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Atrial fibrillation (AF) is the most common sustained arrhythmia worldwide, and its prevalence is expanding owing to advanced age and higher rates of chronic heart disease.1 The standard treatment for stroke reduction in patients with nonvalvular AF is anticoagulation. However, alternative therapy may be advisable in a certain subset of patients, owing to either previous failure of oral anticoagulation or presence of contraindications to anticoagulation.1 The left atrial appendage has been identified as the primary site of thrombus formation in more than 90% of patients with AF.2 The PLAATO3 study in 2002 was the first to demonstrate the use of a device to occlude the left atrial appendage for stroke reduction in patients with AF and provided the fundamental ground for future development in that field. Since its publication several percutaneous left atrial appendage occlusion (LAAO) devices have been developed and tested, including the Watchman, Amulet, and LARIAT, among others.4 The Watchman (Boston Scientific, Marlborough, MA) is the most extensively studied and is the only FDA-approved percutaneous LAAO device currently available in the United States.5 More than 100,000 devices have been implanted since it gained its approval in 2015.6 LAAO devices are approved for use in patients with nonvalvular AF who are not candidates for long-term coagulation with comparable outcomes in terms of risk of stroke, bleeding, and cardiovascular complications.7,8 Percutaneous LAAO has also been used in patients with recurrent cardioembolic stroke while on oral anticoagulation.9 Implantation of any intracardiac device carries the risk of device thrombosis and infection. However, risk of LAAO device infection is low owing to complete endothelialization. Currently, there are no guidelines regarding prophylaxis of bacterial endocarditis with Watchman device placement. Similarly, management of LAAO device infections remains uncertain, with no clear guidelines. We report a case of a 74-year-old man with Watchman device infection that was managed conservatively with a long course of antibiotics without the need for surgical extraction. Key Teaching Points • Left atrial appendage occlusion devices, despite endothelialization, can carry a late risk of device-related infective endocarditis. • Review of literature suggests role of transesophageal echocardiogram in the diagnosis of left atrial appendage occlusion device infections. • While surgical extraction has been previously described, we report a case of successful antibiotic suppression at 6-month follow-up.

Outcomes from randomized controlled trials (RCTs) inform the latest recommendations on percutaneous coronary intervention (PCI) management of a short period of oral anticoagulation (OAC), a P2YWe examined and summarized the outcomes of bleeding and major adverse cardiac events (MACEs) from RCTs and meta-analyses, published between 2013 and 2022, comparing therapy with OAC and a P2YData comparing dual therapy with OAC and a P2YThe addition of aspirin to OAC and a P2Y

Abstract: In-stent restenosis (ISR) is a recognized complication following percutaneous coronary intervention in which the luminal diameter is narrowed through neointimal hyperplasia and vessel remodeling. Although rates of ISR have decreased in most recent years owing to newer generation drug-eluting stents, thinner struts, and better intravascular imaging modalities, ISR remains a prevalent dilemma that proves to be challenging to manage. Several factors have been proposed to contribute to ISR formation, including mechanical stent characteristics, technical factors during the coronary intervention, and biological aspects of drug-eluting stents. Presentation of ISR can range from asymptomatic to late myocardial infarction and could be difficult to differentiate from acute thrombus formation. No definite guidelines are present on the management of ISR. In this review, we will discuss the mechanisms underlying ISR and provide insight into patient-related and procedural risk factors contributing to ISR, in addition to highlighting common treatment approaches utilized in the management of ISR.

Abstract: Cardiotoxicity from chemotherapy regimens has been long reported. However, the understanding of cardiac side effects of biological therapies is rapidly evolving. With cancer patients achieving higher life expectancy due to the use of personalized medicine and novel targeted anticancer agents, the occurrence of cardiotoxicity is becoming more significant. Novel biological therapies include anti-HER2 antibodies, tyrosine kinase inhibitors, bruton kinase inhibitors, antivascular endothelial growth factors, proteasome inhibitors, immunomodulator drugs, and immune checkpoint inhibitors. Potential cardiovascular toxicities linked to these anticancer agents include hypertension, arrhythmias, QT prolongation, myocardial ischemia and infarction, left ventricular dysfunction, congestive heart failure, and thromboembolism. Cardiac biomarkers, electrocardiography, echocardiography and magnetic resonance imaging are common diagnostic modalities used for early detection of these complications and timely intervention. This review discusses the various types of cardiotoxicities caused by novel anticancer biologic agents, their molecular and pathophysiological mechanisms, risk factors, and diagnostic and management strategies that can be used to prevent, minimize, and treat them.

Takotsubo cardiomyopathy (TCM) is characteristically associated with left ventricular apical ballooning and regional wall motion abnormalities that predispose to the formation of left ventricular (LV) thrombi and subsequent thromboembolic events (VTE). There is limited data about the risk factors of developing stroke in the absence of LV thrombi in patients with TCM. Identify risk factors that predispose patients with TCM to develop VTE and stroke. We retrospectively reviewed all patients admitted with a primary diagnosis of stress induced or Takotsubo cardiomyopathy at a large tertiary care center from 2005 to 2019. Patients who met the echocardiographic criteria of TCM, had resolution of WMA on repeat echocardiogram, did not have coronary artery disease if angiography was performed and survived for3 months after index presentation were included in the analysis. Patients were followed for up to a period of 1 year. Multivariate analysis was performed to identify predictors of thromboembolism. Among the 400 patients who presented with TCM, 146 patients were included in the analysis. A total of 13 patients (8.9%) had documented thromboembolic events. Patients with VTE more often had Atrial fibrillation (30.8% vs 6.8%, P = 0.018), higher LV mass (224.5g vs 184g, P = 0.04), lower EF on presentation (31.5% vs 40%, P = 0.011) and were less likely to have undergone coronary angiography following diagnosis (23.1% vs 54.9%, P = 0.04). On multivariate analysis, atrial fibrillation (OR 9.15, CI 1.15-72.70) and low ejection fraction on admission (OR 0.88, CI 0.81-0.97) were independent risk factors for the development of VTE. Atrial fibrillation and low ejection fraction on presentation were associated with higher risk of developing thromboembolic events in patients with TCM.