History Of Paroxysmal Atrial Fibrillation Research Articles

Assessment of mild cognitive dysfunction in patients with atrial fibrillation utilizing the R4Alz assessment test

Abstract Background/Introduction The association between atrial fibrillation and cognitive dysfunction has accumulated a growing body of evidence in recent years. However, establishing such a diagnosis remains challenging, especially in mild oligosymptomatic patients. REMEDES for Alzheimer (R4Alz) is a novel test, designed to assess cognitive control decline at an early stage. Purpose We sought to evaluate the prevalence of early, mild cognitive dysfunction in patients with paroxysmal atrial fibrillation with the use of established and novel diagnostic tools. Methods This is a prospective cross-sectional study that enrolled consecutive patients with history of paroxysmal atrial fibrillation and matched healthy controls, from a tertiary cardiology department. Patients with history of stroke or known cognitive dysfunction of any type were excluded from the study. Demographic and clinical data were collected. All study participants were subjected to Montreal Cognitive Assessment (MoCA) and to R4Alz within the same day. Cognitive function and attention ability is assessed at three stages with R4Alz: working memory updating (R1), supervisory attention system (R2) and task/rule switching and control of inhibition (R3). The primary endpoint was the difference in cognitive function between patients with atrial fibrillation and controls. Secondary endpoints included the correlation between the two assessment tests in both groups. Statistical analysis was performed with R version 4.1.0 and a p-value<0.05 was considered statistically significant. Results Fifty-five patients with atrial fibrillation and thirty-four controls were enrolled in the study (Mean age: 62.6 y, Female gender: 62.9%). MoCA scores (25.4 ± 4.11 for patients with atrial fibrillation vs 22.3 ± 3.72 for healthy controls, p-value <0.001) (Figure 1) as well as scores of all stages of R4ALz {working memory (R1a, R1b, R1c), supervisory attention system (R2) and task/rule switching – inhibition control (R3a1, R3a2, R3b)} were indicative of mild cognitive dysfunction in patients with atrial fibrillation. The control group exhibited significantly better cognitive performance on all assessment tools (Table 1).Figure 1Table 1

The effect of bachmann bundle pacing on diastolic function in patients with non-obstructive HCM

Abstract Background and Objective Patients with non-obstructive HCM (nHCM) have advanced diastolic dysfunction and atrial remodeling, leading to increased heart failure hospitalisations. The objective of this study was to evaluate the role of Bachmann bundle pacing (BBP) in diastolic filling compared to right atrial appendage pacing (RAAP). Methods Forty patients with symptomatic nHCM and normal LV function were prospectively enrolled from January 2021 to June 2023. Inclusion criteria included electrocardiographic evidence of inter-atrial delay, E/e’ > 15, and an indication for ICD implantation. BBP was attempted in twenty patients, others underwent RAAP. A Biotronik Selectra 3D 40-S sheath was used for BBP in patients in whom initial lead implantation was unsuccessful. BBP was defined based on P-wave morphology and fluoroscopic lead position. The RV lead was implanted in the RV apex in all patients and the AV delay was optimized based on diastolic filling period and E/e’. Devices were programmed in DDD mode. During follow up, diastolic function, functional capacity, atrial fibrillation, and heart failure hospitalisations were assessed in both groups. Results Among the forty patients (age 48.2+7.8 yrs, males 75%, ESC-SCD Risk 4.3+0.6%), the baseline P wave duration, E/A, E/e’ were 138.4+16.4 ms, 2.5+0.5, and 17.5+2.4, respectively. Six patients (15%) had a history of paroxysmal AF (3 each in BBP and RAAP groups). Of the 16 patients (80%) who underwent successful BBP, the Selectra 3D 40-S sheath was used in 8 patients (Figure 1, Panel A). During BBP, a bachmann bundle potential was recorded in 7 of 16 patients (43.8%) (Figure 1, Panel C). The pacing threshold (1.5+0.5@0.4ms vs. 0.9+0.3@0.4ms, p=0.026) was higher and the atrial sensing (1.8+0.4 vs. 3.3+0.6, p=0.002) was lower in the BBP group compared to the RAAP group at 4 weeks and 6 months of follow up. There was an acute rise in threshold (2.1@0.4 ms) in 1 BBP patient at 4 weeks of follow up. Patients in the BBP group had a reduction in P wave duration compared to the patients in the RAAP group (-22.5 + 5.4 vs. +5.6 + 3.2 ms, p<0.001). During follow up (11.4 + 3.4 months), there was a significant improvement in diastolic function (E/e’), functional capacity (NYHA Class) and reduction in NT-proBNP in the BBB group compared to the RAAP group (Figure 1). The percentage of atrial pacing was similar in both groups (BBP 73.2 + 7.8 vs. RAAP 78.5 + 9.1 %, p=0.219). The risk of atrial fibrillation/tachycardia (12.5% vs. 35.0%, p=0.022) and heart failure hospitalisations (6.3% vs. 20%, p=0.042) was lower in the BBP group compared with RAAP during follow up. Conclusions BBP is safe and effective in improving diastolic function, functional capacity and heart failure hospitalizations in patients with nHCM.BBP Pacing using Selectra 3D 40-S SheathChange in E/e', NYHA, and NT-pro BNP

YOUNG WOMAN WITH LEFT VENTRICULAR DYSFUNCTION AND MITRAL LAMBL EXCRESCENCE: WHAT TO DO WHEN ISCHEMIC STROKE IS RECURRENT?

Abstract Lambl excrescence describing rare cardiac growths that develop at the valvular coaptation sites of the heart which are seen as a thin, hypermobile and filiform strand on an echocardiogram. These filiform strands can be noted in association with embolic stroke. Also heart failure (HF) and stroke frequently coexist because of an overlap of shared risk factors and subsequent mechanisms and a higher risk of stroke is present also in HF patients in sinus rythm (SR). The clinical case concerns a 54–year–old woman. In March 2020 she was admitted for ischemic stroke by occlusion of middle cerebral artery subjected to thrombolysis and mechanical thromboctomy. Electrocardiogram showed SR and left branch block. Echocardiogram and echocardiogram transesophageal showed left ventricular (LV) dysfunction (EF 40%) withouth clear presence of emboligen sources. Thrombophilic screening and neurological checks were negative. Single antiaggregant therapy has been started. New hospitalization in October 2023 for recurrent ischemic stroke. Echocardiogram showed worsening of LV dysfunction (EF 20%). Transesophageal echocardiogram showed the presence of a filiform filament on the mitral leaflets on the atrial side (Fig 1) without the presence of intracavitary thrombi. Coronary TC angiography (Fig 2) was negative. Cardiac magnetic resonance (Fig 3) confirmed reduced ejection fraction and showed subepicardial late gadolinium enhancement in lateral wall. There are no clear evidence–based guidelines for the treatment of Lambl excrescences. When associated with stroke, an exhaustive stroke workup to identify the potential cause of stroke should always be undertaken. If the workup remains negative without any identifiable cause, then the patients can be treated with antiplatelet agents such as aspirin and clopidogrel or anticoagulation with warfarin. Also the indication to antithrombotic strategies in patients with HF, SR and stroke is controversial. There are no data to support a routine strategy of anticoagulation in patients with HF with LV dysfuncion in SR who do not have history of paroxysmal atrial fibrillation (ESC 2022 HF guidelines). So which therapy to start in young patient, with recurrent strokes, heart failure /severe LV dysfunction and mitral lambl excrescence? Oral anticoagulant? Double platelet antiaggregation? Oral anticoagulant and single platelet antiaggregation? Definitely the choice is not simple but we decided to start warfarin and continue follow–up.

Atrial Arrhythmia in Sickle Cell Anemia: A Missing Piece to Prevent Cerebrovascular Complications?

Background: Although Sickle Cell anemia (SCA) patients carries an increased risk of stroke and an important left atrial (LA) remodeling, the reality of atrial arrythmia (AA) has never been prospectively assessed. Purpose: The aim of this study was to identify the prevalence and predictors of atrial arrhythmia in SCA patients among Drepacoeur registry. Methods: From January 2019 to November 2022, consecutive adult patients with SCA were referred to the physiology department to specifically analyze cardiac function and were prospectively included. They underwent a 24-hour electrocardiogram monitoring (ECG-Holter), transthoracic echocardiography, and laboratory tests on the same day. The primary end point was the occurrence of AA, defined by the presence of excessive supraventricular ectopic activity (ESVEA) on ECG-holter (i.e. >720 premature atrial contractions [PACs] or any run ≥ 20 PACs), recent history of paroxysmal atrial fibrillation (AFib), of persistant AFib. Results: Overall, 130 patients were included. Mean age was 45±12 years, 48% were male. AA was observed in 34 (26%) patients (17 with more than 720 PACs/day, 6 with at least a run ≥ 20 PACs, 11 with recent history of paroxysmal AFib and 5 with persistant AFib). Ageing (52±9 vs. 42±12 years, P=0,004), LA dilation (LAV i, 71±24 vs. 52±14 ml/m², P<0.001) and history of stroke without underlying cerebral vasculopathy (23% vs. 7%, P=0.04) were independently associated with AA. Age and LAV i correlated with PAC load on ECG-holter (R=0,56, P<0,001 and R=0,33, P<0.001 respectively). Interestingly n age over 47 years or a LAV i >55ml/m² could predict AA with a positive prective value of 33% and a negative one of 92%. Conclusion: Atrial arrythmia is common in adult SCA patients and is associated with ageing, LA remodeling and considerably increases the risk of ischemic stroke. This study provides tools for early detection of AA and prevent cardiac and cerebrovascular dramatic complications in this highly vulnerable population.

Left atrial dysfunction during stress in patients with atrial fibrillation

Abstract Background Left atrial (LA) myopathy with paroxysmal and permanent atrial fibrillation (AF) is frequent in chronic coronary syndromes (CCS). Objective This study sought to assess LA function at rest and during stress across the spectrum of AF. Methods In a prospective, multicentric, observational study design, we studied a cohort of 2391 patients (age=67±12 years; 1459, 61% male): 2142 (89.6%) were in sinus rhythm (SR, Group 1), 165 (6.9%) had a history of paroxysmal AF (Group 2) and 84 (3.5%) were in permanent AF (Group 3). All patients were referred for CCS and underwent stress echocardiography (SE) with exercise (n=1092, 45.3%), dobutamine (n=320, 13.4%) or vasodilators (n= 989, 40.3%: dipyridamole n=963 and adenosine n=26). Left atrial volume index (LAVI) and LA reservoir strain (LASr) were assessed at rest and peak stress. Analysis with different vendors was performed offline on anonymized cine-loops by observers unaware of the study hypothesis. Results The progressive increase in LA dysfunction from Group 1 to 3 was accompanied by greater signs of pulmonary congestion and LV dysfunction (see Table 1). In particular, LASr progressively decreased from Group 1 to 3, both at rest and during stress, regardless of the stress employed (see Figure 1). Conclusions LA reservoir function can be easily assessed with deformation imaging at rest and during exercise or pharmacological stress echocardiography. LA dysfunction progressively increases from SR to paroxysmal to permanent AF and is associated with more important LV systolic dysfunction, LV filling pressure, and pulmonary congestion in CCS.Table 1.Echocardiographic parametersFigure 1.LAVI and LASr at rest and peak

Abstract 12764: Reduced EF With Mavacamten Initiation in a Patient With Atrial Fibrillation: A Case Report

Description of Case: A 55-year-old male with a history of paroxysmal atrial fibrillation (AF) and hypertrophic cardiomyopathy (HCM) diagnosed three years prior at an outside institution presented to clinic with exertional dyspnea. Baseline TTE confirmed HCM demonstrating an EF of 69%, mitral systolic anterior motion (SAM), left ventricular outflow tract (LVOT) obstruction, and a peak gradient exceeding 100 mmHg. Initiation of mavacamten 5mg resulted in symptom improvement and a one-month follow-up TTE demonstrating a reduced peak gradient of 74 mmHg and normal EF. However, two months after initiation the patient returned with AF with rapid ventricular response (RVR) and TTE showed a newly reduced EF of 21%. Mavacamten was stopped while home metoprolol XL was increased from 100 to 150 mg daily for rate optimization. Holter monitoring showed a 100% Afib burden with an average heart rate of 108 beats per minute. Stopping mavacamten for four weeks resulted in worsening exertional dyspnea but restoration of EF to 52% on TTE. Mavacamten was reinstated at a lower dose of 2.5 mg, resulting in symptom improvement. Monthly TTE exams over four months consistently demonstrated a normal EF without LVOT obstruction at rest. Discussion: Mavacamten, a promising drug used to treat obstructive HCM, modulates myosin to reduce myosin-actin cross-bridging. Reduction in contractility improves mitral SAM, LVOT obstruction, and symptoms. However, because mavacamten is a negative inotrope it can also precipitate reductions in EF. Generally, patients have a mild drop in EF (~5 points) after initiation. However, our patient had a significant EF drop of over 25 points likely due to both mavacamten initiation and new AF with RVR reducing systolic function. Discontinuation of mavacamten for four weeks and rate optimization likely restored EF. Dose reduced re-initiation of mavacamten resulted in long-term normal EF and improvement in symptoms. This case highlights the need for close monitoring and individualized mavacamten treatment plans. Further research is warranted to understand the interplay and long term outcomes of tachyarrhythmias and mavacamten use.

Rest and Stress Left Atrial Dysfunction in Patients with Atrial Fibrillation.

Left atrial (LA) myopathy with paroxysmal and permanent atrial fibrillation (AF) is frequent in chronic coronary syndromes (CCS) but sometimes occult at rest and elicited by stress. This study sought to assess LA volume and function at rest and during stress across the spectrum of AF. In a prospective, multicenter, observational study design, we enrolled 3042 patients [age = 64 ± 12; 63.8% male] with known or suspected CCS: 2749 were in sinus rhythm (SR, Group 1); 191 in SR with a history of paroxysmal AF (Group 2); and 102 were in permanent AF (Group 3). All patients underwent stress echocardiography (SE). We measured left atrial volume index (LAVI) in all patients and LA Strain reservoir phase (LASr) in a subset of 486 patients. LAVI increased from Group 1 to 3, both at rest (Group 1 = 27.6 ± 12.2, Group 2 = 31.6 ± 12.9, Group 3 = 43.3 ± 19.7 mL/m2, p < 0.001) and at peak stress (Group 1 = 26.2 ± 12.0, Group 2 = 31.2 ± 12.2, Group 3 = 43.9 ± 19.4 mL/m2, p < 0.001). LASr progressively decreased from Group 1 to 3, both at rest (Group 1 = 26.0 ± 8.5%, Group 2 = 23.2 ± 11.2%, Group 3 = 8.5 ± 6.5%, p < 0.001) and at peak stress (Group 1 = 26.9 ± 10.1, Group 2 = 23.8 ± 11.0 Group 3 = 10.7 ± 8.1%, p < 0.001). Stress B-lines (≥2) were more frequent in AF (Group 1 = 29.7% vs. Group 2 = 35.5% vs. Group 3 = 57.4%, p < 0.001). Inducible ischemia was less frequent in SR (Group 1 = 16.1% vs. Group 2 = 24.7% vs. Group 3 = 24.5%, p = 0.001). In CCS, rest and stress LA dilation and reservoir dysfunction are often present in paroxysmal and, more so, in permanent AF and are associated with more frequent inducible ischemia and pulmonary congestion during stress.

Failure of diltiazem to prevent 1:1 conduction of atrial flutter: a case report

BackgroundAtrial flutter with 1:1 conduction to the ventricles is a dangerous cardiac arrhythmia. Contemporary guidelines recommend atrioventricular nodal blocking agents should be co-administered with class 1C anti-arrhythmics, as prophylaxis against 1:1 flutter. No guidance is provided on the type or strength of atrioventricular nodal blockade required, and in practice, these agents are frequently prescribed at low dose, or even omitted, due to their side effect profile.Case presentationA 62 year old Caucasian man with a history of paroxysmal atrial fibrillation treated with flecainide, presented with atrial flutter with 1:1 conduction to the ventricles and was cardioverted. Diltiazem was added to prevent this complication and he again presented with atrial flutter with 1:1 conduction to the ventricles, despite prophylaxis with coadministration of diltiazem.ConclusionsThis case report demonstrates failure of diltiazem to prevent 1:1 flutter in a patient chronically treated with flecainide for paroxysmal atrial fibrillation.

Determine atrial fibrillation burden with a photoplethysmographic mobile sensor: the atrial fibrillation burden trial: detection and quantification of episodes of atrial fibrillation using a cloud analytics service connected to a wearable with photoplethysmographic sensor.

Recent studies suggest that atrial fibrillation (AF) burden (time AF is present) is an independent risk factor for stroke. The aim of this trial was to study the feasibility and accuracy to identify AF episodes and quantify AF burden in patients with a known history of paroxysmal AF with a photoplethysmography (PPG)-based wearable. In this prospective, single-centre trial, the PPG-based estimation of AF burden was compared with measurements of a conventional 48 h Holter electrocardiogram (ECG), which served as the gold standard. An automated algorithm performed PPG analysis, while a cardiologist, blinded for the PPG data, analysed the ECG data. Detected episodes of AF measured by both methods were aligned timewise.Out of 100 patients recruited, 8 had to be excluded due to technical issues. Data from 92 patients were analysed [55.4% male; age 73.3 years (standard deviation, SD: 10.4)]. Twenty-five patients presented AF during the study period. The intraclass correlation coefficient of total AF burden minutes detected by the two measurement methods was 0.88. The percentage of correctly identified AF burden over all patients was 85.1% and the respective parameter for non-AF time was 99.9%. Our results demonstrate that a PPG-based wearable in combination with an analytical algorithm appears to be suitable for a semiquantitative estimation of AF burden in patients with a known history of paroxysmal AF. NCT04563572.

Combined effects of high atrial septal pacing and reactive atrial antitachycardia pacing for reducing atrial fibrillation in sick sinus syndrome.

It is unknown whether atrial fibrillation (AF) burden varies by pacing site in patients with reactive atrial antitachycardia pacing (rATP). We aimed to compare AF burden in patients with high atrial septal pacing (HASp) via delivery catheter and right atrial appendage pacing (RAAp) in patients with sick sinus syndrome (SSS). We retrospectively identified 109 patients with a history of paroxysmal AF and SSS who had received dual-chamber pacemaker implantation between January 2017 and December 2019, of whom 39 and 70 patients had HASp and RAAp, respectively. rATP was initiated after a 1-month post-implantation run-in period. Patients with HASp had a significantly shorter P-wave duration during atrial pacing than those with RAAp (99.3 ± 10.4 vs. 116.0 ± 14.3 ms, p < .001). During the 3-year follow-up period, the incidence of an AF lasting longer than 1 or 7 days was significantly lower (hazard ratio [HR], 0.45; p = .016; HR, 0.24; p = .004) than in those with RAAp. The median time of AF/AT per day in the follow-up periods was significantly shorter in the HASp group than in the RAAp group (10 vs. 18 min/day, p = .018). Atrial lead division did not occur in the HASp group during the follow-up period. HASp via delivery catheter is as safe as RAAp, and HASp combined with rATP is effective for reducing AF burden in patients with SSS and paroxysmal AF.

P357 DOES CARDIAC AMYLOIDOSIS EVER HIDE A SEVERE AORTIC STENOSIS A CASE REPORT

Abstract Case presentation: A 89-year-old man, with an history of paroxysmal atrial fibrillation and chronic renal disease, was admitted to our ER for acute decompensated heart failure. He reported dyspnea on minimal exertion and worsening peripheral edema. He had a history of heart failure and a severe aortic stenosis first diagnosed in 2020 with an echocardiogram demonstrating a left ventricular ejection fraction (LVEF) of 30% and a low-flow low-gradient aortic stenosis (AVA=0,6 cmq, mean pressure gradient=21 mmHg). Besides, in 2019, he underwent a 99m Tc MDP scintigraphy for a prostatic nodule which showed important myocardial uptake of the bone tracer highly suggestive of cardiac amyloidosis. Urinary light chain assessment and determination of immunoglobulin light chain levels were negative for AL amyloidosis. The electrocardiogram showed: sinus rhythm, low voltage in the frontal leads and complete left bundle branch block with secondary repolarization abnormalities. The patient underwent transthoracic echocardiography for staging the severity of the aortic valve stenosis, which revealed borderline results: the aortic valve area was 0.5 cmq with a transaortic mean pressure gradient of 20 mmHg (EF 25%, with GLS of −5%). Low-dose dobutamine stress echocardiography was performed. At rest conditions, there was global hypokinesia with an ejection fraction of 24%. Aortic valve mean pressure was 19 mmHg referring to a calculated aortic valve opening area of 0,78 cmq. Under peak dobutamine stress (30 mcg/kg/min), LVEF increased to 36%. On the basis of these diagnostic findings, aortic stenosis was classified as pseudo-severe due to systolic dysfunction of the left ventricle with preserved contractile reserve. Besides, aortic calcium score of 574 confirmed that the aortic stenosis was non severe. Conclusions This case results exemplary of the fact that amyloidosis does not always hide a severe stenosis. Actually the echo with dobutamine indicates a non-valvular reason for heart-failure and no indication for valve replacement.The discharge suggestions consists of clinical/ echo follow ups and TTR stabilizers. Anyway, Tafamidis is not recommended because of the age and the patient short life expectancy. The implantation of CCM which, during the action potential platea delivers non-excitatory electrical currents and enhances systolic function in patients with heart failure, is proposed to obtain an improvement of symptoms.

E026 Hypertrophic pulmonary osteoarthropathy, rheumatoid arthritis mimic: don’t distract with immunology

Abstract Background/Aims Hypertrophic pulmonary osteoarthropathy is a para-neoplastic syndrome characterized by periosteal bone proliferation, clubbing, swelling of soft tissues and joints which is frequently associated with adenocarcinoma of lung. We hereby present a case series of two very interesting cases who were initially thought to have seropositive inflammatory arthritis, but later on investigation confirmed an underlying lung malignancy-associated secondary hypertrophic pulmonary osteoarthropathy. Methods Case 1:A 62-year-old female with previous history of leucoclastic vasculitis and hypertension, presented to rheumatology with 6 months history of widespread polyarthralgia associated with prolonged early morning stiffness. She had been smoking 10 cigarettes a day for 30 years. Clinical examination revealed no synovitis or restriction of joint movements. C-reactive protein was raised, rheumatoid factor was 284 (Normal 0-15), anti-CCP antibodies were 1 (0-6). She was diagnosed of inflammatory arthritis and started on hydroxychloroquine, with no response. Review at 4 months confirmed new swelling over the fingertips associated with weight loss, loss of appetite and persistent mild cough. Examination confirmed tenderness over the distal radius and proximal tibia with pronounced grade 3 to 4 clubbing in fingers and toes, no clinically detectable active synovitis noted. CT scan showed a large left upper lobe mass, and spinal metastases and biopsy confirmed adenocarcinoma. Results Case 2: A 74-year-old gentleman with 50 pack year history of smoking and past medical history of paroxysmal atrial fibrillation, peripheral vascular disease and Type 2 diabetes mellitus, initially presented with 10 months history of constant pain only in left big toe joint, associated with significant weight loss and on-going shortness of breath for past few months. Investigations revealed rheumatoid factor 1300 (0-15) and anti-CCP antibodies &amp;gt;340 (0-6), C-reactive protein was 54. On examination digital clubbing was noted, no synovitis or restriction of joint movements. Chest X-ray demonstrated right middle zone mass. CT Thorax abdomen &amp; pelvis confirmed malignancy. Conclusion Rheumatoid Factor has a pooled sensitivity of 69% and a specificity of 85%. Sensitivity and specificity of anti-CCP antibodies are 66% and 90.4%, respectively. Both are useful in the diagnosis of rheumatoid arthritis, but can be false positive, and can sometimes be misleading. Studies have shown a direct relation between rheumatoid factor, anti-CCP antibodies and smoking. Titres were significantly higher in heavy smokers. This case series reminds us that hypertrophic pulmonary osteoarthropathy can mimic rheumatoid arthritis. Where clinical features are not convincing of inflammatory arthritis, and red flags like history of smoking and digital clubbing are present, a high index of suspicion is required to rule out a paraneoplastic condition. Disclosure A.B. Awan: None. F. Javaid: None. A. Moorthy: None. K. Sunmboye: None.

Successful mechanical thrombectomy in acute bilateral M1 middle cerebral artery occlusion: a case report and literature review

BackgroundAcute bilateral occlusion of the middle cerebral artery (MCA) is a very rare condition, and most cases are accompanied by a poor prognosis. However, mechanical thrombectomy (MT) for bilateral MCA is challenging. Here, we report a case of acute unilateral MCA occlusion with sequential acute occlusion of the bilateral MCA during intravenous thrombolysis (IVT). We urgently performed bilateral MT of the MCA and effective recanalization.Case presentationThe patient is a 73-year-old man who complained of a sudden adverse influence on speech and an inability to move his left limb for 2 h. He had a history of paroxysmal atrial fibrillation, but had never used any anticoagulants before. Head and neck computed tomography angiography (CTA) showed embolism in the right M1 MCA. During intravenous alteplase thrombolytic therapy, the patient suddenly became unconscious. Cerebral angiography showed occlusion of the M1 segment of the bilateral MCA in the patients. MT of the bilateral MCA was performed using a combination of a stent retriever and an aspiration catheter with mTici 3 revascularization. On the second day, the patient became conscious, although he had remaining symptoms of speech insufficiency and weakness of the left limb. The mRS score was 2 90 days after the operation.ConclusionsAcute bilateral occlusion of the M1 segment of the MCA is extremely rare and is accompanied by high morbidity and high mortality. Intravenous alteplase thrombolysis can increase the risk of atrial thrombus shedding in patients with atrial fibrillation, so patients with acute bilateral MCA occlusion in the M1 segment chose direct MT or bridging therapy, which remains controversial, and the sequence of MT remains to be discussed. Nevertheless, early endovascular treatment can decrease the morbidity and mortality of such patients.

7 EXPLOITABILITY AND DISTRIBUTION OF SLEEP APNEA AND ATRIAL FIBRILLATION BURDEN DURING LONG TERM FOLLOW-UP IN UNSELECTED DUAL-CHAMBER PACEMAKER PATIENTS

Abstract Background Sleep Apnea (SA) and Atrial Fibrillation (AF) are common comorbidities in paced patients (pts). Modern pacemakers (PMs) are capable of storing continuous long-term reliable daily information about: 1) AF burden (AFB); 2) severity of SA, defined by a respiratory disturbances index (RDI) measured by a minute ventilation sensor-based algorithm. Aim of the study This retrospective study aimed to assess exploitability and distributions of daily AFB and RDI over long-term follow-up (FU) in unselected dual-chamber (DC) paced pts implanted with PMs equipped with a dedicated SA monitoring (SAM) algorithm and followed-up in their Institutions. Pts affected by permanent AF were excluded from the study. Methods Data from long-term FU have been collected after implant, together with pts clinical baseline characteristics. Between Aug 2013 and Oct 2018, n=210 pts were implanted with Reply 200/Kora 100 PMs (MicroPort CRM, Saluggia-VC, Italy), equipped with the SAM algorithm. At each FU visit all the daily AFB and RDI data were retrieved from the PM memory. Days of FU have been considered exploitable (Expl-FU) when both the daily AFB and RDI information were available. Results Data from n=864 visits are available for analysis. Pts characteristics: male 56.2%, mean age 76.4±11.1 yrs, BMI 25.6±4.4 Kg/m2; implant indication: sinus node disease 40.5%, AV block 46.2%; 37.1% of pts had a history of paroxysmal AF. The overall FU / Expl-FU durations were 1.94±1.23 / 1.48±1.14 years (23.7% of days were lost due to various technical reasons). The PMs classified RDI as valid in 92.3%±19.5% of nights (85.7% of pts showed &amp;gt;90% of valid nights, Figure 1). Severe or moderate SA was suspected in 43.8% and 59.5% of pts, respectively. An AFB≥25% / 50% was observed in 9.5% / 5.7% of pts (Figure 2). Conclusions In this retrospective study, SA and AF have been shown to highly affect unselected DC paced pts. PM devices proved to be really helpful in consistently and reliably measure both SA (RDI successfully identified in 92.3%±19.5% of nights) and AF (9.5% of pts with AFB≥25%). This is relevant to allow clinicians to implement early preventive actions to improve clinical prognosis.

Abstract 9436: Treatment Options for Left Atrial Septal Pouch: A Case Report

Introduction: Left Atrial Septal pouch (LASP) is defined as an incomplete closure between the septum primum and septum secundum with an elongated septum secundum. This produces a crevice in the left atrium that functions as a source for static blood and atrial dissociation. This in turn could progress to the formation of thrombi within the left atrium that has the potential to embolize causing ischemic infarcts. Case Description: Here we present a 63 year old Hispanic female with a past medical history of paroxysmal atrial fibrillation on apixaban, recurrent strokes, dyslipidemia, and hypertension who presented with expressive aphasia, and prosopagnosia. Previously, the patient was reported of having two cardioembolic cerebral vascular accidents (CVA). Computed tomography of the brain demonstrated an old infarct of the left posterior parietal lobe. Patient was treated with intra-arterial tissue plasminogen activator of the left posterior cerebral artery and right middle cerebral artery. MRI demonstrated four acute punctate infarcts in the left frontal lobe consistent with embolic infarcts. TEE demonstrated a large patent foramen ovale (PFO), a prominent eustachian valve, and LASP. It was determined that her PFO and LASP were the culprit for her recurrent CVA despite appropriate AC. The PFO/LASP were successfully closed with an Amplatzer PFO occluder device. Patient was discharged home. Discussion: The LASP can function as a source of thrombus formation and atrial disassociation, which can cause embolic CVA. No guidelines exist on how to properly address a LASP. One option would be to use a PFO closure device to close LASP. Other options may include AC despite the absence of atrial fibrillation. Conclusions: In conclusion, further studies are necessary in order to establish the most appropriate management in patients with LASP.

Abstract 14411: Transcatheter Closure of Residual Leak Using Gore Cardioform Occluder After Failed Surgical Ligation of Left Atrial Appendage

Introduction: In non-valvular atrial fibrillation, the left atrial appendage (LAA) is the most common site for thromboembolic formation. The current recommendation is that patients with afib and a CHA2DS2-VASC risk score &gt;2 who undergo cardiac surgery should simultaneously have surgical left atrial appendage closure (Grade 1b). A rare complication that can occur includes incomplete LAA surgical closure with the residual leak, leading to an increased risk of stroke or thromboembolic events. We present two cases with residual leaks on follow-up after surgical ligation of LAA. Methods: Two patients aged 75 to 80 years old with a history of paroxysmal atrial fibrillation, surgical mitral valve repair, and surgical left atrial appendage ligation underwent a transesophageal echocardiogram (TEE) to evaluate the LAA. The CHA2DS2-VASC risk score was 3 for both patients. There was evidence of a residual leak greater than 5 mm between the left atrium and left atrial appendage. Results: Given the residual leak and risk scores, both patients had an increased risk of stroke. Therefore both patients underwent successful transcatheter closure of the left atrial appendage using a 20 mm Gore CARDIOFORM occluder. TEE was used to confirm no residual color flow and confirmed complete closure of the defects. Patients were continued on oral anticoagulation (DOAC) for six weeks with the plan to switch to antiplatelets. Conclusions: Studies have shown that surgical ligation of LAA can result in a residual leak which can increase the risk of systemic embolization. Following failed surgical ligation of LAA, transcatheter closure of residual leak with Gore CARDIOFORM occluder may be a safe and effective strategy for management. Further studies are needed to evaluate the safety, efficacy, and outcomes of utilizing a septal occluder device in patients with residual leaks due to failed surgical ligation of LAA.

Selective embolization of thyroid arteries as an alternative treatment of amiodarone-induced hyperthyroidism

Background: A selective embolization of thyroid arteries (SETA) is a rarely performed procedure. Although 35 years have passed since the first description of the SETA application, only about 150-200 procedures have been published so far. Case presentation: We present the case of a patient successfully treated for amiodarone-induced hyperthyroidism using the SETA method. Patient had a history of paroxysmal atrial fibrillation (PAF), diagnosed three years earlier, treated with an anticoagulant - rivaroxaban. During 35 months, amiodarone was used as a method for treating the PAF. During the treatment, the patient developed hyperthyroidism. The patient was treated with thiamazole, propranolol and sodium perchlorate. After obtaining euthyreosis, SETA was performed. The patient underwent selective embolization of the left superior and right inferior thyroid arteries with a sclerosing agent – polyvinyl alcohol with good clinical effect. A thyrosthetics agents were discontinued. Conclusions: This case demonstrates difficulties in differential diagnosis of the type of amiodarone-induced hyperthyroidism. Normal ultrasound image of the thyroid gland and absence of antithyroid antibodies suggests type II of amiodarone-induced hyperthyroidism. While, a good, fast response to thyrostatics – type I. It seems, therefore that, the diagnosis of the mixed type of amiodarone-induced hyperthyroidism is justified. Further research are also required to assess the safety and efficacy of SETA in amiodarone-induced hyperthyroidism in larger groups of patients.

Identifying patients with paroxysmal atrial fibrillation from sinus rhythm ECG using random forests

Paroxysmal atrial fibrillation (PAF) is a cardiac arrhythmia which is often challenging to diagnose because patients may be asymptomatic, and episodes are usually intermittent. In this paper we describe a method for identifying patients with a history of PAF using electrocardiogram (ECG) recordings during sinus rhythm. We analyzed, on a beat-to-beat basis, the P-waves in the sinus rhythm ECGs of 69 patients with a history of PAF and 59 healthy individuals. From each subject’s P-waves, we calculated key electrocardiographic metrics, including some which are proposed here for the first time. Using means testing and feature selection methods, we discerned the features which were most useful for classification, and trained a Random Forest which identified PAF patients. Our approach achieved a 93.45% accuracy, sensitivity of 95.21%, and specificity of 91.40% using P-wave integral and novel amplitude and slope-based features which ranked highest in importance compared to other metrics from the literature. In particular, descriptive statistics of P-wave amplitudes, slopes, and integrals, were effective for identifying subjects with PAF history vs. healthy individuals. Our method has a high sensitivity and discrimination ability, with an AUC=0.9669 which is superior to others’, and can thus be potentially valuable for the early identification of patients who are prone to episodes of PAF, even as part of the standard cardiological checkup that most adults undergo periodically.

RETURN TO LIFE: A CASE OF THE LAZARUS PHENOMENON

RETURN TO LIFE: A CASE OF THE LAZARUS PHENOMENON

Safety and prognostic relevance of acetylcholine testing in patients with stable myocardial ischaemia or myocardial infarction and non-obstructive coronary arteries.

Intracoronary provocation testing with acetylcholine (ACh) is crucial for the diagnosis of functional coronary alterations in patients with suspected myocardial ischaemia and non-obstructive coronary arteries. Our intention was to assess the safety and predictive value for major adverse cardiovascular and cerebrovascular events (MACCE) in patients presenting with ischaemia with non-obstructive coronary arteries (INOCA) or with myocardial infarction with non-obstructive coronary arteries (MINOCA). We prospectively enrolled consecutive INOCA or MINOCA patients undergoing intracoronary ACh provocation testing. A total of 317 patients were enrolled: 174 (54.9%) with INOCA and 143 (45.1%) with MINOCA. Of these, 185 patients (58.4%) had a positive response to the ACh test. Complications during ACh provocative testing were all mild and transient and occurred in 29 (9.1%) patients, with no difference between patients with positive or negative responses to ACh testing, nor between INOCA and MINOCA patients. A history of paroxysmal atrial fibrillation, moderate/severe diastolic dysfunction and a higher QTdispersion at baseline electrocardiogram were independent predictors of complications. MACCE occurred in 30 patients (9.5%) during a median follow-up of 22 months. The incidence of MACCE was higher among patients with a positive ACh test (24 [13.0%] vs 6 [4.5%], p=0.017), and a positive ACh test was an independent predictor of MACCE. ACh provocation testing is associated with a low risk of mild and transient complications, with a similar prevalence in both INOCA and MINOCA patients. Importantly, ACh provocation testing can help to identify patients at higher risk of future clinical events, suggesting a net clinical benefit derived from its use in this clinical setting.