Risk Factor For Embolic Events Research Articles

Abstract 10863: Left Ventricular Apical Injury Augments Stroke Likelihood in Patients With Systolic Dysfunction and No Left Ventricular Thrombus - Multiparametric Tissue Characterization and Strain Assessment via Cardiac Magnetic Resonance

Introduction: Patients (pts) with left ventricular (LV) dysfunction are at increased stroke risk even in absence of LV thrombus (LVT), but conventional indices such as ejection fraction (LVEF) have limited predictive value. Cardiac MRI (CMR) enables precise assessment of LV function and infarction, providing utility to test novel markers for stroke risk. Methods The population comprised pts with LVEF <50% and no LVT on CMR. Stroke was determined by blinded chart review. LV infarction, LVEF, LV and LA geometry, and segmental wall motion were measured on CMR. To further test association of LV contractility with events, radial strain was quantified in LVEF matched (1:1) pts with and without CVA; segmental data were regionally partitioned (base, mid, apex). Results 556 pts were studied; 7% (n=40) had stroke. Pts with stroke were older (68±14 vs 60±15 yo) and more likely to have AF (33 vs 18%) or CAD (55 vs 35%; all p<0.05) but did not differ based on CV risk factors (p=NS). Despite similar LVEF (37±8 vs 38±9%) and LV, LA size (p=NS), stroke pts had higher apical wall motion score (8.5±4.4 vs 6.6±3.6) and infarct size (5.3±6 vs 2.4±4.4%; each p<0.01) - each associated with stroke (p<0.001) independent of infarct or dysfunction in non-apical regions. Both apical wall motion (B=1.12 [1.02-1.22]; p=0.013) and infarct (B=1.10 [1.03-1.17]; p=0.006) associated with stroke controlling for age, clinical AF and CAD ( Table ). Among LVEF matched pts, radial strain tended to be higher in the basal LV (192.0±77.7 vs 165.5±56.1; p=0.09) and equivalent in the mid LV (177.8±63.3 vs 175.1±67.2; p=0.85), but apical radial strain was 30% lower (79.2±42.8 vs 109.1±62.4; p=0.015) in pts with, vs. those without stroke. Conclusion Among pts with LV dysfunction and no LVT, apical injury augments likelihood of stroke. Parallel associations of LV apical strain quantification, wall motion, and infarction with events support apical injury as risk factor for embolic events even in absence of LVT at time of imaging.

Outcomes of Mitral Valve Repair in Children With Infective Endocarditis: A Single-Center Experience

Mitral valve infective endocarditis (IE) in children is rare, and there are few reports on the outcomes of surgery in these patients. This study investigated the long-term outcomes of mitral valve repair in children with IE. Data were retrospectively obtained from medical records and correspondence. Univariable regression analyses were performed and outcomes including survival and freedom from reoperation were analyzed using the Kaplan-Meier method. Surgery for native mitral valve IE was performed in 39 patients between 1987 and 2020. Of these, 92.3% (36/39) of patients underwent mitral valve repair, while 7.7% (3/39) required replacement. Median age was 8 years. Preoperatively, 80.5% (29/36) of patients had moderate or greater mitral regurgitation. Congenital heart disease was present in 38.9% (14/36), while 11.1% (4/36) had rheumatic heart disease and 25.0% (9/36) had prior cardiac surgery. Postoperatively, only 1 patient (2.8%, 1/36) had moderate or greater residual mitral regurgitation. There were 2 early deaths (5.6%, 2/36), with survival being 94.1% (95%CI, 78.5-98.5) at 15 years. At 10 years, freedom from reoperation was 62.9% (95%CI, 41.0-78.5) while freedom from mitral valve replacement was 80.2% (95%CI, 55.5-92.3). Larger vegetation size was a risk factor for embolic events both pre- and postoperatively (OR, 1.15, P=0.02). Mitral valve repair is feasible in the majority of children requiring surgery for mitral valve IE. Survival is excellent, and at 10 years, approximately two-thirds of patients are free from mitral reoperation, and 80% are free from replacement. Larger vegetation size is associated with an increased risk of embolic events.

Prevalence of Atrial Fibrillation in Pacemaker Patients

Background: Current pacemakers allow for the continuous recording of the occurrence of arrhythmic events. One of the most frequent arrhythmias after implantation of a device is atrial fibrillation (AF), an important risk factor for embolic events. The frequency of this arrhythmia in pacemaker patients has not been widely studied. Objectives: This study aimed to evaluate the prevalence, incidence, and predictors of the occurrence of AF in patients with double-chamber pacemakers and without a history of atrial fibrillation prior to [...]

Impact of Left Atrial Appendage Morphology on Recurrence in Embolic Stroke of Undetermined Source and Atrial Cardiopathy.

Background: The left atrial appendage (LAA) is a major source of thrombus and non-chicken wing (CW). LAA morphology is a risk factor for embolic events in atrial fibrillation. However, the association of non-CW morphology with embolic stroke recurrence is unknown in patients with embolic stroke of undetermined source (ESUS) and atrial cardiopathy.Methods: We conducted retrospective analyses using a prospective institutional stroke registry (2013–2017). Patients with ESUS and atrial cardiopathy were enrolled. Atrial cardiopathy was diagnosed if an increased left atrial diameter (>40 mm, men; >38 mm, women), supraventricular tachycardia, or LAA filling defect on computed tomography (CT) were present. Patients admitted >24 h after onset were excluded. LAA morphology was evaluated using CT and categorized into CW vs. non-CW types. The primary outcome was embolic stroke recurrence. Multivariable Cox proportional hazards models were used to examine the independent association between LAA morphology and outcome.Results: Of 157 patients, 81 (51.6%) had CW LAA morphology. The median follow-up was 41.5 (interquartile range 12.3–58.5) months corresponding to 509.8 patient years. In total, 18 participants experienced embolic stroke recurrences (3.80 per 100 patient-years). Non-CW morphology was more associated with embolic stroke recurrence than CW morphology (hazard ratio (HR), 3.17; 95% confidence interval (CI), 1.13–8.91; p = 0.029). After adjusting for CHA2DS2-VASc score and number of potential embolic sources, non-CW morphology showed an independent association with outcome (adjusted HR, 2.90; 95% CI, 1.02–8.23; p = 0.045).Conclusions: The LAA morphology types may help identify high risk of embolic stroke recurrence in ESUS with atrial cardiopathy. LAA morphology in atrial cardiopathy may provide clues for developing therapies tailored to specific mechanisms.

Stroke and Embolic Events in Hypertrophic Cardiomyopathy: Risk Stratification in Patients Without Atrial Fibrillation.

Stroke and systemic embolic events are known to occur as complications of hypertrophic cardiomyopathy (HCM), and these complications are more common in patients with accompanying atrial fibrillation (AF). The diagnosis of AF is sometimes difficult, however, and it is possible that subclinical asymptomatic paroxysmal episodes or a first episode of AF in patients without previously documented AF may lead to embolic events. We investigated the prevalence of embolic events in patients with HCM and evaluated risk factors for these events in patients without documented AF. This study enrolled 593 patients with clinically diagnosed HCM (age at diagnosis, 51.0±15.6 years) from 1980 to 2010. During a mean follow-up of 10.7±7.5 years, 68 (11.5%) experienced stroke and embolic events. AF had been documented before the event in 29 (42.6%) of them. AF was documented for the first time at the time of the event in 5 (7.4%) and after the event in 10 (14.7%). Among the 431 patients without previously documented AF (39 with events and 392 without events), older age at diagnosis and left atrial dimension ≥48 mm were identified as the independent determinants of the embolic event after adjusting for sex and classic prognostic markers related to HCM. The incidence of stroke and embolic events was about 1.0% per year in the HCM cohort. AF had not been previously documented before the event in more than half of patients with events. Older age and enlarged left atrial dimension are possible risk factors for embolic events in patients with HCM without documented AF.

THE ROLE OF ANTICOAGULATION THERAPY IN PATIENTS WITH PROSTHETIC HEART VALVES

Cardiac surgery is the only radical method of treatment of valvular defects (congenital or acquired): valve preservation procedures or prosthetics operations. 250 000 – 280 000 valve prostheses are implanted every year worldwide, while the number of prosthetic valves operation increases by an average of 5–7 % per year (biological prostheses – 8–11 %, mechanical prostheses – 3–5 %). Selection of biological or mechanical types of prosthesis, its location, the presence of associated risk factors for embolic events, such as atrial fibrillation, previous embolism, left ventricular dysfunction, hypercoagulable states determine patient management tactics. Particularly high risk of prosthetic thrombosis and thromboembolic complications can be seen in case of mechanical prosthesis implantation. Numerous prospective and retrospective clinical studies have proven high effectiveness of anticoagulants for reduction the risk of cardioembolic complications. The degree of anticoagulation (optimal international normalized ratio (INR)) is determined by risk factors for prosthetic thrombosis and thromboembolic complications in a patient, as well as thrombogenicity of the prosthesis by itself; INR may range from 2.5 to 4.0. International recommendations take into account the presence/absence of additional risk factors for thromboembolism, and based on warfarin administration with the achievement of target INR values combined with low-dose aspirin. Administration of novel direct oral anticoagulation remedies in patients with prosthetic heart valves has not been studied sufficiently up to date and is contraindicated. Thus, warfarin currently is a drug of choice for the prevention of thromboembolic complications in patients with prosthetic heart valves.

0189: Identification of risk factors for embolic events in left-sided infective endocarditis

Embolic complications (EC) occur in about 30% to 40% of left-sided infective endocarditis (LSIE) and are associated with a poor prognosis. We analysed risk factors for embolic events in the systematic analysis of a large cohort of consecutive patients treated for infective endocarditis (IE). 533 consecutive patients admitted for definite or probable LSIE were included in this study. Mean age was 64 and 26% had a prosthetic valve. The location of IE was aortic in 68%. Causative microorganisms were Streptococcaceae in 40% and Staphylococcaceae in 27%. Rate of valve surgery and mortality during the initial hospital stay were 26% and 11%, respectively. The mean follow up was 5±6 years. Embolic events occur in 164 patients (30%). In multivariate analysis, presence of vegetation was an independent risk factor for embolic event (hazard ratio HR=1.96, p<0.001), whilst older age and Streptococcus infection were independently associated with a lower risk of embolic events (HR=0.99, p=0.02 and HR=0.64, p=0.02 respectively). Patients with LSIE and streptococcal infection have a lower risk of embolic events than others. The presence of vegetations was independently associated with an increased risk of embolic events.

Risk factors for embolism in cardiac myxoma: a retrospective analysis.

BackgroundMyxomas are the most common primary heart tumors and are closely associated with embolic events. Cardiac myxomas typically arise from the interatrial septum at the border of the fossa ovalis in the left atrium. Any other location is considered atypical. Embolism, one of the complications of myxoma, is associated with high morbidity and mortality. The aim of this study was to investigate the risk factors for embolism in patients with cardiac myxoma.Material/MethodsIn this retrospective study, a cohort of 162 patients with cardiac myxomas was surgically treated between January 1998 and June 2014 at 3 cardiac centers in China. Preoperative data, including platelet count, sex, age, and the tumor (size, location, surface, and attachment), were compared between embolic and non-embolic groups of patients.ResultsNo significant differences in vascular risk factors were seen between the 2 groups. However, the percentage of higher platelet count (>300×109/L) and mean platelet volume in the embolic group were significantly higher than in the non-embolic group (P=0.0356, and 0.0113, respectively). Irregular surface and atypical location of the myxomas were also independently associated with increased risk of embolic complications.ConclusionsTumor location, macroscopic appearance, mean platelet volume, and high platelet count are strong risk factors for embolic events in patients with cardiac myxomas.

Invited commentary

The report by Dr Cochennec highlights some very significant issues related to the practice and dissemination of complex aortic procedures. The authors present 113 cases performed during a period of 7 years, which equates to fewer than 20 cases per annum divided among four operators using three endovascular devices. Previous studies have shown a link between surgeon as well as center volumes and outcomes.1Thompson M. Holt P. Loftus I. Forbes T.L. Debate: whether abdominal aortic aneurysm surgery should be centralized at higher-volume centers.J Vasc Surg. 2011; 54: 1208-1214Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar Complex aneurysms represent a small proportion of all aneurysms treated, and it is difficult, even in large vascular centers, to achieve volumes large enough to reap the benefits of truly high volumes. In contrast to “simpler” aortic procedures, treatment of complex aneurysms is not only a question of individual operator experience and skill, but it places significant demands on the supporting structure of the center. Preoperative planning of complex cases is paramount for success. Detailed anatomic analysis as well as extensive specific device knowledge is needed. The learning curve is significantly longer than for infrarenal endovascular aneurysm repair. This indicates that it is better to use a single device and to learn it well rather than to stray between different devices, trying to take advantage of individual stent graft benefits. Certain morphologic features need to be specifically addressed. (1) A “shaggy” aorta is a risk factor for embolic events and poor outcome.2Patel S.D. Constantinou J. Hamilton H. Davis M. Ivancev K. A shaggy aorta is associated with mesenteric embolisation in patients undergoing fenestrated endografts to treat paravisceral aortic aneurysms.Eur J Vasc Endovasc Surg. 2014; 47: 374-379Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar (2) Poor access can lead to difficulties in orienting the device, leading to target vessel loss, resulting in end-organ dysfunction. Very long procedures can lead to compartment syndrome as well as a systemic reperfusion injury causing severe physiologic instability and multiorgan failure in the immediate postoperative phase.3Kristmundsson T. Sonesson B. Malina M. Bjorses K. Dias N. Resch T. Fenestrated endovascular repair for juxtarenal aortic pathology.J Vasc Surg. 2009; 49 (discussion: 754-5): 568-574Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar Patients with complex aneurysmal disease often carry significant comorbidities and generally have a much lower tolerance for perioperative and postoperative complications, which is clearly seen in the current study with significant morbidity and mortality. This furthermore emphasizes the need for appropriate patient selection, workup, and optimization before surgery as well as extensive involvement of anesthetic and intensive care expertise in the preoperative, perioperative, and postoperative period. This can most likely be achieved only in very select high-volume centers dedicated to treatment of complex aortic disease. I thank the authors for their honest reporting and for highlighting the issues in dealing with complex endovascular aortic procedures. Impact of intraoperative adverse events during branched and fenestrated aortic stent grafting on postoperative outcomeJournal of Vascular SurgeryVol. 60Issue 3PreviewFenestrated and branched endovascular devices are increasingly used for complex aortic diseases, and despite the challenging nature of these procedures, early experiences from pioneering centers have been encouraging. The objectives of this retrospective study were to report our experience of intraoperative adverse events (IOAEs) during fenestrated and branched stent grafting and to analyze the impact on clinical outcomes. Full-Text PDF Open Archive

The presence of infection-related antiphospholipid antibodies in infective endocarditis determines a major risk factor for embolic events

OBJECTIVESThe impact of infection-associated antiphospholipid antibodies (APA) on endothelial cell activation, blood coagulation and fibrinolysis was evaluated in patients with infective endocarditis with and without major embolic events.BACKGROUNDAn embolic event is a common and severe complication of infective endocarditis. Despite the fact that APAs are known to be associated with infectious diseases, their pathogenic role in infective endocarditis has not been clearly defined.METHODSThe relationship among the occurrence of major embolic events, echocardiographic vegetation size, endothelial cell activation, thrombin generation, fibrinolysis and APA was examined in 91 patients with definite infective endocarditis, including 26 patients with embolic events and 65 control subjects without embolic events.RESULTSOverall, 14.3% of patients exhibited elevated APA levels. Embolic events occurred more frequently in patients with elevated levels of APA than in patients without (61.5% vs. 23.1%; p = 0.008). Patients with elevated levels of APA showed higher levels of prothrombin-fragment F1+2 (p = 0.005), plasminogen-activator inhibitor 1 (p = 0.0002), von Willebrand factor (p = 0.002) and lower levels of activated protein C (p = 0.001) than patients with normal levels of APA. Thrombin generation and endothelial cell activation were both positively correlated with levels of APA. The occurrence of elevated APA levels was frequently associated with structural valve abnormalities (p = 0.01) and vegetations >1.3 cm (p = 0.002).CONCLUSIONSInfection-associated elevated APA levels in patients with infective endocarditis are related to endothelial cell activation, thrombin generation and impairment of fibrinolysis. This may contribute to the increased risk for major embolic events in these patients.

Insight on aortic atheroembolism from transesophageal and intraoperative echocardiography

Aortic atheroembolism has been regarded as an infrequent cause of stroke. However, recent pathologic studies have found that ulcerated aortic plaques are present in a significant number of patients with cerebral infarction of unknown etiology. Transesophageal echocardiography and epivascular ultrasound of the ascending aorta provide high quality images of the thoracic aorta, and studies using these two techniques have shown that a significant percentage of elderly patients have severe atherosclerotic disease of the ascending aorta and arch. The prevalence of significant aortic atherosclerosis appears to be greater than previously thought, and its presence may be a significant risk factor for embolic events.