Background Atrial fibrillation (AF) is the supra-ventricular tachyarrhythmia mostly encountered in the clinical practice.While appearing silent or with a constellation of symptoms, it confers a 5-fold risk of stroke. Early detection is mandatory to establish the diagnosis and recommend anticoagulation. Besides the arrhythmia recognition through several tools, such as Holter ECG and loop recorders, it has been underlined that cardiac implantable electronic devices with an atrial lead can help in recognizing asymptomatic AF periods, also known as atrial high-rate episodes (AHREs). Materials and Methods 48 patients with AHRE detection at device telemetry checks were enrolled; implanted device were pacemakers (n=31, 64.8%); implantable cardioverter/defibrillators (ICD, n=8, 16.6%); cardiac resynchronization therapy devices with defibrillators (CRT-D, n=9, 18.5%). Male gender was predominant (40 vs. 8), age was > 65years, and mean CHA2DS2VASc was 4.2±2.8. Patients underwent ECG assessment in 6-month intervals (at baseline and during follow-up), MOntreal Cognitive Assessment test, and device interrogation for AHRE of duration >5 minutes and rate >175 beats per minute. Randomization to a direct oral anticoagulant (DOAC) or usual care (aspirin when needed or placebo) was provided in a blind fashion and maintained for the entire study observation until occurrence of overt AF, followed by exclusion from the study. Results We found that 13%-16% of patients with device-detected AHRE developed AF over a mean follow-up of 2.5 year (range 4.6±2.0). These cases were given oral anticoagulation since change of indication according to current guidelines. Most important comorbidities were coronary artery disease (n=18 patients, 36.73%); systemic hypertension (n=41, 83.67%); diabetes (n=13, 26.53%); dyslipidemia (n=23, 46.8%); heart failure (n=17, 35.4%). 30 patients were treated with beta-blockers(62.5%). 2 patients died for gastrointestinal bleeding. One patient was excluded for major bleeding after one month from the enrollment. Total AHREs duration was significantly lower in patients with pacemaker (14 hrs) compared to patients with CRT-D (17 hrs) and ICD (20 hrs, p<0.05). Conclusions The impact of AHREs was higher in patients affected by cardiac dysfunction and concomitant diseases; none of the patients enrolled in the study developed ischemic stroke; major bleedings were observed in both arms. Further studies are warranted for considering oral anticoagulation based on the sole device interrogation in the context of subclinical atrial fibrillation.
Hemorrhages represent one of the most frequent complications during TAVI. Their rapid recognition and a prompt treatment are necessary to avoid hemorrhagic shock, which can lead the patient to death in a short time. We report the case of a 79-year-old woman affected by severe and symptomatic aortic stenosis, who underwent TAVI in our Cath-lab. Through a right femoral echo-guided arterial access, implantation of a 26 mm self-expandable aortic bio-prosthesis and hemostasis in the site of puncture with 18F Manta vascular closure device were performed. At the end of the procedure, through radial artery, a femoral angiography was performed, showing an important leak of contrast medium upper the site of puncture, without any change in arterial pressure or heart rate. After echo-guided cannulation of left femoral artery with 8F sheath, implantation of endoprosthesis in the site of hemorrhage and hemostasis of left femoral artery with 8F AngioSeal VIP vascular closure device were performed. In cardiac intensive care unit (CICU) low dosage of vasoactive agents and blood were administered, guaranteeing a good arterial pressure. Computed tomography (CT) was performed after two days and confirmed the presence of a retroperitoneal hematoma, without active bleeding. After six days, the patient left CICU and was admitted to the cardiological ward, starting a gradual mobilization. However, after 48 hours she reported abdominal pain and became rapidly hypotensive, tachycardic and asthenic, requiring readmission in CICU. Serum exams showed low hemoglobin concentration, an abdominal CT was perfomed, showing an active bleeding from left femoral artery and a homolateral retroperitoneal hematoma. The patient was rapidly lead in the cath lab. Angiography confirmed the hemorrage and an endoprosthesis was successfully implanted in the left femoral artery. Blood and vasoactive agents were administered with a progressive improvement in hemodynamic and clinical conditions of the patients. Post-operative course was complicated by fever and empiric antiobiotic therapy was administered until blood culture revealed no bacterial growth. A third CT showed the stability of the hematomas and the absence of active bleeding, allowing hospital discharge of the patient. Vascular complications are frequent and sneaky during TAVI procedures. A prompt treatment is of paramount importance to prevent hemorrhagic shock. TAVI operators should have experience in the field of peripheral intervention for the management of vascular complications.
Background Hemodialysis sessions exert an acute impact on cardiac geometry and mechanics. The recent development of quantitative measurement of intracardiac fluid-dynamics offers a new opportinuty to better understand the fine changes in intracardiac cardiac hemodynamics associated with hemodialysis sessions. Our aim was to assess the impact of an hemodialytic session on intracardiac flow dynamics. Methods We included 26 consecutive patients on chronic hemodialysis in clinically stable phase. They underwent echocardiography including intracardiac fluid-dynamic analysis by Color Vector Flow Mapping (Hyperdoppler) before and after a single dialysis session. Patients with hemodynamically relevant valvular disease were excluded. A complete fluid-dynamics evaluation included the measurement of multiple parameters such asvortex area (VA); vortex length (VL); vortex depth (VD). Bland Altman Plot has been used to assess intra and inter-observer variability. Changes in fluidodynamics after dialysis sessions were tested using the Wilcoxon matched-pairs test. Results Mean Vortex Area (VA) (p=0.034), Vortex Depth (VD) (p=0.024) and Vortex Length (VL) (p=0.037) were significantly reduced after the dialysis session. A similar trend towards the reduction of Direct Flow (DF) parameter after the session was found, which was significantly larger for patients with larger baseline left ventricular (LV) end-diastolic diameter (r=0.446; p=0.037). On the other hand, mean Vortex Intensity (VI) was significanlty increased after dialysis (p=0.046). Among energy parameters, the intradialytic change in Kinetic Energy Fluctuation (KEF) (r=0.4; p=0.058) and Shear Stress Fluctuation (SSF) (r=0.435; p=0.038) were most closely correlated with intradialytic weigth change. Some fluid-dynamic parameters had similar trends of intradialytic change, with stonger correlations among geometric parameters. Delta changes in VA were closely related to changes in VI (p<0.001) or LV (p<0.001). VI was also correlated with VL (p<0.001) and with Kinetc Energy Dissipation (KED) (p=0.030), which was also correlated with VL (p=0.044). KEF was correlated with KED (p=0.001) and SSF (p=0.022). Finally, chenges in SSF were correlated with those in Flow Force Parameter (p=0.033) and Flow Force Angle (p=0.034), that were very closely correlated each other (p<0.001). Discussion This is the first study assessing the impact of hemodialytic sessions on intracardiac flow dynamics. Measurement of hyperdoppler indices on hemodialysis chair was feasible and reliable in the whole population. Our results uncovered quantitative chenages of echocardiographic parameters of vortex geometry and energy during hemodialysis.
Background in-stent restenosis remains a significant clinical problem for which optimal treatment is under debate. Intravascular lithotripsy (IVL) is mostly used for safe and effective treatment of de novo coronary calcifications, while the use of this technology to support bailout procedures, including stent under-expansion, is still off-label. One of the advantages of lithotripsy is the possible use after stent deployment. Case presentation a 66-year-old male patient was admitted to our Institution due to a medically refractory angina and a coronary computed tomography (CCT) detecting three vessel disease with multiple critical stenosis. The patient had multiple comorbidities including history of hypertension, dyslipidemia, type 2 diabetes and multiple myocardial rivascularization. In 2003 he underwent coronary artery by-pass (CABG) with left internal mammal artery (LIMA) to left anterior descending (LAD) artery and free saphenous vein graft (VG) to the ramus intermedius (RI). In 2009 the patient underwent percutaneous coronary intervention (PCI) of the right coronary artery (RCA) with the implantation of a stent at the central segment, and a second stent at the crux cordis. For recurrent in-stent restenosis of the stent previously implanted at the central segment the patient was treated in 2013 with percutaneous balloon angioplasty (POBA) and in 2017 with the implantation of another drug eluting stent (Resolute Onyx, Medtronic, Santa Rosa, California) overlapping the proximal part of the scaffold. Coronary angiography revealed, a severe coronary artery disease with 80% stenosis of distal left main. The LAD was occluded at the middle segment and the ramus presented 99% stenosis at the proximal segment. The RCA had a diffuse severe in-stent restenosis involving the Resolute Onyx stent. Therefore, the operator decided to treat the restenosis with a direct stenting (Xience, Abbott Vascular Santa Clara, USA), but he was unaware of the fact that there was already an Onyx stent that was barely visible. After implantation, an inadequate expansion of the stents was observed (Figura 1A-B), which persisted despite post-dilation with non-compliant balloon (NCB) at high-pressure (Figure 1C). Given the persistence of stents under-expansion, it was decided to perform bail-out intravascular lithotripsy (IVL) therapy with a Shockwave balloon catheter (Figure 2A). The stent was then post-dilated with a NCB (Figure 2B). The final angiographic image and intravascular ultrasound (IVUS) showed an optimal stent expansion (Figure 3). Conclusion intravascular lithotripsy could be used to treat undilatable stent-in-stent restenosis. Of interest, the case presented demonstrated, for the first time, the possible use of IVL in 2-stent layers, with an optima final stent expansion.
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