Periprocedural Period Research Articles

Periprocedural P2Y12 inhibitors improve perioperative outcomes after carotid stenting by primarily decreasing strokes

ObjectiveThe continuation of antiplatelet agents in the periprocedural period around carotid stenting (CAS) procedures is felt to be mandatory to minimize the risk of periprocedural stroke. However, the optimal antiplatelet regimen is unclear, with some advocating dual antiplatelet therapy, and others supporting the use of P2Y12 inhibitors alone. The objective of this study was to evaluate the periprocedural effect of P2Y12 inhibitors for CAS. MethodsThe Vascular Quality Initiative was used from years 2007 to 2020. All transcarotid artery revascularization (TCAR) and transfemoral carotid artery stenting (TF-CAS) procedures were included. Patients were stratified based on perioperative use of P2Y12 inhibitors as well as symptomatic status. Primary end points were perioperative neurological events (strokes and transient ischemic attacks). Secondary end points were mortality and myocardial infarction. ResultsA total of 31,036 CAS procedures were included for analysis, with 49.8% TCAR and 50.2% TF-CAS cases; 63.8% of patients were male and 82.3% of patients were on a P2Y12 inhibitor. P2Y12 inhibitor use was more common in males, asymptomatic patients, those older than 70 years, and concurrent statin use. P2Y12 inhibitors were more likely to be used in TCAR cases than in TF-CAS cases (87.3% vs 76.8%; P < .001). The rate of periprocedural neurological events in the whole cohort was 2.6%. Patients on P2Y12 inhibitors were significantly less likely to experience a periprocedural neurological event (2.3% vs 3.9%; P < .001) and mortality (0.6% vs 2.1%; P < .001) than those who were not on a P2Y12 inhibitor. There was no effect on the rates of myocardial infarction. On multivariate analysis, both symptomatic and asymptomatic patients on P2Y12 inhibitors were significantly less likely to develop perioperative neurological events. Additionally, the use of P2Y12 inhibitors demonstrated an independent significant effect in reducing of the rate of perioperative stroke (odds ratio, 0.29; 95% confidence interval, 0.25-0.33). Finally, additional analysis of the types of P2Y12 inhibitors used revealed that all seemed to be equally effective in decreasing the periprocedural neurological event rate. ConclusionsThe use of perioperative P2Y12 inhibitors seems to markedly decrease the perioperative neurological event rate with TCAR and TF-CAS in both symptomatic and asymptomatic patients and should be strongly considered. Patients with contraindications to P2Y12 inhibitors may not be appropriate candidates for any CAS procedure. Additionally, alternative types of P2Y12 inhibitors seem to be equally effective as clopidogrel. Finally, an analysis of the Vascular Quality Initiative demonstrates that, even for TCAR cases, only 87.3% of patients seem to be on P2Y12 inhibitors in the periprocedural period, leaving room for significant improvement.

Stroke prevention during and after transcatheter aortic valve implantation: From cerebral protection devices to antithrombotic management.

Since its conception, transcatheter aortic valve implantation (TAVI) has undergone important improvements both in the implantation technique and in transcatheter devices, allowing an enthusiastic adoption of this therapeutic approach in a wide population of patients previously without a surgical option and managed conservatively. Nowadays, patients with severe symptomatic aortic stenosis are typically managed with TAVI, regardless of their risk to surgery, improving the prognosis of patients and thus achieving an exponential global expansion of its use. However, thromboembolic and hemorrhagic complications remain a latent concern in TAVI recipients. Both complications can appear simultaneously in the periprocedural period or during the follow-up, and when minor, they resolved without apparent sequelae, but in a relevant percentage of cases, they are devastating, overshadowing the benefit achieved with TAVI. Our review outlines the etiology and incidence of thromboembolic complications associated with TAVI, the main current strategies for their prevention, and the implications of its pharmacological management at the follow-up in a TAVI population, mostly frail and predisposed to bleeding complications.

Peri-procedural complications following endovascular revascularization for critical limb ischemia.

Revascularization procedures are considered the cornerstone of therapy in patients with critical limb ischemia (CLI) and multiple procedures are often required to attain limb salvage. The aim of the present study is to determine the prevalence of peri-procedural complications after endovascular procedure, and to determine the clinical and biological characteristics of patients associated to the risk of peri-procedural complications. From November 2013 to May 2021, 324 consecutive patients were retrospectively included, of whom 99 underwent more than one revascularization procedure for contralateral CLI or clinical recurrence of CLI. A total of 532 revascularizations were performed. Clinical and biological parameters were recorded at baseline before endovascular revascularization. The occurrence of a peri-procedural complication (local complications, fatal and non-fatal major bleeding or cardiovascular events) was recorded up to 30days after revascularization. Univariate and multivariate analyses were performed to study the parameters associated with per-procedural complications. A P<0.05 was considered as statistically significant. A total of 324 consecutive patients were included, 177 men and 147 women with CLI, with a mean age of 77.6±11.9years. Most of these patients had cardiovascular comorbidities (41% with a history of coronary heart disease, 78% treated hypertensive patients, 49% diabetic patients). Peri-procedural mortality occurred in 13 patients (4%) and 9 patients (2.8%) experienced major amputation at one-month following revascularization. Among the 532 revascularization procedures, 99 major bleeding events (22.8% of the cohort population) and 31 cardiovascular events (8.6% of the cohort population), were recorded in the peri-procedural period. Cardiovascular events were associated with peri-procedural mortality. Complications at the puncture site occurred during 38 of the 532 procedures (10.2% of the cohort population). Compared with patients undergoing a single revascularization procedure, patients with multiple procedures presented a higher risk of major bleeding events (48.5% vs. 11.6%, P<0.0001) and access site complications (20.2% vs. 5.78%, P<0.0001). In multivariate analysis, pulse pressure <60mmHg and hemoglobin level <10g/dl were correlated with the occurrence of major bleeding events; left ventricular ejection fraction<60% and the absence of statin treatment were correlated with the occurrence of cardiovascular complications; a high chronological rank of revascularization was correlated with the occurrence of local complication. Finally, age and gender were not associated with the occurrence of peri-procedural complication. The present results highlight that multiple revascularization procedures for limb salvage are required in almost one third of the population with critical limb ischemia and were associated with the risk of major bleeding events and access site complications. The most frequent complications of peripheral vascular interventions were major bleeding events. Adverse cardiovascular events were related with peri-procedural mortality. Anemia, blood pressure, left ventricular ejection fraction and statin treatment are important parameters to consider for peri-procedural outcomes, independently of age, gender and the chronological rank of revascularization procedure.

S338 The Impact of Smartphone Applications on Bowel Preparation, Compliance With Appointments, Cost-Effectiveness and Patients’ Quality of Life for the Colonoscopy Process: A Scoping Review

S338 The Impact of Smartphone Applications on Bowel Preparation, Compliance With Appointments, Cost-Effectiveness and Patients’ Quality of Life for the Colonoscopy Process: A Scoping Review

Left Atrial Thrombus and Dense Spontaneous Contrast in Direct Oral Anticoagulant Therapy of Atrial Fibrillation: Insights from a Reference Center.

ResumoFundamentoNo tratamento da fibrilação atrial (FA), a arritmia sustentada mais frequente, com ablação por cateter (ABL) ou cardioversão elétrica (CVE), o período periprocedimento é uma das fases mais críticas. Atualmente, o uso de novos anticoagulantes orais de ação direta (DOAC) é cada vez mais frequente, no entanto, no mundo real, ainda existem poucos dados de estudos sobre a incidência de trombo no átrio esquerdo (TrAE) ou contraste espontâneo denso (CE) no ecocardiograma transesofágico (ETE).ObjetivoAnalisar a prevalência de TrAE, por ETE, em pacientes em uso de DOAC submetidos à CVE/ABL. Secundariamente: avaliar a associação de comorbidades com a presença de trombos e CE.MétodosEstudo de coorte retrospectivo, unicêntrico, com pacientes do Ambulatório de Arritmia (InCor-HCFMUSP). Foram selecionados e analisados dados clínicos e ecocardiográficos no prontuário da instituição de pacientes com indicação de procedimentos e em uso de DOACs. Considerado um nível de significância de 5%.ResultadosForam incluídos 354 pacientes, no total de 400 procedimentos, de março de 2012-março de 2018. TrAE foi encontrado em 11 pacientes (2,8%), associado com idade avançada (p=0,007) e CHA2DS2-VASc maior (p<0,001). Foi encontrado CE no AE no procedimento antes da ETE em 29 pacientes (7,3%), com menor FEVE (p <0,038) e maior dimensão do AE (p <0,0001).ConclusãoA incidência de TrAE e CE em pacientes em uso de DOAC no contexto de CVE/ABL de FA, embora pequena, não é desprezível. Pacientes com escore CHA2DS2-VASc maior, principalmente mais idosos e com diâmetro do AE maior, são mais propensos a esses achados ecocardiográficos.

Cross-sectional Study of Percutaneous Intervention in the Elderly in Malaysia: PIELD Study

Background: Worldwide, people are living longer. Most trials do not include elderly patients. Studies in the elderly are primarily subgroup analyses of major trials. Methods: This study investigated the outcomes of percutaneous coronary intervention (PCI) in the elderly (age ≥70 years). The primary outcomes were all-cause mortality and major adverse cardiovascular events (MACE) during the periprocedural period (up to 30 days) and 1 year after PCI. We also investigated the relationship between baseline characteristics and these cardiovascular outcomes. All elderly patients enrolled in the study underwent either urgent or elective PCI between 2007 and 2016. Data were obtained from electronic medical records. Patients (n=3,659) were divided into three groups: early-elderly (age 70–74 years, n=2,316), mid-elderly (age 75–79 years, n=1,037) and late-elderly (age ≥80 years, n=306). Results: All-cause mortality and MACE 30 days after PCI were significantly higher in the late-elderly group. One year after PCI, all-cause mortality remained highest in the late-elderly group, but MACE was highest in the mid-elderly group. Kaplan–Meier survival analysis showed that survival probability 1 year after PCI was highest in early-elderly (92.0%), followed by mid-elderly (88.9%), and lowest in late-elderly group (84.9%). Conclusion: Immediate outcomes (30 days) after PCI, in terms of both MACE and all-cause mortality, favour patients without chronic renal failure undergoing PCI in an elective setting. Mid-term outcomes (1 year) after PCI, in terms of all-cause mortality, favour patients without chronic heart failure or renal failure. In conclusion, revascularisation via PCI is safe, with acceptable short- (30 days) and mid-term (1 year) outcomes, in the elderly population.

Cross-sectional Study of Percutaneous Intervention in the Elderly in Malaysia: PIELD Study

Background: Worldwide, people are living longer. Most trials do not include elderly patients. Studies in the elderly are primarily subgroup analyses of major trials. Methods: This study investigated the outcomes of percutaneous coronary intervention (PCI) in the elderly (age ≥70 years). The primary outcomes were all-cause mortality and major adverse cardiovascular events (MACE) during the periprocedural period (up to 30 days) and 1 year after PCI. We also investigated the relationship between baseline characteristics and these cardiovascular outcomes. All elderly patients enrolled in the study underwent either urgent or elective PCI between 2007 and 2016. Data were obtained from electronic medical records. Patients (n=3,659) were divided into three groups: early-elderly (age 70–74 years, n=2,316), mid-elderly (age 75–79 years, n=1,037) and late-elderly (age ≥80 years, n=306). Results: All-cause mortality and MACE 30 days after PCI were significantly higher in the late-elderly group. One year after PCI, all-cause mortality remained highest in the late-elderly group, but MACE was highest in the mid-elderly group. Kaplan–Meier survival analysis showed that survival probability 1 year after PCI was highest in early-elderly (92.0%), followed by mid-elderly (88.9%), and lowest in late-elderly group (84.9%). Conclusion: Immediate outcomes (30 days) after PCI, in terms of both MACE and all-cause mortality, favour patients without chronic renal failure undergoing PCI in an elective setting. Mid-term outcomes (1 year) after PCI, in terms of all-cause mortality, favour patients without chronic heart failure or renal failure. In conclusion, revascularisation via PCI is safe, with acceptable short- (30 days) and mid-term (1 year) outcomes, in the elderly population.

The impact of smartphone applications on bowel preparation, compliance with appointments, cost-effectiveness, and patients' quality of life for the colonoscopy process: A scoping review.

The aim of this scoping review is to evaluate the impact of smartphone application (SPA) technology in patients undergoing elective colonoscopy to measure compliance with appointments, cost-effectiveness, bowel preparation, and quality of life. The scoping review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. Ovid Medline, Web of Science, Science Direct, Scopus, Cochrane Library, and PubMed were screened up to Oct 14, 2020, and bibliographies of the retrieved articles were included. Based on pre-specified inclusion and exclusion criteria, 8 primary studies were included in the final analysis from a total of 3,979 non-duplicate articles. Seven out of eight studies measured the bowel preparation quality. In six of these studies, patients in the smartphone group had a successful bowel preparation when compared with the control arm; on the other hand, one study did not find any differences between groups. Adherence to colonoscopy screening was assessed by one study. Patients in the digital intervention arm were significantly more likely to complete a screening test. Patient satisfaction during the periprocedural period of colonoscopy was assessed by five studies which reported significantly higher patient satisfaction in the intervention arm compared to the control arm. None of the studies measured cost-effectiveness. We came to the conclusion that a well-designed, user-friendly SPA can help and guide patients undergoing colonoscopy through the process of following up on their appointments, adhering to bowel preparation, and better understanding their disease condition. Future trials investigating SPAs should include cost-effectiveness and adherence to appointments as an endpoint.

The current practice of transcatheter aortic valve replacement in China.

The purpose of this study is to summarize the current practice and experience of transcatheter aortic valve replacement in China. The relevant articles were identified through computerized searches of the CNKI, WANFANG, VIP, and PubMed databases through February 1, 2022, using the search terms: "transcatheter aortic valve replacement," "transcatheter aortic valve implantation,""China." The database searches identified 22 articles, 2092 patients, 57.65% were male, with a mean age of 74.2 ± 6.0 years, 71.51% of patients were classified by New York Heart Association as class Ⅲ/Ⅳ, Society of Thoracic Surgeons score 8.4 ± 4.1, mean left ventricular ejection fraction 52.8 ± 14.2%, mean transvalvular aortic pressure gradient 59.9 ± 18.9 mmHg. The overall procedural success rate was 97.85%, and 2.15% of patients were converted to sternotomy, mainly due to transcatheter aortic bioprosthesis dislocation. The most common vascular access approach was transfemoral (1071 patients, 51.20%). General anesthesia (48.90%) was the commonly used anesthesia technique. The incidence of postprocedural complications was as follows: permanent pacemaker implantation (10.47%), bleeding events (8.60%), mild paravalvular leakage (17.73%), moderate and severe paravalvular leakage (4.16%), vascular complications (3.30%), stroke (1.43%), respectively. The overall periprocedural period and postprocedural 30-day mortality was 2.72%. Among patients undergoing transcatheter aortic valve replacement in China, device implantation success was achieved in 97.85% of cases. The most common vascular access approach was transfemoral. General anesthesia was the most commonly used anesthetic technique. Paravalvular leakage (458 patients, 21.89%) was the most common complication.

Oncologic Interventions: Periprocedural Medications.

Significant advances in ablative and endovascular therapies have allowed interventional radiology to play a substantial role in the management of patients with malignant neoplasms. The evolution of these procedures and the optimization of patient outcomes and experience must take into account various elements of the periprocedural period. Some of the most important considerations within the periprocedural period are the pharmacologic agents used to avoid infectious complications, decrease pain, and manage side effects. In this article, we discuss some of the most commonly used medications in interventional oncology procedures including antibiotics, narcotics, sedatives, antiemetics, and others.

Safety of Prophylactic Anticoagulation During Bedside Procedures: A Prospective Multicenter Observational Study.

Bedside percutaneous dilatational tracheostomy (PDT) and percutaneous endoscopic gastrostomy (PEG) are common procedures performed in the intensive care unit (ICU). Venous thromboembolism (VTE) prophylaxis is frequently prescribed to ICU patients and it remains unclear whether pre-procedure discontinuation is necessary. This multi-center prospective observational study aimed to describe bleeding rates in patients undergoing bedside PEG or PDT who did or did not have VTE prophylaxis held. Decision to hold prophylaxis was made by the operating physician. The primary endpoint was the rate of peri-procedural bleeding complications. Secondary endpoints included quantification of held doses in the peri-procedural period, rate of venous thromboembolism, and characteristics associated with having prophylaxis held. 91 patients were included over a 2-year period. Patients were on average aged 54years, 40% female, mostly admitted to the trauma service (59%), and most commonly underwent bedside PDT (59%). Overall, 21% of patients had doses of pre-procedure prophylaxis held. Bleeding events occurred in 1 patient (1.4%) who had prophylaxis continued and in 1 patient (5.0%) who had prophylaxis held, a rate difference of 3.6% (95% CI-9.5%, 16.7%). One bleeding event was managed with bedside surgical repair and one with blood transfusion. There were 10 VTE events, all of whom had prophylaxis continued during the pre-procedure period but 3 had prophylaxis held after the procedure. Bleeding complications were rare and did not significantly differ depending on whether prophylaxis was held or not. Future research is required to confirm the lack of risk with continuing prophylaxis through bedside procedures.

A call to action for anticoagulation stewardship

A call to action for anticoagulation stewardship

Angiographic Characteristics of Cerebral Perfusion and Hemodynamics of the Bridging Artery After Surgical Treatment of Unilateral Moyamoya Disease.

PurposeTo investigate the characteristics of cerebral perfusion and hemodynamics of bypass grafting in the treatment of moyamoya disease (MMD) using the iFlow color-coded flow map in comparison with magnetic resonance imaging–perfusion-weighted imaging (MRI–PWI) and computational fluid dynamic (CFD) analysis.Materials and MethodsPatients with MMD treated with bypass grafting who had undergone MRI PWI and digital subtraction angiography for iFlow color-coded map was retrospectively enrolled and CFD was performed for calculating the hemodynamic stresses around the bypass grafting.ResultsForty-five patients with unilateral MMD treated with bypass surgery were enrolled. The bypass surgery was successful in all patients, with no severe neurological complications during the periprocedural period. Followed up for 4–12 months (median 5.5), the neurological function was good in all patients. The cerebral blood flow (CBF), cerebral blood volume (CBV), mean transit time (MTT), and time to peak (TTP) were significantly (p < 0.05) improved in the middle cerebral artery distribution area on the surgical side before and after vascular bypass, and the difference of TTP (s) measured from the proximal bifurcation of common carotid artery to the confluence of sinus was also significant (p < 0.05). A significant (p < 0.05) positive correlation existed in the perfusion parameters between the iFlow blood perfusion and the MRI–PWI perfusion, with r-value for TTP of 0.765 (p < 0.01). The iFlow color-coded blood flow map showed warm color changes on the diseased side, similar to those on the contralateral side. In CFD analysis, the hemodynamic stresses were all improved, in and around the bypass grafting and distal vessels, which were beneficial to blood flow entering distal arterial branches.ConclusionThe iFlow color-coded flow map can be used to analyze cerebral perfusion after bypass grafting for MMD, similar to MRI–PWI, and CFD can be used to analyze the hemodynamics after bypass grafting, revealing improved hemodynamics to promote blood flow entering distal arteries.

Comparison of Aortobifemoral Bypass and Endovascular Treatment for Chronic Infrarenal Abdominal Aortic Occlusion From the CHAOS (CHronic Abdominal Aortic Occlusion, ASian Multicenter) Registry.

To directly compare the clinical outcomes of aortobifemoral bypass surgery (ABF) and endovascular treatment (EVT) for chronic total occlusion (CTO) of the infrarenal abdominal aorta (IAA). In this retrospective, multicenter study, we used an international database of 436 patients who underwent revascularization for CTO of the IAA between 2007 and 2017 at 30 Asian cardiovascular centers. After excluding 52 patients who underwent axillobifemoral bypass surgery, 384 patients (139 ABFs and 245 EVTs) were included in the analysis. Propensity score-matched analysis was performed to compare clinical results in the periprocedural period and the long-term. Propensity score matching extracted 88 pairs. Procedure time (ABF; 288 [240-345] minutes vs EVT; 159 [100-205] minutes, p<0.001) and length of hospital stay (17 [12-23] days vs 5 [4-13] days, p<0.001) were significantly shorter in the EVT group than in the ABF group, while the proportions of procedural success (98.9% versus 96.6%, p=0.620), complications (9.1% versus 12.3%, p=0.550), and mortality (2.3% versus 3.8%, p=1.000) were not different between the groups. At 1 months, ABI significantly increased more in the ABF group for both in a limb with the lower (0.56 versus 0.50, p=0.018) and the higher (0.49 versus 0.34, p=0.001) baseline ABI, while the change of the Rutherford category was not significantly different between the groups (p=0.590). At 5 years, compared with the EVT group, the ABF group had significantly better primary patency (89.4±4.3% versus 74.8±4.3%, p=0.035) and survival rates (86.9±4.5% versus 66.2±7.5%, p=0.007). However, there was no significant difference between the groups for secondary patency (100.0%±0.0% versus 93.5%±3.9%, p=0.160) and freedom from target lesion revascularization (TLR) (89.3±4.3% vs 77.3±7.3%, p=0.096). Even with recent advancements in EVT, primary patency was still significantly better for ABF in CTO of the IAA. However, there was no difference between the groups in terms of secondary patency and freedom from TLR at 5 years. Furthermore, there was no difference in procedural success, complications, mortality, and improvement in the Rutherford classification during the periprocedural period, with significantly shorter procedure time and hospital stay in the EVT group.

Neuroprotective association of preoperative renin-angiotensin system blocking agents use in patients undergoing carotid interventions.

The optimal medical management strategy in the periprocedural period for patients undergoing carotid artery interventions is not well described. Renin-angiotensin-system blocking (RASB) agents are considered to be among the first line anti-hypertensive agents; however, their role in the perioperative period is unclear. The objective of this study was to examine the relationship between the use of RASB agents on periprocedural outcomes in patients undergoing carotid interventions-carotid endarterectomy (CEA), transfemoral carotid artery stenting (CAS), and transcervical carotid artery revascularization (TCAR). The Society for Vascular Surgery Quality Initiative database was queried for all patients undergoing CAS, CEA, and TCAR between 2003 and 2020. Patients were stratified into two groups based upon their use of RASB agents in the periprocedural period. The primary endpoint was periprocedural neurologic events (including both strokes and transient ischemic attacks (TIAs)). The secondary endpoints were peri-procedural mortality and significant cardiac events, including myocardial infarction, dysrhythmia, and congestive heart failure. Over 150,000 patients were included in the analysis: 13,666 patients underwent TCAR, 13,811 underwent CAS, and 125,429 underwent CEA for carotid artery stenosis. Overall, 52.2% of patients were maintained on RASB agents. Among patients undergoing CEA, patients on RASB agents had a significantly lower rate of periprocedural neurologic events (1.7% versus 2.0%, p =0.001). The peri-procedural neurological event rate in the TCAR cohort was similarly reduced in those treated with RASB agents, but did not reach statistical significance (2.0% vs 2.4%, p = 0.162). Among patients undergoing CAS, there was no difference in perioperative neurologic events between the RASB treated and untreated cohorts (3.4% vs 3.2%, p = 0.234); however, the use of RASB agents was significantly associated with lower mortality (1.2% vs 1.7%, p =0.001) with CAS. The use of preoperative RAS-blocking agents did not appear to affect the overall rates of adverse cardiac events with any of the three carotid intervention types, or periprocedural mortality following CEA or TCAR. On multivariable analysis, the use of RAS-blocking agents was independently associated with lower rates of post-procedural neurologic events in patients undergoing CEA (OR 0.819, CI 0.747-0.898; p = 0.01) and TCAR (OR 0.869, CI 0.768-0.984; p = 0.026), but not in those undergoing CAS (OR 0.967, CI 0.884-1.057; p = 0.461). The use of peri-procedural RASB agents was associated with a significantly decreased rate of neurologic events in patients undergoing both CEA and TCAR. This effect was not observed in patients undergoing CAS. As carotid interventions warrant absolute minimization of perioperative complications in order to provide maximum efficacy with regard to stroke protection, the potential neuro-protective effect associated with RASB agents use following CEA and TCAR warrants further examination.

Early results of the novel radiofrequency balloon ablation catheter for pulmonary vein isolation

Abstract Funding Acknowledgements Type of funding sources: None. Background Pulmonary vein isolation (PVI) remains the cornerstone for treating of symptomatic atrial fibrillation (AF). Single-shot PVI technologies have evolved as a standard for first-time PVI. A novel radiofrequency balloon ablation catheter is now available to offer single-shot RF pulmonary vein isolation. Purpose To summarize the early experience using the novel RF balloon ablation catheter for patients undergoing PVI in two tertiary centres in Europe. Methods We prospectively assessed the first 38 consecutive patients undergoing PVI using RF balloon ablation catheter for paroxysmal or persistent AF in two high volume centres. Both centres used a standardised approach including ultrasound-guided vascular access, uninterrupted anticoagulation, transeptal puncture via the RF balloon sheath and a limited 3D mapping software-guided LA geometry created with a circular mapping catheter. Radiofrequency application for 60s to the anterior segments and 20s posteriorly was performed in all cases, phrenic pacing was employed for ablation of right PVs. BHS performed all procedures (except 2 cases due to high BMI and severe sleep apnea) under sedation, while all patients from UHZ underwent PVI procedures with general anaesthesia as per institutional protocol. All patients had an oesophageal temperature probe to assess oesophageal temperature during ablation (passed orally under sedation) and had uninterrupted oral anticoagulation throughout the periprocedural period. Results Overall, mean age was 64±8 years, 23 (61%) were male, 24 (63%) of patients had paroxysmal AF. The majority were de novo interventions (92%). There was no significant difference between the patients demographics in the two hospitals. All veins were isolated in both groups with a total of 144 applications (n = 73 in the sedation group, n = 71 in the GA population). Median fluoroscopy time was comparable (sedation group 1.1 minutes vs GA group 1.2 minutes; P = 0.58), but median procedure time was shorter in the sedation group (65 minute vs 106 minutes; P &amp;lt; 0.001). The median number of RF ablation per patient (sedation group 7 vs GA group 9; P = 0.32) and time to isolation of each vein (sedation group 11 seconds vs GA group 10 seconds; P = 0.9) were similar. Number of acute reconnections requiring further ablations were not significantly different between groups (sedation group 11 [15%] vs GA group 14 [20%]; P = 0.96). One patient sustained transient phrenic nerve injury in the sedation group. Conclusion Our early experience shows the novel HS balloon ablation can be performed effectively, efficiently and safely under either GA or conscious sedition. The RF balloon ablation catheter paradigm lends itself to refined workflows, with low fluoroscopy requirements and a short learning curve even in initial cohorts.

Therapeutic effects of alcohol septal ablation in mildly symptomatic patients with hypertrophic obstructive cardiomyopathy

Objective: To observe the therapeutic effects of alcohol septal ablation (ASA) in mildly symptomatic patients (NYHA class Ⅱ) with hypertrophic obstructive cardiomyopathy(HOCM). Methods: This retrospective study included 150 mildly symptomatic patients with HOCM hospitalized in Beijing Anzhen Hospital affiliated to Capital Medical University from March 2001 to December 2017, consisting of medical therapy group (n=102) and ASA group (n=48). Baseline clinical data were collected, patients were followed up to a mean of 6.0 (3.5, 8.1) years. Overall and HCM-related mortality events (including chronic heart failure, atrial fibrillation related stroke, sudden cardiac death) were observed in the two groups. Moreover, the improvement of NYHA function classification and left ventricular outflow tract gradient (LVOTG) were also evaluated. Survival analysis was performed by Kaplan-Meier method. Results: Age of this cohort was (52.9±14.5)years, 92 cases(61.3%) were male. In the follow-up, LVOTG was reduced from (85.8±35.4)mmHg (1 mmHg=0.133 kPa) to (27.7±19.8)mmHg (P<0.001) in the ASA group, and from (66.3±35.0)mmHg to (56.5±27.7)mmHg in medical therapy group(P<0.01). At the last clinical follow-up, there were 32 patients (66.7%) whose LVOTG were<30 mmHg, septal thickness decreased from (20.3±3.8)mm to (16.1±3.4)mm (P<0.001), NYHA classification was also remarkably improved (P<0.001). New-onset atrial fibrillation tended to be lower in the ASA group compared to medical therapy group (9.3%(4/43) vs. 20.8%(20/96),P=0.096). Eleven patients (10.8%) in the medical therapy group and 2 patients (4.2%) in the ASA group died during the follow-up. One patient received pacemaker during the peri-procedural period, 1 patient was implanted with two-chamber pacemaker due to Ⅲ° atrioventricular block at 10 years after operation in the ASA group. Survival free of all-cause mortality of ASA group at 5 and 10 years was 97.9% and 97.9%, respectively, which was comparable to the medical therapy group (P=0.231). Survival free of HCM-related mortality was similar between the two groups (P=0.397). Conclusions: Compared with medical therapy in mildly symptomatic patients with HOCM, long-term survival rate is similar after ASA. Meanwhile, ASA can remarkably reduce LVOTG and improve the clinical status of the patients. Therefore, ASA may be used as an alternative therapy for mildly symptomatic HOCM patients.

Anticoagulant and Antiplatelet Therapy in Periprocedural Period of Elective Gastrointestinal Endoscopy

Anticoagulants and antiplatelet agents are widely used drugs for cardiovascular prevention and reducing the risk of thromboembolic events. Gastrointestinal bleeding represents a serious complication of their use. Gastrointestinal endoscopy is related to bleeding risk – there is bleeding risk stratification according to endoscopic procedures (high- and low-risk ones). Treatment with antithrombotic drugs in the periprocedural endoscopic period is based on balancing the bleeding risk against the thromboembolic risk. Antithrombotic agents in endoscopic procedures with lower bleeding risk are not needed to be withheld. It is recommended temporary discontinuation of antithrombotic treatment in high-risk endoscopic procedures and to consider the use of “bridging” therapy with LWMH for patients on Vitamin K antagonists who are at high thrombotic risk. Evaluating cardiovascular risk and management of antithrombotic therapy could be a challenge for gastrointestinal endoscopists, therefore, collaboration with a cardiologist is of great importance, at least for some patients.

Radiofrequency Ablation and Augmentation in the Management of Spinal Metastases: Clinical Experience in 41 Patients

To evaluate functional outcome after combined radiofrequency ablation and vertebral augmentation in patients with metastatic spinal tumors using visual analog scale and Oswestry Disability Index scores. This retrospective study included 41 patients with metastatic spinal tumors. There were 19 women and 22 men with a mean age of 67 years (range, 45-87 years). Visual analog scale and Oswestry Disability Index were used to assess the intensity of pain and quality of life. The assessments were performed before the procedure and at 1 week and 1, 2, 3, and 6 months after the procedure. No serious complications were seen in the periprocedural period. Two patients (4.8%) had transient neurological motor deficits without cement leakage, and 1 patient had a pulmonary embolism with transient mild symptoms. The comparison of preprocedural visual analog scale and Oswestry Disability Index scores with postprocedural scores up to 6 months after treatment revealed significant pain control and good functional state. Spinal metastasis is a frequent entity in the growing population of patients with cancer. A multidisciplinary approach using several nonsurgical and minimally invasive methods (e.g., radiofrequency ablation, vertebroplasty, balloon kyphoplasty) is key to successful management, and combining these procedures is effective against spinal metastatic pain.

Relationship between dynamic changes of peri-procedure anxiety and short-term prognosis in patients undergoing elective percutaneous coronary intervention for coronary heart disease: A single-center, prospective study.

BackgroundPatients with coronary heart disease (CHD) often experience anxiety, but the current studies on anxiety mostly focused on a certain point in time. Therefore, this study aimed to investigate the dynamic changes of peri-procedure anxiety, status of post-procedure quality of life, and cardiovascular readmission rates in patients with CHD who undergoing elective percutaneous coronary intervention (PCI), and to analyze the influence of peri-procedure anxiety on quality of life and readmission rate after PCI.MethodsThis prospective study was conducted at Changshu NO.1 People’s Hospital. A total of 220 patients with CHD undergoing elective PCI were selected as study subjects. The general information, clinical data, anxiety, quality of life and readmission of patients were collected. Multivariate linear regression was used to examine the effect of peri-procedure anxiety on quality of life, and multivariate logistic regression was used to analyze the influence of peri-procedure anxiety on readmission rate.ResultsThis study showed the anxiety scores at hospitalization appointment(T1), 3 days before procedure(T2), 1 day before procedure(T3), 1 day after procedure(T4) were 57(55,61),64(61,68),54(51.58), and 54(50,60), respectively. And, at 3 months and 6 months after PCI, the scores of Seattle Angina Questionnaire (SAQ) were 346.61(319.06,366.52) and 353.34(334.18,372.84) respectively. During 6 months follow-up, 54 cases were readmitted, with a readmission rate of 25.5%. Statistical analysis showed that T1 with anxiety (P = 0.002) and T2 with anxiety (P = 0.024) were independent risk factors for treatment satisfaction at 3 months after PCI. Anxiety in T4 (P = 0.005) was an independent risk factor on the angina frequency at 6 months after PCI. T2 with anxiety (B = 1.445, P = 0.010, 95%CI:1.409–12.773) and T4 without anxiety (B = -1.587, P = 0.042, 95%CI:-0.044–0.941) were risk factors affecting readmission for cardiovascular reasons within 6 months.ConclusionPatient anxiety at T1 and T2 affects the treatment satisfaction dimension of the SAQ at 3 months after PCI, and anxiety at T4 affects the angina frequency dimension of the SAQ at 6 months after PCI. Anxiety at T2 and no anxiety at T4 increase short-term readmission rates. In the future, interventions should be strengthened at various time points in the peri-procedure period to improve post-procedure rehabilitation effect.