Periprocedural Management Of Patients Research Articles

Periprocedural Management and Multidisciplinary Care Pathways for Patients With Cardiac Implantable Electronic Devices: A Scientific Statement From the American Heart Association.

The rapid technological advancements in cardiac implantable electronic devices such as pacemakers, implantable cardioverter defibrillators, and loop recorders, coupled with a rise in the number of patients with these devices, necessitate an updated clinical framework for periprocedural management. The introduction of leadless pacemakers, subcutaneous and extravascular defibrillators, and novel device communication protocols underscores the imperative for clinical updates. This scientific statement provides an inclusive framework for the periprocedural management of patients with these devices, encompassing the planning phase, procedure, and subsequent care coordinated with the primary device managing clinic. Expert contributions from anesthesiologists, cardiac electrophysiologists, and cardiac nurses are consolidated to appraise current evidence, offer patient and health system management strategies, and highlight key areas for future research. The statement, pertinent to a wide range of health care professionals, underscores the importance of quality care pathways for patient safety, optimal device function, and minimization of hemodynamic disturbances or arrhythmias during procedures. Our primary objective is to deliver quality care to the expanding patient cohort with cardiac implanted electronic devices, offering direction in the era of evolving technologies and laying a foundation for sustained education and practice enhancement.

Periprocedural Management and Multidisciplinary Care Pathways for Patients With Cardiac Implantable Electronic Devices: A Scientific Statement From the American Heart Association.

The rapid technological advancements in cardiac implantable electronic devices such as pacemakers, implantable cardioverter defibrillators, and loop recorders, coupled with a rise in the number of patients with these devices, necessitate an updated clinical framework for periprocedural management. The introduction of leadless pacemakers, subcutaneous and extravascular defibrillators, and novel device communication protocols underscores the imperative for clinical updates. This scientific statement provides an inclusive framework for the periprocedural management of patients with these devices, encompassing the planning phase, procedure, and subsequent care coordinated with the primary device managing clinic. Expert contributions from anesthesiologists, cardiac electrophysiologists, and cardiac nurses are consolidated to appraise current evidence, offer patient and health system management strategies, and highlight key areas for future research. The statement, pertinent to a wide range of health care professionals, underscores the importance of quality care pathways for patient safety, optimal device function, and minimization of hemodynamic disturbances or arrhythmias during procedures. Our primary objective is to deliver quality care to the expanding patient cohort with cardiac implanted electronic devices, offering direction in the era of evolving technologies and laying a foundation for sustained education and practice enhancement.

Cardioneuroablation for vasovagal syncope. Results from an EHRA Survey

Abstract Background Cardioneuroablation (CNA) is a recently introduced catheter-based therapy for vasovagal syncope (VVS), involving the modulation of the cardiac autonomic nervous system. Over the past decade, the body of evidence supporting CNA has consistently grown, sparking increased interest, and leading to broader adoption of this novel therapy for VVS treatment. However, several knowledge gaps persist, particularly concerning clinical indications, methodology, and long-term outcomes. Purpose The aim of this survey is to provide a comprehensive overview of the daily utilization of CNA in Europe. Methods and Results Among 204 participants, half reported that they are already performing CNA in their centres. The survey indicated CNA as an emerging therapy, with most centres initiating this treatment within the last two years. A significant majority of those who responded (71%) adopted a systematic approach by targeting ganglionated plexuses (GPs) in both the right atrium (RA) and left atrium (LA) as their first-line approach. The second most common approach (16%) involved performing ablation LA GPs only in the cases where there is no response following RA ablation. Figure 1 shows the GPs usually targeted for ablation. The most frequent procedural endpoint was the increase in the heart rate. Ninety percent of respondents relied on an anatomical approach for GP localization, while 59% also guided the procedure using electrogram analysis. Less frequently used approaches included pre-procedural imaging (20%), high-frequency stimulation (17%), and spectral analysis (10%). Only 11% of physicians discharged patients who underwent CNA without anticoagulation or antiplatelet therapy. In most cases (58%), respondents discharged their patients with anticoagulation, while 28% on single antiplatelet therapy. Overall, CNA is considered an effective procedure (80% of responders rating its effectiveness at or above 70%) and a safe procedure (with an estimated 1% rate of procedure-related complications, with symptomatic sinus tachycardia being the most frequently reported). Conclusions This survey confirmed high expectations for the future of this therapy, as most responders anticipate that CNA will be indicated as a first-line therapy for patients with recurrent cardioinhibitory VVS. Future efforts are necessary to standardize the procedural flow and peri-procedural patient management.

Cardioneuroablation for vasovagal syncope: insights on patients' selection, centre settings, procedural workflow and endpoints-results from an European Heart Rhythm Association survey.

Cardioneuroablation (CNA) is a catheter-based intervention for recurrent vasovagal syncope (VVS) that consists in the modulation of the parasympathetic cardiac autonomic nervous system. This survey aims to provide a comprehensive overview of current CNA utilization in Europe. A total of 202 participants from 40 different countries replied to the survey. Half of the respondents have performed a CNA during the last 12 months, reflecting that it is considered a treatment option of a subset of patients. Seventy-one per cent of respondents adopt an approach targeting ganglionated plexuses (GPs) systematically in both the right atrium (RA) and left atrium (LA). The second most common strategy (16%) involves LA GP ablation only after no response following RA ablation. The procedural endpoint is frequently an increase in heart rate. Ganglionated plexus localization predominantly relies on an anatomical approach (90%) and electrogram analysis (59%). Less utilized methods include pre-procedural imaging (20%), high-frequency stimulation (17%), and spectral analysis (10%). Post-CNA, anticoagulation or antiplatelet therapy is prescribed, with only 11% of the respondents discharging patients without such medication. Cardioneuroablation is perceived as effective (80% of respondents) and safe (71% estimated <1% rate of procedure-related complications). Half view CNA emerging as a first-line therapy in the near future. This survey offers a snapshot of the current implementation of CNA in Europe. The results show high expectations for the future of CNA, but important heterogeneity exists regarding indications, procedural workflow, and endpoints of CNA. Ongoing efforts are essential to standardize procedural protocols and peri-procedural patient management.

The periprocedural management of patients on a direct oral anticoagulant undergoing an elective gastrointestinal endoscopic procedure

The periprocedural management of patients on a direct oral anticoagulant undergoing an elective gastrointestinal endoscopic procedure

Periprocedural management of patients presenting for neurointerventional procedures using flow diverters for complex intracranial aneurysms: An anesthetist's perspective - A narrative review.

Complex intracranial aneurysms pose significant challenges in the realm of neurointervention, necessitating meticulous planning and execution. This article highlights the crucial roles played by anesthetists in these procedures, including patient assessment, anesthesia planning, and continuous monitoring and maintaining hemodynamic stability, which are pivotal in optimizing patient safety. Understanding these complex procedures and their complications will aid the anesthetist in delivering optimal care and in foreseeing and managing the potential associated complications. The anesthetist's responsibility extends beyond the procedure itself to postprocedure care, ensuring a smooth transition to the recovery phase. Successful periprocedural anesthetic management in flow diverter interventions for complex intracranial aneurysms hinges on carefully orchestrating these elements. Moreover, effective communication and collaboration with the interventional neuroradiologist and the procedural team are emphasized, as they contribute significantly to procedural success. This article underscores the essential requirement for a multidisciplinary team approach when managing patients undergoing neurointerventions. In this collaborative framework, the expertise of the anesthetist harmoniously complements the skills and knowledge of other team members, contributing to the overall success and safety of these procedures. By providing a high level of care throughout the periprocedural period, anesthetists play a pivotal role in enhancing patient outcomes and minimizing the risks associated with these intricate procedures. In conclusion, the periprocedural anesthetic management of neurointervention using flow diverters for complex intracranial aneurysms is a multifaceted process that requires expertise, communication, and collaboration.

Left atrial total emptying fraction measured by cardiovascular magnetic resonance imaging predicts low-voltage areas detected during electroanatomical mapping.

Low-voltage areas (LVAs) found during left atrial (LA) electroanatomical mapping are increasingly targeted by radiofrequency catheter ablation (RFCA) on top of pulmonary vein isolation to improve arrhythmia-free survival in patients with atrial fibrillation (AF). However, pre-procedural prediction of LVAs remains challenging. The purpose of the present study was to describe the association between parameters of LA function and dimensions, respectively, derived from pre-procedural cardiovascular magnetic resonance (CMR) imaging, and the presence of LVAs on LA voltage mapping. Patients who underwent first-time RFCA for paroxysmal or persistent AF and who were in stable sinus rhythm during pre-procedural CMR imaging were included in this study. Cardiovascular magnetic resonance-derived parameters of LA function and dimensions were calculated. Low-voltage areas were defined as areas with bipolar voltage amplitudes of ≤0.5 mV on electroanatomical mapping. In total, 259 consecutive patients were included in this analysis. Low-voltage areas were found in 25 of 259 patients (9.7%). Compared with those without LVAs, patients with LVAs were significantly older, were more likely to be female, had a higher CHA2DS2-VASc score, had larger LA volumes, and had a lower LA total emptying fraction (TEF). In multivariate analysis, only LA TEF [odds ratio (OR) 0.885, 95% confidence interval (CI) 0.846-0.926, P < 0.001] and the CHA2DS2-VASc score (OR 1.507, 95% CI 1.115-2.038, P = 0.008) remained independently associated with the presence of LVAs. Left atrial TEF and the CHA2DS2-VASc score were independently associated with the presence of LVAs found during LA electroanatomical mapping. These findings may help to improve pre-procedural prediction of pro-arrhythmogenic LVAs and to improve peri-procedural patient management.

Pharmacological cardioversion of atrial fibrillation: practical considerations.

The choice between rhythm and rate control strategy represents one of the most intriguing dilemmas in the management of atrial fibrillation (AF). Although the advantage of rhythm over rate control in terms of outcome has not been equivocally proven, the initial management of patients with symptomatic episodes of AF frequently involves an attempt of early cardioversion. As electrical cardioversion (EC) is challenging in terms of fasting status and involvement of anesthesiology team, pharmacological cardioversion (PC) is usually selected as the first step towards rhythm conversion. Proper qualification for PC or EC is similar and should comprise assessment of hemodynamic status, estimation of duration of arrhythmic episode, evaluation of anticoagulation regimen, exclusion of other supraventricular arrhythmias and assessment of the chance of rhythm conversion and persistence of sinus rhythm. Finally, the choice of adequate antiarrhythmic drug (AAD) depends on the presence of structural heart disease and local experience. In patients without structural heart disease, complications occur rarely, hence traditional (propafenone, flecainide) or nonclassical Vaughan-Williams class I (antazoline) or class III (vernakalant, ibutilide or dofetilide) drugs are preferred. The presence of structural heart disease consistent with any left ventricular hypertrophy, heart failure, myocardial ischemia or valvular heart disease confines the choice of AAD to amiodarone. Given the risk of ventricular proarrhythmia of AAD, safety should always prevail over the enticing possibility of rhythm conversion. The present review aims to provide a comprehensible summary of proper qualification for PC, selection of suitable AAD and state-of-the-art periprocedural management of patients with recent-onset AF.

Implementation of the Management of Anticoagulation in the Periprocedural Period App into an Electronic Health Record: A Cost-Effectiveness Analysis.

The Management of Anticoagulation in the Periprocedural Period (MAPPP) app is a free tool providing up-to-date guidelines on the periprocedural management of patients on long-term anticoagulants. After validating its effectiveness in the post-procedural period, we aimed to study its overall cost-effectiveness. SF-12 surveys were sent to eligible patients, converted into SF-6D forms, and subsequently into quality-adjusted life years (QALYs) to calculate the incremental cost-effectiveness ratio (ICER). The number of 30-day readmissions was used to calculate hospitalization costs, utilizing publicly available data. From 1/1/2018 to 1/31/2019, 642 patients were screened for enrollment, with an overall response rate of 94% (164/175) among the consented and 49% (164/336) among all eligible patients. The average QALY score was 0.7134 (95% CI [0.6836, 0.7431]) for the patients whose treatment plan followed the MAPPP app recommendations (acceptance group) and 0.7104 (95% CI [0.6760, 0.7448]) for those who did not (rejection group), without statistically significant differences. The difference in ICER scores was -$429 866.67, with the negative sign demonstrating that acceptance was the dominant strategy. By utilizing QALYs and ICER scores we have shown that the acceptance of MAPPP app recommendations is the dominant strategy for the periprocedural management of patients on long-term anticoagulation.

Patient selection, peri-procedural management, and ablation techniques for catheter ablation of atrial fibrillation: an EHRA survey.

Catheter ablation (CA) of atrial fibrillation (AF) is the therapy of choice for the maintenance of sinus rhythm in patients with symptomatic AF. Time towards interventional treatment and peri-procedural management of patients undergoing AF ablation may vary in daily practice. The scope of this European Heart Rhythm Association (EHRA) survey was to report the current clinical practice regarding the management of patients undergoing AF ablation and physician's adherence to the European Society of Cardiology Guidelines and the EHRA/HRS/ECAS expert consensus statement on the CA for AF. This physician-based survey was conducted among EHRA members, using an internet-based questionnaire developed by the EHRA Scientific Initiatives Committee. A total of 258 physicians participated in the survey. In patients with paroxysmal or persistent AF, 42 and 9% of the physicians would routinely perform AF ablation as first-line therapy respectively, whereas 71% of physicians would consider ablation as first-line therapy in patients with symptomatic AF and left ventricular ejection fraction <35%. Only 14% of the respondents manage cardiovascular risk factors in patients referred for CA using a dedicated AF risk factor management programme. Radiofrequency CA is the preferred technology for first-time AF (56%), followed by cryo-balloon CA (40%). This EHRA survey demonstrated a considerable variation in the management of patients undergoing AF ablation in routine practice and deviations between guideline recommendations and clinical practice.

Periprocedural Management of Patients With Atrial Fibrillation Receiving a Direct Oral Anticoagulant Undergoing a Digestive Endoscopy.

The periprocedural management of patients with atrial fibrillation (AF) using a direct oral anticoagulant (DOAC) undergoing elective gastrointestinal (GI) endoscopic procedure remains uncertain. We investigated the safety of a standardized periprocedural DOAC management strategy. The Periprocedural Anticoagulation Use for Surgery Evaluation cohort study enrolled adult patients receiving a DOAC (apixaban, rivaroxaban, or dabigatran) for AF scheduled for an elective procedure or surgery. This analysis addresses patients undergoing digestive endoscopy. Standardized periprocedural management consisted of DOAC interruption 1 day preendoscopy with resumption 1 day after procedure at low-moderate risk of bleeding or 2 days in case of a high bleeding risk. Thirty-day outcomes included GI bleeding, thromboembolic events, and mortality. Of 556 patients on a DOAC (mean [SD] age of 72.5 [8.6] years; 37.4% female; mean CHADS 2 score 1.7 [1.0]), 8.6% were also on American Society of Anesthesiology (ASA) and 0.7% on clopidogrel. Most of the patients underwent colonoscopies (63.3%) or gastroscopies (14.0%), with 18.9% having both on the same procedural day. The mean total duration of DOAC interruption was 3.9 ± 1.6 days. Four patients experienced an arterial thromboembolic event (0.7%, 0.3%-1.8%) within 24.2 ± 5.9 days of DOAC interruption. GI bleeding events occurred in 2.5% (1.4%-4.2%) within 11.1 ± 8.1 days (range: 0.6; 25.5 days) of endoscopy, with major GI bleeding in 0.9% (0.4%-2.1%). Three patients died (0.5%; 0.2%-1.6%) 15.6-22.3 days after the endoscopy. After a contemporary standardized periprocedural management strategy, patients with AF undergoing DOAC therapy interruption for elective digestive endoscopy experienced low rates of arterial thromboembolism and major bleeding.

Leadless transcatheter pacemaker: Indications, implantation technique and peri-procedural patient management in the Italian clinical practice

BackgroundSafety and efficacy of leadless pacemakers (L-PM) have been demonstrated in multiple clinical trials, but real-world data on patient selection, implantation technique, and peri-procedural patient management in a clinical practice setting are lacking. MethodsConsecutive patients undergoing L-PM implantation in 14 Italian centers were followed in a prospective, multicentre, observational project. Data on baseline patient characteristics, clinical indications, implantation procedure, and peri-procedural patient management were collected. The rate and nature of device-related complications were also recorded. ResultsA total of 782 L-PM patients (68.4% male, 75.6 ± 12.4 years) were included in the analysis. The main patients-related reason leading to the choice of implanting a L-PM rather than a conventional PM was the high-risk of device infection (29.5% of cases). The implantation success rate was 99.2%. The median duration of the procedure was 46 min. In 90% of patients the device was implanted in the septum. Of patients on oral anticoagulant therapy (OAT) (n = 498) the implantation procedure was performed without interrupting (17.5%) or transiently interrupting OAT without heparin bridging (60.6%). During a median follow-up of 20 months major device-related complications occurred in 7 patients (0.9%): vascular access-site complications in 3 patients, device malfunction in 2 patients, pericardial effusion/cardiac tamponade in one patient, device migration in one patient. ConclusionsIn the real world setting of Italian clinical practice L-PM is often reserved for patients at high-risk of infection. The implantation success rate was very high and the risk of major complications was low. Peri-procedural management of OAT was consistent with available scientific evidence.

A94 PERI-PROCEDURAL MANAGEMENT OF PATIENTS RECEIVING A DIRECT ORAL ANTICOAGULANT UNDERGOING A DIGESTIVE ENDOSCOPY

BackgroundThe peri-procedural management of patients on a direct oral anticoagulant (DOAC) requiring an elective digestive (GI) endoscopic procedure remains uncertain.AimsTo investigate the safety of a standardized peri-procedural DOAC management strategy.MethodsThe Perioperative Anticoagulation Use for Surgery Evaluation (PAUSE) cohort study was conducted at 23 clinical centers in North America and Europe. Participants (n=3007) all had atrial fibrillation (AF), were >18 years old, long-term users of Apixaban, Rivaroxaban, or Dabigatran, and scheduled for an elective procedure or surgery; all could adhere to the DOAC interruption protocol. This analysis focuses on the 579 patients undergoing a digestive endoscopic procedure. The DOAC interruption (1–2 days pre-endoscopy) and resumption (1–3 days post-endoscopy) strategy is based on the DOAC molecule, patient renal function, with most GI procedures considered at low-risk for bleeding. Follow-up occurred at 30 days. Outcomes included GI bleeding and thromboembolic events (ischemic stroke, transient ischemic attack, myocardial infarction, systemic embolism, deep vein thrombosis, and pulmonary embolism) and mortality.ResultsOf the 556 patients (72.5 +8.6 yrs; 37.4 % female), 38.9%) were on Apixaban, 36.9% on Rivaroxaban, and 24.3% on Dabigatran; 10.1% were on anti-platelet therapy. The overall CHADS score was 1.7 +1.0. Overall, 525 patients were categorized as having a low risk for bleeding, and 31 were at high-risk. DOAC were stopped 2.0 +0.5 days pre-procedure and restarted 1.9 +1.5 days post-procedure. Overall rates were: all bleeding 4.4% (2.9–6.4), GI bleeding 2.5% (1.4–4.2%), while 0.7% (0.3–1.8%) experienced a thromboembolic event. Additional results are listed in Table 1.ConclusionsPatients with AF undergoing a standardized DOAC therapy interruption management protocol for elective digestive endoscopy experienced low rates of major bleeding and arterial thromboembolism.Variable;Patient cohort N=556High-risk group for bleeding N=31 Low risk group for bleeding N=525* Diagnostic procedure N=430 Therapeutic procedure N=21 Mortality0.5 (0.2; 1.6)0.0 (0.0; 11.0)0.6 (0.2; 1.7)0.5 (0.1; 1.7)0.0 (0.0; 15.5)Thromboembolic event0.7 (0.3; 1.8)0.0 (0.0; 11.0)0.8 (0.3; 2.0)0.9 (0.4; 2.4)0.0 (0.0; 15.5)All Bleeding event4.4 (2.9; 6.4)16.1 (7.1; 32.6)3.7 (2.4; 5.6)3.7 (2.3; 6.0)19.1 (7.7; 40.0)GI Bleed2.5 (1.4; 4.2)9.7 (3.3; 24.9)2.1 (1.2; 3.7)2.1 (1.1; 3.9)4.8 (0.8; 22.7)All results reported as % and 95% CI * outcomes were missing for 4 patients that had the procedureFunding AgenciesNone

Performing an Ultrasound-Guided Percutaneous Needle Kidney Biopsy: An Up-To-Date Procedural Review.

Ultrasound-guided percutaneous renal biopsy (PRB) has revolutionized the clinical practice of nephrology in the last decades. PRB remains an essential tool for the diagnosis, prognosis, and therapeutic management of several renal diseases and for the assessment of renal involvement in systemic diseases. In this study, we examine the different applications and provide a review of the current evidence on the periprocedural management of patients. PRB is recommended in patients with significant proteinuria, hematuria, acute kidney injury, unexpected worsening of renal function, and allograft dysfunction after excluding pre- and post-renal causes. A preliminary ultrasound examination is needed to assess the presence of anatomic anomalies of the kidney and to identify vessels that might be damaged by the needle during the procedure. Kidney biopsy is usually performed in the prone position on the lower pole of the left kidney, whereas in patients with obesity, the supine antero-lateral position is preferred. After preparing a sterile field and the injection of local anesthetics, an automatic spring-loaded biopsy gun is used under ultrasound guidance to obtain samples of renal parenchyma for histopathology. After the procedure, an ultrasound scan must be performed for the prompt identification of potential early bleeding complications. As 33% of complications occur after 8 h and 91% occur within 24 h, the ideal post-procedural observation time is 24 h. PRB is a safe procedure and should be considered a routine part of the clinical practice of nephrology.

Perioperative management of antithrombotic therapy: a case-based narrative review.

The periprocedural management of patients who are receiving vitamin K antagonists, direct oral anticoagulants and antiplatelet therapy is a common and challenging clinical scenario as the decision to interrupt or continue these medications is anchored on patient and procedure-related risks for bleeding and thrombosis. Adding to the complexity of clinical management is the fact that anticoagulants have varied pharmacokinetic and pharmacodynamic properties and indications for clinical use. In many minimal-bleed-risk procedures, anticoagulants can be safely continued, without interruption, whereas in cases where anticoagulants cannot be safely continued, the timing of interruption and resumption, as well as the need for heparin bridging requires consideration. Perioperative antithrombotic management scenarios occur most often in patients with atrial fibrillation, mechanical heart valves, coronary stents, and cerebrovascular disease as such patients are likely to be prescribed anticoagulant and/or antiplatelet therapy. The objective of this case-based narrative review is to provide a practical evidence-based approach to the perioperative management of patients on anticoagulation and antiplatelet therapy. Four clinical scenarios will be provided: (1) managing patients in whom anticoagulants can be continued; (2) perioperative management of direct oral anticoagulants; (3) management of patients on dual antiplatelet therapy; and (4) anticoagulant management for emergency or urgent surgery.

Direct Oral Anticoagulants in Asian Patients with Atrial Fibrillation: Consensus Recommendations by the Asian Pacific Society of Cardiology on Strategies for Thrombotic and Bleeding Risk Management.

The disease burden of AF is greater in Asia-Pacific than other areas of the world. Direct oral anticoagulants (DOACs) have emerged as effective alternatives to vitamin K antagonists (VKA) for preventing thromboembolic events in patients with AF. The Asian Pacific Society of Cardiology developed this consensus statement to guide physicians in the management of AF in Asian populations. Statements were developed by an expert consensus panel who reviewed the available data from patients in Asia-Pacific. Consensus statements were developed then put to an online vote. The resulting 17 statements provide guidance on the assessment of stroke risk of AF patients in the region, the appropriate use of DOACs in these patients, as well as the concomitant use of DOACs and antiplatelets, and the transition to DOACs from VKAs and vice versa. The periprocedural management of patients on DOAC therapy and the management of patients with bleeding while on DOACs are also discussed.

Periprocedural management of patients on edoxaban undergoing pacemaker and cardiac monitoring device implantation - a sub-analysis of the EMIT-AF/VTE study

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo Background Periprocedural management of patients on direct oral anticoagulants undergoing insertion of permanent pacemaker (PPM) and cardiac monitoring devices is mainly based on pharmacokinetic considerations, clinical experience, and expert opinion. Purpose To describe the characteristics, periprocedural management, and events of edoxaban patients undergoing implantation of PPM/monitoring devices. Methods From the global EMIT-AF/VTE registry, which includes edoxaban patients undergoing any diagnostic or therapeutic procedures, those with PPM/cardiac monitoring device implantation were observed from five days prior to 30 days post procedure. Events documented included the incidence of International Society on Thrombosis and Haemostasis defined Major Bleeding, Clinically Relevant Non-Major Bleeding (CRNMB), acute thromboembolic events (ATE) and perioperative edoxaban interruption times. Results PPM or invasive cardiac monitoring devices were implanted in 136 patients. Conformance with European Heart Rhythm Association Guidance for the interruption of anticoagulation was variable: of the cardiac monitoring patients, 62.5% had interruption of treatment, whereas in PPM procedures 23.4% had no interruption. One case of CRNMB and two cases of minor bleeding were documented. All bleedings seem non procedure-related since they occurred &amp;gt; three days post procedure. There were no ATE. Conclusions Relevant complications for edoxaban treated patients undergoing PPM or invasive cardiac monitoring procedures were rare. This population of patients is apparently well managed in routine practice, but further investigation of risk factors is justified. TablePatient characteristics Parameter All subjectsN = 136 All pacemakerN = 128 Insertion first pacemakerN = 89 Change pacemakerN = 39 Monitoring deviceN = 8 Age, mean (SD)Male, n (%) 75.1 (10.1)85 (62.5) 75.0 (10.3)83 (64.8) 75.7 (9.9)57 (64.0) 73.5 (11.2)26 (66.7) 76.3 (4.3)2 (25.0) BMI, mean (SD) 27.1 (5.5) 27.2 (5.6) 27.2 (6.0) 27.3 (4.5) 25.2 (4.3) AF, n (%)‡ 135 (99.3) 127 (99.2) 89 (100.0) 38 (97.4) 8 (100.0) VTE, n (%)‡ 3 (2.2) 3 (2.3) 1 (1.1) 2 (5.1) 0 CrCL, mean (SD) 63.8 (26.4) 64.1 (26.7) 62.3 (26.2) 68.3 (27.9) 58.9 (21.8) CrCL, ≤50, n (%) 43 (31.6) 41 (32.0) 33 (37.1) 8 (20.5) 2 (25.0) HAS-BLED Score, mean (SD) 2.0 (1.2) 1.9 (1.2) 1.9 (1.0) 2.1 (1.6) 2.6 (0.5) CHA2DS2-VASc Score, mean (SD) 3.7 (1.6) 3.7 (1.6) 3.7 (1.5) 3.8 (1.9) 3.1 (0.6) Edoxaban 30 mg/day, n (%) 49 (36.0) 46 (35.9) 32 (36.0) 14 (35.9) 3 (37.5) Edoxaban 60 mg/day, n (%) 86 (63.2) 81 (63.3) 56 (62.9) 25 (64.1) 5 (62.5) AF, atrial fibrillation; BMI, body mass index; CrCL, creatinine clearance; VTE, venous thromboembolism. ‡Two patients had both AF and VTE.

Akılcı ilaç kullanımı: Yeni nesil oral antikoagülanlar

Yeni nesil oral antikoagülanlar, K vitamini antagonistlerinin dezavantajlarına alternatif olarak geliştirilmişlerdir. Günümüzde yeni nesil oral antikoagülanlar, non-valvuler atrial fibrilasyonda inmenin önlenmesinde, total kalça ve diz protezi sonrası derin ven trombozunun önlenmesinde ve tromboemboli tedavisinde kullanılmaktadır. Biz bu makalede yeni nesil oral antikoagülanların özelliklerini ve kullanım alanlarını, laboratuvar izlemini, antidotlarını ve girişimsel işlemlerde hastaların yönetimini gözden geçirdik.

Outcomes of ablation in Wolff-Parkinson-White-syndrome: Data from the German Ablation Registry

AimsCatheter ablation is recommended for symptomatic WPW-syndrome. Commonly perceived low recurrence rates were challenged recently. We sought to identify patient strata at increased risk. MethodOf 12,566 patients enrolled at 52 German Ablation Registry sites from 2007 to 2010, 789 were treated for WPW-syndrome. Patients were included for symptomatic palpitations and tachycardia documentation. Follow-up duration was one year. Overall complications were defined as serious, access-related, and ablation-related. We adjudicated WPW-recurrence for re-ablation during follow-up. Risk strata included: admission for repeat ablation at registry entry; accessory pathway localization; antiarrhythmic medical treatment before the ablation. ResultsWPW-syndrome patients were 42.8 ± 16.2 years on average; 39.9% were women. A majority of 95.9% was symptomatic; in 84.4%, a tachycardia was documented. Seventy-six (9.6%) patients presented for repeat procedures. Accessory pathways were located in the left atrium (71.4%), right atrium (21.1%), septum (4.4%), or coronary sinus diverticula (2.1%). Prior antiarrhythmic medication was used in 43.7% of patients. No serious events occurred. The overall complication rate was 2.5% (ablation related 1.2%, access-related 1.3%). Major determinants for complications were presentation for re-ablation as registry index procedure (6.9% vs 2.2%; p = 0.016) and septal pathway location (left 2.0% vs septal 9.1%, p = 0.014). The overall re-ablation rate was 9.7%. Usage of prior antiarrhythmic medication was associated with higher recurrence rates (12.2% vs. 7.6%; p = 0.035). ConclusionsPatients at higher complication risk may be identified by repeat procedure and septal pathway location. Prior antiarrhythmic medication was associated with higher recurrence rates. Our findings may help improving peri-procedural patient management and information.

Non-cardiac surgery in patients with coronary artery disease: risk evaluation and periprocedural management.

Perioperative cardiovascular complications are important causes of morbidity and mortality associated with non-cardiac surgery, particularly in patients with coronary artery disease (CAD). Although preoperative cardiac risk assessment can facilitate the identification of vulnerable patients and implementation of adequate preventive measures, excessive evaluation might lead to undue resource utilization and surgical delay. Owing to conflicting data, there remains some uncertainty regarding the most beneficial perioperative strategy for patients with CAD. Antithrombotic agents are the cornerstone of secondary prevention of ischaemic events but substantially increase the risk of bleeding. Given that 5-25% of patients undergoing coronary stent implantation require non-cardiac surgery within 2 years, surgery is the most common reason for premature cessation of dual antiplatelet therapy. Perioperative management of antiplatelet therapy, which necessitates concomitant evaluation of the individual thrombotic and bleeding risks related to both clinical and procedural factors, poses a recurring dilemma in clinical practice. Current guidelines do not provide detailed recommendations on this topic, and the optimal approach in these patients is yet to be determined. This Review summarizes the current data guiding preoperative risk stratification as well as periprocedural management of patients with CAD undergoing non-cardiac surgery, including those treated with stents.