LOS was slightly lower in the medical treatment group (7.0 days [4.9-11.1] vs. 7.9 [4.9-13.5]; p = 0.046). CONCLUSION: Medical management outcomes for AC in elderly patients were similar to operative treatments in terms of mortality and cumulative major complications. A conservative approach should always be considered.

Non-invasive telemedical care in heart failure patients and stroke: post hoc analysis of TIM-HF and TIM-HF2 trials.

AIMS: Patients with chronic heart failure (CHF) have an increased risk of ischaemic stroke. We aimed to identify the incidence rate and factors associated with ischaemic stroke or transient ischaemic attack (TIA) in CHF patients as well as the impact of non-invasive telemedical care (NITC) on acute stroke/TIA. METHODS AND RESULTS: We retrospectively analysed baseline characteristics of 2248 CHF patients enrolled to the prospective multicentre Telemedical Interventional Monitoring in Heart Failure study (TIM-HF) and Telemedical Interventional Management in Heart Failure II study (TIM-HF2), randomizing New York Heart Association (NYHA) II/III patients 1:1 to NITC or standard of care. Hospitalizations due to acute ischaemic stroke or TIA during a follow-up of 12 months were analysed. Old age, hyperlipidaemia, lower body mass index, and peripheral arterial occlusive disease (PAOD) were independently associated with present cerebrovascular disease on enrolment. The stroke/TIA rate was 1.5 per 100 patients-years within 12 months after randomization (n = 32, 1.4%). Rate of stroke/TIA within 12 months was in the intervention group similar compared with the control group (50.0% vs. 49.8%; P = 0.98) despite that the rate of newly detected atrial fibrillation (AF) was higher in the intervention group (14.1% vs. 1.6%; P < 0.001). A history of PAOD (OR 2.7, 95% CI 1.2-6.2; P = 0.02) and the highest tertile (OR 3.0, 95% CI 1.1-8.3) of N-terminal pro-brain natriuretic peptide (NT-proBNP) on enrolment were associated with stroke/TIA during follow-up. In patients who suffered acute stroke or TIA during follow-up, echocardiography was part of the diagnostic workup in only 56% after hospital admission. CONCLUSIONS: Annual rate of ischaemic stroke/TIA in NYHA II/III patients is low but higher in those with elevated NT-proBNP levels and history of PAOD at baseline. NITC showed no impact on the stroke rate during 1 year follow-up despite a significantly higher rate of newly detected AF. Irrespective of known CHF, echocardiography was often missing during in-hospital diagnostic workup after acute stroke/TIA.