Embolic Events Research Articles

Revisiting Left Atrial Appendage Closure Versus Oral Anticoagulants in Recurrent Atrial Fibrillation Management: An Updated Systematic Review and Meta-Analysis.

Atrial fibrillation (AF) is a significant public health problem due to its association with coronary heart disease, stroke, and mortality, especially in the elderly. Therefore, traditional warfarin therapy, direct oral anticoagulants (DOACs), and the recent left atrial appendage closure (LAAC) have been compared as treatment approaches. In this regard, we aimed to synthesize the current evidence regarding the comparison these mentioned modalities in patients with AF. A comprehensive database search for records comparing LAAC and DOACs in patients with AF was conducted until December 15, 2023. An updated meta-analysis was conducted using fixed and random effect models to calculate odds ratios (OR) or mean differences (MD) with 95% confidence intervals (CIs) for dichotomous and continuous outcomes, respectively. Eleven studies were eligible that included a total of 68171 patients. Compared to DOACs, the LAAC group had a lower rate of hospital stay duration (MD -1.23; 95% CI -1.51 to -0.95;p< 0.001). There was no statistically significant difference between LAAC and DOACs in terms of the composite outcome of stroke, systemic embolism, cardiovascular death, all-cause mortality, ischemic stroke and thromboembolic events ischemic, major bleeding and cardiovascular mortality (OR 0.83, 95% CI 0.27-2.48,P= 0.73).Our meta-analysis showed a lower rate of hospital stay duration that favors LAAC. However, the risk of composite outcomes of stroke, systemic embolism, cardiovascular death, all-cause mortality, ischemic stroke, thromboembolic events, ischemic stroke, major bleeding, and cardiovascular mortality was similar between the two treatment groups.

Nrf2 Ameliorates Atrial Fibrosis During Antithrombotic Therapy for Atrial Fibrillation by Modulating CYP2C9 Activity.

Anticoagulant therapy can significantly reduce the incidence of stroke and peripheral embolism events in patients with atrial fibrillation (AF). Although warfarin is widely used as an anticoagulant drug, a wrong dose can lead to increased risks of bleeding or blood clots. The aim of this study was to assess whether nuclear factor-erythroid-2-related factor 2 (Nrf2) can improve the efficacy of warfarin through the regulation of cytochrome P450 family 2 subfamily C member 9 (CYP2C9) using a rat model of AF. Results showed that AF significantly reduced Nrf2 in myocardial tissue of sham-operated rats. Furthermore, Nrf2 overexpression effectively reduced AF-induced atrial fibrosis by reducing collagen in the left atrium, inhibiting the expression of the fibrosis-related genes collagen I and transforming growth factor-β1 in rats with AF. Nrf2 overexpression can activate CYP2C9, decrease the serum concentration of warfarin, and decrease prothrombin time and international normalized ratio in AF rats. In this article, Nrf2 overexpression protects against fibrosis, increased survival in AF rats, and activated CYP2C9 expression, thus broadening the therapeutic range of warfarin in AF rats.

Competing stroke mechanisms despite adequate oral anticoagulant therapy: the role of transesophageal echocardiography.

Ischemic strokes in patients on oral anticoagulant therapy (OAT) despite optimal adherence pose a therapeutic challenge. We assessed the utility of transesophageal echocardiography (TEE) in identifying potential competing cardiac causes for stroke that occurred despite adequate OAT. This retrospective observational study included patients admitted for acute ischemic stroke between January 2022 and June 2023 who were on OAT for an established long-term indication. Transthoracic and transesophageal echocardiography, along with assessment of OAT adherence, were conducted. Demographic data, OAT details, and stroke characteristics were analysed to determine the influence of TEE findings on therapeutic decisions. We included 26 patients. TEE identified potential cardiac competing stroke mechanisms in 88% of cases, with valvular thrombi and left atrial or appendage thrombus being predominant. Infective endocarditis, often asymptomatic, was unexpectedly prevalent. TEE significantly influenced therapeutic decisions, especially in cases where transthoracic echocardiography was inconclusive. TEE may be crucial for unravelling the mechanisms of ischemic stroke in patients on adequate OAT, guiding precise therapeutic strategies and potentially reducing the risk of recurrent embolic events. Our findings underscore the limitations of standard echocardiography in detecting cardiac embolic sources and emphasize the importance of tailored decision-making in secondary stroke prevention.

Aortic and Mitral Valve Endocarditis-Simply Left-Sided Endocarditis or Different Entities Requiring Individual Consideration?-Insights from the CAMPAIGN Database.

Background: Aortic valve infective endocarditis (AV-IE) and mitral valve infective endocarditis (MV-IE) are often grouped together as one entity: left-sided endocarditis. However, there are significant differences between the valves in terms of anatomy, physiology, pressure, and calcification tendency. This study aimed to compare AV-IE and MV-IE in terms of patient characteristics, pathogen profiles, postoperative outcomes, and predictors of mortality. Methods: We retrospectively analyzed data from 3899 patients operated on for isolated AV-IE or MV-IE in six German cardiac surgery centers between 1994 and 2018. Univariable and multivariable analyses were performed to analyze the risk factors for 30 day and 1 year mortality. A Log-rank test was used to test for differences in long-term mortality. Results: Patients with MV-IE were more likely to be female (41.1% vs. 20.3%.; p < 0.001). Vegetation was detected more frequently in the MV-IE group (66.6% vs. 57.1%; p < 0.001). Accordingly, the rates of cerebral embolic events (25.4% vs. 17.7%; p < 0.001) and stroke (28.2% vs. 19.3%; p < 0.001) were higher in the MV-IE group. Staphylococci had a higher prevalence in the MV-IE group (50.2% vs. 36.4%; p < 0.001). Patients with MV-IE had comparable 30 day mortality (16.7% vs. 14.6%; p = 0.095) but significantly higher 1 year mortality (35.3% vs. 29.0%; p < 0.001) than those with AV-IE. Kaplan-Meier survival analysis showed significantly lower long-term survival in patients with MV-IE (log-rank p < 0.001). Conclusions: Due to the relevant differences between MV-IE and AV-IE, it might be useful to provide individualized, valve-specific guideline recommendations rather than general recommendations for left-sided IE.

RARE CASE OF SPONTANEOUS HEMOPERICARDIUM IN A PATIENT RECEIVING APIXABAN: CASE REPORT

Apixaban is a new oral anticoagulant (NOAC) available since 2012, indicated particularly for the prevention of embolic events in patients with non-valvular atrial fibrillation [1]. It is a direct inhibitor of factor Xa, with a half-life of around 12 hours. This new anticoagulant is associated with a lower risk of bleeding than vitamin K antagonists (VKAs) such as warfarin and requires less monitoring [2]. However, several recently published cases have demonstrated a correlation between Apixaban and the occurrence of pericardial effusion. We report the case of a 75-year-old hypertensive man diagnosed with atrial fibrillation 3 months ago, treated with Apixaban 5mg twice daily. He presented to the emergency department with rapidly worsening dyspnea, and echocardiography revealed a large pericardial effusion requiring drainage. A full etiological work-up was carried out, revealing no underlying pathology or triggering event to explain his pericardial effusion. We believe that his recently introduced anticoagulant therapy is the true cause.

Diagnostic Challenges in Identifying Atrial Myxoma as a Cause of Transient Ischemic Attacks: A Case Report

Abstract Background A 67-year-old woman presented to hospital on multiple occasions with transient neurological symptoms over a period of 20 months. Initial diagnostics, including computed tomography (CT), carotid Dopplers, and electrocardiogram, were unremarkable. Magnetic resonance imaging (MRI) was arranged following the third neurological event which revealed multi-territory acute ischemic events, suggestive of a cardioembolic source. Transoesophageal echocardiography identified a large mobile atrial myxoma, histologically confirmed. Atrial myxoma, though rare, is an important cause of thromboembolic stroke, underscoring the need for comprehensive cardiac evaluation in cerebrovascular incidents. Methods The patient's case was reviewed, focusing on initial presentations, diagnostic workup, and subsequent management. Initial presentations included transient visual disturbances and transient leg weakness. Routine tests were conducted, including CT brain, carotid Dopplers, and blood tests. MRI and transoesophageal echocardiography were performed which ultimately identified the underlying cause of the patient’s neurological events. Results Initial evaluations (CT, carotid Dopplers) were normal. An MRI performed 20 months after her initial presentation revealed small acute infarcts in the right cerebellar hemisphere and left superior parietal lobe. Transoesophageal echocardiography subsequently detected a large atrial myxoma. The patient's transient symptoms and negative initial workup delayed the diagnosis, highlighting the necessity of including cardiac imaging early in the stroke workup, especially in cases of suspected cardioembolic events. Conclusion This case illustrates the critical role of thorough cardiac evaluation, including echocardiography, in diagnosing the cause of transient ischemic attacks (TIA) and strokes. The patient’s initial negative findings delayed the identification of a cardioembolic source, emphasizing the importance of comprehensive diagnostic protocols for suspected cerebrovascular events. Urgent surgical resection is essential for atrial myxoma to prevent recurrent embolic events. This report highlights the diagnostic and management challenges of cardiac myxomas, advocating for a more rigorous approach to stroke evaluation and timely intervention.

Impact of multidisciplinary Endocarditis Team on management of infective endocarditis

Infective Endocarditis (IE) is a complex, life-threatening disease. The aim of the present study was to evaluate the impact of the Endocarditis-Team on management of IE. This observational study conducted at a university hospital (2015‒22), included adult patients with IE. The study period was divided in two periods: before (pre-Endocarditis-Team; pre-ET) and after the establishment of the Endocarditis-Team (post-Endocarditis-Team; post-ET) on January 2018. Among 505 IE episodes (187 in pre-Endocarditis-Team, 318 in post-ET period), 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography was more commonly used in post-ET period (14 % vs. 28 %; p < 0.001). Overall, thirty-day and one-year mortality were 14 % and 27 %, respectively; no difference was observed between the two periods. In post-ET period, the administration of 4-weeks, rather than 6-weeks, of intravenous antimicrobial treatment was higher than in the post-ET period (15 % vs. 45 %; p < 0.001). Indication for surgery was present in 115 (61 %) patients in pre-ET and in 153 (48 %) in the post-ET period. In post-ET period, among patients with indication, valve surgery was more frequently performed (66 % vs. 78 %; p = 0.038). Such difference was due to a higher acceptance of operative indication by the cardiac surgeon (69 % vs. 94 %; p = 0.013). The observed increase in number of patients benefiting from cardiac surgery in the post-ET period led to a decrease of subsequent embolic events, since among patients with operative indication (n = 268), new embolic events after the establishment of the indication were more common in the pre-ET period compared to post-ET (23 % vs. 12 %; p = 0.033). After the implementation of the multidisciplinary Endocarditis-Team we observed several improvements in the general management of IE patients.

Cerebral Embolic Protection Devices: Are There Any Indications in Transcatheter Aortic Valve Replacement?

Stroke following transcatheter aortic valve replacement (TAVR) is a significant and life-threatening adverse event. The vast majority of these incidents occur during the TAVR procedure or within the first 24 h following TAVR, with a notable prevalence of cerebral embolic events. In response to this concern, cerebral embolic protection devices (CEPDs) have been designed to mitigate the risk of peri-procedural ischemic stroke during TAVR. The primary objective of CEPDs is to diminish the intraprocedural burden associated with new silent ischemic brain injuries. Despite the development of several CEPDs, their clinical efficacy remains uncertain. In this review, we delve into a comprehensive analysis of the utilization of CEPDs in patients undergoing TAVR, exploring insights from the existing literature. Additionally, we aim to present future perspectives and discuss the clinical implications associated with the incorporation of CEPDs in TAVR procedures.

SP7.11 - Long term mortality risk factors for patients that underwent a Carotid surgery

Abstract Aims Carotid endarterectomy is the gold standard intervention to reduce carotid stenosis induced embolic cerebrovascular events. Current literature lacks long-term large sample analysis for post-carotid surgery mortality risks. The aim of this study was to determine long term all-cause mortality after carotid surgery. Method Single centre 10-year retrospective observational study of CEA mortality evaluating pre, intra and post-operative factors between 2010 and 2020. The data was manually extracted from the hospital’s database. Odds ratios and mortality rates were calculated and adjusted for age by adapting linear regression. Results 970 patients’ data were identified with an average follow up of 6.65 ±3.37 years for an average mortality rate of 31.9%. There was a non-significant (p&amp;gt;0.05) age adjusted odd of survival between gender (aOR 1.81 ±0.298) elective admission (aOR 0.932 ±0.321) and symptomatic patients (aOR 1.274 ±0.47). There was a significantly (p&amp;gt;0.05) decreased chance of survival for current smokers (aOR 0.433 ±0.54) and patients on ACE/ARB (aOR 0.516 ±0.091). On the other hand, single (aOR 2.934 ±0.531) and dual anti-platelet (aOR 4.964 ±0.286) showed a significant (p&amp;gt;0.05) protective effect. The 5-year age-adjusted death rate was elevated for all patients at 1.42. Conclusion The results highlight the smoking cessation, DAPT and appropriate prophylaxis remain important factors in increasing survival odds post carotid surgery. 30% mortality at 5 years is similar to those after Aortic interventions in these arteriopathic patients with extensive co morbidities.

Outcomes With the WATCHMAN FLX in Everyday Clinical Practice From the NCDR Left Atrial Appendage Occlusion Registry.

PINNACLE FLX (Protection Against Embolism for Nonvalvular AF Patients: Investigational Device Evaluation of the WATCHMAN FLX LAA Closure Technology) demonstrated improved outcomes and low incidence of adverse events with the WATCHMAN FLX device in a controlled setting. The National Cardiovascular Disease Registry's Left Atrial Appendage Occlusion Registry was utilized to assess the safety and effectiveness of WATCHMAN FLX in contemporary clinical practice in the United States. The WATCHMAN FLX Device Surveillance Post Approval Analysis Plan used data from the Left Atrial Appendage Occlusion registry to identify patients undergoing WATCHMAN FLX implantation between August 2020 and September 2022. The key safety end point was defined as all-cause death, ischemic stroke, systemic embolism, or device or procedure-related events requiring open cardiac surgery or major endovascular intervention between device implantation and hospital discharge. Major adverse events were reported at hospital discharge, 45 days, and 1 year. Among 97 185 patients in the Left Atrial Appendage Occlusion registry undergoing WATCHMAN FLX, successful implantation occurred in 97.5% (n=94 784) of patients. The key safety end point occurred in 0.45% of patients. At 45 days post-procedure, all-cause death occurred in 0.81% patients, ischemic stroke in 0.23%, major bleeding in 3.1%, pericardial effusion requiring intervention in 0.50%, device-related thrombus in 0.44%, and device embolism in 0.04% patients. No peri-device leak was observed in 83.1% of patients at 45 days. At 1 year, the rate of all-cause death was 8.2%, the rate of any stroke was 1.5% (ischemic stroke, 1.2%), and major bleeding occurred in 6.4% of patients. In a large contemporary cohort of patients with the WATCHMAN FLX device, the rates of implant success and clinical outcomes through 1 year were comparable with the PINNACLE FLX study, demonstrating that favorable outcomes achieved in the pivotal approval study can be replicated in routine clinical practice.

INFECTIOUS ENDOCARDITIS ON MECHANICAL MITRAL PROSTHESIS, SEVERE PRESENTATION AND FAVOURABLE OUTCOME

Infective endocarditis (IE) is a serious and potentially fatal condition that affects the hearts inner lining, especially the heart valves. Despite advances in medical diagnosis and treatment, IE continues to pose significant challenges due to its severe complications, including embolic events, abscess formation, valve perforation, and spondylodiscitis. The left-sided heart valves (aortic and mitral) are most commonly affected by this infection. Identifying the portal of entry of the causative pathogen is crucial for effective management of the condition.This case report discusses a patient with Enterococcus faecalis infective endocarditis, who had mechanical aortic and mitral valve replacements. The infections portal of entry was traced to a digestive adenocarcinoma, which is a rare but notable cause. The case is particularly significant due to the positive outcome achieved through a combination of medical and surgical interventions, highlighting the importance of a comprehensive approach to treatment.

Residual Stroke Risk Among Patients With Atrial Fibrillation Prescribed Oral Anticoagulants: A Patient-Level Meta-Analysis From COMBINE AF.

Despite oral anticoagulation, patients with atrial fibrillation (AF) remain at risk of ischemic stroke and systemic embolism (SE) events. For patients whose residual risk is sufficiently high, additional therapies might be useful to mitigate stroke risk. Individual patient data from 5 landmark trials testing oral anticoagulation in AF were pooled in A Collaboration Between Multiple Institutions to Better Investigate Non-Vitamin K Antagonist Oral Anticoagulant Use in AF (COMBINE AF). We calculated the rate of ischemic stroke/SE among oral anticoagulation-treated patients with a CHA2DS2-VASc score≥2, across strata of CHA2DS2-VASc score, stroke history, and AF type, as either paroxysmal or nonparoxysmal. We included 71 794 patients with AF (median age 72 years, interquartile range, 13 years, 61.3% male) randomized to a direct oral anticoagulant or vitamin K antagonist, and followed for a mean of 2.1 (±0.8) years. The median CHA2DS2-VASc score was 4 (interquartile range, 3-5), 18.8% had a prior stroke, and 76.4% had nonparoxysmal AF. The overall rate of stroke/SE was 1.33%/y (95% CI, 1.27-1.39); 1.38%/y (95% CI, 1.31-1.45) for nonparoxysmal AF, and 1.15%/y (95% CI, 1.05-1.27) for paroxysmal AF. The rate of ischemic stroke/SE increased by a rate ratio of 1.36 (95% CI, 1.32-1.41) per 1-point increase in CHA2DS2-VASc, reaching 1.67%/y (95% CI, 1.59-1.75) ≥4 CHA2DS2-VASc points. Patients with both nonparoxysmal AF and CHA2DS2-VASc ≥4 had a stroke/SE rate of 1.75%/y (95% CI, 1.66-1.85). In patients with a prior stroke, the risk was 2.51%/y (95% CI, 2.33-2.71). AF type, CHA2DS2-VASc score, and stroke history can identify patients with AF, who despite oral anticoagulation have a residual stroke/SE risk of 1.5% to 2.5% per year. Evaluation of additional stroke/SE prevention strategies in high-risk patients is warranted.

Microembolizations in the arterial cerebral circulation during atrial fibrillation ablation: cryoballoon technique advantages and neurocognitive safety-results of a prospective observational study.

The significance of micro-embolic signals (MESs) during atrial fibrillation (AF) ablation is unclear. Previous studies had limitations, and cryoballoon (CB) ablation patients were under-represented. Minimizing MESs is recommended due to their uncertain neurocognitive impact. This prospective observational study included AF patients from a German centre between February 2021 and August 2022. Patients were equally divided into paroxysmal (Group A) and persistent (Group B) AF. Group A received cryoballoon-pulmonary vein isolation only, while Group B also had left atrial roof ablation. MESs were detected using transcranial Doppler ultrasonography during ablation. Neurocognitive status was assessed pre- and post-procedure and at 3 months using the CERAD Plus battery. The study analyzed 100 patients with a median age of 65.5 years. A total of 19 698 MESs were observed, with 80% being gaseous and 20% solid in origin, primarily occurring during pulmonary vein angiography and the balloon freeze and thawing phase. The median MES per patient was 130 (IQR: 92-256) in total, 298 (IQR: 177-413) in bilateral (36%), and 110 (IQR: 71-130) in unilateral (64%) recordings. No significant difference in total MES counts was found between the groups. None of the 11 neuropsychological tests showed cognitive decline post-procedure or at 3 months. Our observations confirm that neurocognitive abilities are not affected either 24 h or 3 months after AF ablation using the CB technique. However, despite the low MES burden associated with the CB, more work is needed to reduce small embolic events during AF ablation.

Predictors and risk factors of pulmonary embolism after total hip arthroplasty: an NSQIP study.

Pulmonary embolism (PE) is a well-known contributor to morbidity after total hip arthroplasty (THA). Considerable efforts have been invested in reducing PE occurrence through pharmacological and perioperative interventions. Nonetheless, the effectiveness of these strategies in reducing the incidence and overall mortality associated with pulmonary embolism events remains a matter of debate. Therefore, identifying risky patients has been gaining importance. We utilised data from the National Surgical Quality Improvement Program (NSQIP) participant usage file (PUF) database spanning the years 2016 to 2021. All preoperative parameters were analysed with chi-square afterwards, meaningful ones were run with logistic regression test. A study examined factors influencing pulmonary embolism (PE) prevalence in 235,393 total hip arthroplasty patients. Univariate analysis identified significant associations between PE and female gender, diabetes, smoking, dyspnea, CHF, COPD, hypertension (HT), bleeding disorders, disseminated cancer, steroid use, and functional health status. Multivariate analysis revealed male gender as protective, while COPD, hypertension, and disseminated cancer increased PE risk. Notably, smoking appeared protective. PE patients had higher return-to-operation rates (41.7% vs. 2.2%) but similar 30-day mortality (0.2% vs. 0.04%), though mortality's odds ratio was not significant. Our findings suggest that certain patient characteristics, such as COPD and metastatic malignancy, significantly influence the likelihood of PE development.

Clinical characteristics and prognostic importance of anticoagulant use in ischemic left ventricular aneurysm: a retrospective cohort study

There is insufficient data on systemic embolic events (SSEs) in patients with ischemic left ventricular aneurysm (LVA) concerning the impact of anticoagulation therapy. In this retrospective cohort study with 1043 patients with ischemic LVA, SSEs occurred in 7.2% over 2.4 years. After adjusting for relevant factors, the use of anticoagulants was independently associated with a lower incidence of SSE (3.1% vs. 9.0%, P < 0.001; subdistribution hazard ratios (SHR) 0.21, 95% confidence intervals (CI) 0.10-0.44, P < 0.001), with no significant difference in net adverse clinical events (NACEs) (10.6% vs. 13.3%, P = 0.225). Specifically, anticoagulation in patients with apical segment akinesis significantly reduced SSEs (3.9% vs. 13.6%, P = 0.002) and NACE rates (7.8% vs. 19.4%, P = 0.002). Major bleeding rates did not significantly differ between groups (5.6% vs. 3.5%, P = 0.111). These findings highlight the SSE risk in ischemic LVA and suggest potential benefits of anticoagulation, particularly in those with apical segment akinesis. These findings need to be validated in independent datasets.

Abstract Mo074: Overexpression of IPP2 Impairs Intracellular Calcium Handling, Leading to Arrhythmogenic Events

Cardiac arrhythmias, which are disruptions in the heart's electrical activities, critically affect the ventricular conduction system, impairing efficient blood circulation. These disturbances result in irregular heartbeats, contributing to patient mortality or causing harm to distant organs via embolic events. Given the severe implications, a profound understanding of the molecular mechanisms driving arrhythmia is crucial for devising specific treatments. This study unveils a pioneering link between the overexpression of IPP2 (Protein Phosphatase 1 Regulatory Inhibitor Subunit 2), driven by the Myh6 promoter (termed TgIPP2), and the onset of age-dependent cardiac arrhythmias. The electrical abnormalities observed in TgIPP2 overexpressing mice include a spectrum of dysfunctions such as axis deviations, elongated QRS and PR intervals, absence of P waves, AV dissociation, ventricular tachyarrhythmia, and heightened T waves. Investigating the pathophysiology behind these electrical anomalies, we subjected young adult mice to catecholamine challenges at low doses and conducted surface electrocardiogram (EKG) monitoring. TgIPP2 mice demonstrated a notable increase in arrhythmogenic episode frequency and duration following 0.2 mg/kg isoproterenol injection compared to their control counterparts. Through a protein phosphorylation analysis, we identified a key regulator of the ryanodine receptor, which modulates calcium release from the sarcoplasmic reticulum, correlating with the extended PR intervals and the delayed peaking of T waves. Therapeutic trials employing RyR blockers, specifically dantrolene, successfully normalized the erratic cardiac rhythms in aged TgIPP2 mice. However, beta blockers or L-type calcium channel blockers induced sudden cardiac death in this model. The study reveals that IPP2-induced aberrant phosphorylation disrupts calcium homeostasis, leading to arrhythmias. In conclusion, our research marks a significant advancement in understanding arrhythmogenic mechanisms, demonstrating that IPP2 overexpression directly triggers arrhythmia, particularly affecting the atrioventricular (AV) node, atria, and ventricles. The discovery that aberrant phosphorylation, especially of the RyR regulator, plays a pivotal role in initiating cardiac arrhythmias opens new pathways for targeted anti-arrhythmic therapies.

Timing, type, and impact of thromboembolic events caused by flow diversion: a 10-year experience.

Thromboembolic (TE) events are among the most feared complications after flow diversion (FD) and have been reported to occur even with adequate dual antiplatelet therapy. Herein, the authors characterize thrombotic and embolic events that developed after FD, focusing on the morbidity of each of these events and the predisposing factors associated with their development. A retrospective analysis of aneurysms treated with FD at a single institution in the US between 2013 and 2023 was performed. The authors documented the emergence of intraprocedural and postoperative TE events. A survival analysis and a Cox regression model was conducted to identify predictors associated with these events. The authors included 651 procedures performed in 591 patients to treat 746 aneurysms. TE events occurred in 38 of the procedures performed (5.8%), causing permanent deficit in 20 patients and death in 4 patients. Eleven cases presented with acute stent thrombosis, 11 with large-vessel occlusion, and 9 with perforator strokes. At a median follow-up of 9.5 months, 73.0% of patients with an ischemic event had a modified Rankin Scale score ≤ 2. Three of the deaths were secondary to occlusion at the basilar trunk and vertebral artery. In patients with TE events in the anterior circulation, 7 of 11 patients with middle cerebral artery occlusion and 9 of 12 patients with internal carotid artery occlusion achieved independence. Time-to-event Cox regression analysis demonstrated that TE events were more frequent in patients exhibiting aspirin resistance (hazard ratio 2.66; 95% CI 1.10-6.70). TE events after FD result from multiple factors, including age, aneurysm characteristics, aneurysm location, antiplatelet resistance, and procedural factors. In our cohort, we found the highest morbidity for patients with TE events presenting with large-vessel occlusion at the middle cerebral artery, and vertebrobasilar system.

Dual direct oral anticoagulant therapy in challenging thrombosis: a case series

BackgroundWhile anticoagulation therapy is highly effective at treating venous thromboembolism, some patients can develop rapidly progressive thrombosis in multiple organs or sites despite therapeutic anticoagulation. Effective strategies to manage life-threatening thrombosis in these patients are elusive. ObjectivesWe describe our experience using dual direct oral anticoagulant (DOAC) therapy with a factor (F)Xa inhibitor (such as rivaroxaban or apixaban) and a FIIa inhibitor (dabigatran) for refractory cases of thrombosis. MethodsA retrospective chart review of all patients treated with simultaneous dabigatran and an oral FXa inhibitor at our institution was conducted. We included all patients over the age of 18. The study was approved by the University of British Columbia Research Ethics Board (REB number: H23-02575). ResultsEight patients were included. All patients initiated standard therapeutic anticoagulation upon diagnosis of acute venous thromboembolism with a median of 3 breakthrough thrombotic events prior to dual DOAC use. Five patients had a positive heparin-induced thrombocytopenia screen, but only 2 had heparin-induced thrombocytopenia confirmed on serotonin release assay testing. There were no recurrent deep vein thrombosis, pulmonary embolism, or bleeding events during dual DOAC use. Most patients ultimately transitioned to a single oral FXa inhibitor. ConclusionDual DOAC therapy may be a useful strategy for managing challenging thrombosis cases resistant to conventional anticoagulation. Further research is warranted to validate these findings and explore the broader applicability of dual DOAC therapy in challenging thrombotic scenarios.

Multiple aortic valve papillary fibroelastomas causing recurrent cerebrovascular events

IntroductionPapillary fibroelastomas (PFE) are benign, rare primary cardiac tumors often discovered incidentally during cardiac imaging or as part of a workup for thromboembolic or obstructive events. We present a case of multiple PFE on the aortic valve's right coronary and non-coronary leaflets, presenting as recurrent cerebrovascular events managed by resection with valve preservation. Case SummaryA 53-year-old male presented with an acute right frontal cerebrovascular accident and a history of recurrent transient ischemic attacks. A transesophageal echocardiogram (TEE) revealed a 10 × 8 mm mass on the right coronary cusp of the aortic valve. Differential diagnosis included PFE versus thrombus. Following a neurology evaluation, the patient was anticoagulated and scheduled for urgent cardiac surgery. During surgery, an 8 × 7 mm mass was sharply excised from the right coronary leaflet's anterior surface. Further examination revealed additional masses: a 3 mm mass on the underside of the right coronary leaflet, a 2 mm mass on the non-coronary leaflet, and another 2 mm mass on its underside. All masses were excised, and pathology confirmed the diagnosis of PFE. The patient's post-operative course was unremarkable, and a pre-discharge transthoracic echocardiogram (TTE) demonstrated complete removal of the aortic valve masses with normal ventricular and aortic valve function. DiscussionPFE are rare benign cardiac tumors with a significant risk of thromboembolic or obstructive events, including stroke. Grossly, they are attached to the endocardium by a short fibrous pedicle with multiple papillary fronds resembling a sea anemone. More than 95 % originate from the left heart, most commonly affecting the aortic valve. Diagnosis is primarily through echocardiography, with TEE being more sensitive than TTE. Surgical excision is curative, offering an excellent long-term prognosis. ConclusionAll patients with suspected embolic cerebrovascular events should undergo echocardiographic evaluation to assess for potential cardiac etiologies. Surgical resection of PFE results in uniformly excellent clinical outcomes, with aortic valve preservation achievable in over 98 % of cases.

Best Practices for Optimizing Patients Undergoing Surgical Procedures to Prevent Postoperative Venous Thromboembolism: A Quality Improvement Project.

Introduction Current studies suggest that both chemical and mechanical venous thromboembolism (VTE) prophylaxis is underused, which is concerning due to the potential lethality of VTEs. The Caprini risk score is a preoperative VTE risk assessment that determines a patient's risk of enduring a VTE. The objective of this study was to examine postoperative cases of VTE to determine if accurate VTE risk stratification was performed and whether appropriateVTE prophylaxis was administered. Methods A retrospective analysis was conducted on 23 reported cases of VTE that occurred at a Central Florida hospitalfrom April 1, 2021, to March 31, 2022. Relevant demographic and medical information was gathered from each patient chart to calculate an individual Caprini risk score and determine the type of chemical VTE prophylaxis that was received. Results Out of 23 reported cases of VTE in surgical patients, 17 were ultimately determined to have suffered VTE associated with their hospitalization and surgery. Thirteen out of 17 (76%) received appropriate perioperative chemical deep vein thrombosis (DVT) prophylaxis based on the calculated Caprini risk score and corresponding recommendations. Four out of 17 (24%) were determined to have received insufficient perioperative chemical DVT prophylaxis. Conclusion Consistent utilization of a DVT/pulmonary embolism (PE) risk stratification tool, such as the Caprini risk score calculator, is essential in the prevention of postoperative VTE. Hospitalscan improve the utilization of such a tool and thereby reduce the number of embolic events by making it more visible and accessible to the overseeing provider in the electronic medical record (EMR).