Periprocedural Management Research Articles

Optimal anticoagulant strategy for periprocedural management of atrial fibrillation ablation: a systematic review and network meta-analysis

Abstract Background This network meta-analysis was performed to rank the safety and efficacy of periprocedural anticoagulant strategies in patients undergoing atrial fibrillation ablation. Methods MEDLINE, EMBASE, CENTRAL, and Web of Science were searched to identify randomized controlled trials comparing anticoagulant regimens in patients undergoing atrial fibrillation ablation up to July 1, 2021. The primary efficacy and safety outcomes were thromboembolic and major bleeding events, respectively, and the net clinical benefit was investigated as the primary-outcome composite. Results Seventeen studies were included (n = 6950). The mean age ranged from 59 to 70 years; 74% of patients were men and 55% had paroxysmal atrial fibrillation. Compared with the uninterrupted vitamin-K antagonist strategy, the odds ratios for the composite of primary safety and efficacy outcomes were 0.61 (95%CI: 0.31–1.17) with uninterrupted direct oral anticoagulants, 0.63 (95%CI: 0.26–1.54) with interrupted direct oral anticoagulants, and 8.02 (95%CI: 2.35–27.45) with interrupted vitamin-K antagonists. Uninterrupted dabigatran significantly reduced the risk of the composite of primary safety and efficacy outcomes (odds ratio, 0.21; 95%CI, 0.08–0.55). Conclusion Uninterrupted direct oral anticoagulants are preferred alternatives to uninterrupted vitamin-K antagonists. Interrupted direct oral anticoagulants may be feasible as alternatives. Our results support the use of uninterrupted direct oral anticoagulants as the optimal periprocedural anticoagulant strategy for patients undergoing atrial fibrillation ablation.

Pharmacotherapy of acute ST-elevation myocardial infarction and the pharmacist's role, part 1: Patient presentation through revascularization.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Key pharmacotherapeutic modalities and considerations for the patient with ST-elevation myocardial infarction (STEMI) across the critical initial phases of care are reviewed. Despite established value in the emergency department (ED), cardiac care, and intensive care settings, there is currently little published literature describing or supporting clinical pharmacist roles in the acute management of STEMI. The high-risk period from hospital presentation through revascularization and stabilization involves complex pharmacotherapeutic decision points, many operational medication needs, and multiple layers of quality oversight. While rife with opportunities for pharmacists to optimize care, this timeframe appears inconsistently targeted by clinical pharmacy services, which may halt after ED evaluation and then resume upon postcatheterization cardiac unit admission. Herein we review the key pharmacotherapeutic modalities and considerations for the patient with STEMI across the critical initial phases of care. These include supportive therapies prior to revascularization, the host of antithrombotics involved in revascularization by percutaneous coronary intervention and/or fibrinolysis, and other periprocedural medications. Important practice guidelines and clinical resources are summarized from the clinical pharmacist perspective, and roles and responsibilities of the responding pharmacist are suggested. A companion article will extend the review to periprocedural adverse event management, key early decision-making regarding long-term risk reduction, and pharmacist involvement in institutional quality improvement efforts. We aim to support inpatient pharmacy departments in advancing clinical services for this critical patient population, and we call for further research delineating pharmacist impact on patient and institutional STEMI outcomes. Patients presenting with STEMI rapidly traverse multiple phases of care and receive a host of antithrombotic and supportive medications during acute management, presenting many important pharmacotherapeutic decision points and roles for pharmacists.

Clinical Consequences of Delayed Gastric Emptying With GLP-1 Receptor Agonists and Tirzepatide.

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are established therapeutics for type 2 diabetes and obesity. Among other mechanisms, they slow gastric emptying and motility of the small intestine. This helps limiting postprandial glycemic excursions and reducing chylomicron formation and triglyceride absorption. Conversely, motility effects may have detrimental consequences, e.g., retained gastric contents at endoscopy or general anesthesia, potentially complicated by pulmonary aspiration, or bowel obstruction. We searched the PubMed database for studies involving GLP-1RA therapy and adverse gastrointestinal/biliary events. Retained gastric contents at the time of upper gastrointestinal endoscopy are found more frequently with GLP-1 RAs, but rarely are associated with pulmonary aspiration. Well-justified recommendations for the peri-procedural management of GLP-1RAs (e.g., whether to withhold these medications, and for how long) are compromised by limited evidence. Important aspects to be considered are (a) their long half-lives, (b) the capacity of GLP-1 receptor agonism to slow gastric emptying even at physiological GLP-1 concentrations, (c) tachyphylaxis observed with prolonged treatment, and (d) the limited effect on gastric emptying in individuals with slow gastric emptying before initiating treatment. Little information is available on the influence of diabetes mellitus itself (i.e., in the absence of GLP-1 RA treatment) on retained gastric contents and pulmonary aspiration. Prolonged fasting periods regarding solid meal components, point-of-care ultrasound examination for retained gastric content, and the use of prokinetic medications like erythromycin may prove helpful, and are an important area needing further study to increase patient safety for those treated with GLP-1 RAs.

Management of antithrombotic therapy in patients undergoing dental procedures

A growing number of patients receiving antithrombotic therapy require dental procedures. Dental interventions in these patients can be challenging, as the risk of bleeding from the continuation of antithrombotic therapy needs to be weighed against the thromboembolic risk associated with drug interruption or de-escalation. Most minor dental procedures, including simple dental cleaning and filling, pose minimal bleeding risk, and antiplatelet or anticoagulation therapy can be continued without interruption. Local hemostatic measures, such as tranexamic mouthwash, can be used, as needed, to reduce bleeding events following these interventions. Managing antithrombotic therapy during more invasive dental interventions and oral surgeries with a higher risk of perioperative bleeding necessitates the consideration of specific factors influencing the bleeding risk and thromboembolism. In patients receiving antithrombotic therapy for primary prevention, temporary interruption is reasonable. In others, the decisions may be more complex and more nuanced. In this article, we review the current evidence for managing patients receiving oral antiplatelet or anticoagulant drugs scheduled for various dental procedures and present a practical approach for the periprocedural management of antithrombotic treatments.

Incidence and clinical impact of inappropriate periprocedural and perioperative management of antiplatelet therapy

Background and aimsThere is little evidence on the impact of current recommendations on the use of antiplatelet therapy during the perioperative and periprocedural period in our setting. The aim of this study was to analyze the incidence and clinical impact of inappropriate use of antiplatelet therapy in a population of patients undergoing surgery or a diagnostic or therapeutic procedure in “real life” in Spain. MethodsA prospective multicenter observational study of patients treated with antiplatelet agents requiring intervention was conducted. The incidence of thrombotic and hemorrhagic events at 30 days was analyzed according to peri-intervention management of antiplatelet therapy. ResultsWe included 643 patients (31.9% women, 39.0% over 75 years of age), most of them (87.7%) receiving aspirin as antiplatelet therapy at a dose of 100mg/day. Indications for antiplatelet therapy were ischemic heart disease (44.9%), cerebrovascular disease (21.7%), and peripheral vascular disease (23.0%). Ischemic risk was low in 74.3%, while 51.6% had a low bleeding risk of the intervention. Periprocedural management was considered appropriate in 61.7% of cases. 30-day incidence of the combined primary endpoint of thrombotic events and major bleeding (12.1% versus 5.0%; p=0.002) and 30-day mortality (5.2% versus 1.5%; p=0.008) were significantly higher in patients with inappropriate periprocedural management of antiplatelet agents. ConclusionsDespite current recommendations for the use of antiplatelet drugs in the perioperative/periprocedural period, their implementation in the “real world” remains low. Inappropriate use is associated with an increased incidence of adverse events, both thrombotic and hemorrhagic.

Pain control during intrauterine device insertion: Transcutaneous electrical nerve stimulation.

Current practice lacks effective periprocedural pain management during common gynecological procedures such as intrauterine device insertion, increasing the possibility of significant pain and adverse reaction to such procedures. Because of this, pain can often be a barrier for a patient in choosing a form of contraception that best serves them. Transcutaneous electrical nerve stimulation offers an option for effective pain control during intrauterine device insertion. This case review characterizes five cases where patients were offered transcutaneous electrical nerve stimulation for pain control during intrauterine device insertion. The patients reported a range of no pain to moderate pain during intrauterine device insertion and rated their pain experience as better compared with prior insertions. Although limited to a case review, our findings suggest a promising clinical indication for transcutaneous electrical nerve stimulation as a pain management strategy for intrauterine device insertion.

Exosomes, peptides and peri-procedure management – comparative investigations

Introduction: Exosome technology is a promising new advancement in therapeutic options but is still in its early stages, leading to uncertainties. A small pilot study compared traditional peptide technology (Regenerating Skin Nectar with TriHex Technology® and TriHex Technology® peptide + Octapeptide) to two leading exosome products (Stem cell derived Lyophilized exosomes and Platelet derived exosomes) for post-procedure use. These studies were carried out on pre-clinical (ex vivo) and clinical front to investigate effects on the extracellular matrix, dermo-epidermal junction, and skin tolerance as post-procedure outcomes. Methods and materials: The ex vivo model study was conducted by 3D Genomics using photodamaged skin from facelift patients. The skin was divided, processed under BSL2 conditions and cultured in transwells with specific media. Treatments, including peptides and platelet-derived products, were applied daily for 7 days, while stem cell-derived exosomes were applied as a single application as per the described usage. One set was left untreated as a control. Skin samples were treated and analyzed using immunohistochemistry staining for tropoelastin and CD44. RNA was isolated after treatments and sequenced to assess changes in gene expression. The study aimed to compare the effects of different treatments on skin regeneration and tolerance. Clinically, the participants underwent microneedling of the face and applied exosomes and peptides on each side of the face as comparisons. Participants completed questionnaires on Day 0. On Days 0,1,2,3 and 4 participants completed their self-healing ratings and were also assessed by an assessor on their healing rating on a 5-point scale. Results: The plated exosome products exhibited significant toxicity in the ex vivo model and neither of the exosome products produced relevant changes in gene expression or regenerative effects in this model. Participants in the small clinical series experienced unpleasant burning and stinging in keeping with the effects seen in the ex vivo model. In contrast, the peptide technology showed favorable gene expression upregulation and histological changes in the extracellular matrix and was well-tolerated and comfortable for post-procedure use, as has been demonstrated in multiple clinical trials. Conclusion: The overall impression from these pilot studies suggests that peptide formulations are better tolerated and more effectively target ECM regenerative effects. Conversely, exosome preparations appear to be prone to skin reactions and lack clear targeting of skin regenerative pathways.

A Tool Integrated into the Electronic Health Record to Guide Proper Decision-Making Regarding Peri-Endoscopic Anticoagulant Management: A Retrospective Cohort Study.

Background-Anticoagulants, such as vitamin-K antagonists (VKA) and direct oral anticoagulants (DOAC), are widely used among patients who undergo endoscopic procedures. To balance between bleeding and thromboembolic risks, careful decisions must be made about whether and for how long anticoagulants have to be stopped peri-endoscopically and if bridging is necessary. We created a tool in the electronic health records system (EHR) HIX (Microsoft) for invasive procedures to aid this decision-making. By selecting the anticoagulant indication or thrombo-embolic risk and the bleeding risk of the procedure, the tool automatically generates advice for periprocedural anticoagulant management. Objectives-This study assesses whether the tool is used properly peri-endoscopically. Secondly, it examines how many bleeding and thromboembolic events have occurred since the implementation of the tool. Methods-This retrospective study included all orders placed for endoscopies for patients using VKA or DOAC between 2018 and 2021. Results-In total, 986 endoscopies were included for analysis. In 89%, the tool was used correctly; the main error was selecting the wrong bleeding risk (7.5%). The cumulative incidence for moderate or severe bleeding events for DOAC and VKA was 2 (0.5%) and 0, respectively. The cumulative incidence of thromboembolic events for DOAC and VKA was 1 (0.2%) for each. Conclusions-This study evaluates the use of an EHR-integrated decision-making tool to aid peri-endoscopic anticoagulant management. By analysing the usage of the tool, we formulated several suggestions to improve the tool. Although this study is not a comparative one, we can conclude that the thromboembolic and major bleeding risks were low.

How We Would Treat Our Own Congenital Cardiac Catheterization Laboratory Patient

The field of congenital cardiac catheterization (CCC) has changed dramatically since it began eight decades ago. New techniques and devices have expanded the indications for interventional catheterization. Heart teams who care for patients in the pediatric and congenital cardiac catheterization laboratory are confronted with a growing number of patients presenting for a wide range of increasingly technically-challenging cases. Multiple societies have published expert guidelines for CCC management to provide recommendations for best practice. We reviewed risk stratification strategies for CCC and describe our institution's comprehensive, multidisciplinary approach to the periprocedural management of patients with congenital heart disease undergoing cardiac catheterization, using the index case of a 6-year-old patient with multiple heart defects. We concluded that risk stratification and a comprehensive, multidisciplinary team approach that begins when a procedure is booked is essential to inform management and optimize outcomes. Clinical decision-making should be informed by expert guidelines and evolving risk stratification research.

Feasibility of single antiplatelet therapy after stent assisted coiling for ruptured intracranial aneurysms.

We retrospectively analyzed clinical data to evaluate the safety and efficacy of single antiplatelet therapy (SAPT) after stent-assisted coil embolization (SAC) for ruptured cerebral aneurysms. In total, 176 stent-assisted coil embolization procedures were investigated. Among them, 77 ruptured and 99 unruptured aneurysms were grouped and compared respectively. In the ruptured group, only SAPT (aspirin) was administered after the procedure. Meanwhile, in the unruptured group, dual antiplatelet therapy (DAPT) (aspirin and clopidogrel) was administered before and after the procedure following standard guidelines. We compared both groups in regards to thromboembolic complications by analyzing post procedural diffusion-weighted images (DWI), hyperacute thrombosis during the procedure, and post-procedural symptoms. The single antiplatelet therapy ruptured intracranial aneurysm (SAPT-RIA) group had 77 saccular aneurysms (62 ICA, 3 MCA, 4 ACA, 8 posterior circulation) with a mean diameter of 8.07 mm. The dual antiplatelet therapy unruptured intracranial aneurysm (DAPT-UIA) group had 99 aneurysms (81 ICA, 5 MCA, 3 ACA, 10 posterior circulation) with a mean diameter of 6.32 mm. DWI positivity rates were similar between groups, but hyperacute thrombosis was higher in the SAPT-RIA group (10.4%) compared to none in the DAPT-UIA group. Each group had one symptomatic complication. SAPT could be a viable option for the peri-procedural management of SAC in acutely ruptured cases.

Same-day discharge coronary interventions: How to succeed?

Percutaneous coronary interventions(PCI) are the cornerstone of treatment in patients with coronary artery disease, generating substantial costs for the healthcare system. Considerable improvement in PCI technique, stent technology and antiplatelet therapy led to a complication rate of <5%, a success rate of >95% and lack of routine cardiothoracic surgical support. Thereby, the concept of same-day discharge following PCI has been proposed due to comparable efficacy, safety, and socioeconomic benefits to inpatient PCI. Although single-vessel disease was the primary indication for outpatient (OP) PCI, more complex scenarios such as multivessel disease, left main disease and chronic total occlusions were shown to be feasible and safe in OP setting as well. Currently available data shows that OP PCI leads to cost optimization, increased PCI center capacity, decrease in nosocomial infections rate and increased patient satisfaction, along with good clinical outcomes. Although OP PCI seems promising in a subset of well-prepared and compliant patients without severe comorbidities, there are some challenges to overcome before its routine implementation. To prevent unnecessary hospitalizations and unsafe same-day discharges, interventional cardiology teams should be trained to perform reliable risk-benefit assessments. Standardized forms should be created to obtain informed consent and instruct OP PCI patients and their relatives about postprocedural management. Here, we summarize the available data on OP and inpatient PCI outcomes, discuss the opportunities and challenges of OP PCI and propose a periprocedural patient management checklist, with the goal of facilitating OP PCI implementation in interventional cardiology centers.

Reconstructive Endovascular Treatment of Compensative-Flow-Related Posterior Circulation Aneurysms With Anterior Circulation Artery Occlusion.

The aim of this study was to delineate the reconstructive endovascular treatment and periprocedural management of compensative-flow-related posterior circulation aneurysms with anterior circulation artery occlusion. A total of 87 patients were enrolled in this retrospective double-center cohort study from May 2011 to November 2023. The baseline demographics, aneurysm characteristics, etiology and status of anterior circulation artery occlusion, treatment modalities, anesthesia management, complications, and clinical and angiographic outcomes of the patients were retrospectively analyzed in this study. Atherosclerosis and moyamoya disease were found to be the two main etiologies of anterior circulation artery occlusion. The mean American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology scores were significantly higher in patients with posterior communicating artery trunk collaterals than those with posterior cerebral artery pial collaterals (P < .05). Treatment strategies included stent-assisted coiling (55, 63.2%), standard coiling (22, 25.3%), and flow diversion or flow diversion-assisted coiling (8, 9.2%). The overall rate of procedure-related ischemic and hemorrhagic complications (10.3%) was considered acceptable. The ischemic complication was significantly associated with a >20% drop in mean arterial pressure (P < .05) during the procedure. Finally, 86.2% of all patients showed a modified Rankin Scale score of 0 to 2 at the final clinical follow-up. Our study indicates that reconstructive endovascular treatments are feasible and effective strategies for compensative-flow-related posterior circulation aneurysms with anterior circulation artery occlusion. However, these treatments are associated with a risk of periprocedural ischemic complications, which can be reduced by collateral arterial assessment, appropriate periprocedural anesthesia management, and antiplatelet treatment.

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.

Incidence, Predictors, and Outcomes of Clinically Significant Post-Endoscopic Retrograde Cholangiopancreatography Bleeding: A Contemporary Multicenter Study.

Clinically significant post-endoscopic retrograde cholangiopancreatography (ERCP) bleeding (CSPEB) is common. Contemporary estimates of risk are lacking. We aimed to identify risk factors of and outcomes after CSPEB. We analyzed multicenter prospective ERCP data between 2018 and 2024 with 30-day follow-up. The primary outcome was CSPEB, defined as hematemesis, melena, or hematochezia resulting in (i) hemoglobin drop ≥ 20 g/L or transfusion and/or (ii) endoscopy to evaluate suspected bleeding and/or (iii) unplanned healthcare visitation and/or prolongation of existing admission. Firth logistic regression was used. P values <0.05 were significant, with odds ratios (ORs) and 95% confidence intervals reported. CSPEB occurred after 129 (1.5%) of 8,517 ERCPs (mean onset 3.2 days), with 110 of 4,849 events (2.3%) occurring after higher risk interventions (sphincterotomy, sphincteroplasty, precut sphincterotomy, and/or needle-knife access). Patients with CSPEB required endoscopy and transfusion in 86.0% and 53.5% of cases, respectively, with 3 cases (2.3%) being fatal. P2Y 12 inhibitors were held for a median of 4 days (interquartile range 4) before higher risk ERCP. After higher risk interventions, P2Y 12 inhibitors (OR 3.33, 1.26-7.74), warfarin (OR 8.54, 3.32-19.81), dabigatran (OR 13.40, 2.06-59.96), rivaroxaban (OR 7.42, 3.43-15.24), and apixaban (OR 4.16, 1.99-8.20) were associated with CSPEB. Significant intraprocedural bleeding after sphincterotomy (OR 2.32, 1.06-4.60), but not after sphincteroplasty, was also associated. Concomitant cardiorespiratory events occurred more frequently within 30 days after CSPEB (OR 12.71, 4.75-32.54). Risks of antiplatelet-related CSPEB may be underestimated by endoscopists based on observations of suboptimal holding before higher risk ERCP. Appropriate periprocedural antithrombotic management is essential and could represent novel quality initiative targets.

Optimizing pediatric periprocedural pain management part II-Adjunct therapies to support the use of infiltrative anesthetics.

Pediatric procedure-related pain management is often incompletely understood, inadequately addressed, and critical in influencing a child's lifelong relationship with the larger healthcare community. We present a comprehensive review of infiltrative anesthetics, including a comparison of their mechanisms of action and relative safety and efficacy data to help guide clinical selection. We also describe the multimodal utilization of adjunct therapies-in series and in parallel-to support the optimization of pediatric periprocedural pain management, enhance the patient experience, and provide alternatives to sedation medication and general anesthesia.

Real world management of individuals with severe FXI deficiency and its impact on clinical outcomes: Experience from a haemophilia treatment centre.

The management of Factor XI deficiency is challenged by a variable association between FXI level and bleeding phenotype. Additionally, there is scarce data describing management strategies and their outcomes, specifically bleeding, thrombosis, and other complications. To evaluate bleeding, thrombosis, and other complications in individuals with severe FXI deficiency seen in our comprehensive haemophilia treatment centre (HTC). Peri-procedural management strategies and the resulting impact on bleeding and other clinically relevant outcomes were reported. Retrospective review of the electronic medical record of adult patients with severe FXI deficiency (<20% activity) seen at a New York City comprehensive HTC between 2017 and 2022. Procedures, haemostatic management, and outcomes were collected and analysed. We identified 38 individuals (64%) females with severe FXI deficiency. The mean age was 56±21 years (SD). The median FXI activity level was 3% (IQR: 1-8%). The mean BAT score was 3.1±2.4; (52%) individuals did not have a history of bleeding. A total of 256 surgeries and procedures were performed. There was reduced bleeding with preventative or reactive treatment during procedures. Arterial but not venous thrombotic complications were observed. Plasma was mostly used for procedures associated with higher risk of bleeding and antifibrinolytics for procedures at sites of high fibrinolysis. Current management strategies pose a burden of care for these patients and manifested as nonbleeding adverse events and changes in clinical management. These findings highlight the need for novel investigation in predicting and managing bleeding for individuals with severe FXI deficiency.

Examining the Efficacy and Safety of Combined Locoregional Therapy and Immunotherapy in Treating Hepatocellular Carcinoma.

More than 800,000 people worldwide are diagnosed with HCC (hepatocellular carcinoma) each year, with approximately 700,000 deaths alone occurring in that same year. Treatment of HCC presents complex therapeutic challenges, particularly in intermediate and advanced stages. LRTs such as transarterial chemoembolization (TACE) and ablations have been the mainstay treatment for early to intermediate-stage HCC, and systemic therapies are used to treat intermediate-late-stage HCC. However, novel literature describing combining LRT with systemic therapies has shown promising results. This review explores recent advances in both liver-directed techniques for hepatocellular carcinoma, including bland transarterial embolization, chemoembolization, radioembolization, and ablative therapies in conjunction as well as with systemic therapies, with a focus on combination therapies, patient selection, procedural technique, periprocedural management, and outcomes. Our findings suggest that LRT combined with systemic therapies is a viable strategy for improving progression-free survival and time to progression for patients with intermediate-to-late-stage HCC. However, further investigation is required to refine treatment protocols and define patient cohorts that would benefit the most.

Process Measures to Improve Outcomes During Peri-Procedure Management of Coagulopathy in Cirrhosis.

Process Measures to Improve Outcomes During Peri-Procedure Management of Coagulopathy in Cirrhosis.

Predictors of Complications Related to Cardiac Ablation for Atrial Arrhythmias

The heterogeneity of the patient population and the lack of uniform approaches to periprocedural management highlight the importance of investigating the predictors of catheter ablation (CA) related complications in patients with atrial arrhythmias.Aim of the study: to identify risk factors for procedure-related (PR) and procedural sedation and analgesia (PSA)-related complications in patients with atrial arrhythmias.Materials and Methods. A single-center retrospective cohort observational study analyzed 2,340 electronic medical records (EMRs) from the I.I. Mechnikov NWSMU database from 2015 to 2022. A total of 1,793 EMRs were included in the study. All the patients underwent radiofrequency CA for atrial arrhythmia under procedural sedation and analgesia. The risk factors for PR- and PSA-related complications were identified using single-factor regression analysis and multivariate logistic regression with Jamovi 2.3.21 and IBM SPSS Statistics 26 software.Results. The PR- and PSA-related complication rates were 3.29% and 0.73 %, respectively. Hemopericardium/cardiac tamponade with an incidence of 1.45% and cerebral stroke/TIA documented in 1.17% of cases predominated among the PR complications. PSA-related complications included postoperative nausea and vomiting syndrome (0.22 %) and respiratory depression (requiring mechanical ventilation in 0.06% and non-invasive ventilation in 0.45%). Of all PR complications, 30.5% were documented in patients aged 70-74 years. BMI &gt;30.0 kg/m2 (adjusted OR, 1.963; 95% CI, 1.09-3.36; P=0.023), age &gt;69 years (adjusted OR, 3.081; 95% CI, 1.764-5.383; P&lt;0.001), pain severity on the numerical rating scale (NRS) &gt;3 points (adjusted OR, 4.317; 95% CI, 2.390-7.800; P&lt;0.001), and previous CA procedure in the patient's history (adjusted OR, 10.276; 95% CI, 4.006-26.354; P&lt;0.001) were found to be risk factors for the development of PR complications, whereas BMI &gt;35 kg/m2 (adjusted OR, 4.955; 95% CI, 1.485-16.535; P=0.009) and duration of CA procedure &gt;142 min (adjusted OR, 11.070; 95% CI, 2.440-50.228; P=0.002) were found to be risk factors of PSA complications.Conclusion. The following independent predictors of CA-related complications were identified: patient-related factors such as BMI &gt;30.0 kg/m2 and age &gt;69 years, as well as procedure-related factors such as duration of CA &gt;142 min, history of CA, and pain intensity &gt;3 NPRS points.

Stroke outcomes following durable left ventricular assist device implant in patients bridged with micro-axial flow pump: Insights from a large registry.

Stroke after durable left ventricular assist device (d-LVAD) implantation portends high mortality. The incidence of ischemic and hemorrhagic stroke and the impact on stroke outcomes of temporary mechanical circulatory support (tMCS) management among patients requiring bridge to d-LVAD with micro-axial flow-pump (mAFP, Abiomed) is unsettled. Consecutive patients, who underwent d-LVAD implantation after being bridged with mAFP at 19 institutions, were retrospectively included. The incidence of early ischemic and hemorrhagic stroke after d-LVAD implantation (<60 days) and association of pre-d-LVAD characteristics and peri-procedural management with a specific focus on tMCS strategies were studied. Among 341 patients, who underwent d-LVAD implantation after mAFP implantation (male gender 83.6%, age 58 [48-65] years, mAFP 5.0/5.5 72.4%), the early ischemic stroke incidence was 10.8% and early hemorrhagic stroke 2.9%. The tMCS characteristics (type of mAFP device and access, support duration, upgrade from intra-aortic balloon pump, ECMELLA, ECMELLA at d-LVAD implantation, hemolysis, and bleeding) were not associated with ischemic stroke after d-LVAD implant. Conversely, the device model (mAFP 2.5/CP vs. mAFP 5.0/5.5: HR 5.6, 95%CI 1.4-22.7, p = 0.015), hemolysis on mAFP support (HR 10.5, 95% CI 1.3-85.3, p = 0.028) and ECMELLA at d-LVAD implantation (HR 5.0, 95% CI 1.4-18.7, p = 0.016) were associated with increased risk of hemorrhagic stroke after d-LVAD implantation. Both early ischemic (HR 2.7, 95% CI 1.9-4.5, p < 0.001) and hemorrhagic (HR 3.43, 95% CI 1.49-7.88, p = 0.004) stroke were associated with increased 1-year mortality. Among patients undergoing d-LVAD implantation following mAFP support, tMCS characteristics do not impact ischemic stroke occurrence, while several factors are associated with hemorrhagic stroke suggesting a proactive treatment target to reduce this complication.