Incidence Of Periprocedural Complications Research Articles

New hope for patients and challenges for the multidisciplinary arrhythmia team: a hybrid convergent approach for atrial fibrillation treatment.

Available data suggest the important role of ablation of the left atrial posterior wall and epicardial myocardial layers in rhythm control therapy in patients with persistent drug‑refractory atrial fibrillation (AF). However, endocardial ablation is not always effective in transmural substrate modification. The alternative treatment option is minimally invasive hybrid approach (HABL) combining the strengths of surgical and catheter ablation. This study aimed to assess the periprocedural safety as well as acute and long‑term outcomes of HABL for AF. This is a retrospective single‑center study of patients who underwent HABL using the minimally invasive transabdominal approach between July 2009 and January 2020. Demographic in‑hospital data and 12‑month follow‑up results were obtained. The number of hospitalizations, cardioversions, re‑ablations, and severe adverse events in a 3‑year period before and after HABL were compared using data from the national healthcare provider. In total, 158 patients (mean [SD] age, 51.02 [10.67] years) who underwent HABL were included; 61.4% had persistent AF. There was a 4.4% incidence of periprocedural complications without any fatalities. In 66% of patients, additional endocardial substrate modification was needed, in 52.6% on the posterior wall. In the 12‑month follow‑up, most patients (78.3%) remained free of arrhythmias. There was a significant reduction in the number of hospitalizations (for AF, 1.65 vs 0.54; or any other cause, 2.56 vs 1.31 per patient), cardioversions, and re‑ablations after HABL (all P <0.05). The hybrid multidisciplinary approach for treatment of AF is a safe and very effective treatment method in long‑term follow‑up, which reduces healthcare burden. It could be considered as an alternative therapeutic option especially in patients with persistent AF.

Abstract 17312: Incidence of Periprocedural Complications in Patients With Percutaneous Coronary Intervention of Chronic Total Occlusions and Impact of Mortality

Background: Percutaneous recanalization of coronary chronic total occlusions (CTO) remains one of the biggest challenges in interventional cardiology and is known to be associated with higher complication rate compared to regular coronary angioplasty. The aim of the current study is to explore the frequency and clinical outcomes of patients with procedural complications. Methods: All patients with CTOs were included in prospective registry. CTO was defined as a total obstruction of a coronary artery with thrombolysis in myocardial infarction (TIMI) grade flow of 0 and duration of more than three months. Frequency of periprocedural complications were analyzed and all patients were followed-up for vital status. Results: For the purpose of current analysis we included 595 patients (66±10 years, 78% males) who underwent a total of 661 PCIs of chronic total occlusions. 623 procedures (94.3%) were successful with TIMI 3 final flow. In 10.9% (n=72) of the procedures there was a periprocedural complication defined as: coronary perforation (type I-III) 3.02% (n=20), puncture site haematoma 1.7%(n=11), coronary intramural haematoma 1.5%(n=10), coronary dissection n=5(0.8%). In 4 people (0.6%) there was perforation with formation of haemopericardium (type IV coronary perforation). On logistic regression analysis factors found to be significantly predictive for occurrence of complication were carotid artery disease (OR=4.794, CI: 1.718-13.374, p = 0.038) and renal failure (OR=1.774, CI: 1.060-2.967, p=0.016). At a median follow-up of 31 months (IQR 13-49) the overall death rate was 20.7% (n=123) and was significantly lower in noncomplicated vs complicated group (104/525, 19.8% vs 19/69, 27.5%, log-rank p=0.042). On Cox-regression analysis procedural complication was independent predictor of death (OR= 1.650, CI 1.011- 2.692, p= 0.042). Conclusion: In patients undergoing PCI for CTO the presence of periprocedural complication was independent predictors of mortality and these subjects had higher mortality rate at a median follow-up of 31 months.

Outcomes on safety and efficacy of left atrial appendage occlusion in end stage renal disease patients undergoing dialysis

BackgroundIn patients with end stage renal disease and atrial fibrillation (AF), undergoing chronic dialysis, direct oral agents are contraindicated and warfarin does not fully prevent embolic events while increasing the bleeding risk. The high hemorrhagic risk represents the main problem in this population. Aim of the study was to estimate the safety and efficacy for thromboembolic prevention of left atrial appendage (LAA) occlusion in a cohort of dialysis patients with AF and high hemorrhagic risk.MethodsNinety-two dialysis patients with AF who underwent LAA occlusion were recruited. For comparative purposes, two cohorts of dialysis patients with AF, one taking warfarin (oral anticoagulant therapy, OAT cohort, n = 114) and the other not taking any OAT (no-therapy cohort, n = 148) were included in the study. Primary endpoints were (1) incidence of peri-procedural complications, (2) incidence of 2-year thromboembolic and hemorrhagic events, (3) mortality at 2 years. In order to evaluate the effect of the LAA occlusion on the endpoints with respect to the OAT and No-therapy cohorts, a multivariable Cox regression model was applied adjusted for possible confounding factors.ResultsThe device was successfully implanted in 100% of cases. Two major peri-procedural complications were reported. No thromboembolic events occurred at 2-year follow-up. The adjusted multivariable Cox regression model showed no difference in bleeding risk in the OAT compared to the LAA occlusion cohort in the first 3 months of follow-up [HR 1.65 (95% CI 0.43–6.33)], when most of patients were taking two antiplatelet drugs. In the following 21 months the bleeding incidence became higher in OAT patients [HR 6.48 (95% CI 1.32–31.72)]. Overall mortality was greater in both the OAT [HR 2.76 (95% CI 1.31–5.86)] and No-Therapy [HR 3.09 (95% CI 1.59–5.98)] cohorts compared to LAA occlusion patients.ConclusionsThe study could open the way to a non-pharmacological option for thromboembolic protection in dialysis patients with AF and high bleeding risk.

Diabetes and periprocedural outcomes in patients treated with rotablation during percutaneous coronary interventions.

This study is to assess differences in periprocedural outcomes among diabetic and non-diabetic patients treated with percutaneous coronary intervention (PCI) and rotational atherectomy (RA). Under assessment were 221,187 patients from the Polish Cardiovascular Intervention Society national registry (ORPKI) including all PCIs performed in Poland in 2015 and 2016. Data was extracted of 975 patients treated with RA - 336 (34.5%) diabetics and 639 (65.5%) non-diabetics. Periprocedural complications were defined as overall rate or particular complications such as deaths, no-reflows, perforations, dissections, cerebral strokes or bleedings.. Multivariate analysis was performed to assess predictors of periprocedural complications. The mean age was similar in diabetics and non-diabetics (70.9 ± 9.0 vs. 72.1 ± 9.9; p = 0.06). Diabetics were more often females (p < 0.01), with arterial hypertension (p < 0.01), kidney failure (p < 0.01) and prior myocardial infarction (p = 0.01). No significant differences were observed in overall or individual periprocedural complications and angiographic success was expressed as thrombolysis in myocardial infarction grade 3 flow after PCI. At baseline, de-novo lesions accounted for 96.5% in diabetics and 99% in non-diabetics (p < 0.01), while overall rate of restenosis was 3.5% and 1%, respectively (p < 0.01). Diabetes was an independent predictor of periprocedural complications in the overall group of patients treated with PCI (OR 1.11, 95% CI 1.04-1.194; p < 0.001). The negative impact of diabetes on the incidence of periprocedural complications and angiographic effectiveness in the group of patients treated with RA is mitigated in the comparison to the non-RA group.

Protocolized use of catheter-directed thrombolysis and echocardiography is highly effective in reversing acute right heart dysfunction in severe submassive pulmonary embolism patients.

The objective of this study was to evaluate the efficacy of protocolized use of catheter-directed thrombolysis and echocardiography in submassive pulmonary embolism patients. A retrospective study at a single institution of 28 patients that presented with submassive pulmonary embolism from July 2016 to September 2019 was performed. All patients were diagnosed using chest computed tomography demonstrating a pulmonary embolism and abnormal right ventricular to left ventricular ratio. Patients with severe right heart dysfunction (right ventricular to left ventricular ratio ⩾1.4) were protocolized to receive catheter-directed thrombolysis via EkoSonic catheters (EKOS Corporation, Bothell, WA, United States). Transthoracic echocardiogram was performed after 24 hours to assess right ventricular function and determine the need to continue thrombolysis. Patients after discharge then received follow-up echocardiograms at 6 weeks to determine new post-treatment baseline. The mean patient age was 54.6 years, mean body mass index was 35.0, and mean right ventricular to left ventricular ratio on admission computed tomography imaging was 1.70. Interval mean right ventricular to left ventricular ratio on echocardiography during thrombolysis therapy was 1.01 (p < 0.00001). Patients were tachycardic on admission (mean heart rate 102.2 beats per minute) with improvement by completion of thrombolysis (mean heart rate 72.9 beats per minute) (p < 0.00001). There was a 0% incidence of periprocedural complications. Overall 30-day complication rate was 7.1% (n = 1 arrhythmia, n = 1 delayed intracranial hemorrhage). At 6-week follow-up, 91% of the patients who received echocardiography had normal right ventricular function. This retrospective study demonstrates the effectiveness of protocolized use of catheter-directed thrombolysis and echocardiography in reversing severe right heart dysfunction in submassive pulmonary embolism patients.

P19 Mid-term results of coronary intervention with directional coronary atherectomy compared with conventional stenting for LMT related lesion - a single center experience

Abstract Background The technology of percutaneous coronary intervention (PCI) has dramatically advanced and now patients can get various treatment options for left main trunk (LMT) lesion. On the other hand, Directional Coronary Atherectomy (DCA) has appeared again on the stage of PCI as a technique of debulking plaques. Purpose of this study was to compare procedural and mid-term outcomes between DCA and conventional stenting for LMT related lesions. Methods We extracted cases treated with PCI for LMT related lesion and retrospectively examined backgrounds of patients, postprocedural events and whether dual antiplatelet therapy (DAPT) had been stopped or not. In order to rule out selection bias, conventional stenting cases were collected in the era prior to starting DCA treatment. In this study, we defined Major Adverse Cardiovascular Events (MACE) as cardiovascular death, restenosis in the target lesions and acute coronary syndrome (ACS). Results From April, 2014 to September, 2017, consecutive 85 patients underwent LMT stenting. Fifty-four patients enrolled in the non-DCA group excluding patients post CABG, treated with rotablator, with ACS and unexpected incidental LMT stenting. From May, 2016 to September, 2018, consecutive 26 cases underwent DCA (DCA group), in whom 15 cases were treated with the Drug Coating Balloon (DCB) subsequent DCA. The purposes of DCA were to avoid LMT stent or stent to other lesions and plaque reduction. In terms of patient’s characteristics, there was no significant difference in sex, BMI, coronary risk factors. Renal function was significantly better in DCA group than non-DCA group (eGFR 69.0 vs 59.5 ml/min/1.73m2; p = 0.028), and the amount of contrast medium used (124 vs 94 ml; p = 0.003) and duration of fluoroscopy time (47.7 vs 35.8 minutes; p = 0.007) were significantly greater in the DCA group than non-DCA group. However, there was no significant difference in incidence of periprocedural complications (0 vs 7 cases, p = 0.09), all cause of death (0 vs 8(14.8%); p = 0.161(Log-Rank)) and MACE (2(7.7%) vs 11(20.1%); p = 0.261(Log-Rank)) between the two groups. In addition, DAPT had been significantly stopped earlier in DCA group than non-DCA group (9(36%) vs 13(24.1%) cases; &amp;lt;0.0001(Log-Rank))(Figure). Conclusions LMT stenting has a high risk for the fatal event in case of in-stent-restenosis and it makes difficult to stop DAPT in any case even at other surgical treatments. The appropriate plaque debulking by DCA can avoid deploying stents in LMT, shorten stent length and shorten DAPT duration. Hence, DCA is very effective for patients ahead of other surgeries. Although the procedure with DCA needs more contrast medium and longer fluoroscopy time, DCA will be a good option for treatment in LMT related lesion for appropriate cases. New DCA might be useful and safe enough for treating LMT related lesion. DCB may also contribute to the improvement of outcomes in treatment with DCA. Abstract P19 Figure

PROTOCOLIZED USE OF CATHETER-DIRECTED THROMBOLYSIS AND ECHOCARDIOGRAPHY IS HIGHLY EFFECTIVE IN REVERSING ACUTE RIGHT HEART DYSFUNCTION IN SEVERE SUBMASSIVE PULMONARY EMBOLISM PATIENTS

SESSION TITLE: Monday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM PURPOSE: The purpose of this study was to evaluate the efficacy of protocolized use of catheter-directed thrombolysis and echocardiography in submassive pulmonary embolism patients presenting with severe right heart dysfunction. METHODS: A retrospective study at a single academic institution of 23 patients that presented with submassive pulmonary embolism (PE) from July 2016 to April 2018 was performed. All patients were diagnosed using chest computed tomography (CT) demonstrating clot in the pulmonary vasculature as well as right ventricle dysfunction based on abnormal right ventricle to left ventricle (RV/LV ratio). Patients with severe right heart dysfunction (RV/LV≥ ratio 1.4) were protocolized to receive catheter directed thrombolysis via EkoSonic catheters (EKOS Corporation, Bothell, WA) in the pulmonary vasculature for thrombolysis with Alteplase (tPA) at 1 mg per hour total. Transthoracic Echocardiography was then performed the following day to assess right ventricle function and determine the need to continue thrombolysis. Patients after discharge then received follow up echocardiograms at 6 weeks to determine new post-treatment baseline. RESULTS: The mean patient age was 54.7 years and mean body mass index (BMI) was 35.3. Mean RV/LV ratio on admission CT imaging was 1.68, with a mean troponin of 0.35. Interval mean RV/LV ratio on echocardiography during thrombolysis therapy was 1.00 (P<.00001). Patients were tachycardic on admission (mean heart rate 102 beats per minute (BPM) with improvement by completion of thrombolysis (mean heart rate 74 BPM) (P<.00001). Twelve of 23 patients (52%) had thrombolysis terminated at 24 hours interval based on echocardiography findings, with the remainder receiving 24 additional hours of therapy. There was a 0% incidence of peri-procedural complications. Overall 30-day complication rate was 8.7% (N=1 arrythmia, N=1 delayed intracranial hemorrhage). At 6-week follow up, 89% of patients who received echocardiography had normal right ventricular function. CONCLUSIONS: This retrospective study demonstrates the effectiveness of protocolized use of catheter-directed thrombolysis and echocardiography in reversing severe right heart dysfunction in submassive pulmonary embolism patients. CLINICAL IMPLICATIONS: Protocolized use of Echocardiography with catheter-directed thrombolysis is effective at reversing severe right heart dysfunction in submissive pulmonary embolism patients without requiring repeat imaging studies or invasive follow up procedures. DISCLOSURES: No relevant relationships by Jaideep Das Gupta, source=Web Response No relevant relationships by Sundeep Guliani, source=Web Response No relevant relationships by John Marek, source=Web Response No relevant relationships by Jon Marinaro, source=Web Response No relevant relationships by Mohammed Rana, source=Web Response

Gender Differences in Outcomes After Implantation of Left Ventricular Assist Devices

Left ventricular assist device (LVAD) implantation has historically been underutilized in women compared with men. It was hypothesized that the introduction of continuous-flow LVADs would lead to more LVAD implantations in women and possibly narrow the gender gap. Patients who underwent LVAD implantation between 2009 and 2014 were identified using the national inpatient sample. A total of 3511 patients (17,251 when weighted) underwent LVAD implantation in the United States between 2009 and 2014. Mean age was 56 years and there were 817 women in the study sample (23.32%). LVAD implantations in women doubled from 2009 to 2014, but men continued to receive LVAD 3 times more than women. Inpatient mortality after LVAD placement was similar between men and women (13.42% women vs 12.85% men; odds ratio, 1.05; P= .16). Most common complications after LVAD implantation in both genders included acute kidney injury, bleeding requiring blood transfusion, and postoperative sepsis. There were no gender-specific differences in the incidence of periprocedural complications, including postoperative cardiac tamponade, postoperative thromboembolism, or sepsis. In addition, no significant difference was found in length of stay and median hospitalization cost. The use of extracorporeal membrane oxygenation did not differ between men and women. Subgroup analysis in patients older than 65 years of age showed higher in-hospital mortality but no differences between genders. The number of women undergoing LVAD implantation has increased with the introduction of continuous-flow LVADs, but a gender gap still exists. Most major in-hospital outcomes after LVAD implantation are similar between genders.

Direct Stenting Versus Stenting After Pre-dilation in Primary PCI for ST-Elevation Myocardial Infarction

Background: Direct stenting and stenting after pre-dilation are strategies used in the setting of Primary PCI for ST-elevation Myocardial Infarction (STEMI). There is a paucity of evidence to guide one treatment strategy over the other. Methods: We performed a retrospective review of a registry of Primary PCI for STEMIs between April 2013 and November 2018. Procedures were performed at Wollongong Hospital, a large tertiary centre in NSW, Australia. We collected data on baseline characteristics, procedural characteristics, procedural complications, and follow up data on Major Adverse Cardiovascular Events (MACE). Results: Data were collected on a total of 310 patients who were treated with Primary PCI for STEMI. Of these, 260 (83.9%) were treated with stenting after pre-dilatation, 38 (12.3%) were treated with a direct stenting strategy (including 11 with aspiration thrombectomy, 28 without), and 12 (3.9%) of patients were treated with “Plain Old Balloon Angioplasty” (POBA). Mean follow up duration was 29 months. There was a complication rate of 7.9% in the direct stenting arm (including a 5.3% risk of slow flow or no-reflow). This was higher than the rate for stenting with pre-dilatation, with a 6.9% rate of procedural complication (including a 1.9% risk of slow flow/no-reflow), though this did not reach statistical significance (p = 0.83). Incidence of MACE on follow up was 15.8% for the direct stenting arm vs 17% for the stenting with pre-dilatation (p = 0.86). Conclusion: In our cohort, there was no statistically significant difference in incidence of peri-procedural complications and MACE between direct stenting and stenting after pre-dilation.

Safety and efficacy of coronary rotational atherectomy in elderly patients with coronary heart disease

Objective To analyze the safety and efficacy of coronary rotational atherectomy in elderly patients with coronary heart disease. Methods A total of 107 consecutive patients with coronary artery disease receiving rotational atherectomy from January 2012 to December 2016 were retrospectively analyzed.Patients were divided into an ≥75 years group(n=44)and a <75 years group(n=63). We compared the characteristics of rotational atherectomy, peri-procedural complications, instant procedure success rates and 1-year cardiovascular events, including angina, re-infarction, hospitalization due to heart failure, repeat revascularization and cardiac death. Results There was no significant difference in the target coronary vessel, reference vessel diameter, maximal diameter of the burr and ratio of maximal diameter of the burr to reference vessel diameter between the two groups(all P>0.05). Compared with 0.05). The incidence of peri-procedural complications had no significant difference between the ≥75 years group and the <75 years group(8 cases or 18.2% vs.13 cases or 20.6%, P=0.753). One case of burr entrapment occurred in each group with successful retrieval.The procedure success rate was 96.8%(61 cases)in the <75 years group and 100% in the ≥75 years group(P=0.640). No acute or sub-acute stent thrombosis or urgent coronary artery bypass graft occurred in the two groups during hospitalization.No cardiac death occurred in either group. Conclusions Coronary rotational atherectomy is effective and safe in elderly patients with coronary disease with a high instant procedure success rate. Key words: Coronary artery disease; Atherectomy, coronary

Acute and long-term outcomes of epicardial left atrial appendage ligation with the second-generation LARIAT device: a high-volume electrophysiology center experience.

Epicardial left atrial appendage (LAA) ligation may be an alternative to oral anticoagulation management and to endocardial LAA closure devices. We report long-term results after LAA ligation with the second-generation LARIAT device. Retrospective study was performed on patients who underwent LAA ligation at our center. Follow-up included patient visits and transesophageal echocardiography (TEE) to assess LAA-to-LA leakages. 76 patients with an indication for LAA closure underwent cardiac CT-based screening with 16 patients (21%) excluded from LAA ligation due to anatomical reasons. Finally, 48 patients (70 ± 9 years, 23 women) underwent LAA ligation with successful LAA closure in 44 patients (92%). Major periprocedural complications occurred in three patients (6%; one major femoral bleeding, one pneumothorax with surgical drainage, one right ventricular perforation with concomitant stroke). Additionally, minor complications occurred in 27% of the patients with mild pericarditis in eight of these patients being the most common adverse event. Clinical follow-up (median of 443 days, interquartile range 158; 773) was obtained from 38 patients. One thromboembolic event (transient ischemic attack) occurred. Complete LAA closure was demonstrated in 23/35 patients (66%) with TEE follow-up. Major leakages > 5mm without documentation of intracardiac thrombi were documented in four patients (11%). Epicardial LAA ligation with the second-generation LARIAT device was associated with a high acute success rate comparable to endocardial LAA closure devices. LAA ligation was accompanied by a relevant incidence of periprocedural complications with mild pericarditis being the most common adverse event. Follow-up demonstrated a moderate incidence of leakages after LAA exclusion, no intracardiac thrombus formation and only a single thromboembolic event. The effectiveness in preventing thromboembolic events needs further investigation in larger patient cohorts.

Implant success and safety of left atrial appendage occlusion in end stage renal disease patients: Peri-procedural outcomes from an Italian dialysis population

AimsTo estimate the safety and the efficacy of the off label left atrial appendage (LAA) occlusion in chronic dialysis patients with atrial fibrillation (AF). In this preliminary paper, we report the design of the study and the data on peri-procedural complications. MethodsThis is a prospective cohort study. Primary endpoints are i) incidence of peri-procedural complications, ii) cumulative incidence of two-year thromboembolic events iii) cumulative incidence of two-year bleedings iiii) mortality at two years. Adverse events and death within 30 days of the procedure were recorded. ResultsFifty patients who underwent LAA occlusion between May 2014 and September 2017 were recruited. Both the mean age of the sample study and the dialysis duration were high [71.8 (9.6) years and 59.4 (78.2) months, respectively]. Most patients (84%) were hypertensive and 62% suffered a previous major bleeding. About half of them presented cardiovascular diseases. CHA2DS2VASCs and HASBLED scores were 4.0 (1.5) and 4.4 (0.9), respectively. Most patients (88%) showed atrial dilatation and 44% left ventricular hypertrophy; 32% had left ventricular ejection fraction <50%. Fifty five percent of patients had permanent AF and 32% paroxysmal AF. All devices were implanted successfully. No deaths or major adverse events were reported during a 30-day follow-up. Three episodes of peri-procedural access site bleeding were reported, requiring no transfusion. ConclusionsOur preliminary data suggest the feasibility and safety of LAA occlusion in patients undergoing dialysis. Only the follow-up of these patients over time can provide evidence that LAA occlusion is effective in preventing of thromboembolic events in this very high-risk population.

Feasibility of Left Atrial Appendage Occlusion for Left Atrial Appendage Thrombus in Patients With Persistent Atrial Fibrillation

This study sought to investigate the safety of percutaneous left atrial appendage (LAA) occlusion for stroke prevention in patients with nonvalvular atrial fibrillation who have LAA thrombus. From October 2010 to October 2016, LAA occlusions were performed in facilities within a Korean multicenter registry in patients without (n = 132) or with (n = 10) LAA thrombus (detected during preprocedural assessments). The incidences of periprocedural complications, including stroke, pericardial tamponade, major bleeding, and device embolization, were assessed and compared between the groups. The incidence of periprocedural complications was not significantly different between patients with and without LAA thrombus (0% vs 5% [6 of 132]; p = 0.49). During the mean 23.2 ± 17.5-month follow-up duration, 7 major adverse cardiac events occurred (1 cardiovascular death, 6 ischemic strokes), but overall event rates were not significantly different between the groups (14% vs 9%; p = 0.47). In conclusion, percutaneous LAA occlusion in nonvalvular atrial fibrillation patients with LAA thrombus may be a safe and feasible alternative to anticoagulation in select patients at a high risk of bleeding or contraindication to anticoagulation, or in whom anticoagulation failed to prevent stroke.

Emergency extracorporeal membrane oxygenation in transcatheter aortic valve implantation: A two-center experience of incidence, outcome and temporal trends from 2010 to 2015.

Although the incidence of periprocedural complications has decreased in transcatheter aortic valve implantation (TAVI), life-threatening complications occur and emergency veno-arterial extracorporeal membrane oxygenation (vaECMO) can provide immediate circulatory stabilization. We report our two-center experience of vaECMO during life-threatening complications in TAVI. From January 2010 to December 2015, 1,810 consecutive patients underwent TAVI at two centers. Clinical characteristics, type of complication, outcome and temporal trends in the requirement of emergency vaECMO were evaluated. Life-threatening complications requiring vaECMO occurred in 1.8% of cases (33 patients; 22 transfemoral, 11 transapical). Indications for vaECMO were ventricular rupture (30%, 10/33), low output (15%, 5/33), bleeding (12%, 4/33), coronary artery impairment (9%, 3/33), ventricular arrhythmias (6%, 2/33), severe aortic regurgitation (6%, 2/33), aortic annular rupture (6%, 2/33), and aortic dissection (3%, 1/33). In 4 cases, no definite cause for hemodynamic instability was identified. Conversion to open heart surgery was necessary in 42% of patients (14/33). Percutaneous coronary intervention was performed in all cases with coronary artery impairment (9%, 3/33). Patients with severe aortic regurgitation (6%, 2/33) underwent emergency valve-in-valve implantation. Other patients received, in addition to vaECMO support conservative treatment (42%, 14/33). In-hospital mortality and 30-day mortality were 46% (15/33). Of patients discharged, 67% (12/18) had no neurological impairment, whereas mild and severe neurological impairment was found in 11% (2/18) and 22% (4/18), respectively. From 2010 to 2015, with increasing procedures (from n = 43 to n = 553) requirement of vaECMO decreased from 9.3% to 0.9% (P for the trend <0.001). Over a 6-year period, need for emergency vaECMO during TAVI significantly decreased over time. Despite high in-hospital mortality, vaECMO represents a feasible strategy for hemodynamic support in case of life-threatening complications.

Interventional and surgical occlusion of the left atrial appendage

With a steadily increasing prevalence, atrial fibrillation (AF) is the most common sustained cardiac arrhythmia worldwide and an independent risk factor for stroke caused by thromboembolic events. The left atrial appendage (LAA) is the primary source of thromboemboli in patients with nonvalvular AF who have a stroke. Novel strategies (such as mechanical and nonpharmacological intervention) targeting the LAA in patients with AF for stroke prevention have become a major focus during the past decade. Some devices for percutaneous LAA occlusion are supported by robust clinical data obtained from randomized trials or large registries, and are a valid alternative to pharmacological stroke prevention. However, the incidence of periprocedural complications and the presence of device-related thrombi or residual LAA leaks, whose long-term clinical implications are still unknown, are limiting factors in wider acceptability of these techniques. In this Review, we discuss the available techniques for LAA occlusion in patients with nonvalvular AF at high risk of stroke. We describe the pharmacological and mechanical approaches to LAA occlusion, and provide the current clinical evidence for various strategies. We particularly focus on the current management of the LAA, and discuss the challenges and future implications of the available approaches to LAA occlusion.

Comparison of Stent-Assisted Coiling and Balloon-Assisted Coiling in the Treatment of Ruptured Wide-Necked Intracranial Aneurysms in the Acute Period

The purpose of this study was to compare the efficacy, stability, and safety of stent-assisted coiling (SAC) and balloon-assisted coiling (BAC) in the treatment of ruptured wide-necked aneurysms in the acute period. Consecutive patients including 65 cases treated with SAC and 32 with BAC were reviewed at the authors' institution between November 2011 and December 2014. The efficacy of these 2 approaches and the incidence of periprocedural complications were retrospectively evaluated. Morphologic analysis showed a lower fundus/neck ratio (1.2 vs. 1.6) in the aneurysms treated with SAC versus BAC (P < 0.001). The mean neck width of aneurysms was 4.0 mm in the patients treated with SAC versus 3.4 mm in those treated with BAC (P < 0.04). Coil protrusion into the parent vessels during embolization was an independent risk factor for cerebral ischemic events (odds ratio [OR], 4.08; 95% confidence interval [CI], 1.03-16.2). Neck width (OR, 0.65; 95% CI, 0.44-0.97) and aneurysm perforation during procedure (OR, 6.24; 95% CI, 1.21-32.3) were independent predictors of complete occlusion (Raymond 1) by immediate postembolization angiography. There was no statistical difference between the 2 techniques regarding the rate of aneurysm occlusion at the end of procedure, periprocedural complications, and favorable outcome at discharge and follow-up. These findings suggested that SAC was more appropriate than BAC for ruptured wide-necked aneurysms with lower fundus/neck ratio or wider neck size. However, periprocedural complications, occlusion rates, and favorable outcomes did not differ between the 2 techniques.

178-01: Low incidence of peri-procedural complications after Cryoballoon ablation of atrial fibrillation based on atrial fibrillation type (paroxysmal vs persistent) and left expertise (high volume vs low volume)

178-01: Low incidence of peri-procedural complications after Cryoballoon ablation of atrial fibrillation based on atrial fibrillation type (paroxysmal vs persistent) and left expertise (high volume vs low volume)

Acute and early outcomes of focal impulse and rotor modulation (FIRM)-guided rotors-only ablation in patients with nonparoxysmal atrial fibrillation

Focal impulse and rotor modulation (FIRM)-guided ablation targets sites that are thought to sustain atrial fibrillation (AF). The purpose of this study was to evaluate the acute and mid-term outcomes of FIRM-guided only ablation in patients with nonparoxysmal AF. We prospectively enrolled patients with persistent and long-standing persistent (LSP) AF at three centers to undergo FIRM-guided only ablation. We evaluated acute procedural success (defined as AF termination, organization, or ≥10% slowing), safety (incidence of periprocedural complications), and long-term success (single-procedure freedom from atrial tachycardia [AT]/AF off antiarrhythmic drugs [AAD] after a 2-month blanking period). Twenty-nine patients with persistent (N = 20) and LSP (N = 9) AF underwent FIRM mapping. Rotors were presents in all patients, with a mean of 4 ± 1.2 per patient (62% were left atrial); 1 focal impulse was identified. All sources were successfully ablated, and overall acute success rate was 41% (0 AF termination, 2 AF slowing, 10 AF organization). There were no major procedure-related adverse events. After a mean 5.7 months of follow-up, single-procedure freedom from AT/AF without AADs was 17%. In nonparoxysmal AF patients, targeted ablation of FIRM-identified rotors is not effective in obtaining AF termination, organization, or slowing during the procedure. After mid-term follow-up, the strategy of ablating FIRM-identified rotors alone did not prevent recurrence from AT/AF.

Differences in activated clotting time among uninterrupted anticoagulants during the periprocedural period of atrial fibrillation ablation.

Close monitoring of intraoperative activated clotting time (ACT) is crucial to prevent complications during the periprocedural period of atrial fibrillation (AF) ablation. However, little is known about the ACT in patients receiving new oral anticoagulant agents (NOACs). The purpose of this study was to evaluate change in the ACT among anticoagulant agents used during the periprocedural period of AF ablation. We examined 869 consecutive patients who underwent AF ablation between April 2012 and August 2014 and received NOACs (n = 499), including dabigatran, rivaroxaban, and apixaban, or warfarin (n = 370) for uninterrupted periprocedural anticoagulation. Changes in intraprocedural ACT were investigated among the anticoagulant agents. Furthermore, the incidence of periprocedural events was estimated. The average time in minutes required for achieving a target ACT >300 seconds was significantly longer in the dabigatran group (DG) and apixaban group (AG) than in the warfarin group (WG) and rivaroxaban group (RG) (60 and 70 minutes vs 8 and 9 minutes, respectively; P < .001). In addition, the proportion of patients who achieved the target ACT after initial heparin bolus was significantly lower in the DG and AG than in the WG and RG (36% and 26% vs 84% and 78%, respectively; P < .001). Furthermore, the incidence of periprocedural complications was equivalent among the groups. The average time required to reach the target ACT was longer in the DG and AG than in the WG and RG.

The impact of age on the efficacy and safety of catheter ablation for long-standing persistent atrial fibrillation

Catheter ablation (CA) has been the most effective treatment for both paroxysmal and persistent atrial fibrillation (AF). However, the impact of age on CA for persistent AF is not well defined. Between January 2010 and August 2011, 258 consecutive patients (85 females, 32.9%), with long-standing persistent AF who underwent CA were prospectively recruited. Age-related differences in clinical presentation, peri-procedural complications, and outcomes were compared. The study population included 258 patients (85 females, 32.9%): 71 patients in Group I (≤ 55 years), 89 patients in Group II (56-65 years), and 98 patients in Group III (≥ 66 years). Younger patients were more likely to have lone AF (49.3% in Group I, 32.6% in Group II, and 30.6% in Group III; P = 0.029). There was a significant difference in the success rate with advancing age after a single CA (69.0% in Group I, 50.6% in Group II, 40.8% in Group III; P = 0.001). A Cox regression analysis demonstrated age (for each 10 years increase, HR 1.307, CI 1.081-1.580; P = 0.006), sex (HR 1.460, CI 1.017-2.097; P = 0.040) and total AF duration (per year, HR 1.033, CI 1.006-1.060; P = 0.015) as the independent predictors for recurrence after the first CA. However, there was no significant difference in the incidence of peri-procedural complications among the three groups. In this consecutive series of patients with long-standing persistent AF, female gender, total AF duration and advanced age were associated with the success of a single CA. The overall rate of complications was similar among all age groups.