Risk Of Embolism In Patients Research Articles

Complex left appendage morphology is associated with Embolic Stroke of Undetermined Source.

Variations in the left atrial appendage (LAA) morphology are associated with different embolic risk in patients with atrial fibrillation (AF). Data are scarce regarding the association between LAA morphology and Embolic stroke of undetermined source (ESUS). Using cardiac computed tomography (CCT) scans, LAA morphology was categorized as either chicken wing (CW), cactus, windsock, or cauliflower. Furthermore, we examined the presence of large secondary lobes arising from the main lobe, considering their existence as indicative of a complex LAA morphology. LAA morphologies were compared between ESUS (n = 134) and AF patients (n = 120); and between ESUS patients with (n = 24) and without (n = 110) subsequent AF diagnosis during long-term follow-up. ESUS patients had a significantly higher prevalence of cauliflower morphology compared to AF group (52% vs 34%, respectively, p = 0.01); however, no significant difference was found between the groups when categorizing LAA morphology to either CW or non-CW. ESUS patients had significantly higher prevalence of large secondary lobes compared with AF patients (50% vs 29%, respectively, p = 0.001). When comparing ESUS patients with and without AF diagnosis during follow-up (20-48 months of follow-up, median 31 months), there were no significant differences in the prevalence of the "classical" morphologies, but large secondary lobes were significantly more prevalent among those without subsequent AF diagnosis. ESUS patients have a high prevalence of complex LAA morphology, which might be associated with an increased risk for thrombus formation even in the absence of AF.

Intraoperative Infusion of Dextran Confers No Additional Benefit after Carotid Endarterectomy but Is Associated with Increased Perioperative Major Adverse Cardiac Events

Intraoperative dextran infusion has been associated with reduction of an embolic risk in patients undergoing carotid endarterectomy (CEA). Nonetheless, dextran has been associated with adverse reactions including anaphylaxis, hemorrhage, cardiac and renal complications. Herein, we aimed to compare the perioperative outcomes of CEA stratified by the use of intraoperative dextran infusion using a large multi-institutional dataset. Patients undergoing CEA between 2008 and 2022 from the Vascular Quality Initiative database were reviewed. Patients were categorized by use of intraoperative dextran infusion, and demographics, procedural data and in-hospital outcomes were compared. Logistic regression analysis was utilized to adjust for differences in patients while assessing the association between postoperative outcomes and intraoperative infusion of dextran. Of 140,893 patients undergoing CEA, 9,935 (7.1%) patients had intraoperative dextran infusion. Patients with intraoperative dextran infusion were older with lower rates of symptomatic stenosis (24.7% vs 29.3%; P<0.001) and preoperative use of antiplatelets, anticoagulants and statins. Additionally, they were more likely to have severe carotid stenosis (> 80%; 49% vs 45%; P<0.001) and undergo CEA under general anesthesia (96.4% vs 92.3%; P<0.001) with more frequent use of shunt (64.4% vs 49.5%; P<.001). After adjustment, multivariable analysis showed that intraoperative dextran infusion was associated with higher odds of in-hospital major adverse cardiac events (MACE) including myocardial infarction (MI; odds ratio [OR], 1.76, 95% confidence interval [CI]: 1.34-2.3, P<0.001), congestive heart failure (CHF; OR, 2.15, 95% CI: 1.67-2.77, P=0.001) and hemodynamic instability requiring vasoactive agents (OR, 1.08, 95% CI: 1.03-1.13, P=0.001). However, it was not associated with decreased odds of stroke (OR, 0.92, 95% CI: 0.74-1.16, P=0.489) or death (OR, 0.88, 95% CI: 0.58-1.35, P=0.554). These trends persisted even when stratified by symptomatic status and degree of stenosis. Intraoperative infusion of dextran was associated with increased odds of MACE including MI, CHF and persistent hemodynamic instability without decreasing the risk of stroke perioperatively. Given these results, judicious use of dextran in patients undergoing CEA is recommended. Furthermore, careful perioperative cardiac management is warranted in select patients receiving intraoperative dextran during CEA.

Intraoperative Infusion Of Dextran Confers No Additional Benefit After Carotid Endarterectomy But Is Associated With Increased Major Adverse Cardiac Events

Several studies have shown the potential efficacy of dextran therapy to reduce an embolic risk in patients undergoing carotid endarterectomy (CEA). Nonetheless, dextran has been associated with adverse reactions including anaphylaxis, hemorrhage, cardiac and renal complications. Herein, we aimed to compare the perioperative outcomes of CEA stratified by the use of dextran using a large multi-institutional dataset.

RELAY™ Branched device: The story of an aortic arch device.

The management of aortic arch pathologies represents a great challenge and is associated with high rates of mortality and morbidity. The invasive and radical open surgical repair (OSR) is the standard of care for this group of patients. A superior endovascular approach via thoracic endovascular aortic repair (TEVAR) has been introduced to treat arch pathologies with specifically designed endografts. This approach was shown to benefit patients who are deemed "high risk" for undergoing OSR as it is a greatly less invasiveness option and thus, yields lower rates of morbidity and mortality. This commentary aims to discuss the recent study by Tan and colleagues,which reports original data on the neurological outcomes after endovascular repair of the aortic arch using the RELAY™ Branched device. We carried out a literature search on multiple electronic databases, including PubMed, Ovid, Google Scholar, Scopus, and EMBASE, to collate research evidence on the neurological outcomes of endovascular aortic arch repair with TEVAR. Tan and colleagues showed through their original clinical data that the RELAY™ Branched device has a high rate of technical success and favorable neurological outcomes. There were no reported neurological deficits in patients who received the triple-branched RELAY™ Branched device. The RELAY™ branched endograft is well-established for candidates for aortic arch endovascular repair with favorable neurological outcomes. Multiple considerations can help control the incidence of stroke following endovascular repair. These include optimization of the supra-aortic vessels' revascularization, weighting the embolic risk in patients with atheromatous disease, and careful preoperative assessment to select the best candidates for arch endovascular repair.

Bleeding and embolic risk in patients with atrial fibrillation and cancer

Introduction and objectivesThe impact of cancer on clinical outcomes in patients with atrial fibrillation (AF) is unclear. The aim of this study was to assess how cancer influences the prediction and risk of embolic and hemorrhagic events in patients with AF. MethodsThe study population comprised 16 056 patients from a Spanish health area diagnosed with AF between 2014 and 2018. Of these, 1137 (7.1%) had a history of cancer. During a median follow-up of 4.9 years, we assessed the relationship between cancer and bleeding and embolic events by competing risk analysis, considering death as a competing risk. ResultsNo association was detected between an increased risk of embolic events and cancer overall (sHR, 0.73; 95%CI, 0.41-1.26), active cancer, or any subgroup of cancer. However, cancer was associated with an increased risk of bleeding, although only in patients with active cancer (sHR, 1.42; 95%CI, 1.20-1.67) or prior radiotherapy (sHR, 1.40; 95%CI, 1.19-1.65). Both the CHA2DS2-VASc and HAS-BLED scores showed suboptimal performance to predict embolic and bleeding risk (c-statistic <0.50), respectively, in nonanticoagulated patients with active cancer. The ratio between the increase in bleeding and the decrease in embolisms with anticoagulation was similar in patients with and without cancer (5.6 vs 7.8; P <.001). ConclusionsCancer was not associated with an increased risk of embolic events in AF patients, only with an increased risk of bleeding. However, active cancer worsened the ability of the CHA2DS2-VASc and HAS-BLED scores to predict embolic and bleeding events, respectively, in nonanticoagulated patients.

Investigation of Routine Blood Parameters for Predicting Embolic Risk in Patients With Nonvalvular Atrial Fibrillation

Introduction: Nonvalvular atrial fibrillation (NV-AF) is an important risk factor for cardiac thromboembolic disorders. However, there is not an exact biomarker for evaluating risk in these patients. In this study, we aimed to investigate the routine blood test and inflammatory markers in NV-AF patients with or without embolic complications. Materials and Methods: Routine complete blood count (CBC) and a clinical biochemistry analysis of 214 NV-AF patients (151 with embolic complication and 63 without embolic complication) were recorded retrospectively. Obtained results compared between NV-AF with embolic group and NV-AF without an embolic group. Results: The most of the CBC and biochemical markers were found as similar (P &gt; 0.05) between groups except white blood cell count, lymphocyte ratio (Lym%), neutrophil ratio (Neu%), eosinophil ratio (Eus%), neutrophil count (Neu), mean corpuscular hemoglobin concentration, blood urea nitrogen, cholesterol, low-density lipid, sodium (Na), total bilirubin, direct bilirubin, plasma iron levels, and neutrophil to lymphocyte ratio (NLR) (P &lt; 0.05). Conclusion: The inflammatory markers, especially NLR, seem to be useful for embolic risk stratification in NVAF patients.

305 Usefulness of CHA2DS2-VASc scoring system for predicting risk of embolism in patients with cardiac tumours: a single-centre study

Abstract Aims The link between pro-protein convertase subtilisin/kexin 9 (PCSK9) and inflammatory-related disease has been supported in several experimental and human studies, which show how the protein could acts independent its canonical mechanism, by activation of inflammatory, apoptotic and immune pathways. Among these, TLR4/NFKB signalling pathway has been found to be one of the main pathways mediating the PCSK9-induced increase of pro-inflammatory and pro-thrombotic molecules, such as TNF-alpha, IL-6, IL-1, MCP-1, and TF. To investigate the direct involvement of hTLR4 in recognition of exogenous human recombinant (hr) PCSK9. Methods and results Experiments were carried out in three cell line: (i) HEK293-hTLR4-GFP cell lines obtained by stable co-transfection of HEK293 cells with the pUNO1-hTLR4-GFP, a plasmid expressing the hTLR4 gene fused to a GFP gene; (ii) HEK293-hTLR4+ cells obtained by co-transfection of hTLR4 receptor and its accessory proteins MD-2 and CD14, and an inducible secreted embryonic alkaline phosphatase (SEAP) reporter gene; (iii) HEK293-Null2 cells, a cell line lacking TLR4 expression, used as negative control. NFkB activity were measured by the SEAP reporter gene assay using a fluorescence detection method, while localization of hTLR4 and exogenous hrPCSK9 by confocal microscopy. hrPCSK9 (1 µg/mL) activates NFkB in HEK293-hTLR4+ cells [SEAP activity-OD 620 nm: from a baseline of 0.18 ± 0.06 to 0.68 ± 0.05 (N = 8), P &amp;lt; 0.001] to an extent comparable to lipopolysaccharide, the specific agonist of TLR4. Co-localization of hrPCSK9 and TLR4s was clearly documented by quantitative confocal microscopy in HEK293-hTLR4-GFP cell line, that comprises the analysis of more than 80 fields in ∼2.105 cells/well and showing a percentage of co-localization of ∼4% in membrane spots (P &amp;lt; 0.01). Conclusions Our data support the results reported in previous studies that attribute to PCSK9 a pathophysiological role in development of chronic inflammation and related-diseases such as atherothrombosis. A behavior that extends far beyond LDLR degradation, via a mechanism that might be mediated at least in part by recognition of PCSK9 by the TLRs and later activation of NFkB intracellular pathway. Future studies will be important to better investigate the specific binding site engaged in the PCSK9-TLR interaction and to discriminate the intracellular transduction pathways involved in this response, in order to provide a theoretical basis for the development of innovative therapeutic strategies.

Usefulness of CHA2DS2-VASc scoring system for predicting risk of embolism in patients with cardiac tumours: a single-centre study

Abstract Background The CHA2DS2-VASc score is the most used in predicting thromboembolic risk in patients with atrial fibrillation (AF). However, a higher CHA2DS2-VASc score predicts cardiovascular events even in patients without AF. Up to date, there is limited evidence about the association between CHA2DS2-VASc score and the embolic risk in patient with cardiac tumours (CT). Purpose To evaluate the role of the CHA2DS2-VASc score in predicting embolism and to identify other markers of embolization in patients with CT. Methods We included all patients with a CT who had a complete echocardiographic evaluation and a histologic diagnosis. We excluded patients with cardiac thrombi because of their higher embolic risk. Results Our sample consisted of 221 patients (mean age 60.9±15.6, 7% female). 132 (59.7%) patients had benign CT, usually left-sided (84.8%). In the malignant tumours, 28 (31.5%) were primary and 61 (68.5%) were metastasis. Compared to benign tumours, malignant ones were predominantly right-sided (47.2%) or with pericardial (20.2%) or great-vessels involvement (16.9%). A total of 59 patients (26.6%) experienced an embolic event, of which 33 patients had peripheral embolism, while 28 had pulmonary embolism (PE), 2 patients had both. Patients with embolism were older (p=0.013), had a higher prevalence of diabetes or previous stroke (p=0.019 and p&amp;lt;0.001), had left-sided and not-infiltrating CT (p=0.001 and p=0.04). We did not find any differences in AF prevalence, atrium volumes or other CT characteristics. Moreover, patients who developed an embolic event had a higher CHA2DS2-VASc score than those without embolism (p&amp;lt;0.001). In particular, a CHA2DS2-VASc score &amp;gt;3 had an AUC=0.835 in predicting a peripheral embolic event in the overall population (p&amp;lt;0.001). At multivariate analysis, only CHA2DS2-VASc and left-side localization were significantly associated with embolization (p&amp;lt;0.001 and p=0.009). Also in patients with right-sided CT, CHA2DS2-VASc score (p=0.017), together with some tumours characteristics (mobility, pericardial effusion and absence of myocardial infiltration (p&amp;lt;0.04 for all) was associated with PE. Embolization did not impact survival when considering the overall population. Otherwise, when focusing on patients with malignant CT, those who had an embolic event had a worse prognosis (p=0.02), as well as those with PE (p=0.037). Conclusions CHA2DS2-VASc and left-side localization are the best markers of embolism. In particular, CHA2DS2-VASc seems to predict embolization in CT, regardless of histology or localization. Many patients with CT and embolism may not be offered surgical treatment given their assumed high-risk profile. By contrast, our analysis showed that survival is not related to the embolic event per se, but by histology. In patients with CT and high CHA2DS2-VASc score, further studies are needed to evaluate the best therapeutic strategy to minimize the embolic risk. Funding Acknowledgement Type of funding sources: None.

Predicting Atrial Fibrillation with High Risk of Embolization with Atrial Strain and NT-proBNP.

The aim of the study was to determine markers of atrial dysfunction in patients with cryptogenic stroke to predict episodes of paroxysmal atrial fibrillation with high risk of embolization (HpAF). We classified patients included in the Crypto-AF study, Cryptogenic Stroke registry, to detect paroxysmal atrial fibrillation (pAF) with wearable Holter, according to the longest episode of pAF in three groups: without pAF detection, episodes of pAF shorter than 5h, and episodes of pAF longer than 5h (HpAF). Atrial dysfunction surrogates were evaluated: EKG pattern, Holter record and echocardiography parameters (left atria volume (LAVI), and peak atrial longitudinal and contraction strain (PALS and PACS). The level of N-terminal pro b-type natriuretic peptide (NT-proBNP) was determined. All patients were followed for 2years to detect pAF and stroke recurrence. From 308 patients, 253 patients with high quality Holter analysis were selected. The distribution was No pAF 78.6% (n = 199), pAF < 5h 7.9% (n = 20), and HpAF > 5h 13.4% (n = 34). Age of the patients and combination of PALS and NT-proBNP independently predicted HpAF OR 1.07 (1.00; 1.15) and OR 3.05 (1.08; 8.60) respectively. The validity of PALS and NT-proBNP to detect patients at risk of HpAF was higher than the validity of age (AUC 0.82, sensitivity 78.95%, specificity 63%). Patients with PALS < 25% and NT-proBNP > 283pg/ml had more detection of pAF during follow-up 35% vs. 5.1% OR 2.33 (1.05-5.13) (p < 0.001). Multimodal assessment of atrial dysfunction with PALS and NT-proBNP improved the prediction of pAF episodes with high embolic risk in patients with cryptogenic stroke.

Real-World Experience with Left Atrial Appendage Occlusion

Left atrial appendage occlusion (LAAO) offers hope to reduce the risk for embolism in patients with atrial fibrillation, without the use of

Epidemiology, morbidity and mortality in Behçet's disease: a cohort study using The Health Improvement Network (THIN).

The epidemiology of Behçet's disease (BD) has not been well characterized in the UK. Evidence on the risk of cardiovascular disease, thromboembolic disease and mortality in patients with BD compared with the general population is scarce. We used a large UK primary care database to investigate the epidemiology of BD. A retrospective matched cohort study was used to assess the following outcomes: risk of cardiovascular, thromboembolic disease and mortality. Controls were selected at a 1:4 ratio (age and gender matched). Cox proportional hazard models were used to derive adjusted hazard ratios (aHR). The prevalence of BD was 14.61 (95% CI 13.35-15.88) per 100000 population in 2017. A total of 1281 patients with BD were compared with 5124 age- and gender-matched controls. There was significantly increased risk of ischaemic heart disease [aHR 3.09 (1.28-7.44)], venous thrombosis [aHR 4.80 (2.42-9.54)] and mortality [aHR 1.40 (1.07-1.84)] in patients with BD compared with corresponding controls. Patients with BD were at higher risk of pulmonary embolism compared with corresponding controls at baseline [adjusted odds ratio 4.64 (2.66-8.09), P < 0.0001]. The majority of patients with pulmonary embolism and a diagnosis of BD had pulmonary embolism preceding the diagnosis of BD, not after (87.5%; n = 28/32). BD has a higher prevalence than previously thought. Physicians should be aware of the increased risk of developing ischaemic heart disease, stroke/transient ischaemic attack and deep venous thrombosis in patients with BD at an earlier age compared with the general population. Risk of embolism in patients with BD might vary across the disease course.

Evaluation of the potential predictors of embolism in patients with left atrial myxoma.

Cardiac myxomas are the most common primary intracardiac tumors. Although myxomas are histologically benign, they are potentially dangerous due to potential risk of systemic and cerebral embolism. In this study, we aimed to investigate the potential predictors of embolism in patients with left atrial myxoma. This single-center retrospective study enrolled 93 patients (mean age: 52.9±15.3years, female: 70 [75.3%]) with left atrial myxomas between 2014 and 2018. The patients were classified into two groups (embolic vs nonembolic) to investigate possible predictors of embolism. Demographic, laboratory, and echocardiographic parameters were recorded into a dataset and compared between patients with and without embolism. The study population was composed of 13 (14%) patients in embolic (11 cerebrovascular and 2 peripheral) and 80 (86%) patients in nonembolic group. Demographic and laboratory parameters were similar between the groups. Tumor sizes were significantly higher in the embolic group than in the nonembolic group (5.59±1.08 vs 4.29±0.61; P=0.001). By multivariate analysis, increased tumor size, increased left atrial diameter, and the presence of atrial fibrillation and irregular tumor surface were identified as independent predictors of embolism. In ROC curve analyses, tumor size above 4.6cm predicted embolism with a sensitivity of 77% and a specificity of 73% (AUC: 0.858; 95% CI: 0.752-0.964; P<0.001). The presence of atrial fibrillation, irregular tumor surface, increased tumor size, and increased left atrial diameter is associated with increased risk of embolism in patients with left atrial myxoma. Early surgery should be scheduled for such patients due to increased potential for embolism.

Both aspirin and statin therapy reduce embolic events in patients with infective endocarditis

Embolic events (EE) are major complications of infective endocarditis (IE). Animal models have demonstrated the benefit of aspirin (ASP) and statins (ST) in their prevention, but clinical studies have given conflicting results. To evaluate the benefit of prior ASP or ST therapy on embolic risk in patients with IE. In a retrospective study from 2010 to 2016, the impact of daily ASP or ST therapy on admission on the risk of EE in patients with IE was assessed. The primary end point was EE occurring before or during hospitalization. Among 529 pts with IE, 135 (25%) were treated by ASP, 130 (24%) were treated by ST at the time of diagnosis. EE occurred in 264 (50%) pts including 242 (46%) before and 61 (11%) after initiation of antibiotics. As compared with the 394 pts without prior ASP therapy, the 135 ASP pts were older (67.8 ± 11 vs. 64.4 ± 16 P = 0.02), had more frequent history of renal failure ( P = 0.0008) and presented with less frequent EE [53 (39%) vs. 211 (53%) P = 0.01] and similar hemorrhagic complications (8 (5.9%) vs. 45 (11%) P = NS). As compared with the 399 patients without previous ST therapy, the 130 ST patients were older (63.6 ± 16 vs. 70.2 ± 9 P < 0.0005), had more frequent history of diabetes, hypertension, and atrial fibrillation, and presented with less frequent EE [55 (42%) vs. 209 (52%) P = 0.04] and similar hemorrhagic complications (9 (7%) vs. 44 (11%) P = NS). Factors associated with increased EE were IVDA (OR 2.68 [1.45; 5.22]), vegetation length (OR 1.07 [1.05; 1.09]), and staphylococcus aureus (OR 1.51 [1.05; 2.18]), while ASP (OR 0.56 [0.38; 0.83]), and ST (OR 0.67 [0.45; 0.99] were protective. By multivariate analysis, only ASP (OR 0.6 [0.4; 0.92]) was protective against EE. Prior aspirin and statin therapy reduces EE in patients with IE without increasing hemorrhagic risk. Additional prospective studies are warranted to assess the benefit of both therapies in reducing morbidity and mortality in IE.

Risk of Pulmonary Embolism in Patients With Isolated Great Saphenous Vein Thrombus.

Risks associated with isolated great saphenous vein (GSV) thrombosis remain controversial. The purpose of this study is to identify the risk of pulmonary embolism (PE) in patients with isolated GSV thrombosis, particularly those with thrombus within 3 cm of the sapheno-femoral junction. A retrospective chart review of color flow Doppler lower extremity venous ultrasound examinations from an academic hospital from 2011 to 2016 was conducted. Seventy-eight patients were identified as having acute thrombus in their GSV and were then further stratified based on the presence or absence of concomitant deep venous thrombosis (DVT). A control group of 49 patients who presented with leg swelling and were found to have a normal color flow Doppler examination was also identified. Patients without thrombus (n = 49), patients with isolated GSV thrombus (n = 29), and patients with GSV thrombus with concomitant DVT (n = 49) underwent full chart review to determine whether any patients developed PE. This was diagnosed specifically by computed tomography angiogram or ventilation/perfusion scan, within 60 days of initial diagnosis of lower extremity thrombus. In our analysis, there was no significant difference in the risk of PE in patients with isolated GSV thrombus compared with a control group of normal patients (3.5% vs 2.0%, P = 0.38). However, patients with GSV thrombus and concomitant DVT had a significantly increased risk of PE compared with patients with isolated GSV thrombus (26.5% vs 3.5%, P = 0.01). We found that the risk of PE in patients with isolated GSV thrombus is not significantly increased compared with a normal cohort.

P3538Influence of single nucleotide polymorphisms (SNPs) within genes encoding platelet glycoprotein receptors and blood-coagulation factors on embolic risk in patients with infective endocarditis (IE)

P3538Influence of single nucleotide polymorphisms (SNPs) within genes encoding platelet glycoprotein receptors and blood-coagulation factors on embolic risk in patients with infective endocarditis (IE)

Association of Vegetation Size With Embolic Risk in Patients With Infective Endocarditis

Infective endocarditis is a life-threating condition with annual mortality of as much as 40% and is associated with embolic events in as many as 80% of cases. These embolic events have notable prognostic implications and have been linked to increased length of stay in intensive care units and mortality. A vegetation size greater than 10 mm has often been suggested as an optimal cutoff to estimate the risk of embolism, but the evidence is based largely on small observational studies. To study the association of vegetation size greater than 10 mm with embolic events using meta-analytic techniques. A computerized literature search of all publications in the PubMed and EMBASE databases from inception to May 1, 2017, was performed with search terms including varying combinations of infective endocarditis, emboli, vegetation size, pulmonary infarct, stroke, splenic emboli, renal emboli, retinal emboli, and mesenteric emboli. This search was last assessed as being up to date on May 1, 2017. Observational studies or randomized clinical trials that evaluated the association of vegetation size greater than 10 mm with embolic events in adult patients with infective endocarditis were included. Conference abstracts and non-English language literature were excluded. The search was conducted by 2 independent reviewers blinded to the other's work. Following PRISMA guidelines, the 2 reviewers independently extracted data; disputes were resolved with consensus or by a third investigator. Categorical dichotomous data were summarized across treatment arms using Mantel-Haenszel odds ratios (ORs) with 95% CIs. Heterogeneity of effects was evaluated using the Higgins I2 statistic. The search yielded 21 unique studies published from 1983 to 2016 with a total of 6646 unique patients with infective endocarditis and 5116 vegetations with available dimensions. Patients with a vegetation size greater than 10 mm had increased odds of embolic events (OR, 2.28; 95% CI, 1.71-3.05; P < .001) and mortality (OR, 1.63; 95% CI, 1.13-2.35; P = .009) compared with those with a vegetation size less than 10 mm. In this meta-analysis of 21 studies, patients with vegetation size greater than 10 mm had significantly increased odds of embolism and mortality. Understanding the risk of embolization will allow clinicians to adequately risk stratify patients and will also help facilitate discussions regarding surgery in patients with a vegetation size greater than 10 mm.

Left Atrial Appendage Closure Devices for Stroke Prevention in Patients with Non-Valvular AF

The left atrial appendage (LAA) may be involved in offloading atrial pressure during left ventricular systole. As ventricular rate increases, LAA emptying decreases during early diastole causing increased risk of thrombus formation particularly in patients with non-valvular AF (NVAF). The LAA is the site of thrombus formation in more than 90 % of patients with NVAF, so is an important target for thromboembolic prophylaxis in these patients. Anticoagulation therapy is used to treat NVAF, but it has long-term complications and may be contraindicated in some patients. Therefore, alternative strategies to reduce embolic risk in patients with AF have been developed. These include percutaneous, thoracoscopic, and open closure strategies. This study reviews the safety and efficacy of these strategies, comparing these approaches and devices with pharmacological strategies. There is little data to endorse one strategy over another. Given the minimal evidence available, recommendations in support of LAA occlusion remain weak and guidelines have called for more research and coding of endpoints for this emerging technology.

Transapical Endovascular Repair of Thoracic Aortic Pathology

Alternative access for thoracic endovascular aortic repair (TEVAR) has been explored for patients with unsuitable femoral and iliac access, but few cases of transapical access have been described. We report our experience with transapical access for various aortic pathologies. We reviewed 6 cases undergoing transapical access for endovascular repair of thoracic aortic pathology between December 2013 and August 2015. Five patients had an aortic arch aneurysm and 1 patient presented with Stanford type A subacute aortic dissection. Transapical access was indicated to avoid approach through the severely atherosclerotic thoracic descending aorta in 4 patients and severely kinked aorta in 1 patient and to treat an ascending aortic dissection lesion in 1 patient. Transapical endografting was completed in all patients. Significant aortic valve regurgitation occurred in 3 patients when a large bore sheath was placed across the aortic valve. There was 1 death attributed to global cerebral ischemia due to carotid dissection after carotid bypass and chimney stent-graft insertion. There were no access-related complications. Computed tomography revealed complete exclusion of the aortic aneurysm in 4 patients, and shrinkage of the false lumen in 1 patient with aortic dissection. Transapical access for TEVAR would be a potential alternative when the anatomy is unfit for routine retrograde approach. This method might have potential benefit of reducing the risk of embolism in patients with severe atherosclerotic thoracic descending aorta. However, certain safety concerns must be addressed, including maintenance of hemodynamics, wire exteriorization for navigation of the device tip, and rapid pacing during deployment.

Ischemic stroke classification and risk of embolism in patients with Chagas disease.

Ischemic stroke (IS) and Chagas disease are strongly related. Nevertheless, little attention has been paid to this association and its natural history. The current guidelines concerning the management and secondary prevention of IS are largely based on the incomplete information or extrapolation of knowledge from other stroke etiologies. We performed a retrospective study which compared stroke etiologies among a cohort of hospitalized patients with IS and Chagas disease. The Instituto de Pesquisa Evandro Chagas/Fundação Oswaldo Cruz (IPEC/FIOCRUZ) embolic score was also used to identify and evaluate the risk of embolism in this population. A total of 86 patients were included in the analysis. The mean age of the study population was 58years, and 60% were men. According to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) Classification, 45% of the strokes were of undetermined etiology and 45% of cardioembolic origin, while the Stop Stroke Study/Causative Classification System (SSS/CCS) TOAST indicated that 34% were undetermined and 50% cardioembolic (p<0.01); 44% of these patients were classified as having a high embolic risk according to the IPEC/FIOCRUZ score. Among the undetermined causes, 83.3% fulfilled the criteria for embolic stroke of undetermined source (ESUS). The SSS/CCS TOAST etiological classification system was superior to the classical TOAST criteria in identifying a cardioembolic etiology in patients with ischemic stroke and Chagas disease. The IPEC/FIOCRUZ score did not correlate with the number of patients who were determined to have cardioembolic stroke etiologies. The current guidelines for stroke prevention should be reviewed in this population.

Reversal of dabigatran by idarucizumab: when and how?

ABSTRACTIntroduction: Anticoagulants are highly effective in reducing the risk of embolism in patients with atrial fibrillation and in the treatment of venous thromboembolism. However, interfering with the coagulation system increases the risk of bleeding. Non-vitamin K oral anticoagulants (NOACs) are associated with a reduced risk of major and life-threatening bleeding compared to warfarin, but the absence of a specific reversal agent has caused concern among clinicians.Areas covered: This article describes the indications for and practical use of idarucizumab, a specific reversal agent for the direct thrombin inhibitor dabigatran.Expert commentary: Each year, 3-5% of anticoagulated patients will experience major bleeding and about 10% will require invasive interventions. While most of these situations can be managed without the need for a reversal agent, the ability to promptly switch off anticoagulant activity is likely beneficial in severe bleeding situations and can help to avoid delays and improve safety in the management of patients requiring urgent procedures. Idarucizumab rapidly and completely reverses the anticoagulant effect of dabigatran in vitro, in healthy volunteers, and in patients presenting with severe bleeding or requiring urgent procedures. Further clinical data will help to understand the clinical impact of rapid reversal on the outcome of bleeding patients.