Arterial Embolic Events Research Articles

Cardiovascular Events with De Novo Use of Everolimus in Heart Transplant Recipients: 24-Month Analysis of the A2310 Study

Purpose Everolimus (EVR) has demonstrated robust evidence for reducing the incidence of chronic allograft vasculopathy at 12 month (IVUS) and may be beneficial in minimizing the risk of cardiovascular events in heart transplant (HTx) recipients. Methods and Materials A2310, a 24 month (M), open-label, multicenter study, randomized 721 HTx recipients to either EVR 1.5mg (C0 3-8ng/mL; N=282) or EVR 3mg (C0 6-12ng/mL; N=168) + reduced cyclosporine (CsA) or MMF 3g (N=271) + standard CsA; with steroids±induction. Here we report the 24 M results assessing the incidence of cardiovascular events (CVE) per patient by treatment. CVE included events related to graft dysfunction, ischaemic heart disease, cerebrovascular disorders, and arterial embolic and thrombotic events. Results Comparison of events are presented only for EVR 1.5 mg vs MMF groups, since enrollment into the EVR 3.0mg arm was stopped early due to higher mortality. By M24 comparable proportions of patients in both groups experienced any CVE. Analyzing the time course of the CVE, patients in the EVR 1.5mg group experienced significantly less events occurring after the first month post-Tx than those in the MMF group, driven by lower incidences of graft dysfunction, ischaemic heart disease and cerebrovascular disorders ( Table ). When occurrence of CVE during the first and the second study year were analyzed separately, the difference in favor of EVR 1.5mg was more pronounced during the second year of follow-up. Conclusions The lower rates of CVE after the first post-operative month in the EVR 1.5mg group may represent the clinical expression of its antiproliferative effect on the vascular intima. Further research is needed to confirm this hypothesis.

Managing atrial fibrillation in the CRT patient: Controversy or consensus?

The cumulative incidence of new onset atrial fibrillation (AF) in patients undergoing cardiac resynchronization therapy (CRT) is substantial, exceeding 25% in multiple recent studies. Although AF patients undergoing CRT show improved echocardiographic parameters, functional status, and quality of life in, they benefit to a lesser degree than do patients in normal sinus rhythm. They also exhibit a trend toward increased mortality. Understanding the barriers to response from CRT among AF patients is critical to addressing the needs of growing populations of patients with AF and HF. Foremost among these are suboptimal biventricular pacing, often characterized by fusion or pseudo-fusion complexes, leading to inefficient CRT delivery. Furthermore, AF increases the risk of inappropriate shocks, which lead to substantial psychiatric morbidity, increased risk of heart failure hospitalization, and may also increase mortality. Assiduous rate control is reasonable for all AF patients receiving CRT, but there is a paucity of data regarding specific antiarrhythmic drug therapy recommendations. For patients with permanent AF and severe symptoms, atrioventricular junction ablation appears effective in improving response by ensuring biventricular capture and reducing implantable cardioverter-defibrillator shock burden in selected patients. Catheter-based techniques such as pulmonary vein isolation appear more attractive and in the future may offer further advantages and lower risks, particularly for patients with paroxysmal AF.

P029 * Brain natriuretic peptide as a predictor of volume overload in childrenwith congenital cardiac shunt lesion

P029 * Brain natriuretic peptide as a predictor of volume overload in childrenwith congenital cardiac shunt lesion

A multicentric prospective study in usual care: D-dimer and cardiovascular events in patients with atrial fibrillation

AimAtrial fibrillation (AF), the most frequent arrhythmia, is a major independent cardiovascular (CV) risk factor, especially in elderly patients. The interest of Ddimer (DD) measurement for predicting CV risk has been suggested in some subgroups of patients with AF but little is known about the negative prognostic value of DD measurement. The primary aim was to assess whether DD measurement and monitoring could predict the occurrence of subsequent CV events, defined as MI, stroke or transient ischemic attack and arterial embolic events. Methods and resultsIt was a prospective observational study including patients with AF. Overall 425 patients (mean age 77years) were included and followed-up every 4months for a 16-months-mean duration. During this period, 26 patients experienced an endpoint of combined CV events. Patients with DD lower than 334ng/ml had a very low risk of suffering of CV events (1.7%). Patients who will suffer from a CV event had a higher DD value, just before the occurrence of the CV event, while patients without CV event kept stable levels. ConclusionWe identified a DD threshold defining at any time patients at low risk of CV event. In addition, patients with higher DD levels are at higher risk of CV events, even if they are receiving oral anticoagulants. Otherwise, DD measurement is relevant in elderly patients. DD measurement and monitoring are useful to assess the risk of CV events in usual care. The implications of DD measurement on the choice and the intensity of the antithrombotic treatment remain to be determined.

Risk and fate of residual interatrial shunting after transcatheter closure of patent foramen ovale: a long term follow up study

BackgroundPercutaneous transcatheter closure of patent foramen ovale (PFO) in cryptogenic stroke is an alternative to medical therapy. There is still debate on different outcome for each currently available device. The impact of residual shunting after PFO-clo- sure on recurrent arterial embolism is unknown.Aims(i) To evaluate the prevalence of residual interatrial shunting after device- closure of PFO, (ii) to identify risk factors predicting residual interatrial shunting after device implantation, and (iii) to investigate the outcome of patients after PFO-closure during long- term follow- up (FU).Methods and resultsBetween 2000- 2005 PFO-closure was performed in 124 patients using four different devices: Amplatzer PFO-(n = 52), CardioSeal (n = 33), Helex (n = 23) and Premere (n = 16) occluder. All patients underwent serial contrast-enhanced transesophageal echocardiography (TEE) for 24 months after PFO- closure; clinical FU was at minimum 5 years up to 9.75 years (mean 6.67 ± 1.31 years). Overall-closure rate was 87% at 2 years, device-specific closure time curves differed significantly (p-logrank = 0.003). Independent risk factors for residual-shunting were implantation of a Helex occluder (hazard ratio [HR] 12.6, 95% confidence interval [CI] 2.6- 57.4, p = 0.002), PFO- canal- lengths (HR 1.2, 95%CI 1.1- 1.3, p = 0.004) and extend of atrial-septal-aneurysm (HR 1.1, 95%CI 0.9- 1.3; p = 0.05). 4 (3.2%) arterial embolic events occurred during a FU-period of 817.2 patient-years, actuarial annual thromboembolic-risk was 0.49%. All ischemic events were not related to residual PFO-shunting or device-related thrombus- formation.ConclusionSuccess rates of PFO- closure are mainly dependent on occluder-type, extend of concomitant atrial-septum-aneurysm and PFO-canal- length. Importantly, residual shunting after PFO-closure was not associated with recurrence of arterial embolism during long-term follow-up.

Great vessel/cardiac extension and tumor embolism in pleuropulmonary blastoma: A report from the International Pleuropulmonary Blastoma Registry

Types II and III pleuropulmonary blastoma (PPB) are aggressive sarcomas of lung and pleura in young children. Similar to cavoatrial extension of Wilms tumor, PPB may extend into thoracic great vessels and the heart and may involve both venous and arterial circulations and right and left cardiac chambers. Serious embolic complications occur. Review International PPB Registry databases and literature (1) for PPB cases with vascular/cardiac extension and (2) for neoadjuvant chemotherapy results in vascular extension cases. Among 179 Registry-confirmed and approximately 200 literature Type II and III PPB cases, 11 examples (approximately 3%) of great vessel/cardiac extension were identified; 1 case is presented in detail. Nine cases involved the left circulation, one the right and one both. Various radiographic techniques including echography, computed tomography and gated magnetic resonance imaging identified vascular tumor. Seven children had arterial embolic events: cerebrovascular accidents (six, including one femoral artery occlusion) and acute aortic occlusion (1). Six of these seven died from complications that may be attributed to vascular involvement. In three of four children with vascular involvement, neoadjuvant chemotherapy lessened the involvement; in one the effect could not be assessed. None of these four had embolic events. Effect on survival could not be assessed due to small numbers. Involvement of thoracic great vessels and the heart is a serious complication of PPB, with fatal embolic complications possible. Radiographic evaluation of the central circulation should be performed in children with suspected or diagnosed PPB to identify this complication.

Cerebral venous sinus thrombosis following sildenafil administration; a case report

Background: Sildenafil is a selective inhibitor of phosphodiesterase type 5 (PDE5) which currently used for the treatment of erection dysfunction (ED). Medicine approved by the FDA for treatment of pulmonary hypertension. Although there is no evidence of hypercoagulation states being associated with the use of PDE5 inhibitors, several animal studies suggest that PDE5 inhibitors may cause arterial and venous thrombotic or embolic events. Case report: The patient was a 37 year old man who had suffered sever headache and tonic- clonic generalized seizure. In neurological examination, he had decreased level of consciousness and he had no other positive finding in examination. The patient has been constantly taken 100 mg of Sildenafil once a day without medical supervision over the last month. Brain computerized tomography (CT) showed a small hemorrhage in left frontal lobe with suspicious to cerebral venous sinus thrombosis (CVST) lumbar puncture was performed. Increased cerebrospinal fluid pressure suggested the probability of CVST. Brain MRI result confirmed superior sagittal sinus thrombosis. Conclusion: Cerebral venous sinus thromboses need to be considered a potential side effect of Sildenafil administration.

Hydrogen peroxide ingestion associated with portal venousgas and treatment with hyperbaric oxygen: a case seriesand review of the literature

Introduction. Ingestion of concentrated hydrogen peroxide (H2O2) has been associated with venous and arterial gas embolic events, hemorrhagic gastritis, gastrointestinal bleeding, shock, and death. Although H2O2 is generally considered a benign ingestion in low concentrations, case reports have described serious toxicity following high concentration exposures. Hyperbaric oxygen (HBO) has been used with success in managing patients suffering from gas embolism with and without manifestations of ischemia. Methods. Poison center records were searched from July 1999 to January 2010 for patients with H2O2 exposure and HBO treatment. Cases were reviewed for the concentration of H2O2, symptoms, CT scan findings of portal gas embolism, HBO treatment, and outcome. Results. Eleven cases of portal gas embolism were found. Ages ranged from 4 to 89 years. All but one ingestion was accidental in nature. In 10 cases 35% H2O2 was ingested and in 1 case 12% H2O2 was ingested. All abdominal CT scans demonstrated portal venous gas embolism in all cases. Hyperbaric treatment was successful in completely resolving all portal venous gas bubbles in nine patients (80%) and nearly resolving them in two others. Ten patients were able to be discharged home within 1 day, and one patient had a 3.5-day length of stay. Conclusions. HBO was successful in resolving portal venous gas embolism from accidental concentrated H2O2 ingestions.

Cryptogenic Emboli in Patients with Patent Foramen Ovale or Atrial Septal Defect Associated with the Use of Nonsteroidal Anti-Inflammatory Drugs

Background: Nonaspirin, nonsteroidal anti-inflammatory drugs (NANSAIDs) have been associated with arterial thromboembolic events in the general population. Our objective was to determine the prevalence of NANSAID use in patients diagnosed with cryptogenic emboli or paradoxical embolic events from a patent foramen ovale (PFO) or atrial septal defect (ASD) compared with a control population with an incidental PFO/ASD and no history of embolic events. Methods: We performed a retrospective case-control study of 90 age-matched patients to assess the association of NANSAIDs with cryptogenic arterial embolic events in patients with and without a history of PFO/ASD. Odds ratios (ORs) were obtained by χ² analysis. Multivariate analysis was conducted with a logistical regression method. Results: Patients with cryptogenic embolic events had a high prevalence of prescription NANSAID use regardless of the presence of a PFO/ASD and were far more likely to have a history of NANSAID use than those with an incidentally discovered PFO/ASD and no history of arterial emboli (OR 4.30, 95% confidence interval 1.14–13.07, p = 0.01). Conclusions: Many patients previously diagnosed with paradoxical emboli may be experiencing the prothrombotic effects of NANSAIDs rather than a paradoxical mechanism for their arterial embolic event.

Thrombus flottant d’une artère sous-clavière droite aberrante (arteria lusoria) : une cause rare d’embolies artérielles périphériques

Introduction Floating thrombus in an aberrant right subclavian artery is a rare cause of peripheral arterial embolic events. Case report We report a 45-year-old woman who presented with an ischemia of the right superior limb from embolic event. The diagnosis of mobile thrombus in an aberrant right subclavian artery was obtained with transoesophageal echocardiography and computed tomography. After three weeks of oral anticoagulant therapy, there was no significant resolution of the thrombus, and a surgical treatment was performed to prevent further embolization. The surgical procedure consisted of thrombectomy and reimplantation of the aberrant right subclavian artery to the right carotid artery. Postoperative recovery was uneventful. Conclusion This case report illustrates that transoesophageal echography and computed tomography are useful to detect mobile thrombus of the thoracic aorta and is warranted in any embolic event in young patients.

Pulmonary embolism after tadalafil ingestion

Tadalafil is a phosphodiesterase 5 (PDE5) inhibitor that is used to treat male erectile dysfunction. It is currently undergoing clinical trials for the treatment of pulmonary hypertension. Although at present there is no evidence of hypercoagulation states being associated with the use of PDE5 inhibitors, several studies suggest that PDE5 inhibitors may, in rare cases, cause arterial and venous thrombotic or embolic events in the heart, eye, brain, and ear. We report a 54-year-old male patient with reduced plasma levels of protein C who developed pulmonary embolism (PE) just after he started taking tadalafil. The Naranjo probability scale indicates tadalafil as the possible cause of a PE in our patient. To the best of our knowledge, this is the first case report of tadalafil-induced PE in the literature.

Risk of Thromboembolism in Heart Failure: An Analysis From the Sudden Cardiac Death in Heart Failure Trial (SCD‐HeFT)

Risk of Thromboembolism in Heart Failure: An Analysis From the Sudden Cardiac Death in Heart Failure Trial (SCD‐HeFT)

Iatrogenic Brachial and Femoral Artery Complications Following Venipuncture in Children

Catheter- or noncatheter-related peripheral arterial complications such as arterial pseudoaneurysm, embolus, or arteriovenous fistula may be seen in the pediatric age group. The most common etiologies defined for arterial complications are peripheral arterial puncture performed for a routine arterial blood gas analysis, arterial catheters placed for invasive monitorization of children, or catheterization performed for diagnostic purposes through the peripheral arterial system, most commonly the femoral artery. Nine children with peripheral arterial complications, whose ages varied between 2 months and 2.5 years, were enrolled in this study. All patients were treated surgically. Following physical examination, Doppler ultrasonography, computed tomography angiography, magnetic resonance angiography, or digital subtraction angiography were used as diagnostic tools. We studied thrombophilic panels preoperatively. Six patients had brachial artery pseudoaneurysms that developed accidentally during venipuncture, I had a brachial arteriovenous fistula that developed after an accidental brachial artery puncture during routine peripheral blood analysis. In the remaining 2 patients, peripheral arterial embolic events were detected. One had a left brachial arterial embolus and the other had a sudden onset right femoral artery embolus that was detected via diagnostic interventions. No morbidity such as amputation, extremity loss, or mortality occurred due to the arterial events or surgery. All patients were discharged from the hospital in good clinical condition. In all patients, follow-up at 3 or 6 months revealed palpable peripheral artery pulsations of the ulnar and radial arteries at wrist level. Because the incidence of peripheral arterial complications is relatively low in children compared to adults, the diagnostic and therapeutic approaches are extrapolated from the adult guidelines. We proposed that early diagnosis and surgical approach prevented the complications from further developing in the affected extremity in these particular cases.

Monitored Atrial Fibrillation Duration Predicts Arterial Embolic Events in Patients Suffering From Bradycardia and Atrial Fibrillation Implanted With Antitachycardia Pacemakers

The aim of our study was to evaluate arterial embolism (AE) occurrence rates and predictors in patients suffering from bradycardia and wearing a pacemaker with antitachycardia pacing therapies. Atrial fibrillation (AF) is associated with a high incidence of AE. A total of 725 patients (360 men, age 71 +/- 11 years) were implanted with a DDDRP pacemaker (Medtronic AT500, Medtronic Inc., Minneapolis, Minnesota). At baseline 225 (31.0%) patients received antiplatelet therapy and 264 (36.4%) patients received anticoagulation agents. Over a median 22-month follow-up (25th to 75th interquartile range 16 to 30 months), AE occurred in 14 (1.9%) patients: 7 patients suffered a nonfatal ischemic stroke (0.6% per year), 4 patients had transient ischemic attack (0.34% per year), and 3 patients had embolic complications. Among baseline patients' characteristics, multivariate logistic analysis showed that embolic events are independently associated to ischemic heart disease (7.0 odds ratio [OR], 95% confidence interval [CI] 2.3 to 21.3, p = 0.001), prior embolic event (7.3 OR, 95% CI 1.2 to 43.9, p = 0.029), diabetes (5.0 OR, 95% CI 1.2 to 15.7, p = 0.032), and hypertension (4.1 OR, 95% CI 1.1 to 15.6, p = 0.036). The risk of embolism, adjusted for known risk factors, was 3.1 times increased (95% CI 1.1 to 10.5, p = 0.044) in patients with device-detected atrial fibrillation episodes longer than one day during follow-up. In a cohort of patients with bradycardia and AF, arterial embolism was common in patients with ischemic cardiopathy, hypertension, diabetes mellitus, and in patients with known stroke risk factors. Atrial fibrillation occurrences longer than one day were independently associated with embolic events.

556 Arterial embolic events in patients suffering from bradycardia and atrial fibrillation implanted with antitachycardia pacemakers

556 Arterial embolic events in patients suffering from bradycardia and atrial fibrillation implanted with antitachycardia pacemakers

556 Arterial embolic events in patients suffering from bradycardia and atrial fibrillation implanted with antitachycardia pacemakers

556 Arterial embolic events in patients suffering from bradycardia and atrial fibrillation implanted with antitachycardia pacemakers

Does Aspirin Prevent Emboli in Infective Endocarditis?

Methods: A multicenter, randomized, double-blind, placebo controlled trial was conducted in 19 centers—18 in Canada and one in the United States. Of the planned study size of 368 patients (based on power considerations), 115 were ultimately randomized. Enrolled patients met a modified Duke criteria definition for diagnosis of endocarditis and were aged between 16 and 80 years. Patients were excluded if a paravalvular abscess was seen by echocardiography, if they were expected to have surgery within a week, if they already had a current or evolving central nervous system vascular event, or if they had a contraindication to aspirin, such as an episode of gastrointestinal bleeding or peptic ulcer disease in the prior 12 months, allergy to aspirin, or a bleeding diathesis. Patients already taking aspirin for other reasons also were excluded. Patients were randomly assigned to receive 325 mg daily of aspirin or placebo for 4 weeks. Anticoagulation for prosthetic valves was continued. Patients were followed clinically, and when clinically indicated, were studied radiologically. Additional studies, such as computed tomograms of the head at baseline and after therapy, were encouraged but not required. Patients also were followed by transthoracic echocardiography (transesophageal studies were encouraged) to assess changes in vegetations. The primary outcome was clinically significant major arterial embolic events. Secondary outcomes included subclinical emboli, death, bleeding, valvular surgery, and echocardiographic progression of vegetations.

Thrombus flottant de la crosse de l’aorte : une cause rare d’embolies artérielles périphériques: À propos d’un cas clinique

Floating thrombus in the aortic arch is a rare and often under-diagnosed source of peripheral arterial embolic events. We report a case of a patient seen with arterial embolic events: ischemia of the left superior limb and transient stroke. The diagnosis was performed with transesophageal echocardiography and computed tomography. The thrombus completely disappeared after 15 days of oral anticoagulant therapy. Although rare, this diagnosis mustn’t be overlooked in the search for an etiology of recurrent and disseminated peripheral ischemic events because the detrimental functional risk related to a delayed diagnosis.

Difficultés diagnostiques d’un thrombus de la crosse aortique

Introduction. – Thrombosis of the aortic arch is a rare and often underdiagnosed source of peripherical arterial embolic events. Exegesis. – We report a case with a non-typical initial clinical presentation of polyarteritis nodosa. A mobile thrombus in the aortic arch was secondarily suspected when disseminated arterial embolism appeared. Transthoracic echocardiography failed twice to diagnosticate the source of embolism. The diagnosis was only performed with transesophageal echocardiography and confirmed by computed tomography and magnetic resonance imaging of the thoracic aorta.The thrombus completely disappeared after six months of oral anticoagulant therapy. Conclusion. – Although rare, this diagnosis mustn’t be disregarded in an etiologic view of recurrent and disseminated peripherical ischemic events (even clinically silent ones) under penalty of detrimental functional consequences due to a delayed diagnosis.

Patent Foramen Ovale Complicated by Paradoxical Embolism and Brain Infarct in a Patient with Advanced Ovarian Cancer

Background. Recent investigations of patients with cerebral and peripheral arterial emboli of unknown cause suggest that paradoxical embolism through a patent formen ovale might be responsible for more arterial embolic events than previously realized.Case. A 60-year-old woman with advanced ovarian cancer presented with sudden onset of expressive aphasia and right upper hemiplegia postoperatively. A patent foramen ovale diagnosed by echocardiography with contrast combined with the presence of thrombosis in her right femoral vein leads us to speculate that her stroke was secondary to a paradoxical embolism.Conclusion. Paradoxical embolism should be considered in the differential diagnosis of ovarian cancer patients with embolic stroke and it may be appropriate to include a cardiac echo as part of the diagnostic evaluation.