Cerebrovascular Embolic Events Research Articles

Prevalence and risk factors of embolic cerebrovascular events associated with Chagas heart disease.

Patients with Chagas disease are at increased risk for stroke that may result in major clinical disability and death. Identification of risk factors involved in the genesis of thromboembolic events related to this disease may lead to improved therapeutic decision making and outcomes. This study sought to assess the prevalence of ischemic cerebrovascular events (ICE) among patients with Chagas heart disease and to identify the risk factors associated with cardioembolism in this population. This study involved 330 patients, 193 were men (58%), with a mean age of 49 ± 12 years with Chagas disease classified in the chronic cardiac form of the disease. Comprehensive echocardiography was performed to search a substrate for cardioembolic events, especially apical aneurysm and intracavitary thrombus. Most of the patients were classified as New York Heart Association classes I or II (75%) with mean left ventricular (LV) ejection fraction of 39 ± 14%. Sixty-seven patients had a previous ICE with the overall prevalence of 20%. Apical aneurysms were detected in 128 patients (39%), whereas LV mural thrombi were found in 48 patients (15%). In multivariate analysis including the potential predictors of ICE, apical aneurysm (adjusted odds ratio [OR]: 2.19, 95% confidence interval [CI]: 1.11 to 4.34; p= 0.024) and LV thrombus (adjusted OR: 2.43, 95% CI: 1.09 to 5.42; p= 0.030) emerged as important determinants of ICE, after adjusting for anticoagulation therapy. In a selected population referred to a tertiary center for Chagas disease that included patients with different severities of cardiac involvement, the prevalence of ICE was 20%. The presence of apical aneurysm and intracavitary thrombus were independently associated with ICE, after adjustment for other risk factors for stroke.

Right ventricular marantic endocarditis

A 68-year-old female presented with chest pain and breathlessness. She had breast carcinoma treated 17 years ago, with further surgical excision for recurrence 7 years ago. Computerised tomography (CT) demonstrated bi-lateral pulmonary embolism, with extensive lymphadenopathy and lung metastases. She was treated with therapeutic heparin. Echocardiography revealed a right ventricular mass attached to the tricuspid valve chordae (Fig. 1; Videos 1 and 2), which could be thrombus, marantic or infective vegetation. Blood cultures were negative. Lymph node biopsy showed malignant cells, likely of breast origin. Despite therapeutic anti-coagulation, echocardiogram 3 weeks after initial presentation demonstrated enlargement of the original mass and an additional mass (Fig. 1; Videos 3 and 4), implying that these were most probably marantic. We retrospectively reviewed the CT performed at first presentation, which also demonstrated the original right ventricular mass (Fig. 1). She died from recurrent embolic cerebrovascular events, confirmed on MRI, within a month from initial presentation. In advanced stages of malignancy, marantic endocarditis or non-bacterial thrombotic endocarditis can develop in hypercoagulable states. It has a rapidly progressive course, with embolisation of vegetations to other organs. The sterile vegetations consist of fibrin and platelets (1, 2). Patients should be anti-coagulated. In terminal cases, surgery rarely alters the final outcome (2, 3). Figure 1 (A and B) Right ventricular mass (arrowed) attached to the tricuspid valve chordae apparatus on echocardiography, in apical four-chamber view, and modified parasternal right ventricular inflow view respectively; (C and D) repeat echocardiogram demonstrating ... Video 1 The initial right ventricular mass attached to the tricuspid valve chordae apparatus on echocardiography, in modified parasternal right ventricular inflow view. Download Video 1 via http://dx.doi.org/10.1530/ERP-14-0066-v1 Download Video 1 Video 2 The initial right ventricular mass attached to the tricuspid valve chordae apparatus on echocardiography, in apical four-chamber view. Download Video 2 via http://dx.doi.org/10.1530/ERP-14-0066-v2 Download Video 2 Video 3 Repeat echocardiogram demonstrating enlargement of the original mass and an additional mass, in modified parasternal right ventricular inflow view. Download Video 3 via http://dx.doi.org/10.1530/ERP-14-0066-v3 Download Video 3 Video 4 Repeat echocardiogram demonstrating enlargement of the original mass and an additional mass, in apical four-chamber view. Download Video 4 via http://dx.doi.org/10.1530/ERP-14-0066-v4 Download Video 4

Abstract 11452: Are Patients With Caseous Calcification of the Mitral Annulus But Without Atrial Fibrillation at Increased Risk of Cerebral Embolization?

Background: Caseous calcification of the mitral annulus (CCMA) is very uncommon, and is frequently misdiagnosed as an intracardiac tumor, thrombus, abscess, or simply as mitral annular calcification (MAC). These masses are generally believed to have a benign prognosis. The aims of this study are to increase the awareness of this unusual variant of MAC, and to determine whether patients with CCMA are at increased risk of cerebral embolization in patients with or without atrial fibrillation (AF). Methods: A comprehensive literature search was done to determine whether patients with CCMA are at increased risk of cerebral embolization, using the following search modules: caseous calcification of the mitral annulus, mitral annular calcification, cerebral embolization with mitral annulus calcification, risk of stroke with mitral annular calcification. Results: Among the 496 articles listed in PubMed.gov, ScienceDirect.com, and Google Scholar, a total of 129 patients with CCMA were identified in 85 publications, and 31 articles were reviewed to evaluate the incidence of stroke in 1800 patients with MAC. Literature review revealed that the incidence of cerebrovascular events (CVE) associated with CCMA is 18.6% (24 of 129) which is even higher than the risk of embolic CVE reported in patients with MAC, 11.6% (209 of 1800) (range 4.8% to 24.1%). Only 2 of 24 patients (8.3%) with CCMA who suffered a CVE had history of AF, whereas the majority (22 of 24, or 91.7%) of CCMA patients with a CVE did not have AF. Conclusions: Despite the fact that several reports suggest that CCMA is a benign condition, CCMA may be potentially serious, because of the increased risk of cerebral embolization, even in patients without atrial fibrillation.

Role of LA Shape in Predicting Embolic Cerebrovascular Events in Mitral Stenosis: Mechanistic Insights From 3D Echocardiography

This study was designed to assess the role of left atrial (LA) shape in predicting embolic cerebrovascular events (ECE) in patients with mitral stenosis (MS). Patients with rheumatic MS are at increased risk for ECE. LA remodeling in response to MS involves not only chamber dilation but also changes in the shape. We hypothesized that a more spherical LA shape may be associated with increased embolic events due to predisposition to thrombus formation or to atrial arrhythmias compared with an elliptical-shaped LA of comparable volume. A total of 212 patients with MS and 20 control subjects were enrolled. LA volume, LA emptying fraction, and cross-sectional area were measured by 3-dimensional (3D) transthoracic echocardiography. LA shape was expressed as the ratio of measured LA end-systolic volume to hypothetical sphere volume ([4/3π r(3)] where rwas obtained from 3D cross-sectional area). The lower the LA shape index, the more spherical the shape. A total of 41 patients presented with ECE at the time of enrollment or during follow-up. On multivariate analysis, LA 3D emptying fraction (adjusted odds ratio [OR]: 0.96; 95% confidence interval [CI]: 0.92 to 0.99; p= 0.028) and LA shape index (OR: 0.73; 95% CI: 0.61 to 0.87; p < 0.001) emerged as important factors associated with ECE, after adjustment for age and anticoagulation therapy. In patients in sinus rhythm, LA shape index remained associated with ECE (OR: 0.79; 95% CI: 0.67 to 0.94; p= 0.007), independent of age and LA function. An invitro phantom atrial model demonstrated more stagnant flow profiles in spherical compared with ellipsoidal chamber. In rheumatic MS patients, differential LA remodeling affects ECE risk. A more spherical LA shape was independently associated with an increased risk for ECE, adding incremental value in predicting events beyond that provided by age and LA function.

Free-floating thrombus of carotid artery : A case report

Free-floating thrombus (FFT) of carotid artery is very rare condition with high risk of embolic cerebrovascular events. The natural history and optimal treatment options are unknown. Here, we report a 47-year-old female patient who had transient ischemic attack and diagnosed with FFT in common carotid artery. Carotid endarterectomy and patch plasty was performed. Recovery was uneventful, and the patient was discharged symptom-free with warfarin and antiplatelet therapy.

SEMI-AUTOMATED DETECTION AND QUANTIFICATION OF AORTIC ATHEROMAS FROM 3D TRANSESOPHAGEAL ECHOCARDIOGRAPHY

Aortic atherosclerosis is an important risk factor for embolic cerebrovascular events. Quantification of descending aorta atheromas with 2D transesophageal echocardiography (TEE) is time-consuming and likely underestimates the 3D plaque burden. We aimed to assess the feasibility and accuracy of a

Complications of catheter ablation for atrial fibrillation in a high-volume centre with the use of intracardiac echocardiography

Catheter ablation (CA) for atrial fibrillation (AF) is a complex procedure that is associated with higher risk of complications. This study aimed at exploring the complication rate and corresponding risk factors in a high-volume centre with routine use of intracardiac echocardiography (ICE). In total 1192 consecutive AF ablation procedures (100% ICE-guided; 96.4% 3D-navigated; point-by-point radiofrequency ablation with open-irrigated tip catheter; 22.4% robotic navigation; 25.4% repeated ablation) were performed in 959 patients (aged 58 ± 9 years; 70.8% males; 35.9% persistent AF) between March 2006 and December 2010. Ablation endpoint in paroxysmal AF was complete electrical pulmonary vein isolation (PVI). Complex ablation was defined as PVI plus stepwise strategy for left atrial substrate ablation (43.5%) in persistent AF. Forty major complications (3.3%) during the procedure or within the 3 month follow-up were observed. No death or atrioesophageal fistula occurred. Three patients (0.25%) had cardiac tamponade/hemopericardium and five patients (0.42%) had cerebrovascular embolic event. Vascular injury was the most frequent (2.3%) complication. Low body weight was the only significant risk factor with 0.8% increase of complication rate per 10 kg of body weight decrease (P = 0.013). A trend for increase in complication rate was also observed for advanced age, female gender, and complex procedure. Atrial fibrillation ablation procedures guided by ICE in a high-volume centre are associated with low rate of serious complications. The composite risk score consisting of body weight, age, gender, and complexity of procedure predicted complications.

Atrial fibrillation and the risk of incident dementia: A meta-analysis

The risk of cerebrovascular embolic events with atrial fibrillation (AF) is potentially linked to an increased risk of cognitive decline and dementia. However, epidemiologic studies exploring the association between AF and incident dementia have reported conflicting results. The purpose of this study was to perform a meta-analysis of observational studies specifically designed to evaluate the prospective relationship between AF and incident dementia. We searched PubMed, CENTRAL, BioMedCentral, Embase, Cardiosource, clinicaltrials.gov, and ISI Web of Science (January 1980 to May 2012). No language restriction was applied. Two independent reviewers screened titles and abstracts to identify population-based studies that prospectively evaluated the association between AF and the incidence of dementia in patients not suffering an acute stroke and with normal cognitive function at baseline, providing the hazard ratio (HR) obtained in multiple Cox regression analyses, and adjusted for all confounding variables. Two independent reviewers assessed risk of bias according to the Cochrane Collaboration, and extracted patient and study characteristics and the adjusted HR of incident dementia with its 95% confidence interval (CI) of patients with AF vs those without AF. Eight studies with 77,668 patients were included in the analysis. All studies had a prospective observational design and included elderly patients (mean age range 61-84 years) with normal cognitive function at baseline, of whom 11,700 (15%) had AF. After a mean follow-up of 7.7 ± 9.1 years (range 1.8-30 years), 4773 of 73,321 (6.5%) patients developed dementia. Two studies did not report the rates of dementia at follow-up but reported the adjusted HR and were included in the pooled analysis. At pooled analysis adjusted for baseline confounders and covariates, AF was independently associated with increased risk of incident dementia (HR = 1.42 [95% CI 1.17-1.72], P <.001). AF is independently associated with increased risk of dementia. Patients with AF should be periodically screened for dementia, which should be included among the outcomes assessed in AF treatment trials.

Stratifying risk: asymptomatic carotid disease

Stroke generates significant healthcare expenses and it is also a social and economic burden. The carotid artery atherosclerotic plaque instability is responsible for a third of all embolic strokes. The degree of stenosis has been deliberately used to justify carotid artery interventions in thousands of patients worldwide. However, the annual risk of stroke in asymptomatic carotid artery disease is low. Plaque morphology and its kinetics have gained ground to explain cerebrovascular and retinal embolic events. This review provides the readers with an insightful and critical analysis of the risk stratification of asymptomatic carotid artery disease in order to assist in selecting potential candidates for a carotid intervention.

Evolution of mobile plaque to complete division of carotid lumen

As such plaques are unstable and associated with higher risk of embolic cerebrovascular events, carotid endarterectomy could be the best treatment option. [3,4]

Vertebral Artery Orifice Stenosis: A Report of 43 Cases from Northwest Iran Treated with Angioplasty and Stenting

More than one quarter of all transient ischemic attacks (TIA's) and ischemic strokes involve tissue supplied by the vertebrobasilar (VB) circulation. Vertebral artery stenotic lesion, particularly at the origin of the vertebral artery, is not uncommon but it is a less studied area. Here we present our endovascular treatment experience in a group of patients with vertebral artery orifice stenosis. We enrolled a group of patients with vertebral artery orifice stenosis who presented with confirmed posterior circulation stroke. Vertebrobasilar insufficiency syndrome was confirmed by imaging studies and clinical findings. Vertebral artery stenosis diagnosed by CT or MR Angiography and confirmed by Conventional and digital subtraction angiography (DSA). Angiography was performed by using of femoral or radial artery approach. From October 2008 to January 2010, forty-three consecutive patients (69.8% men) underwent stent placement for symptomatic vertebral artery orifice stenosis. Mean degree of stenosis was 70.45 +/- 7.455 percent and mean age was 71.65 +/- 7.743 years . In the 22 patients (22/43, 51.16%) stenosis were in left side. In the thirty patients (30/43, 69.6%) there was evidence of atherosclerotic disease in the internal carotid artery and in the 23% contra lateral vertebral artery was involved. There were five different cases with left renal artery stenosis especially in the men with left vertebral artery stenosis. Initial technical success rate was 100%. No cerebrovascular complications or embolic events occurred. Six months control angiography follow-up revealed one patient with stent occlusion and moderate (40%) restenosis in the another patient. According to our finding angioplasty and stenting for vertebral artery orifice stenosis is safe and effective. Patients with vertebral artery orifice disease frequently have coexistent atherosclerotic stenosis in the other major extracranial arteries including carotid and renal arteries.

Sustained long‐term benefit of patent foramen ovale closure on migraine

This single-center, observational, prospective study evaluated the impact of patent foramen ovale (PFO) closure on migraine attacks over time. PFO closure may reduce the frequency and severity of migraine headaches in patients with significant right-to-left shunts. Between May 2000 and September 2009, 305 consecutive patients (mean age, 43 ± 12 years; 54.5% women) with a prior embolic cerebrovascular event underwent PFO closure with the Amplatzer PFO occluder for recurrence prevention. All patients had right-to-left shunts; the shunts were associated with migraine symptoms in 77 (25%), either alone (n = 64, 83%) or with aura (n = 13, 17%). Septal aneurysm was present in 15 (19.5%) migraine patients, and 43 (56%) had a previous transient brain ischemic attack. All migraine patients had a computed tomography scan or magnetic resonance imaging, indicating a previous brain ischemic lesion. All 305 patients underwent transthoracic echocardiography with clinical follow-up at 24 hr, at 3, 6, and 12 months, and then yearly. An acute migraine attack occurred 24-48 hr after PFO closure in 28 (36.4%) of 77 patients. There was a significant reduction (>50%) in the number and intensity of attacks in 46 (60.5%) of 77 patients at the 3-month follow-up. At the 12-month follow-up, migraine had ceased in 23 (46%) patients, and 20 (40%) had a reduction in the migraine recurrence rate and disabling symptoms. These results were maintained at follow-up (mean, 28 ± 27 months). There was overall improvement in migraine in 89% of the treated patients. Percutaneous PFO closure in migraineurs may provide beneficial mid-term and long-term results, with significant reduction in the intensity and frequency of headache symptoms.

Thromboembolic Complications in Patients With Newly Diagnosed Dilated Cardiomyopathy Immediately After Initiation of Congestive Heart Failure Treatment: Just a Coincidence or Should We Pay More Attention?

Recently, we have experienced cerebrovascular embolic events in 2 consecutive patients in our outpatient clinic. Accordingly, we want to share our comments with literature on these 2 patients. Both patients had newly diagnosed left ventricular (LV) dysfunction, sinus rhythm, and cerebrovascular event within the first week after initiation of heart failure treatment. Although, our cases are not enough to make a general statement or conclusion, we can recommend that patients with newly diagnosed severe LV dysfunction with normal sinus rhythm and without echocardiographically visible thrombus should also be closely followed up for thromboembolic complications at least during the first weeks of congestive heart failure treatment.

Internal Carotid Artery Stenting for Blunt Carotid Artery Injuries With an Associated Pseudoaneurysm

Blunt carotid artery injuries (BCI) are being recognized and treated with increasing frequency because of improved screening protocols. Recent advances in endovascular techniques using microcoils, angioplasty, and stenting offer a new treatment strategy for those patients with traumatic pseudoaneurysms (PA) (BCI and PA). Experience with these techniques is limited because of the rarity of these injuries. Early anticoagulation (AC) or antiplatelet (AP) therapy combined with carotid artery stenting is a safe alternative to AC alone for the treatment of grade III carotid artery injuries (BCI and PA). Prospective cohort study. A rural, community Level I trauma center. All patients with a nonocclusive BCI and PA during a 5.5 year period from June 23, 2000 to December 31, 2005 were included in the study. : Eleven patients with grade BCI and PA underwent endovascular repair. Nine patients (81%) had associated traumatic intracranial hemorrhage. AC (heparin drip) or AP therapy (clopidogrel or aspirin or both) was initiated in all patients within 48 hours of diagnosis of BCI. Time from admission to AC or AP was 21 +/- 9.5 hours (mean +/- SD). Mortality rate was 18% (2 of 11). One death was attributed to severe brain injury. The other was attributed to a stroke from the carotid injury. No patient had radiologic progression of traumatic intracranial hemorrhage on head computed tomography despite AP or AC. One patient sustained a mild embolic cerebrovascular ischemic event before stenting. No other survivors developed a stroke or any other evidence of cerebral ischemic symptoms. Two recurrent PAs developed during hospitalization and were successfully managed with an additional stent. All survivors were discharged with a good neurologic outcome. Seven patients had follow-up from 6 months to 4 years: one developed asymptomatic 50% stenosis at 6 months requiring successful angioplasty. All others showed complete healing without stenosis. Carotid artery stenting is safe and effective initial therapy for patients with nonocclusive BCI and PA. Initial intermediate-term follow-up also fails to demonstrate significant morbidity for up to 4 years.

Cardiovascular Manifestations Seen in Obstructive Sleep Apnea

Patients with obstructive sleep apnea (OSA) have an increased prevalence of systemic and pulmonary hypertension, left ventricular (LV) hypertrophy, LV systolic and diastolic dysfunction, and congestive heart failure, increased platelet aggregability, and increased susceptibility to thrombotic and embolic cardiac and cerebrovascular events. Patients with OSA have an increased prevalence of coronary artery disease, myocardial infarction, nocturnal angina, and myocardial ischemia, arrhythmias, and sudden cardiac death. Patients with OSA also have an increased prevalence of stroke. Treatment of OSA with continuous positive airway pressure improves cardiac efficiency in patients with heart failure, causes a reduction in the frequency of nocturnal ischemic ST-segment depression, relieves nocturnal angina, and causes a reduction in the occurrence of new cardiovascular events and an increase in the time to such events.

Culture-Positive and Culture-Negative Endocarditis in Patients With Cancer

Endocarditis is uncommon in patients with cancer. The characteristics of culture-positive (CPE) and culture-negative endocarditis (CNE) in high-risk cancer patients are not known; therefore we sought to evaluate the disease characteristics in patients with endocarditis at a comprehensive cancer center. We retrospectively reviewed the transthoracic (TTE) and transesophageal (TEE) echocardiograms obtained from 654 consecutive cancer patients in whom endocarditis was suspected between 1994 and 2004. Endocarditis was confirmed in 45 (7%) of 654 patients using modified Duke University criteria based on information obtained from hospital records and computerized data systems. In 21 (95%) of 22 cases, TEE examinations were diagnostic, and 16 (42%) of 38 patients with initially nondiagnostic TTE studies had the diagnosis confirmed by TEE study; this difference between diagnostic TEE and initial nondiagnostic TTE was significant (p < 0.0001). Among the 26 (58%) patients with CPE, Staphylococcus aureus (35%) was the most common organism isolated, followed by coagulase-negative Staphylococcus species (23%). Eighteen (78%) of 23 patients with a central venous catheter had CPE, whereas only 8 (36%) of 22 patients without a central venous catheter had CPE (odds ratio [OR], 6.3; 95% confidence interval [CI], 1.69-23.53; p < 0.006). Vegetations were larger in patients with CPE than in patients with CNE (median +/- standard deviation, 10 +/- 8.8 vs. 8.7 +/- 3.9 mm). Fifteen patients (58%) with CPE and 10 (53%) with CNE had embolic complications. We note that cutaneous and septic pulmonary emboli were more common in patients with CPE than in patients with CNE (31% vs. 11% and 15% vs. 0%, respectively), whereas embolic cerebrovascular and fatal embolic coronary events were more common in patients with CNE than in those with CPE (37% vs. 12% and 21% vs. 0%, respectively; p = 0.026). The 4-week endocarditis-attributable death rate did not differ significantly between the groups (CPE, 15% vs. CNE, 32%; p = 0.28). On stepwise multivariate regression analysis, patients with neutropenia (OR, 22.52; 95% CI, 2.25-225.48; p < 0.008) and those with embolic cerebrovascular events (OR, 17.07; 95% CI, 1.63-178.45; p < 0.01) had an increased probability of death due to endocarditis. The clinical spectrums of CPE and CNE differed in these patients with cancer. In patients with CNE, embolic cerebrovascular and fatal myocardial infarction were relatively common.

Interatrial block as a predictor of embolic stroke

Interatrial block (IAB), defined as a prolonged (>/=110 ms) P wave, is remarkably prevalent in general hospital populations and is associated with an enlarged, poorly contractile left atrium. The investigators sought to determine whether there is an increased incidence of IAB in patients with embolic strokes. Patients' medical records were reviewed for evidence of embolic cerebrovascular events and IAB. One hundred four patients were identified. In 61 patients in normal sinus rhythm, 49 (80%) had IAB. This was almost twice the prevalence of 2 previous studies (41% and 47%). Therefore, IAB may represent a new risk factor for stroke.

Surgical treatment for secundum atrial septal defects in patients >40 years old: A randomized clinical trial

ObjectivesWe prospectively examined whether surgical treatment of secundum atrial septal defects (ASDs) in patients ≥40 years old improves their long-term clinical outcome. BackgroundSurgical treatment of secundum ASDs in adults >40 years old is a subject of controversy because of the perception of good long-term clinical outcomes in patients with unrepaired ASDs and the lack of data from randomized trials. MethodsWe recruited 521 patients >40 years old with secundum ASDs referred for treatment; 48 were excluded. Patients were randomly assigned to surgical closure (n = 232) or medical treatment (n = 241). The primary and secondary end points were a composite of major cardiovascular events (death, pulmonary embolism, major arrhythmic event, embolic cerebrovascular event, recurrent pulmonary infection, functional class deterioration or heart failure) and overall mortality, respectively. We assessed possible prognostic markers. The analysis was performed on an intention-to-treat basis. ResultsThe median follow-up period was 7.3 years (range 2 to 13). The risk of having the primary end point was significantly higher in the medical group, which had a univariate hazards ratio of 1.99 (95% confidence interval [CI] 1.23 to 3.22) and a multivariate hazards ratio of 1.85 (95% CI 1.08 to 3.17). Although the survival analysis did not reveal differences in overall mortality between the surgical and medical treatments (hazards ratio 1.71, 95% CI 0.76 to 3.86), the multivariate analysis, adjusted by age at entry, mean pulmonary artery pressure and cardiac index, demonstrated significant differences between the study groups (hazards ratio 4.09, 95% CI 1.41 to 11.89). ConclusionsSurgical closure was superior to medical treatment in improving both the composite of major cardiovascular events and overall mortality in patients >40 years old with secundum ASDs. This superiority was related to the mean pulmonary artery pressure, age at diagnosis and cardiac index. Because of the higher risk of morbidity and mortality, we believe that anatomic closure should always be attempted as the initial treatment for ASDs in adults >40 years old with pulmonary artery systolic pressure <70 mm Hg and a pulmonary/systemic output ratio ≥1.7. The operation must be performed as soon as possible, even if the symptoms or the hemodynamic impact seems to be minimal.

The totally implantable Novacor Left Ventricular Assist System

The Novacor Left Ventricular Assist System (LVAS) (Novacor Corp, Oakland, CA) was initially console-based and has been available since 1993 in a wearable configuration. It has been successfully used for the past 16 years as a bridge to cardiac transplantation in patients with end-stage congestive heart failure. The Stanford experience represents 53 patients (48 male, 5 female) with a mean age of 44 ± 13 years (16 to 62) and a mean support time of 56 ± 76 days (1 to 374). Complications with LVAS use consisted predominantly of bleeding (43%), infection, (30%), and embolic cerebrovascular events (24.5%). Sixty-six percent of the supported patients were successfully bridged to cardiac transplantation. In animal studies, 4 sheep had the totally implantable configuration in place for a cumulative duration of 1 year with 1 animal supported for 260 days. The next generation Novacor LVAS will be small, quiet, and fully implantable without the need for volume compensation. It will also provide physiologic pulsatile flow and will be fail-safe.

Catheter Closure of Atrial Septal Defects and Patent Foramen Ovale in Patients with an Atrial Septal Aneurysm Using Different Devices

Atrial septal aneurysm is frequently associated with patent foramen ovale (PFO) and atrial septal defects (ASD). Moreover, a relationship between atrial septal aneurysm and embolic cerebrovascular events has been suggested. The aims of this study were to analyze morphological and functional characteristics of atrial septal aneurysm in PFO and ASD patients and to assess the feasibility and efficacy of different devices for transcatheter closure and the influence of atrial septal aneurysm. Between March 1997 and May 2000 transcatheter ASD or PFO closure was attempted in 63 patients (mean age 47 +/- 13 years) with an atrial septal aneurysm using one of the following devices: Angelwings (n = 3), Cardioseal (n = 5), Cardioseal-Starflex (n = 7), Amplatzer (n = 11), Amplatzer-PFO (n = 5), PFO-Star (n = 25), or Helex (n = 7). Implantation was primarily successful (after the first or second attempt) in all patients. One PFO-Star device embolized 12 hours after the procedure. During follow-up (0.6-37 months, mean 10.4 +/- 9.2) a residual shunt could be detected by transesophageal echocardiography after 2 weeks in four patients and after 6 months in one patient. Three PFO patients had cerebrovascular events after implantation. Two patients had a transient ischemic attack (TIA) and one patient a stroke. A thrombus formation on the device detected in three patients disappeared after antithrombotic therapy. We conclude that ASDs and PFOs with an associated atrial septal aneurysm can be closed with different available devices. There seem to be no additional risks compared with patients without atrial septal aneurysm.