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Europace : European Pacing,... May 2024Blood stasis is crucial in developing left atrial (LA) thrombi. LA appendage peak flow velocity (LAAFV) is a quantitative parameter for estimating thromboembolic risk.... (Observational Study)
Observational Study
Impact of left atrial appendage flow velocity on thrombus resolution and clinical outcomes in patients with atrial fibrillation and silent left atrial thrombi: insights from the LAT study.
AIMS
Blood stasis is crucial in developing left atrial (LA) thrombi. LA appendage peak flow velocity (LAAFV) is a quantitative parameter for estimating thromboembolic risk. However, its impact on LA thrombus resolution and clinical outcomes remains unclear.
METHODS AND RESULTS
The LAT study was a multicentre observational study investigating patients with atrial fibrillation (AF) and silent LA thrombi detected by transoesophageal echocardiography (TEE). Among 17 436 TEE procedures for patients with AF, 297 patients (1.7%) had silent LA thrombi. Excluding patients without follow-up examinations, we enrolled 169 whose baseline LAAFV was available. Oral anticoagulation use increased from 85.7% at baseline to 97.0% at the final follow-up (P < 0.001). During 1 year, LA thrombus resolution was confirmed in 130 (76.9%) patients within 76 (34-138) days. Conversely, 26 had residual LA thrombi, 8 had thromboembolisms, and 5 required surgical removal. These patients with failed thrombus resolution had lower baseline LAAFV than those with successful resolution (18.0 [15.8-22.0] vs. 22.2 [17.0-35.0], P = 0.003). Despite limited predictive power (area under the curve, 0.659; P = 0.001), LAAFV ≤ 20.0 cm/s (best cut-off) significantly predicted failed LA thrombus resolution, even after adjusting for potential confounders (odds ratio, 2.72; 95% confidence interval, 1.22-6.09; P = 0.015). The incidence of adverse outcomes including ischaemic stroke/systemic embolism, major bleeding, or all-cause death was significantly higher in patients with reduced LAAFV than in those with preserved LAAFV (28.4% vs. 11.6%, log-rank P = 0.005).
CONCLUSION
Failed LA thrombus resolution was not rare in patients with AF and silent LA thrombi. Reduced LAAFV was associated with failed LA thrombus resolution and adverse clinical outcomes.
Topics: Humans; Atrial Fibrillation; Male; Female; Atrial Appendage; Aged; Thrombosis; Echocardiography, Transesophageal; Middle Aged; Blood Flow Velocity; Anticoagulants; Risk Factors; Treatment Outcome; Asymptomatic Diseases; Time Factors; Heart Diseases; Thromboembolism; Aged, 80 and over; Atrial Function, Left
PubMed: 38691672
DOI: 10.1093/europace/euae120 -
Clinical Case Reports May 2024Besides thromboses, it's crucial to also consider the rare possibility of tumors like papillary fibroelastomas when evaluating worsening cardiopulmonary symptoms in...
KEY CLINICAL MESSAGE
Besides thromboses, it's crucial to also consider the rare possibility of tumors like papillary fibroelastomas when evaluating worsening cardiopulmonary symptoms in patients with severe rheumatic mitral stenosis and atrial fibrillation.
ABSTRACT
Cardiac papillary fibroelastoma is a rare and benign endocardial tumor typically found on the aortic valve. The simultaneous occurrence of rheumatic heart disease affecting the mitral valve and papillary fibroelastoma on the aortic valve is infrequent, with limited documented instances. This unique case can enhance our understanding of the clinical presentation, diagnostic approaches, management options, and implications for patient outcomes in these two conditions. We present the case of a 47-year-old woman who was admitted to the hospital due to worsening dyspnea and fatigue, during which time she discovered an aortic valve papillary fibroelastoma. Further investigations revealed two thrombi in her left atrium and left atrial appendage, along with significant rheumatic mitral valve stenosis. The patient underwent thrombectomy, mitral valve replacement, and valve-sparing aortic valve tumor resection. Following surgery, the patient's recovery was unremarkable. This case report emphasizes the need for a comprehensive evaluation in patients with rheumatic mitral stenosis, considering all possible etiologies. While thrombi are typical in mitral stenosis and atrial fibrillation, the rare presence of tumors like papillary fibroelastomas should be recognized, underscoring the importance of further assessment when suspicion arises. Importantly, individuals with asymptomatic cardiac papillary fibroelastomas should undergo surgical treatment to minimize the potential risk of tumoral embolization.
PubMed: 38689685
DOI: 10.1002/ccr3.8845 -
NPJ Digital Medicine Apr 2024Integrating video clips in the discharge process may enhance patients' understanding and awareness of their condition. To determine the effect of video clip-integrated...
Integrating video clips in the discharge process may enhance patients' understanding and awareness of their condition. To determine the effect of video clip-integrated discharge discussion on patient comprehension of atrial fibrillation (AF) and deep vein thrombosis (DVT), and their main complications (stroke and pulmonary embolism), we designed a multicentre, pragmatic, parallel groups, randomised clinical trial, that was conducted at two Emergency Units in Italy. A convenience sample of 144 adult patients (or their caregivers) discharged home with either AF or DVT were randomised to receive standard verbal instructions (control) or video clip-integrated doctor-patient discharge discussion. Participants were guided by the discharging physician through the clip. Mean score for primary outcome (knowledge of the diagnosis and its potential complication) (range 0-18) was 5.87 (95% CI, 5.02-6.72] in the control group and 8.28 (95% CI, 7.27-9.31) in the intervention group (mean difference, -2.41; 95% CI, -3.73 to -1.09; p < 0.001). Among secondary outcomes, mean score for knowledge of the prescribed therapy (range 0-6) was 2.98 (95% CI, 2.57-3.39) in the control group and 3.20 (95% CI, 2.73-3.67) in the study group (mean difference, -0.22; 95% CI, -0.84 to 0.39). Mean score for satisfaction (range 0-12) was 7.34 (95% CI, 6.45-8.23) in the control arm and 7.97 (95% CI, 7.15-8.78) in the intervention arm (mean difference, -0.625; 95% CI -1.82 to 0.57). Initiation rate of newly prescribed anticoagulants was 80% (36/45) in the control group and 90.2% (46/51) in the intervention group. Among 109 patients reached at a median follow up of 21 (IQR 16-28) months, 5.55% (3/54) in the control arm and 1.82% (1/55) in the intervention arm had developed stroke or pulmonary embolism. In this trial, video clip-integrated doctor-patient discharge discussion, improved participants comprehension of AF and DVT and their main complications. Physicians should consider integrating these inexpensive tools during the discharge process of patients with AF or DVT.Trial Registration: ClinicalTrials.gov Identifier "NCT03734406".
PubMed: 38688958
DOI: 10.1038/s41746-024-01107-7 -
Annals of Noninvasive Electrocardiology... May 2024To avoid causing a thromboembolic event in patients undergoing catheter ablation for atrial fibrillation (AF), patients are treated with oral anticoagulants (OAC) prior...
BACKGROUND
To avoid causing a thromboembolic event in patients undergoing catheter ablation for atrial fibrillation (AF), patients are treated with oral anticoagulants (OAC) prior to the procedure. Despite being on anticoagulants, some patients develop a left atrial appendage thrombus (LAAT). To exclude the presence of LAAT, transesophageal ultrasound (TEE) is performed in all patients prior to the procedure. We hypothesized continuous treatment with anticoagulants would result in a low prevalence of LAAT, in patients with low CHADS-VASc score.
METHOD
Medical records of consecutive patients planned to undergo AF ablation at Lund University Hospital during the years 2018-2020 were reviewed retrospectively. Examination protocols from transesophageal and transthoracic echocardiography were examined for LAAT and spontaneous echo contrast (SEC). Patients with LAAT and SEC were compared to patients without using Mann-Whitney U-test and Pearson Chi-squared analysis to test for correlation.
RESULTS
Of 553 patients, three patients (0.54%) had LAAT, and 18 (3.25%) had spontaneous contrast (SEC). Patients with LAAT or SEC had a higher CHADS-VASc score, more often presented in AF at TEE and less often had a normal sized left atrium.
CONCLUSION
There is a low prevalence of LAAT and SEC in patients with AF scheduled for pulmonary vein isolation. Patients with SEC or LAAT tend to have paroxysmal AF less often and more often presented in AF at admission. No patients with CHADS-VASc 0, paroxysmal AF, normal sized left atrium and sinus rhythm at TEE were found to have LAAT or SEC.
Topics: Humans; Echocardiography, Transesophageal; Atrial Appendage; Male; Female; Pulmonary Veins; Atrial Fibrillation; Catheter Ablation; Retrospective Studies; Thrombosis; Prevalence; Middle Aged; Aged; Anticoagulants; Heart Diseases
PubMed: 38682420
DOI: 10.1111/anec.13119 -
Frontiers in Medicine 2024There is still a controversy about the superiority of liposomal bupivacaine (LB) over traditional local anesthetics in postoperative analgesia after thoracic surgery....
Effect of liposomal bupivacaine for preoperative erector spinae plane block on postoperative pain following video-assisted thoracoscopic lung surgery: a protocol for a multicenter, randomized, double-blind, clinical trial.
BACKGROUND
There is still a controversy about the superiority of liposomal bupivacaine (LB) over traditional local anesthetics in postoperative analgesia after thoracic surgery. This study aims to determine the effect of LB versus bupivacaine hydrochloride (HCl) for preoperative ultrasound-guided erector spinae plane block (ESPB) on postoperative acute and chronic pain in patients undergoing video-assisted thoracoscopic lung surgery.
METHODS
This multicenter, randomized, double-blind, controlled trial will include 272 adult patients scheduled for elective video-assisted thoracoscopic lung surgery. Patients will be randomly assigned, 1:1 and stratified by site, to the liposomal bupivacaine (LB) group or the bupivacaine (BUPI) HCl group. All patients will receive ultrasound-guided ESPB with either LB or bupivacaine HCl before surgery and patient-controlled intravenous analgesia (PCIA) as rescue analgesia after surgery. The numeric rating scale (NRS) score will be assessed after surgery. The primary outcome is the area under the curve of pain scores at rest for 0-72 h postoperatively. The secondary outcomes include the total amount of opioid rescue analgesics through 0-72 h postoperatively, time to the first press on the PCIA device as rescue analgesia, the area under the curve of pain scores on activity for 0-72 h postoperatively, NRS scores at rest and on activity at different time points during the 0-72 h postoperative period, Quality of Recovery 15 scores at 72 h after surgery, and NRS scores on activity on postsurgical day 14 and postsurgical 3 months. Adverse events after the surgery are followed up to the postsurgical day 7, including postoperative nausea and vomiting, fever, constipation, dizziness, headache, insomnia, itching, prolonged chest tube leakage, new-onset atrial fibrillation, severe ventricular arrhythmia, deep venous thrombosis, pulmonary embolism, pulmonary atelectasis, cardiac arrest, ileus, urinary retention, chylothorax, pneumothorax, and organ failure. Analyzes will be performed first according to the intention to treat principle and second with the per-protocol analysis.
DISCUSSION
We hypothesize that LB for preoperative ultrasound-guided ESPB would be more effective than bupivacaine HCl in reducing postoperative pain in video-assisted thoracoscopic lung surgery. Our results will contribute to the optimization of postoperative analgesia regimens for patients undergoing video-assisted thoracoscopic lung surgery.http://www.chictr.org.cn, identifier ChiCTR2300074852.
PubMed: 38681056
DOI: 10.3389/fmed.2024.1359878 -
International Journal of Molecular... Apr 2024Accurate etiologic diagnosis provides an appropriate secondary prevention and better prognosis in ischemic stroke (IS) patients; still, 45% of IS are cryptogenic, urging...
Accurate etiologic diagnosis provides an appropriate secondary prevention and better prognosis in ischemic stroke (IS) patients; still, 45% of IS are cryptogenic, urging us to enhance diagnostic precision. We have studied the transcriptomic content of plasma extracellular vesicles (EVs) ( = 21) to identify potential biomarkers of IS etiologies. The proteins encoded by the selected genes were measured in the sera of IS patients ( = 114) and in hypertensive patients with ( = 78) and without atrial fibrillation (AF) ( = 20). IGFBP-2, the most promising candidate, was studied using immunohistochemistry in the IS thrombi ( = 23) and atrium of AF patients ( = 13). In vitro, the IGFBP-2 blockade was analyzed using thromboelastometry and endothelial cell cultures. We identified 745 differentially expressed genes among EVs of cardioembolic, atherothrombotic, and ESUS groups. From these, IGFBP-2 (cutoff > 247.6 ng/mL) emerged as a potential circulating biomarker of embolic IS [OR = 8.70 (1.84-41.13) = 0.003], which was increased in patients with AF vs. controls ( < 0.001) and was augmented in cardioembolic vs. atherothrombotic thrombi ( < 0.01). Ex vivo, the blockage of IGFBP-2 reduced clot firmness ( < 0.01) and lysis time ( < 0.001) and in vitro, diminished endothelial permeability ( < 0.05) and transmigration ( = 0.06). IGFBP-2 could be a biomarker of embolic IS and a new therapeutic target involved in clot formation and endothelial dysfunction.
Topics: Humans; Extracellular Vesicles; Biomarkers; Male; Female; Aged; Thrombosis; Ischemic Stroke; Insulin-Like Growth Factor Binding Protein 2; Middle Aged; Gene Expression Profiling; Transcriptome; Atrial Fibrillation
PubMed: 38673963
DOI: 10.3390/ijms25084379 -
Life (Basel, Switzerland) Apr 2024Lipomatous hypertrophy of the interatrial septum (LHIAS) represents a benign proliferation of lipoid cells at the level of the interatrial septum (IAS) inducing an...
Lipomatous hypertrophy of the interatrial septum (LHIAS) represents a benign proliferation of lipoid cells at the level of the interatrial septum (IAS) inducing an important thickening of this structure. It respects the fossa ovalis (FO) region, having a typical "hourglass" echocardiographic appearance. There are certain cases though, with unusual appearances and/or with associated pathologies that may induce similar lesions in the heart, in which the differential diagnosis cannot be guaranteed using only the standard methods. The final diagnosis has important implications in these patients' treatment plan. In this paper, we present an unusual case of a female patient undergoing chemotherapy for lung carcinoma, suspected of right atrial thrombosis/metastasis. As the diagnosis was unclear after transthoracic echocardiography (TTE), inducing the suspicion of an IAS mass with atrial wall infiltration, bi- and tridimensional transesophageal echocardiography (TOE) was performed, revealing a severely and homogenously hypertrophied IAS respecting the FO, but lacking a clear visualization of the atrial wall. The diagnosis of LHIAS was established by cardiac magnetic resonance (CMR) that certified the adipose nature of the structure, excluding the need for invasive investigations and/or treatment options. Multimodality imaging is very important for the clinician in adopting the best management plan for each individual patient.
PubMed: 38672784
DOI: 10.3390/life14040514 -
Medicine Apr 2024To explore the anticoagulant effect and safety of utilizing different doses of rivaroxaban for the treatment of patients with atrial fibrillation (AF) in the real world.... (Observational Study)
Observational Study
To explore the anticoagulant effect and safety of utilizing different doses of rivaroxaban for the treatment of patients with atrial fibrillation (AF) in the real world. A retrospective case-control analysis was performed by applying the hospital database, and 3595 patients with non-valvular atrial fibrillation (NVAF) who were hospitalized and taking rivaroxaban at Wuhan Asia Heart Hospital and Wuhan Asia General Hospital from March 2018 to December 2021 were included in the study, and were divided into the rivaroxaban 10 mg and 15 mg groups according to the daily prescribed dose, of which 443 cases were in the 10 mg group and 3152 cases were in the 15 mg group. The patients were followed up regularly, and the incidence of thrombotic events, bleeding events and all-cause deaths were recorded and compared between the 2 groups, and logistic regression was applied to analyze the influencing factors for the occurrence of adverse events. Comparison of the incidence of thrombosis, bleeding and all-cause death between the 2 groups of patients showed that the 10 mg group was higher than the 15 mg group, but the difference was not statistically significant (χ2 = 0.36, 3.26, 1.99, all P > .05); the incidence of total adverse events between the 2 groups of patients was higher in the 10 mg group than in the 15 mg group, with a statistically significant difference (χ2 = 4.53, P = .033); multifactorial logistic regression results showed that age [OR (95% CI) = 1.02 (1.00-1.04)], diabetes mellitus [OR (95% CI) = 1.69 (1.09-2.62)], D-dimer level [OR (95% CI) = 1.06 (1.00-1.11)] and persistent AF [OR (95% CI) = 1.54 (1.03-2.31)] were risk factors for adverse events (P < .05). In the real world, Asian clinicians recommend rivaroxaban 10 mg once daily for NVAF patients for a variety of reasons; however, this dose is not superior or even inferior to the 15 mg group in terms of effectiveness and safety. Advanced age, elevated D-dimer levels, history of diabetes mellitus, and persistent AF are risk factors for adverse events, and the optimal dosage of rivaroxaban or optimal anticoagulation strategy for Asian patients with nonvalvular AF requires further study.
Topics: Humans; Rivaroxaban; Atrial Fibrillation; Male; Female; Retrospective Studies; Aged; Factor Xa Inhibitors; Middle Aged; Hemorrhage; Case-Control Studies; Dose-Response Relationship, Drug; Incidence; Thrombosis; Risk Factors; Aged, 80 and over
PubMed: 38669357
DOI: 10.1097/MD.0000000000038053 -
European Heart Journal. Case Reports Apr 2024Anomalous aortic origin of a coronary artery from the opposite sinus is a rare congenital abnormality that may be encountered during primary percutaneous coronary...
BACKGROUND
Anomalous aortic origin of a coronary artery from the opposite sinus is a rare congenital abnormality that may be encountered during primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI).
CASE SUMMARY
A 65-year-old man presented with chest pain and signs of heart failure. Electrocardiogram demonstrated atrial fibrillation with ST elevation in the high lateral leads, and he was taken emergently to the cardiac catheterization laboratory for primary PCI. Coronary angiography identified the culprit to be an occluded anomalous left main coronary artery (LMCA) arising from the right coronary cusp, and primary PCI was successfully performed in the LMCA and the left anterior descending artery (LAD). Computed tomography angiography confirmed a benign retroaortic course of the anomalous LMCA with no additional high-risk features, as well as a new left atrial appendage thrombus. He subsequently developed deep venous thrombosis, acute pulmonary embolism, and acute kidney injury secondary to renal artery embolism with associated infarction. Workup for patent foramen ovale and thrombophilia were negative, and he was discharged in a stable condition. At 2-month follow-up, he was asymptomatic with no evidence of myocardial ischaemia on stress cardiac magnetic resonance imaging.
DISCUSSION
We present the first reported case of an occluded anomalous LMCA arising from the right coronary sinus in a patient presenting with STEMI. Rapid recognition of this congenital anomaly and selection of an appropriate guide catheter were keys to achieving timely reperfusion and a good outcome in this case.
PubMed: 38665427
DOI: 10.1093/ehjcr/ytae192 -
Research and Practice in Thrombosis and... Mar 2024A State of the Art lecture titled "Cancer and Arterial Thrombosis: Therapeutic Options" was presented at the International Society on Thrombosis and Haemostasis Congress...
A State of the Art lecture titled "Cancer and Arterial Thrombosis: Therapeutic Options" was presented at the International Society on Thrombosis and Haemostasis Congress in 2023. This State of the Art review delves into the complex relationship between cancer and arterial thromboembolism (ATE), encompassing acute coronary syndrome, ischemic strokes, and peripheral arterial disease. The burden of cancer-associated ATE is not well defined, but studies indicate elevated risks, particularly in the 6 months after a cancer diagnosis. Incidence varies among cancer subtypes, with lung cancer displaying the highest rates. Additionally, the pathophysiology of cancer-associated ATE involves a multifaceted interplay of cancer-induced hypercoagulopathy, cancer therapy-related thrombosis, and personal risk factor contributors. ATEs are clinically heterogeneous and in the context of cancer have particular mechanistic differences compared with ATE patients without cancer. This requires modifications in approach and tailored management considerations. Specific etiologies contributing to ATE, such as coronary vasospasm and non-bacterial-thrombotic endocarditis, need to be considered. The diagnosis of cancer alone usually does not contraindicate patients to standard guideline-based therapies for the management of ATE, although nuances in treatment may need to be considered in light of the underlying cancer. Atrial fibrillation in cancer patients further complicates the thrombotic landscape. Cancer patients with atrial fibrillation are at a higher risk of ATE, necessitating careful consideration of anticoagulation therapy as clinical benefits and bleeding risks need to be weighed. ATE may also be a presenting sign of underlying malignancy, which requires increased awareness and focused clinical evaluation for cancer in selected cases. Finally, we summarize relevant new data on this topic presented during the 2023 International Society on Thrombosis and Haemostasis Congress.
PubMed: 38660456
DOI: 10.1016/j.rpth.2024.102393