Cerebrovascular Embolic Events Research Articles

Experience and insights from a prolonged electrocardiographic monitorization with a wearable system after an embolic stroke of unknown source.

Embolic cerebrovascular events that remain of unknown etiology after a thorough diagnostic evaluation, are known as Embolic Strokes of Undetermined Source (ESUS). Subclinical atrial fibrillation (AF) represents a significant underlying cause of ESUS. Our aims were to examine the overall diagnostic yield of a prolonged cardiac monitoring wearable system (PCMw) after an ESUS to detect AF and factors associated with it, including the time frame from the ESUS event to PCMw initiation. Additionally, to evaluate the frequency of unexpected arrhythmic events (UAE) and their prognostic implications. We retrospectively analyzed 200 ECG recordings (3-leads, 30days duration) by means of a PCMw in patients with an ESUS to detect AF lasting longer than 30s, between 2017 and 2021. UAE were defined as arrhythmia events that were not correlated to the main reason of prolonged cardiac monitoring. AF was detected in 21 patients (10.5%). Patients with AF had more left atrial enlargement (OR=4.22 [1.59-6.85]; p=.01) and atrial arrythmias in the initial 24-h Holter during hospitalization (OR=5.73 [2.03-16.49]; p=.001). The detection of AF was significatively higher if the PCMw was worn within the first 30days after the ESUS compared to beyond 30days (17% vs. 10.3%; p=.002). Fifty three patients (26.5%) had UAE during PCMw. In six of them these findings led to targeted treatment. PCMw represents a feasible non-invasive device that could reliably detect subclinical AF episodes after an ESUS. Diagnostic yield was significatively higher when used within the first 30days after the event, especially in selected patients. UAE were common, but did not impact prognosis.

Clinical presentation and neurovascular manifestations of cardiac myxomas and papillary fibroelastomas: a retrospective single-institution cohort study.

Primary cardiac tumors are often benign and commonly present as cardiac myxomas (CMs) or papillary fibroelastomas (CPFEs). There is a paucity of prognostic indicators for tumor burden or potential for embolic cerebrovascular events (CVEs). This study was performed to address these gaps. Medical records at the University of Florida Health Shands Hospital between 1996 and 2021 were screened to identify patients with CMs or CPFEs. Clinical features, echocardiographic reports, and CVE outcomes were quantitatively assessed. A total of 55 patients were included in the study: 28 CM (50.9%) and 27 CPFE (49.1%) patients. Baseline patient characteristics were similar among patients. The neutrophil-lymphocyte ratio was correlated (p < 0.005 in all cases) to three metrics of tumor size in both CM (r = 64-67%) and CPFE (r = 56-59%). CVEs were the presenting symptom in 30 (54.5%) patients. CVE recurrence was high; the 5-year CVE recurrence rate in patients with tumor resection was 24.0% compared to 60.0% without resection. No baseline patient characteristics or tumor features were associated with an initial presentation of CVEs compared to any other indication. Univariate analysis indicated that prolonged duration to surgical resection, left atrial enlargement, male sex, and a neutrophil-lymphocyte ratio >3.0 at the follow-up were significantly associated with 5-year CVE recurrence. Left atrial enlargement and a neutrophil-lymphocyte ratio >3.0 at the follow-up remained significantly associated with 5-year CVE recurrence in multivariate analysis. The neutrophil-lymphocyte ratio may prognosticate tumor size and recurrence of neurologic events. An increased risk of CVE within 5 years of mass resection is almost exclusive to patients initially presenting with CVEs.

Left Atrial Appendage Closure: What Do We Know?

Atrial fibrillation (AF) is the most common arrhythmia in the United States and the most common cause of embolic cerebrovascular events, with the majority of these thrombi originating in the left atrial appendage. The left atrial appendage (LAA) has separate developmental, ultrastructural, and physiological characteristics from the left atrium. Although LAA anatomy is highly variable, it can be categorized into 4 types: cactus, cauliflower, chicken wing, and windsock. The cauliflower type is associated with higher stroke risk in patients with nonvalvular AF. Although the cornerstone of therapy to prevent embolic strokes from AF has been anticoagulation with thrombin inhibitors, a large group of patients are unable to tolerate anticoagulation due to bleeding. This has led to the development and advancement of multiple surgical and percutaneous LAA closure devices to prevent embolic cerebrovascular accidents without the need for anticoagulation. In this article, we discuss the outcomes of major studies that utilized surgical LAA occlusion and its effectiveness. Furthermore, we summarize nonsurgical methods of LAA closure and future directions regarding LAA closure.

Familial cardiolaminopathy due to a previously undescribed LMNA gene mutation

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Cardiolaminopathies are rare genetic alterations, which present diverse mechanical and electrical alterations. OBJECTIVE To present a family carrying an LMNA gene mutation that although not described manifest clinical and electrocardiographic characteristics of the disease. Methods We present the case of two sisters and one brother, aged 65, 57 and 51 years, respectively. At the beginning of their fourth decade, all of them debuted with atrial flutter associated with second and third degree atrioventricular block. Two of them (one or the sisters and the brother) underwent ablation of isthmus-dependent atrial flutter. However, in both, the flutter recurred and no new interventional treatment was further offered. The male subject received a pacemaker implant for treatment of AV block; some years later, he presented a cerebrovascular event and subsequently a recurrence, both while in oral anticoagulation and, actually remains with moderate motor deficit and dysarthria. The youngest woman suffered an embolic cerebrovascular event when she was 50 y/o; she remained asymptomatic in relation to the rhythm disorder and refused a pacemaker. The oldest sister who is asymptomatic, received a pacemaker when she was 45 y/o and now is anticoagulated. By echocardiography, all siblings presented left ejection fraction in between 40 and 50% with decreased strain values and normal left ventricular geometry. Results Recently in our country it is possible to carry out a genetic test, for which the three were subjected to it. In this family, the genetic testing was done using a comercial kit for 172 genes. The result was a Frameshift Indels (non misense) mutation NM_170707.3 c.1526del p.(Pro509LeufsTer39) Exon:9/12, in all three. The caveat is that this LMNA gene mutation has not been previously described. In light of these results, the youngest woman with total AV block and sequelae of cerebrovascular disease and mild left ventricular dysfunction, received an implantable cardiac defibrillator (ICD) implant for primary prevention of sudden death and her siblings are undergoing an upgrade to ICD. Conclusion The mutation found in this family is unique and for the first time reported in the LMNA gene in the world. Genetic diagnosis is limited in our country, which makes it difficult to determine this type of pathology. However, given the clinical presentation of an electrical disorder in all the siblings of a family, in this particular case, it was mandatory to perform this test. These results allow us to better understand the prognosis and intervene appropriately to prevent sudden death, even though there is no treatment to avoid the progression of the disease.

Effectiveness of atrial fibrillation on high-intensity transient signals to cerebral circulation during TAVI

Abstract Background Cerebral microemboliazations remain a major concern peri-operatively and following Transcatheter Aortic Valve Implantation (TAVI). We evaluated whether atrial fibrillation may predispose to an increased number of cerebrovascular emboli during the procedure. Purpose The aim of the study was to evaluate, using a transcranial doppler, the effect of atrial fibrillation on transient high-intensity signals to middle cerebral arteries during transcatheter aortic valve implantation. Methods Consecutive patients who underwent transfemoral TAVI with Evolut™ R bioprosthesis, were categorized into two groups. Group A patients with permanent atrial fibrillation (AF) on anticoagulation, Group B patients with sinus rhythm (SR). Dual antiplatelet therapy with aspirin and clopidogrel was administered to all patients 24 hours prior to the procedure at loading dose, with patients in Group A receiving in addition low-molecular-weight-heparin. The number of detected High Intensity Transient Signals (HITS) was assessed using Rimed Digi-Lite™ Transcranial Doppler on both cerebral arteries during the following phases of the procedure; Phase 0: 30 minutes prior to procedure initiation, Phase I: between access site puncture and introduction of the delivery system, Phase II: during the implantation of the bioprosthesis, until the removal of the delivery system. All implantations were performed without predilation. Furthermore, patients were evaluated by neurologist before TAVI and on discharge day. Safety was evaluated according to VARC-2 criteria. Results Twenty-eight patients were evaluated (81±6 years, 16 males (57.1%)). Group A had higher number of total (786±95 vs. 604±103, p=0.002) as well as Phase I HITS (393±94 vs. 285±86, p=0.002). One cerebrovascular event was recorded in Group A and one patient categorized to Group B developed major bleeding due to conversion to femoral surgical cut-down. The average number of received blood units, was higher in AF compared to SR Group (Group 1: 0.8±1.9 vs. Group 2: 0.5±0.7, p: 0.886), without however, reaching statistical significance. Conclusion Patients with atrial fibrillation had larger burden of embolic HITS during TAVI indicating high risk patients for embolic cerebrovascular events. This may has implications for future strategies for cerebral embolic protection. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): Ippokrateio General Hospital of Athens

Stroke and presence of patent foramen ovale in sickle cell disease.

Sickle cell disease (SCD) is an inherited monogenic hemoglobinopathy characterized by formation of sickle erythrocytes under conditions of deoxygenation. Sickle erythrocytes can lead to thrombus formation and vaso-occlusive episodes that may result in hemolytic anemia, pain crisis and multiple organ damage. Moreover, SCD is characterized by endothelial damage, increased inflammatory response, platelet activation and aggravation, and activation of both the intrinsic and the extrinsic coagulation pathways. Cerebrovascular events constitute an important clinical complication of SCD. Children with SCD have a 300-fold higher risk of acute stroke and by the age of 45 about 25% of patients have suffered an overt stoke. Management and prevention of stroke in patients with SCD is not well defined. Moreover, the presence of patent foramen ovale (PFO) increases the risk of the occurrence of an embolic cerebrovascular event. The role of PFO closure and antiplatelet or anticoagulation therapy has not been well investigated. Moreover, during COVID-19 pandemic and taking into account the increased rates of thrombotic events and the difficulties in blood transfusion, management of SCD patients is even more challenging and difficult, since data are scarce regarding stroke occurrence and management in this specific population in the COVID-19 era. This review focuses on pathophysiology of stroke in patients with SCD and possible treatment strategies in the presence of PFO.

Can Anticoagulation Be Stopped After Ablation of Atrial Fibrillation?

This review discusses the pros and cons of discontinuing oral anticoagulation therapy (OAT) after catheter ablation of atrial fibrillation (AF), and data from relevant studies, and summarizes the most recent Expert Consensus recommendations on the topic. Patients with AF are at risk of cerebrovascular embolic events (CVEs) including stroke and transient ischemic attacks. OAT can be effective in preventing CVEs, while catheter ablation is an effective treatment to eliminate AF. Whether OAT can be safely discontinued after successful AF ablation remains a controversial topic. Retrospective studies have suggested that successful AF ablation may mitigate the risk of CVE such that OAT may be discontinued in select patients after AF ablation. In certain patients with AF who undergo successful AF ablation, OAT might be able to be safely discontinued with continued long-term rhythm monitoring.

Acute Abdominal Pain in a COVID-19 Patient

Clinical Images in Nephrology and Dialysis Case Report A 69-year-old woman with a medical history of diabetes, hypertension, coronary artery disease, and acute embolic cerebrovascular event postcardiac catheterization in 2016 presented to the emergency department with acute abdominal pain. Before this, she had been evaluated for symptoms of cough, shortness of breath, and myalgias which were conservatively managed with improvement. She now presented with intermittent pain of diffuse, nonspecific distribution, associated with nausea and nonbloody emesis. The patient also had lower back pain but not in either flank region. She denied history of trauma or urinary symptoms. Her medications included aspirin, clopidogrel, furosemide, and insulin. Examination was significant for diffuse nonspecific abdominal tenderness without rebound or guarding. Laboratory assessment revealed creatinine of 1.10 mg/dl, elevated level of c-reactive protein at 20 mg/dl, sedimentation rate of 112 mm/h, lactic dehydrogenase level of 458 U/L, fibrinogen level of 737 mg/dl, and she tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Urine evaluation had 1.5 g of protein/g creatinine without hematuria. A computed tomography of the abdomen and pelvis with intravenous contrast revealed a nonocclusive thrombus in the left renal artery (Figure 1, A and B) with several large wedge-shaped areas of decreased enhancement, consistent with multiple left renal infarctions (Figure 1C). She was started on an intravenous heparin drip and transitioned to apixaban. During her hospitalization, her abdominal pain improved, renal function remained preserved, and she was then discharged.Figure 1.: Computerized tomography (CT) scan. (A and B) Thrombus in the left renal artery represented by greens arrows. (C) Decreased enhancement consistent with multiple left renal infarctions represented by red arrow.Discussion What began as a series of cases of viral pneumonia initially described in Wuhan, Hubei, China, rapidly spread to emerge as a global pandemic. The virus was identified as SARS-CoV-2 and is the cause of coronavirus disease 2019 (COVID-19). Kidney injury has been associated with this infection, although the exact mechanism of injury remains unclear. Increased severity of illness has been associated with the development of coagulopathy (1). Laboratory abnormalities including leukopenia, lymphopenia, elevated prothrombin time, and d-dimer have been found in patients who are critically ill (2). A case series from Wuhan described patients with COVD-19 testing positive for anti-cardiolipin IgA and anti–β2-glycoprotein I IgA and IgG antibodies (3). Although not specific to this infection, it is hypothesized to be associated with the development of both micro- and macrovascular thrombi. A small study observed a mortality benefit in patients with severe sepsis receiving anticoagulation with low mol wt heparin (low mol wt heparin 40% versus controls 64%) (4). These preliminary data have led international societies to recommend anticoagulation in patients who are critically ill and infected with SARS-CoV-2. Literature has described both microvascular and macrovascular coagulopathy to be associated with severe COVID-19 infection (1); however, abnormal coagulation with the development of clots has not been described in patients with relatively mild disease. Whereas venous thromboembolism and pulmonary embolism have been reported (5), no reports of renal artery thrombosis or renal infarction have been described. Our patient with relatively mild COVID-19 had derangements in coagulation markers and had a renal artery thrombus with renal infarction. Further studies are warranted to evaluate whether renal infarctions are playing a role in the AKI and whether prophylactic anticoagulation could have benefit in renal outcomes. Teaching Points Patients who present with SARS-CoV-2 infection, regardless of severity of disease, should be evaluated for coagulopathy and development of thrombi because these may potentially contribute to infarction and end-organ damage. Renal infarction should be considered part of the differential when evaluating a patient with COVID-19 presenting with abdominal pain or AKI. Initiation of anticoagulation should be considered in those who are critically ill, although it would be imperative to weigh the risks and benefits of this intervention. Disclosures All authors have nothing to disclose. Funding None.

Safety and Efficacy of Cryoballoon Ablation for the Treatment of Atrial Fibrillation in Diabetic Patients.

Cryoballoon based catheter ablation (CB-CA) is an established therapy for treatment of symptomatic atrial fibrillation (AF). However, data about AF ablation using the CB in the diabetic population is sparse. The aim of this single center retrospective study is to evaluate the safety and efficacy of CB ablation in patients with diabetes mellitus (DM) as compared to patients without DM. Between July 2015 and December 2017, 397 consecutive patients underwent CB-CA for AF. Forty-eight consecutive patients with DM (DM group, study group) were compared with propensity score-matched patients without DM (n=48, control group). All patients underwent pulmonary vein isolation (PVI) using the second-generation CB (CB2). The mean age in the DM group was 66.9±9.5 years and 69.5±8.8 in the non-DM group (p=0.18). During a follow-up of 12.7±5.1 months, single procedure success rate for the DM and the non-DM group was 68.7% and 70.8%, respectively (p=0.82). The most common complication was transient phrenic nerve palsy (4 DM group vs. 0 non-DM group, p=0.04). No severe complication such as procedure related deaths, atrio-esophageal fistula or cerebrovascular embolic events occurred. Our data strengthen the value of CB2 based ablation for the treatment of AF as an effective and safe procedure in DM patients, with similar success rates when compared with a non-DM population.

P1320 Percutaneous mitral valve leaflet plication to reduce systolic anterior motion and mitral regurgitation using the transcatheter mitral clip system

Abstract A 72-year-old female patient with a past medical history of severe mitral regurgitation, atrial fibrillation and embolic cerebrovascular events was admitted to our institution. The patient was under optimal medical therapy and complained for progressive worsening of activity-related dyspnea with limitation of physical activity (NYHA III). Transthoracic echocardiography showed the presence of severe mitral regurgitation with a central jet. There was prolapse of both mitral valve leaflets and interestingly the anterior leaflet presented systolic anterior motion (SAM) at the same time. There was no significant left ventricular outflow tract obstruction (LVOT). Further evaluation of the regurgitant mitral valve with a transesophageal echocardiography (TOE) confirmed the above findings and the mechanism of MV regurgitation was attributed to prolapse in addition to SAM of an elongated anterior leaflet. Laboratory test showed elevated NT-pro-BNP levels. A coronary angiography was performed and excluded significant coronary artery disease. The findings were assessed by our institution’s HEART TEAM and, in the presence of high surgical risk (LogEuroscore 32,76%), a decision for transcatheter mitral valve repair with a Mitral Clip implantation was taken. The Mitral Clip was succesfully implanted with immediate significant reduction of the regurgitant jet and no signs of stenotic behavior of the repaired valve. There was only mild mitral valve regurgitation. Notably, after the procedure there was elimination of the SAM and no LVOT obstruction (Figure). In accordance to the echocardiography findings, the patient demonstrated a significant clinical improvement and was discharged home 1 day after the procedure. Mitral clip implantation in this case showed improvement of the MR by reducing the SAM of the mitral valve. Abstract P1320 Figure.

Central Ambulatory Veno-Arterial Extracorporeal Membrane Oxygenation in Lung Transplantation

Purpose Central veno-arterial (VA) ECMO provides reliable cardiopulmonary support in selected patients with end-stage lung diseases and severe pulmonary hypertension or cardiac instability. Ambulation dramatically improves patient outcomes. We investigated the outcomes of a new technique of ambulatory central VA ECMO via tunneled cannula insertion and right thoracotomy. Methods Candidates for lung transplantation who required respiratory and cardiac support were taken to the operating room for central VA ECMO cannulation. In the OR, the right 3rd rib is identified and a medial segment is removed. The pericardium is opened and pursestrings are placed on the mid-ascending aorta and right atrial appendage. Aortic and venous cannula are advanced through 1cm incisions lateral to the thoracic incision. Heparin is administered and the aorta and right atrium are then cannulated. A chest tube is placed and the incision is closed. A prospectively maintained institutional database was analyzed. All patients who were cannulated for central ECMO via right thoracotomy for the purpose of ambulatory circulatory support were included. Results Fifteen patients underwent central VA-ECMO cannulation from April 2016 to July 2018 via the above technique. The mean age was 51 (range 29-67). 8 (53%) were male. The indications for VA ECMO were end-stage lung diseases and pulmonary hypertension/cardiac instability in all patients. 12 patients ultimately underwent lung transplantation, and 3 patients expired prior to definitive therapy. The mean duration of ECMO support was 546.4 hours (range of 46-2004 hours). All patients were either ambulatory while on ECMO, or able to stand. One patient had post-operative bleeding requiring return to the operating room. One patient had an embolic cerebrovascular event without residual deficits. All patients who survived to transplantation were discharged from the hospital. Conclusion We describe a central ECMO cannulation strategy that allows ambulation while avoiding the vascular, infectious, and flow limiting issues associated with alternative site cannulation. The above technique offers a minimal access approach that allows full pre-transplant optimization with an acceptable risk profile.

ASSOCIATION BETWEEN ATRIAL SEPTAL DEFECTS AND EMBOLIC CEREBROVASCULAR EVENTS IN ADULT PATIENTS ADMITTED FOR ACUTE PULMONARY EMBOLISM

Atrial septal defect is a common congenital heart disease. We designed a propensity-match analysis to describe the outcomes of acute PE in patients with ASD. Our primary outcome of interest was embolic cerebrovascular events (stroke/TIA). Using the National Inpatient Sample database, we extracted

Abstract 16778: Effectiveness of Platelet Inhibition on Reducing High-Intensity Transient Signals to Cerebral Circulation During Tavi

Introduction: Despite the established dual antiplatelet treatment, embolic cerebrovascular events remain a major concern peri-operatively and following Transcatheter Aortic valve Implantation (TAVI). High Residual Platelet Reactivity (RPR) may contribute to platelet aggregation, propagating thrombosis on implanted materials. Therefore, we evaluated whether high RPR may predispose to an increased number of cerebrovascular emboli during the procedure. Methods: Consecutive patients who underwent transfemoral TAVI with Evolut™ R bioprosthesis were prospectively studied. Dual antiplatelet therapy with aspirin and a P2Y12 inhibitor was administered to all patients 24 hours prior to the procedure at loading dose. The number of detected High Intensity Transient Signals (HITS) was assessed using Rimed Digi-Lite™ Transcranial Doppler on both cerebral arteries during the following phases of the procedure; Phase 0: 30 minutes prior to procedure initiation, Phase I: between access site puncture and introduction of the delivery system, Phase II: during the implantation of the bioprosthesis, until the removal of the delivery system. Platelet inhibition was measured prior to the procedure and expressed in PRU, using the VerifyNow® assay and defined as high RPR if PRU≥208. Results: Out of 28 total patients (81±7 years, 18 males (64%)), 12 patients (81±9 years, 8 males (66.7%)) had PRU ≥208 (high RPR group), while 16 patients (81±5 years, 10 males (62.5%)) had PRU&lt;208 (low RPR group). All device implantations were performed without balloon pre-dilation. Among the high RPR group, a statistically significant higher number of HITS was recorded compared to the low RPR group (707±149 vs. 530±152, p: 0.004). This was mainly driven by the number of HITS detected during Phase II, compared to the rest procedure stages (247±84 vs. 165±28, p:0.004). A statistical significant correlation of PRU with the total number of HITS was found (r2: 0.25, p: 0.006). Conclusions: High RPR after dual antiplatelet loading resulted in larger burden of embolic HITS during TAVI. This may has implications for future strategies for cerebral embolic protection.

Safety and efficacy of cryoballoon ablation for the treatment of atrial fibrillation in elderly patients.

Catheter ablation (CA) is an established therapy for treatment of atrial fibrillation (AF). However, data about AF ablation using the cryoballoon (CB) in the elderly population are sparse. The aim of this single center retrospective study is to evaluate the safety and efficacy of CB ablation in patients ≥ 75years compared to patients < 75years. Fifty-five consecutive patients aged ≥ 75years (elderly group) were compared with 183 patients aged < 75years (control group). All patients underwent pulmonary vein isolation (PVI) using the second-generation CB. The mean age in the elderly group was 78 ± 2.8years and 60.8 ± 9.5 in the control group (p < 0.001). During 11.8 ± 5.4months of follow-up, single procedure success rate for the elderly and the control group was 72.8 and 76%, respectively (p = 0.37). During redo ablation (n = 40), low-voltage areas in the LA were more frequently observed in elderly patients compared to the control group [1.0 (IQR 0-2.0) segments vs 2.0 (IQR 2.0-3.0) segments, respectively, p = 0.03]. The most common complication was transient phrenic nerve palsy, which only occurred in patients < 75years (0 vs 7, p = 0.33). No severe complication such as procedure-related deaths, atrio-esophageal fistula, or cerebrovascular embolic events occurred. Our data strengthen the value of CB ablation for the treatment of AF as an effective and safe procedure in elderly patients, with similar success and complication rates when compared with a younger population.

Left Ventricular Thrombi in Takotsubo Syndrome: Incidence, Predictors, and Management: Results From the GEIST (German Italian Stress Cardiomyopathy) Registry.

BackgroundLeft ventricular (LV) thrombi during Takotsubo syndrome represent a potential complication and can be associated with cerebrovascular embolic events. The aim of this study was to evaluate the exact incidence, predictors, and management strategies of LV thrombi in patients with Takotsubo syndrome.Methods and ResultsWe enrolled 541 consecutive patients in a multicenter international registry. Clinical features and echocardiographic data at admission, during hospitalization, and after 3 months were evaluated. Survival rates for long‐term follow‐up (mean 984±908 days) were recorded. Twelve Takotsubo syndrome patients (2.2%) developed LV thrombi (all female presenting with apical ballooning pattern). All patients with LV thrombi were treated with oral anticoagulation therapy; however, 2 (17%) had a stroke before treatment initiation. These patients were characterized by a higher prevalence of ST‐elevation (56% versus 16%; P<0.001) and higher troponin I levels (10.8±18.3 ng/mL versus 3.5±4.3 ng/mL; P=0.001) as compared with those without LV thrombi. At multivariate analysis including age, sex, LV ejection fraction, ST‐elevation at admission, and apical ballooning pattern, troponin I level >10 ng/mL was the only predictor for LV thrombosis (hazard ratio 6.6, confidence interval, 1.01–40.0; P=0.04). After 3 months all LV thrombi disappeared. Oral anticoagulation therapy was interrupted in all patients except 1. At long‐term follow‐up, the survival rate was not different between patients with and without LV thrombi (84% versus 85%; P=0.99).Conclusions LV thrombi have a relatively low incidence among patients with Takotsubo syndrome and were detected in female patients with apical ballooning pattern and increased troponin levels. Oral anticoagulation therapy for 3 months seems reasonable in these high‐risk patients.

Cierre percutáneo de la orejuela izquierda: revisión sistemática de los resultados de seguridad y eficacia

Introduction and objectivesThe aim of the present study is to systematically review the success rate of percutaneous left atrial appendage closure, its efficacy and safety, and the incidence of peri-device leakage. MethodsA bibliographic search was performed using the Google Scholar, MEDLINE, EMBASE and Cochrane databases, restricting this search in English and collecting articles published until 2016. Our analysis was limited to those studies that met the following inclusion criteria: 1) studies with a prospective unicenter, prospective multicenter and retrospective multicentre design. 2) Studies that had a sample size ≥ 80 patients. ResultsData from the two clinical trials (PROTECT-AF and PREVAIL) suggest that percutaneous exclusion of the left atrial appendage provides a similar long-term rate of cerebrovascular embolic events and mortality compared to warfarin therapy. In the PROTECT AF study, an incidence of peri-device leak of 39% is documented. The remaining studies, which analyze patients with contraindications to anticoagulation and without a control group, report a significant rate of severe complications related to the procedure (up to 13,7%), the most frequent cause being pericardial effusion and/or cardiac tamponade. ConclusionsPercutaneous closure of the left atrial appendage is associated with a significant incidence of severe periprocedural complications and peri-device leak.

Subacute Subclinical Brain Infarctions after Transcatheter Aortic Valve Implantation Negatively Impact Cognitive Function in Long-Term Follow-Up.

AimsTo date every post-procedural cerebrovascular embolic event (CVE) is dreaded for its potential to accelerate cognitive decline after transcatheter aortic valve implantation (TAVI). This study differentiates the impact of acute (procedural) and post-acute cerebrovascular embolic events (CVEs) on cognitive performance.MethodsMagnetic resonance imaging (MRI) before, early and late after TAVI was performed to quantify embolic burden. Quantification of diffusion- and T1-weighted lesions, as well as white-matter and total brain volumes, as well as cognitive function testing (MMSE) were assessed in 28 patients with a medium follow-up period of 34 months.ResultsProcedural diffusion-weighted lesions were observed in 17 patients (61%), but demonstrated locoregional remnants only in a minority of patients in long-term follow-up (6.5%). Acute CVEs did not impact the trajectory of late silent brain infarctions (SBI), white-matter hyperintensities, and cerebral atrophy. Functionally, early CVEs did not affect cognitive function. In contrast, patients with “new” SBIs after TAVI had a trend to cognitive deterioration in long-term follow-up (“new”SBI: MMSE -1.4 / no “new”SBI: MMSE +1.5, p = 0.067). Interestingly, only a fraction of these “new” SBIs evolved from procedural CVEs (22.2%).ConclusionsAquired SBIs after TAVI, but not DW-CVE per se are associated with functional impairment long-term after TAVI. In the context of subacute thrombosis seen in TAVI prostheses, these findings set the stage for tailored stroke prevention and comprehensive surrogate endpoint definitions in neuroprotective trials.

Silent cerebral emboli following percutaneous closure of atrial septal defect in pediatric patients: a diffusion-weighted MRI study.

The aim of this prospective study was to investigate the incidence of silent cerebrovascular embolic events associated with percutaneous closure of atrial septal defect (ASD) in pediatric patients. A total of 23 consecutive pediatric patients (mean age, 10.4±3.8 years; range, 4-17 years) admitted for transcatheter closure of ASD were recruited in the study. The patients were scanned with a 1.5 Tesla clinical scanner. Two cranial magnetic resonance imaging (MRI) examinations were acquired before the procedure and within 24 hours following the catheterization. MRI included turbo spin-echo fluid-attenuated inversion recovery (FLAIR) sequence and diffusion-weighted imaging technique with single-shot echo-planar spin-echo sequence. The transcatheter closure of ASD was performed by three expert interventional cardiologists. Amplatzer septal occluder device was implemented for the closure of the defect. No contrast medium was administered in the course of the procedure. None of the patients had diffusion restricted cerebral lesions resembling microembolic infarctions on postprocedural MRI. Preprocedural MRI of two patients revealed nonspecific hyperintense white matter lesions on FLAIR images with increased diffusion, which were considered to be older ischemic lesions associated with previously occurred paradoxical embolism. The current study suggests that percutaneous closure of the ASD, when performed by experienced hands, may be free of cerebral microembolization in pediatric patients. However, due to the relatively small sample size, further studies with larger patient groups are needed for the validation of our preliminary results.

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