Rate Of Cerebrovascular Events Research Articles

Direct Oral Anticoagulants Versus Vitamin K Antagonists After Mitral Valve Transcatheter Edge-to-Edge Repair in Patients With Atrial Fibrillation: A Single-Center Observational Study.

Mitral valve transcatheter edge-to-edge repair (M-TEER) has emerged as a viable therapy option in patients with severe mitral regurgitation and high surgical risk. Although atrial fibrillation is common among patients undergoing M-TEER, the optimal anticoagulatory treatment after the intervention is unknown. A single-center retrospective observational analysis was conducted using data from the M-TEER registry at the University Hospital Cologne collected from 2019 untill 2021 including patients undergoing M-TEER between November 2012 and April 2019. Patients with atrial fibrillation receiving consistent anticoagulation following M-TEER were categorized into a direct oral anticoagulant or a vitamin K antagonist (VKA) group. The primary end point was a composite of ischemic cerebrovascular and bleeding events. Additionally, overall survival was assessed. Among 613 patients undergoing M-TEER, 206 met the inclusion criteria, with 61 receiving direct oral anticoagulants and 145 receiving VKAs. After a median follow-up of 833 (interquartile range, 355-1271) days, the incidence of the composite primary end point did not differ between direct oral anticoagulant and VKA groups (hazard ratio [HR], 0.51 [95% CI, 0.23-1.12]; P=0.07). Similarly, rates of ischemic cerebrovascular events and bleeding events were similar between groups. However, the overall mortality rate was higher in the VKA group (HR, 2.56 [95% CI, 1.54-4.26]; P=0.002). In the multivariable analysis, oral anticoagulation with a VKA was an independent predictor for death (adjusted HR, 2.23 [95% CI, 1.08-5.06]; P=0.03). Our findings suggest that direct oral anticoagulants may offer comparable efficacy and safety to VKAs in preventing thromboembolic events following M-TEER in patients with atrial fibrillation. Further randomized trials are needed to confirm these results and establish optimal anticoagulation strategies in this patient population.

Amphetamine use as a predictor of cardiovascular and cerebrovascular mortality and morbidity: a longitudinal cohort study of criminal justice clients

IntroductionAmphetamine use is an increasing problem, and studies suggest a connection between amphetamine use and cardiovascular and cerebrovascular pathology. However, few long-term studies examine amphetamine users' risk of cardiovascular and cerebrovascular pathology, in comparison to users of other drugs. In addition, in a criminal justice system, illicit drug use and psychiatric comorbidity is common, whereas structured treatment and follow-up is uncommon, and stimulant use is common in this setting. The aim of this study was to investigate the risk of cardiovascular and cerebrovascular morbidity and mortality for intravenous drug users with different drugs as the primary drug, using data from the criminal justice system.MethodsA cohort of injecting substance users (N = 2,422) was identified in the Swedish criminal justice system through interviews with the Addiction Severity Index (ASI) between January 2001 and August 2006. Data on age, sex, self-reported injection drug, tobacco use, and time in prison or custody were retrieved from the ASI database. The clients were followed in national registers up to 2014 with respect to cardiovascular and cerebrovascular morbidity and mortality. Potential predictors of cardiovascular and cerebrovascular events were investigated.ResultSelf-reported main drug was amphetamine in 51.5% (n = 1,247), polysubstance use in 33% (n = 799), and heroin in 15.5% (n = 376) of the cohort. Total observational time for the entire cohort was 23,911 person-years [median 10.3 years (IQR 9.3–11.2 years)]. The highest incidence rates of both cardiovascular and cerebrovascular events were found among amphetamine users. Bivariate analyses showed a significantly higher percentage of cardiovascular events in amphetamine users compared to other substance users (p < 0.044). Amphetamine was not significantly associated with cardiovascular or cerebrovascular events, compared to the main drug heroin or polysubstance use.ConclusionIn this study on substance-using criminal justice clients, while the highest incidence rates of both cardiovascular and cerebrovascular events were found among amphetamine-using individuals, the study did not provide evidence of an independent association. The study highlights the need to take co-factors into account, such as comorbidities and socio-economic factors. More studies are needed to distinguish substance-specific pathology from the impact of other unhealthy lifestyle factors among substance-using individuals.

A systematic literature review to evaluate the cardiac and cerebrovascular outcomes of patients with Fabry disease treated with agalsidase Beta.

Agalsidase beta is used to treat Fabry disease (FD); however, data on cardiac and cerebrovascular outcomes with agalsidase beta treatment come from studies with limited numbers of patients. A systematic literature review of studies reporting on the efficacy and effectiveness of agalsidase beta in FD was conducted. Studies were identified in searches of MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials from January 2000-June 2022. Outcomes of interest included cardiac structure and mass, cardiac events, and cerebrovascular events. Fifty-two citations (41 studies) were included. Reductions in interventricular septal thickness (IVST) and/or left ventricular posterior wall thickness (LVPWT) were demonstrated in six studies (follow-up 1-6 years, n = 4 using echocardiography, n = 2 cardiac MRI). IVST ranged from 12.1-14.9 mm at baseline and 10.8-14.1 mm at follow-up (all p < 0.05). LVPWT ranged from 11.7-16.0 mm at baseline and 10.7-13.0 mm at follow-up (all p < 0.05). Significant reductions in cardiac mass were demonstrated after 1 year of treatment in a single-arm study using cardiac MRI [left ventricular mass (LVM) 193-178 g; LVM index 102-94 g/m2; both p < 0.05]. Rates of composite cardiac events (3.8%-24.0%; four studies, follow-up 2-10 years) and cerebrovascular events (0.0%-18.9%; 12 studies, follow-up 1-10 years) were numerically lower than rates for placebo (follow-up 3 years). Literature over the last 20 years indicates that agalsidase beta treatment may lead to stabilization or regression of cardiac structural thickness and mass, and reduction in cardiac and cerebrovascular events relative to placebo.

Current and Projected Burden of Ischemic Cerebrovascular Events: Nationwide Estimates From the Dijon Stroke Registry, France.

This study aimed to assess attack rates of ischemic cerebrovascular events (CVEs) in a population-based registry and to estimate the current and projected burden of the disease in whole France. All cases of ischemic CVE (including ischemic stroke and transient ischemic attack) were prospectively identified through the population-based Dijon Stroke Registry, France (2013-2020). Annual attack rates and temporal trends were assessed. The number of patients in whole France and projections by 2050 were estimated by standardization to age- and sex-specific attack rates. A total of 2869 cases of ischemic CVE were recorded (mean age, 75.7±15.9 years, 54.4% women) including 1763 ischemic stroke and 1106 transient ischemic attack (crude attack rate, 230/100 000 per year). The age-standardized rate was 237 (95% CI, 229-246), with rates of 144 (95% CI, 137-150) for ischemic stroke and 93 (95% CI, 88-98) for transient ischemic attack. The rates were 152 (95% CI, 145-159) and 85 (95% CI, 80-90), respectively, when considering the tissue-based American Heart Association/American Stroke Association definition. The attack rate during the 2019 to 2020 period was slightly lower than that observed during 2013 to 2014 (age-standardized attack rate ratio, 0.90[95% CI, 0.81-0.99]; P=0.035) but did not differ from that of other periods. The number of ischemic CVEs was estimated to be 164 126 annually in France during 2013 to 2020. An increase of 35% and 56% is expected by 2035 and 2050, respectively. Our study highlighted a high burden of ischemic CVE that has been largely underestimated in France by administrative databases. Despite roughly stable attack rates over time, the absolute number of cases is expected to dramatically increase in coming years, thus questioning the sustainability of the health care system.

Time trends of catheter-directed treatment in acute pulmonary embolism in Germany.

Catheter-directed treatment (CDT) is an innovative treatment for patients with elevated risk pulmonary embolism (PE) to resolve embolus and restore pulmonary perfusion. We aimed to analyse the use and the benefit of CDT in PE patients in Germany. The German nationwide inpatient sample was used to include all hospitalizations of patients with PE from 2005 to 2020 in Germany. PE patients were stratified for CDT usage. Temporal trends and the impact of CDT on case fatality and other outcomes were investigated. Overall, 1,373,084 hospitalizations of patients with PE (55.9% aged ≥70 years; 53.0% females) were included in this study from 2005 to 2020, and among these, 427,238 (31.1%) patients were categorized as having elevated-risk PE and 3330 (0.2%) were treated with CDT with annual increase from 0.17% (2005) to 0.51% (2020). PE patients of younger age, male sex, with previous surgery, and elevated-risk PE were more often treated with CDT. In patients with elevated risk-PE, CDT attributed to a lower observed rate of major adverse cardiac and cerebrovascular events (major adverse cardiac and cerebrovascular events [MACCE]; 28.2% vs 34.2%; P< .001) and in-hospital case fatality (24.9% vs 31.0%; P< .001). CDT was associated with reduced MACCE (OR, 0.91; 95% CI, 0.83-0.99) and with a trend toward lower case fatality (OR, 0.92; 95% CI, 0.84-1.01). The benefit of CDT regarding case fatality was age-dependent. Although the annual rate of CDT increased in Germany between 2005 and 2020, only 0.2% of the PE patients were treated with CDT. Selection criteria for CDT treatment were younger age, male sex, previous surgery, and elevated risk-PE. CDT treatment was associated with reduced MACCE and case-fatality rate in PE patients with elevated-risk PE.

Abstract 4125606: Systolic Blood Pressure During Sleep Determined by Pulse Transit Time Predicts Worsening Heart Failure in Patients with Heart Failure

Introduction: Intensive blood pressure (BP) lowering therapy is associated with lower rates of major adverse cardiac and cerebrovascular events in the general population. On the other hand, lower daytime systolic BP (SBP) is associated with higher mortality in patients with heart failure (HF). However, prognostic impact of SBP during sleep was unclear in patients with HF. Methods and Results: We measured continuous SBP during sleep non-invasively by pulse transit time in 379 patients with HF (median age 71, male 53.6%). Beat-to-beat SBP was calculated based on pulse transit time, which was defined as the travel time from the R-wave of electrocardiogram to the pulse wave at the finger detected by plethysmography. Mean values of SBP during sleep were used in the present study. The primary endpoint was hospitalization for worsening HF. The patients were divided into three groups based on the tertiles of SBP during sleep: High SBP group (median SBP 138 mmHg, n = 127), Middle SBP group (median SBP 117 mmHg, n = 127), and Low SBP group (median SBP 100 mmHg, n = 125). The Low SBP group showed the youngest age (High, Middle, and Low groups; 73, 73, 68 years, P &lt; 0.001). Levels of B-type natriuretic peptide (207.7, 216.7, and 407.2 pg/mL, P = 0.039) and estimated glomerular filtration rate (52.6, 54.0, and 57.1 mL/min/1.73 m 2 , P = 0.041) were the highest in the Low SBP group. During the follow-up period of median 1,083 days after SBP measurement, 66 patients experienced hospitalization for worsening HF. Kaplan-Meier analysis revealed that primary endpoint occurred most frequently in the Low SBP group ( Figure ). Multivariable Cox proportional hazard analysis showed that the lowest SBP tertile was associated with the primary endpoint compared to the highest SBP tertile (hazard ratio 2.546, 95% confidence interval 1.257–5.158, P = 0.009). Conclusion: Low SBP during sleep was associated with hospitalization for HF in patients with HF.

Sex-Based Differences in Long-Term Outcomes Following Transcatheter Closure of Patent Foramen Ovale for Cryptogenic Stroke.

Evidence from trials suggests that patent foramen ovale closure is superior to medical therapy alone in reducing stroke recurrence in men but not in women. Evidence from real-world data on the impact of sex on outcomes after patent foramen ovale closure, however, remains scarce. Therefore, the present study aimed to assess sex-based differences in long-term outcomes after transcatheter closure of patent foramen ovale. This was a single-center, retrospective cohort study enrolling patients who underwent transcatheter patent foramen ovale closure to prevent recurrent cerebrovascular events. Detailed information from medical charts was entered into a clinical registry, which has been linked to population-based administrative health databases in Ontario. Procedural, short, and long-term outcomes have been compared by sex. Of the 783 patients included in the sample, 349 (44.5%) were women and 434 (55.5%) were men. Women were younger and had a higher rate of migraine, while men had a higher prevalence of cardiovascular risk factors. No differences were observed in procedural and 30-day outcomes by sex. At a median follow-up of 14 years, the event rates of recurrent cerebrovascular events, survival, and new-onset atrial fibrillation were not different by sex. In adjusted analysis, men experienced higher rates of pacemaker implantation (hazard ratio, 5.62 [95% CI, 1.57-20.1]). No sex-based differences in recurrent cerebrovascular events, survival, or new-onset atrial fibrillation were observed in this study, suggesting equal benefits for both sexes. Future studies should report outcomes by sex to enhance the reproducibility of our findings and help support guideline development.

Presence of patent foramen ovale does not increase cerebrovascular event rates in patients with atrial fibrillation following left atrial appendage closure

ObjectiveBoth atrial fibrillation (AF) and patent foramen ovale (PFO) has been associated with occurrences of ischemic stroke. The aim of this study was to investigate whether patients with concomitant AF and PFO were at an increased risk of stroke, and whether PFO closure was necessary for the prevention of stroke in AF patients who underwent left atrial appendage closure (LAAC). MethodWe retrospectively analyzed 614 patients who underwent LAAC at Wuhan Asia Heart Hospital from May 2014 to April 2021. We compared the baseline clinical characteristics and ischemic stroke rates before LAAC, major adverse cardiovascular events (MACEs) and other long-term outcomes between AF patients with and without PFO after LAAC. The predictor for ischemic stroke or TIA after LAAC was analyzed with univariate and multivariable Cox regression, and the long-term cumulative survival rates of AF patients with PFO compared to those without PFO after LAAC were analyzed with the Kaplan–Meier graph. ResultsA total of 614 patients who underwent LAAC and had completed follow-up data were included in our study. Among them, 74 patients were diagnosed with AF with PFO, and 540 with AF without PFO. There was no significant difference between their baseline clinical data, including ischemic stroke rates (p = 0.961). Patients with and without PFO had similar device implantation success rates (98.6 % vs 99.4 %, P = 0.403) and procedure-related complications. During follow-up (medium follow-up period 36.9 months), no significant difference was observed in the incidence of MACEs (8.1 % in PFO group vs 5.7 % in non-PFO group, P = 0.432) or the cumulative ischemic stroke/TIA rates (5.4 % in PFO group vs 4.3 % in non-PFO group, P = 0.554). The Cox multivariable regression analysis indicated that the presence of PFO in patients with AF had no correlation with ischemic stroke or TIA after LAAC implantation (HR 1.685, 95 % CI 0.570–4.978, P = 0.345). The only predictor for ischemic stroke/TIA events after LAAC was major leakage (>5 mm) seen on transesophageal echocardiography (TEE) or left atrial CTA at the 45-day follow-up (HR 10.352, 95 % CI 1.221–87.736, P = 0.032). ConclusionAF patients with PFO are not at increased risk for ischemic stroke or TIA before LAAC. The presence of PFO in AF patients did not affect the success rate and safety of LAAC. The presence of mild PFO is not a viable predictor of stroke events in AF patients who underwent LAAC during long-term follow-up. Major leakage (>5 mm) is associated with a higher ischemic stroke/TIA rate in AF patients who underwent LAAC.

Catheter ablation vs medical management for atrial fibrillation in patients with heart failure: a systematic review and metanalysis

Abstract Background Current guidelines recommend a class IIa recommendation for catheter ablation in Atrial Fibrillation [AFIB]. Traditionally, catheter ablation has been known to be more effective in maintaining sinus rhythm than pharmacological management. However, there is sparse evidence to suggest that this translates to improved clinical outcomes in patients with heart failure. We did a systematic review and meta-analysis of randomized trials to compare the efficacy of ablation vs medical management for AFIB in heart failure. Methods A systematic search was conducted for randomized trials from inception to Jan 2024 for studies comparing the outcomes of catheter ablation vs medical management for AFIB in heart failure. The primary outcome was all-cause mortality. Secondary outcomes were cardiovascular (CV) mortality, heart failure hospitalizations, change in LV ejection fraction (LVEF), AF recurrence rate, 6-minute walk test (6MWT), change in MLHFQ scores and cerebrovascular events. Random-effects models were used to calculate the pooled incidence, mean difference (MD), and risk ratios (RRs) with 95% confidence intervals (CIs). Results A total of 10 RCTs with 2,348 patients were included in this study. Pulmonary vein isolation was the mainstay ablation strategy used. Compared with medical management, Ablation was associated with a significant reduction in all-cause mortality (RR- 0.61; 95% CI, 0.48-0.78; P&amp;lt;0.0001). Ablation was also associated with lower cardiovascular (CV) mortality (RR- 0.52; 95% CI, 0.36-0.75; P&amp;lt;0.0004), heart failure hospitalizations (RR- 0.67; 95% CI, 0.54-0.82; P&amp;lt;0.0001) and AF recurrence rate (RR- 0.43; 95% CI, 0.25-0.75; P&amp;lt;0.003). The study showed an improvement in LVEF (RR - 6.05; 95% CI, 3.35-8.75; P&amp;lt;0.0001), 6MWT (RR- 13.99; 95% CI, 4.18-23.81; P&amp;lt;0.005) and in MLHFQ score (RR -6.98; 95% CI, -12.03 to -1.93; P&amp;lt;0.007. There was a statistically significant difference between the 2 cohorts in the rates of cerebrovascular events (RR- 0.68; 95% CI, 0.35-1.30; P&amp;lt;0.24). Conclusion Randomized trials have shown clear benefits with catheter ablation compared to medical management for AFIB in heart failure. Ablation has demonstrated significantly lower all-cause mortality, reduced CV mortality, HF hospitalizations, AFIB recurrence rate, and improvement in LVEF. Patients who underwent catheter ablation showed improvement in functional outcomes like 6MWT and MLHFQ scores. There was no difference in the incidence of cerebrovascular events compared to medical management. This study adds to the growing evidence in the literature for ablation therapy; however, more trials are needed to identify patients for optimal benefits across the spectrum of heart failure patients.Forest PlotsForest Plots

Rationale and design of the multicentric randomized EVAOLD trial: Evaluation of a strategy guided by imaging versus routine invasive strategy in elderly patients with ischemia

BackgroundThe management of myocardial infarction without ST segment elevation (NSTEMI) in elderly patients remains challenging, in particular the benefit/risk balance of routine revascularization remains uncertain. Study designEVAOLD is s a multicenter, prospective, open-label trial with 2 parallel arms in NSTEMI patients ≥ 80 years of age. The aim of the trial is to test whether a strategy of selective invasive management guided by ischemia stress imaging (IMG group) will be non-inferior in preventing Major Adverse Cardiac and Cerebrovascular Events (MACCE, ie all-cause death, non-fatal myocardial infarction, non-fatal stroke) rates at 1 year compared with a routine invasive strategy (INV Group). Geriatric assessment and cost- effectiveness analysis will also be performed. A sample size of 1756 patients (assuming a 10% rate of patients lost to follow-up) is needed to show non-inferiority with 80% power. Non-inferiority based on exponential survival curves will be declared if the upper limit of the one-sided 97.5% confidence interval for the hazard ratio is lower than 1.24, corresponding to a non-inferiority margin of 7% in absolute difference and an event rate of 40% in the INV group. ConclusionEVAOLD is a nationwide, prospective, open-label trial testing the non-inferiority of a strategy of selective invasive management guided by ischemia stress imaging versus routine invasive strategy in elderly NSTEMI patients. ClinicalTrials.gov Identifier: NCT03289728

Sarcopenia Influences Clinical Outcome in Hospitalized Patients with Peripheral Artery Disease Aged 75 Years and Older

ObjectivesSarcopenia represents a relevant comorbidity in patients with peripheral artery disease (PAD). However, only few studies exist assessing the clinical burden of sarcopenia in PAD. MethodsAll hospitalizations of patients aged ≥75 years who were admitted due to PAD within 2005-2020 in Germany were included in the study and stratified for sarcopenia. Temporal trends and the impact of sarcopenia on treatment procedures as well as adverse in-hospital events were investigated. ResultsOverall, 1,166,848 hospitalization-cases of patients admitted due to PAD (median age 81.0 [78.0-85.0] years; 49.5% female sex) were included, of which 2109 (0.2%) were coded with sarcopenia. Prevalence of sarcopenia in these patients increased during the observational period from 0.05% in 2005 to 0.34% in 2020 (β 2.61 [95%CI 2.42 to 2.80], P<0.001). Sarcopenic PAD patients were more often female (52.1% vs. 49.5%, P=0.015), obese (6.6% vs. 5.5%, P=0.021) and revealed higher prevalences of comorbidities (Charlson comorbidity index, 7.00 [6.00-9.00] vs. 6.00 [5.00-7.00], P<0.001). Sarcopenia was associated with reduced usage of reperfusion treatments (endovascular intervention: OR 0.409 [95%CI 0.358-0.466], P<0.001; surgical revascularization: OR 0.705 [95%CI 0.617-0.805],P<0.001), but higher conduction of amputation (OR 1.365 [95%CI 1.231-1.514], P<0.001) and higher rates of major adverse cardiovascular and cerebrovascular events (OR 1.313 [95%CI 1.141-1.512], P<0.001) and in-hospital death (OR 1.229 [95%CI 1.052-1.436], P=0.009). ConclusionsSarcopenia is an under-recognized condition in PAD patients of high clinical relevance causing a crucial disease burden. Awareness of the ailment needs to be increased in daily clinical practice to identify sarcopenia and improve clinical outcome of this vulnerable patient group.

7578 SGLT2 Inhibitor Is Associated With A Decreased Risk Of Cerebrovascular Events And Dementia Compared To Thiazolidinedione In Subjects With Type 2 Diabetes

Abstract Disclosure: H. Park: None. S. Park: None. H. Kim: None. D. Byun: None. Subjects with type 2 diabetes (T2D) are at higher risk of developing cerebrovascular disease, cognitive decline, and dementia. Hyperinsulinemia and insulin resistance in the brain have been linked to amyloid beta metabolism, raising the risk of Alzheimer's dementia. Recently, several clinical studies have shown potential beneficial effects of sodium glucose co-transporter-2 (SGLT2) inhibitors, and thiazolidinediones, in the risk of cerebrovascular events and dementia in T2D. This study was aimed to investigate the comparative efficacy of SGLT2 inhibitors and thiazolidinediones in modifying the risk of cerebrovascular events, dementia, and Alzheimer's dementia. Using the common data model, we analyzed patients from December 31, 2011 to December 30, 2022 from 15 hospitals in South Korea. Clinical outcomes between SGLT2 inhibitors and thiazolidinediones were compared using hazard ratios (HRs), with large-scale propensity score matching and a random-effects model applied. Our analyses showed that subjects on SGLT2 inhibitors had a significantly reduced rate of cerebrovascular events (HR 0.2787, 95% CI 0.1882-0.4127, p&amp;lt;0.00001), dementia (HR 0.5395, 95% CI 0.3824-0.7614, p=0.0004), and Alzheimer's dementia (HR 0.586, 95% CI 0.4634-0.7411, p&amp;lt;0.00001), compared to those on thiazolidinediones. In summary, these results suggest that SGLT2 inhibitor administration is associated with a lower risk of cerebrovascular events, dementia, and Alzheimer's dementia compared to thiazolidinedione in subjects with T2D. Further studies are warranted to confirm our findings and elucidate the underlying mechanisms. Presentation: 6/3/2024

Procedural safety of rotational atherectomy and modified balloon angioplasty: insights from a German national registry.

Modified balloons (MB) and rotational atherectomy (RA) are recommended tools for treatment of coronary plaques with superficial calcium. Knowledge about in-hospital safety is limited. Patients with coronary artery disease who underwent coronary angiography with RA or MB angioplasty in Germany were identified via ICD and OPS codes from 2017 to 2020. Acute coronary syndromes were excluded. Since patients were not randomized toward MB or RA, potential confounding factors were taken into account using the propensity score methods. Thereby, inverse probability weighting was applied. Ten thousand.ninety-twopatients underwent RA with an increasing trend from 1817 in 2017 toward 3166 in 2020. MBs were used in 22,378 patients also with an increasing trend from 4771 in 2017 toward 6078 in 2020. Patients receiving RA were older (74.23 ± 8.68 vs. 71.86 ± 10.02, p < 0.001), had a higher Charlson Comorbidity Index (2.07 ± 1.75 vs. 1.99 ± 1.76, p = 0.001) and more frequently left main (17.96% vs. 12.91%, p < 0.001) or three vessel disease (66.25% vs. 58.10%, p < 0.001). Adjusted procedural risk of major adverse cardiac and cerebrovascular events (MACCE) was similar in both groups, while pericardial effusion (RR 2.69; 95% CI 1.88-3.86, p < 0.001), pericardial puncture/pericardiotomy/pericardial tamponade (RR 2.66; 95% CI 1.85-3.81, p < 0.001) and bleeding (RR 1.65; 95% CI 1.12-2.43, p < 0.011) occurred more frequently in patients receiving RA. Patients treated with RA at high volume centers were hospitalized shorter (p = 0.005) and had a lower rate of acute cerebrovascular events (p < 0.001). Rate of MACCE, bleeding and pericardial puncture were not influenced by the annual RA numbers per center. MBs had a lower risk of bleeding and pericardial puncture. Patients treated at centers with high annual RA procedure numbers had a lower risk of acute cerebrovascular events and were hospitalized shorter.

Comparative efficacy of totally thoracoscopic, mini-thoracotomy, and mini-sternotomy approaches in aortic valve replacement

Aortic valve replacement (AVR) is a critical procedure for patients with aortic valve diseases. This study compares the effectiveness of three minimally-invasive surgical approaches for AVR: totally thoracoscopic (TT), right anterior mini-thoracotomy, and upper mini-sternotomy. We analyzed retrospective data from 130 patients who underwent one of these surgeries, focusing on various factors such as duration of hospital stay, operation time, times for cardiopulmonary bypass and aortic cross-clamping, postoperative complications, levels of cardiac biomarkers, pain intensity using the Visual Analog Scale, and mid-term survival rates. Results show that while the TT method had the longest operation times, it also had the shortest hospital stays and faster pain reduction post-surgery. Although the TT group initially showed higher cardiac biomarker levels after surgery, these levels normalized by the third day, similar to the other groups. There were no significant differences in mid-term survival and major adverse cardiac and cerebrovascular event (MACCE) rates among the groups. These findings suggest that the TT method, despite longer surgical times, offers a quicker initial recovery, making it a viable option for AVR.

Sternum-sparing multivessel coronary surgery as a routine procedure: Midterm results of total coronary revascularization via left anterior thoracotomy

ObjectiveA sternum-sparing approach of minimally invasive total coronary revascularization via left anterior thoracotomy demonstrated promising early outcomes in unselected patients with coronary artery multivessel disease. Follow-up data are still missing. MethodsFrom November 2019 to September 2023, coronary artery bypass grafting via left anterior minithoracotomy on cardiopulmonary bypass and cardioplegic cardiac arrest was performed as a routine procedure in 392 consecutive, nonemergency patients (345 men; 67.0 ± 9.9 years; range, 32-88 years). All patients had multivessel coronary artery disease (77.6% 3-vessel-disease, 22.4% 2-vessel-disease, and 32.9% left main stenosis). Patients at old age (older than a 80 years, 12.5%), with severe left ventricular dysfunction (ejection fraction <30%, 7.9%), diabetes mellitus (34.9%), massive obesity (body mass index > 35, 8.9%), and chronic lung disease (17.1%) were included. Mean European System for Cardiac Operative Risk Evaluation II score was 2.9 ± 2.8. Mean midterm follow-up (100%) was 15.2 ± 10.7 months (range, 0.1-39.5 months). ResultsLeft internal thoracic artery (99.0%), radial artery (70.4%), and saphenous vein grafts (57.4%) were used, and 70.4% of patients received at least 2 arterial grafts. A total of 3.0 ± 0.8 anastomoses (range, 2-5 anastomoses) per patient were performed to revascularize the territories of left anterior descending (98.7%), circumflex (91.6%), and right coronary (70.9%) artery. Complete anatomical revascularization was achieved in 95.1%. At follow-up, all-cause-mortality, myocardial infarction, repeat revascularization, and stroke was 3.1%, 1.5%, 5.4%, and 0.7%, respectively. Overall major adverse cardiac and cerebrovascular events rate was 8.7%. ConclusionsThis is the first report of midterm follow-up after routine sternum-sparing total coronary revascularization via left anterior thoracotomy for multivessel coronary artery disease with a high rate of multiple arterial grafting and complete anatomical revascularization. Outcome was favorable and similar to that of contemporary conventional coronary artery bypass grafting.

Interventional treatment in elderly patients with severe aortic valve stenosis and coronary artery disease

Aortic stenosis (AS) is a valvular heart disease commonly found in the elderly patients and frequently is associated with coronary artery disease (CAD). The impact of CAD severity and of the percutaneous coronary intervention (PCI) on post-TAVI outcomes is frequently debated. Purpose. Comparison of clinical and hemodynamic outcomes, as well as the rate of major adverse cardiovascular and cerebrovascular events (MACE) in patients undergoing TAVI with PCI (patients with AS and CAD) versus isolated TAVI (patients with AS). Material and methods. Our team conducted a prospective study that included 41 patients, with an age greater than 70 years old, who were diagnosed with severe aortic valve stenosis. After performing coronary angiography, the patients were divided into two groups: 32 patients without significant coronary lesions and 9 patients with multivessel lesions with a Syntax Score &lt;22 and who subsequently underwent coronary angioplasty (PCI). Results. The TAVI procedure was performed with a 100% success rate. After the procedure, the ejection fraction increased inconsiderably in all patients, but the average pressure gradient decreased impressively, the average value being12.59 ± 5.62 mmHg vs 14.78 ± 8.73 mmHg, p&lt; 0.001. The peak velocity of the jet through the aortic valve is 2.36 ± 0.50 m/s vs 2.53 ± 0.83 m/s, p&lt; 0.001.Conclusion. The one-year post-procedural follow-up showed that both groups of patients had a similar rate of MACE, with a significant improvement in clinical-hemodynamic parameters according to transthoracic echocardiography data.

Omitting transesophageal echocardiography before catheter ablation of atrial fibrillation

BackgroundData about necessity of performing transesophageal echocardiography (TOE) prior to every catheter ablation (CA) of atrial fibrillation (AF) is scarce. We aimed to evaluate the safety of an individualized risk-based approach to TOE with respect to thromboembolic cerebrovascular events (CVE) in patients undergoing CA for AF or left atrial tachycardia (AT).MethodsWe performed a retrospective clinical study based on our institutional registry database. Patients undergoing CA for AF or left-sided AT following initial AF ablation at two participating centers were enrolled. Prior to the procedure, patients were scheduled for TOE only if they had a history of thromboembolic stroke, left atrial appendage (LAA) thrombus, or inappropriate anticoagulation regimen in the previous 3 to 4 weeks. The incidence of periprocedural cerebrovascular thromboembolic events was assessed.ResultsWe analyzed 1155 patients (median age 70 years, 54.8% male, 48.1% had persistent AF/AT). In 261 patients, a TOE was performed; in 2 patients (0.7%), an LAA thrombus was detected, which led to cancellation of the catheter ablation; in 894 patients, the TOE was omitted. Of the 1153 (0.35%) patients who underwent ablation, 4 (0.35%) experienced a CVE (one TIA and three strokes). The rate of CVE in our study does not exceed that reported in most multicenter trials. The low event rates limited statistical analysis of possible risk factors for CVE. In all 4 patients with CVE, post-CVE imaging showed the absence of LAA thrombus.ConclusionsAn individualized selective approach to TOE before catheter ablation of AF or left AT showed a very low risk of overt intraprocedural thromboembolic events for the population in our study. A further randomized controlled study is needed to determine whether TOE prior to catheter ablation without ICE could be omitted in patients with uninterrupted OAC without previous thromboembolic events or a history of left atrial thrombus.

Immediate Versus Staged Complete Revascularization in Patients With Acute Coronary Syndrome: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

A strategy of complete revascularization (CR) is recommended in patients with acute coronary syndrome (ACS) and multivessel disease (MVD). However, the optimal timing of CR remains equivocal. We searched MEDLINE, Embase, the Cochrane Library, and ClinicalTrials.gov for randomized controlled trials (RCTs) comparing immediate CR (ICR) with staged CR (SCR) in patients with ACS and MVD. Our primary outcomes were all-cause and cardiovascular mortality. All outcomes were assessed at three time points: in-hospital or at 30 days, at 6 months-1 year, and at > 1 year. Data were pooled in RevMan 5.4 using risk ratio (RR) as the effect measure. A total of 9 RCTs (7506 patients) were included in our review. Seven trials enrolled ST-segment elevation myocardial infarction (STEMI) patients, one enrolled non-STEMI patients only, and one enrolled patients with all types of ACS. There was no difference between ICR and SCR regarding all-cause and cardiovascular mortality at any time window. ICR reduced the rate of myocardial infarction (MI) and decreased the rate of repeat revascularization at 6 months and beyond. The rates of cerebrovascular events and stent thrombosis were similar between the two groups. In conclusion, the current meta-analysis demonstrated a lower rate of MI and a reduction in repeat revascularization at and after 6 months with ICR strategy in patients with mainly STEMI and MVD. The two groups had no difference in the risk of all-cause and cardiovascular mortality. Further RCTs are needed to provide more definitive conclusions and investigate complete revascularization strategies in other ACS.

Comparing long-term outcomes of septal myectomy and mitral valve replacement in hypertrophic cardiomyopathy patients: A retrospective cohort study in Iran.

Hypertrophic cardiomyopathy (HCM) affects millions of individuals worldwide. In severe cases, it can cause life-threatening conditions such as left ventricular outflow tract (LVOT) obstruction, mitral regurgitation (MR), and sudden cardiac death, making surgical treatment necessary. This study aimed to report the long-term outcomes of HCM patients undergoing septal myectomy or mitral valve replacement (MVR) and compare the results between different types of surgeries. This was a retrospective cohort study on HCM patients who underwent surgical treatment in an Iranian referral center between 2005 and 2021. Patients were divided into three groups according to the type of surgery received: septal myectomy, MVR, or a combination of both surgeries. Patient characteristics, surgical and echocardiographic features, and in-hospital and long-term outcomes were reported and compared between the three groups. A total of 102 patients with an average age of 53.3 ± 16.9 were included. Twenty-six patients had septal myectomy, 23 had MVR, and 53 had combined septal myectomy and MVR surgery. All surgeries were associated with a significant reduction in interventricular septum thickness and LVOT gradients. After a median of 6.8-year follow-up time, patients with an isolated septal myectomy had significantly lower mortality and major adverse cardiac and cerebrovascular events rates than the other groups. Isolated septal myectomy showed better long-term survival rates and can correct HCM-related MR, while MVR should be preserved only for intrinsic valve defects. More extensive studies are needed to confirm these findings and achieve a comprehensive guideline on surgical treatment of HCM.

Age-Dependent Detection of Atrial Fibrillation with Implantable Cardiac Monitors in Patients with Cryptogenic Stroke.

Background Continuous monitoring using implantable cardiac monitors (ICMs) results in atrial fibrillation (AF) detection rates of up to 30% in patients with cryptogenic stroke (CS). Although higher age is an independent risk factor for AF, there are no age-specific recommendations for the implantation of ICM. Objective The aim of this study was to analyze age-related AF rates in patients with CS and continuous rhythm monitoring, to determine the rates of oral anticoagulation (OAC) and recurrent cerebrovascular events (stroke or transient ischemic attack) in patients with ICM-detected AF, and to describe the temporal relationship of AF detection and recurrent cerebrovascular events. Methods In this observational study, patients with CS provided with ICMs were systematically followed. All patients underwent 72-hour electrocardiography monitoring, transcranial Doppler ultrasound, and transthoracic echocardiography prior to ICM insertion. Follow-up included a regular outpatient presentation every 3 months with medical history, physical examination, and interrogation of the ICM. Results One-hundred eighty-six patients (mean age: 65 ± 12 years, 54% female) were included in this analysis. AF was detected in 6, 27, 56, and 65% ( p < 0.001) of patients aged less than 60, 60 to 69, 70 to 79, and more than or equal to 80 years, respectively. All patients with AF under 60 years had an impaired left ventricular systolic function. OAC was initiated in 85% of the patients with AF. Recurrent cerebrovascular events occurred in 34 patients of whom 14 had a diagnosis of AF. In nine patients, AF was diagnosed before the occurrence of a recurrent cerebrovascular event. Conclusion AF prevalence increased with age and was absent in CS patients younger than 60 years and with preserved left ventricular ejection fraction. The temporal relationship of AF and recurrent cerebrovascular events was weak.