Editorial Comment: Non-Vitamin K Antagonist Oral Anticoagulants for Thromboembolic Prevention in Patients with Atrial Fibrillation and Concomitant Mitral Stenosis: A Retrospective Observational Study.

Atrial fibrillation (AF) increases the risks of ischemic stroke and systemic embolism, especially in patients with mitral stenosis (MS). Non-vitamin K antagonist oral anticoagulants (NOACs) are effective in preventing AF-related stroke and systemic embolic events. However, patients with AF and concomitant moderate-to-severe MS have been excluded from previous pivotal studies. We aimed to evaluate and compare the efficacy and safety of NOACs with vitamin K antagonists (VKAs) in this patient group. This retrospective observational study used data from the Chang Gung Research Database. We enrolled patients with AF and concomitant moderate-to-severe MS between January 2010 and December 2019. Propensity score matching was used to balance covariates between the NOAC and VKA groups. The risks of stroke, systemic embolism, and bleeding events were assessed following treatment. After PSM, 115 patients with AF and concomitant moderate-to-severe MS were analyzed, of whom 32 were treated with NOACs and 83 with VKAs. There were no significant differences in the composite efficacy outcomes and bleeding risk between the NOAC and VKA groups. However, the all-cause mortality incidence rate was significantly lower in the NOAC group. Cox regression analysis showed that CHA2DS2-VASc score, but not mitral valve area, was a significant predictor of the composite efficacy outcomes. NOACs were as effective as VKAs in preventing stroke and systemic embolic events, with comparable bleeding risks in AF patients with concomitant moderate-to-severe MS. CHA2DS2-VASc score was superior to mitral valve area in predicting composite efficacy outcomes.

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Multivalvular cardiac disease has been associated with increased mortality and morbidity as compared to isolated valve disease. The treatment of choice for combined degenerative aortic and mitral stenotic disease is considered to be double valve surgery, but it is associated with poorer outcomes when compared to isolated valve surgical correction, especially in high-risk populations. There is considerable interest in utilizing transcatheter therapies in multivalvular disease. The prevalence and outcomes of patients undergoing transcatheter aortic valve replacement (TAVR) for aortic stenosis (AS) with concomitant mitral stenosis (MS) have not been studied extensively. Currently, there are no specific recommendations or guidelines for managing these patients. A search of PubMed and Cochrane databases was performed for studies and metaanalyses of patients undergoing TAVR for severe AS with concomitant MS. Our research demonstrates that most patients undergoing TAVR for severe AS with concomitant mitral valve stenosis tend to be elderly with degenerative valve disease. Short-term outcomes, such as postoperative hospital stay, as well as long-term outcomes, such as 1-year mortality, are worse in TAVR with severe MS. TAVR in mild to moderate MS shows no significant differences in outcomes compared with TAVR for isolated severe AS. Most studies have shown that in subjects undergoing TAVR with concomitant MS, severe MS is associated with worse outcomes, while mild to moderate MS shows no significant difference compared with the absence of MS. Limitations of our study are mainly related to the small number of high-quality clinical trials examining TAVR in patients with combined AS and MS. With the aging population, TAVR has been a more attractive option for the treatment of severe symptomatic AS. The optimal treatment of patients with AS along with MS is not clear. Thus, further research is needed in this field.

ObjectivesWith the approval of new non-vitamin K antagonist oral anticoagulants for stroke prevention in non-valvular atrial fibrillation (NVAF), it is anticipated that their introduction may change NVAF treatment patterns; however,...

Introduction: Long-term freedom from atrial fibrillation (AF) after catheter ablation and, consequently, the potential for stroke reduction remain unpredictable. Recently, left atrial appendage closure (LAAC) became an effective mechanical alternative to oral anticoagulation (OAC) for stroke prevention in AF patients. Objective: This study aims to evaluate the feasibility and safety of combined treatment for AF with catheter ablation (CA) with the high-power short duration technique associated with LAAC in one single procedure. Methods: Patients with non-valvular AF who underwent combined CA and LAAC procedure were included in the retrospective observational study. Between April 2018 and October 2020, 13 patients with AF were included, eight (61,54%) males, eight (61.54%) with persistent AF (PersAF), mean age 68.54 (65–84) years old, mean time from AF diagnosis to treatment 13.08 (3–33) months, mean CHA2VASC2 5.08 (3–7), all patients with coronary or vascular disease, 12 (92.31%) with hypertension, five (38.46%) with left ventricular dysfunction, four (30.77%) prior strokes using OAC and four (30.77%) patients with diabetes. Indications for LAAC included history of contraindication to OAC because of severe bleeding in eight (61.54%), previous stroke in four (30.77%) and two (13.08%) patients with LAA thrombus, despite the use of two different OAC (one associated with bleeding). One patient had a pseudoaneurysm in femoral artery, and two patients died of non-procedure complications after 30 days. At six months, angiotomography showed successful complete sealing of the LAA in seven (77.72%) of nine patients evaluated, and the two patients without it had a leak of less than 2 mm. After mean follow-up of 14 months (five to 33), 10 (90.91%) of the 11 patients were in sinus rhythm. Three (27.27%) patients, one in blanking period, recovered sinus rhythm after amiodarone. No cardioembolic or bleeding events occurred. Conclusion: In this small observational study, we showed the feasibility and safety of the combined therapy with AF catheter ablation with LAAC with a high rate of sinus rhythm and no cardioembolic event.

To present a case of pulmonary arteriovenous malformation (AVM) that showed progressive enlargement in a patient with concomitant rheumatic mitral stenosis. A 73-year-old woman first presented eight years ago because of an uncomplicated acute myocardial infarction. She was noted to have rheumatic mitral stenosis. Six years later, she developed symptomatic sick sinus syndrome for which a permanent pacemaker was implanted. Chest x-ray revealed new development of an opacity in the middle zone of the right lung. Two years later, she was admitted to hospital because of progressive dyspnoea. Chest x-ray showed further increase in size of the right middle zone opacity. She died of cardiopulmonary failure on the 18th day in hospital. Autopsy revealed a pulmonary AVM, replacing the entire right middle lobe. The elevated pulmonary vascular resistance caused by mitral stenosis may have increased the preferential flow of blood through the AVM, leading to its rapid enlargement. Patients with concomitant pulmonary AVM and mitral stenosis need to be recognised, as close follow-up and early treatment may be desirable.

Atrial fibrillation (AF) and the associated risk of stroke are emerging epidemics throughout the world. Suboptimal use of oral anticoagulants for stroke prevention has been widely reported from observational studies. In recent years, direct oral anticoagulants (DOACs) have been introduced for thromboprophylaxis. We conducted a systematic literature review to evaluate current practices of anticoagulation in AF, pharmacologic features and adoption patterns of DOACs, their impacts on proportion of eligible patients with AF who receive oral anticoagulants, persisting challenges and future prospects for optimal anticoagulation. In conducting this review, we considered the results of relevant prospective and retrospective observational studies from real-world practice settings. PubMed (MEDLINE), Scopus (RIS), Google Scholar, EMBASE and Web of Science were used to source relevant literature. There were no date limitations, while language was limited to English. Selection was limited to articles from peer reviewed journals and related to our topic. Most studies identified in this review indicated suboptimal use of anticoagulants is a persisting challenge despite the availability of DOACs. Underuse of oral anticoagulants is apparent particularly in patients with a high risk of stroke. DOAC adoption trends are quite variable, with slow integration into clinical practice reported in most countries; there has been limited impact to date on prescribing practice. Available data from clinical practice suggest that suboptimal oral anticoagulant use in patients with AF and poor compliance with guidelines still remain commonplace despite transition to a new era of anticoagulation featuring DOACs.

Non-vitamin K antagonist oral anticoagulants (NOACs) are a major advance for stroke prevention in atrial fibrillation (AF). Use of the vitamin K antagonist (VKA), warfarin, has dropped 40% since 2010 in our institution. There is limited Irish hospital data on NOAC prescribing for stroke prevention. Single centre, retrospective observational cohort study of consecutive AF patients at increased risk of stroke and/or awaiting electrical cardioversion. Data on prescribed NOACs from February 2010 till July 2015 was collected from the electronic inpatient record. Appropriateness of prescriptions was based on CHA2DS2-VASC score and accuracy on individual NOAC SPCs. Potential drug interactions and bleeding risk were also quantified. A total of 348 patients AF and increased risk of stroke (CHA2DS2-VASC score > 1 for men and > 2 for women) were studied. Forty-eight percent were female with a mean age 71 ± 18.6years, 52% of whom were > 75. Mean CHA2DS2-Vasc and HAS-BLED scores were 4.1 ± 1.8 and 1.4 ± 0.8, respectively. Rivaroxaban, dabigatran and apixaban were prescribed to 154 (54.2%), 106 (34.3%) and 41 (13.2%) patients, respectively. 20.4% had inaccurate prescriptions; 92.9% (n = 65) underdosed and 7.1% (n = 5) on inappropriately higher doses. Neither choice of NOAC, age, history of anaemia, previous bleeding or co-prescribed antiplatelets influenced the accuracy of prescription (p = NS), but decreased renal function appeared to do so (p = 0.05). Our study highlights significant inaccuracies in NOAC prescribing. Patients commenced on NOACs should be assessed and followed up in a multidisciplinary AF clinic to ensure safe and effective prescribing and stroke prevention.

Objectives: The aim of this study is to evaluate clinical characteristics and long-term outcome of the patients with bio-prosthetic mitral valve replacement at a tertiary care hospital of a South Asian country.
 Methodology: The study is a retrospective observational observational study involving patients who underwent bio-prosthetic mitral valve replacement at a tertiary care hospital in Karachi, Pakistan, between 2006 and 2020, and had at least two complete echocardiograms. Patients with incomplete clinical data, no electronic reports of echocardiograms, and mechanical mitral valve replacement were excluded.
 Results: This is a retrospective observational study, conducted at a tertiary care hospital. We included a total of 502 patients who underwent bio-prosthetic mitral valve replacement from the year 2006 to 2020. Patients were divided into two groups based on normal functioning bio-prosthetic mitral valve and bio-prosthetic mitral valve dysfunction (BMVD). Out of 502 patients, 322 (64%) were female, mean age at the time of surgery was 49.42 ± 14.56 years. Mitral regurgitation was more common, found in 279 (55.6%) patients followed by mitral stenosis in 188 (37.5%) patients. Mitral valve replacement was done as an elective procedure due to NYHA II to IV symptoms at the time of surgery in 446 (88.8%) patients. In the mean follow-up of 6.59 + 2.99 years, bio-prosthetic mitral valve dysfunction (BMVD) was observed in 183 (36.5%) patients. However, re-do mitral valve surgery was done in only 49 (9.8%) patients. Comparing the two groups, individuals with normal functioning bio-prosthetic mitral valve had a mean age of 51.6 + 14.27 years, while those with BMVD had a mean age of 45.639 + 14.33 years at the time of index surgery (p value=0.000). There were more long-term complications including heart failure (n = 16, 8.74%), atrial fibrillation (n = 11, 6.01%) and death (n = 6, 3.28%) in BMVD group which were statistically significant.
 Conclusion: This study is distinct because it demonstrates the outcomes of bio-prosthetic valve replacement in a relatively younger South Asian population. Due to rapid degeneration of bio-prosthetic valve in younger patients, a significant number of cases developed BMVD along with poor long-term clinical outcomes even at a short follow up period of less than ten years. These findings are like international data and signify that mechanical mitral valve replacement may be a more reasonable alternative in younger patients.

Oral Anticoagulants and Renal Impairment: The Convoluting Dilemma

Oral anticoagulation (OAC) is the mainstay of treatment for the prevention of strokes in patients with atrial fibrillation (AF). Direct oral anticoagulants (DOACs) account for increasing OAC in patients with AF. However, prescribing DOACs for patients with established AF poses various challenges and general practice pharmacists may have an important role in supporting their management. To investigate the effectiveness of pharmacist-led interventions in general practice in optimising the use of OAC therapies in AF. A retrospective observational study in general practices in Bradford. The data were collected retrospectively from 1 November 2018-31 December 2019 using electronic health record data. The data were analysed: 1) to identify patients with AF not on OAC; 2) to describe inappropriate DOAC prescriptions; and 3) to calculate HAS-BLED scores. Overall, 76.3% (n = 470) of patients with AF received OAC therapy, and of these, 63.4% received DOACs. Pharmacist-led interventions increased DOAC prescribing by 6.0% (P = 0.03). Inappropriate DOAC use was identified in 24.5% of patients with AF, with underdosed and overdosed identified in 9.7% and 14.8%, respectively. Post-intervention, inappropriate prescribing was reduced to 1.7%. The mean HAS-BLED score decreased from 3.00 to 2.22 (P<0.01). Successful transition from vitamin K antagonist (VKA) therapy to DOACs was achieved in 25.7% of patients. Pharmacist-led interventions have successfully improved the use of OAC therapies in patients with AF, and effectively managed the bleeding risks and transition from VKA to DOAC therapy, in line with guidelines.

This document is a compilation of the current American College of Cardiology Foundation/American Heart Association (ACCF/AHA) practice guideline recommendations for atrial fibrillation (AF) from the “ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation),”* the “2011 ACCF/AHA/HRS Focused Update on the Management of Patients With Atrial Fibrillation (Updating the 2006 Guideline)”† and the “2011 ACCF/AHA/HRS Focused Update on the Management of Patients With Atrial Fibrillation (Update on Dabigatran).”‡ Updated and new recommendations from 2011 are noted and outdated recommendations have been removed. No new evidence was reviewed, and no recommendations included herein are original to this document. The ACCF/AHA Task Force on Practice Guidelines chooses to republish the recommendations in this format to provide the complete set of practice guideline recommendations in a single resource. ### 1.1. Pharmacological and Nonpharmacological Therapeutic Options #### 1.1.1. Rate Control During AF Class I 1. Measurement of the heart rate at rest and control of the rate using …

Bioprosthetic Valve Thrombosis while on a Novel Oral Anticoagulant for Atrial Fibrillation

We herein aimed for analysis of influence of mitral annular calcification (MAC) and mitral stenosis (MS) on outcomes in transcatheter aortic valve implantation (TAVI). Between 11/2009 and 06/2017, 1,058 patients underwent TAVI in the presence of concomitant MAC or MS at our center. Subgroups were built and multivariate logistic regression, COX regression, Kaplan-Meier survival analyses, and receiver operating characteristics method were performed. Thirty-day mortality was 7.5% (79/1,058) with highest mortality in patients severe MS (MAC: 3.4% vs. mild MS: 5.9% vs. moderate MS: 15.0% vs. severe MS: 72.7%; p < 0.001). Moderate-to-severe MS (odds ratio [OR]: 7.75, confidence interval [CI]: 3.94-16.26, p < 0.001), impaired left ventricular ejection fraction (OR: 1.38, CI: 1.10-1.72, p < 0.01), and coronary artery disease (OR: 1.36, CI: 1.11-1.67, p < 0.01) were predictive of 30-day survival. Left ventricular systolic/end-diastolic pressure drop of <59.5 mm Hg / <19.5 mm Hg was associated with increased mortality. TAVI in the presence of MAC and mild MS is associated with acceptable acute outcomes but should be considered high-risk procedures in patients with moderate and especially those with severe MS. Our results suggest adverse hemodynamics after TAVI with concomitant MS, which may be caused by underfilling of the left ventricle leading to low-cardiac output.

ObjectiveOne legitimate aim of the pharmaceutical industry is maximizing profit. In an ageing population this can for example be achieved with preventive therapies for older patients. Atrial fibrillation is an...