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Background Data on Device-related Thrombus (DRT) after left atrial appendage closure (LAAC) remain scarce. This study aimed to investigate risk factors for DRT from centers reporting to the EUROC-DRT registry. Methods We included 537 patients (112 with DRT and 425 without DRT) who had undergone LAAC between 12/2008 and 04/2019. Baseline and implantation characteristics, anti-thrombotic treatment and clinical outcomes were compared between both groups in uni- and multivariate analyses. Additional propensity-score matching (PSM) was conducted to focus on the role of implantation characteristics. Results Patients with DRT showed higher rates of previous stroke/transient ischemic attack (TIA) (49.1% vs. 34.7%, p < 0.01), spontaneous echocardiographic contrast (SEC) (44.9% vs. 27.7%, p < 0.01) and lower left atrial appendage (LAA) peak emptying velocity (35.4 +/- 18.5 vs. 42.4 +/- 18.0 cm/s, p= 0.02). Occluders implanted in DRT patients were larger (25.5 +/- 3.8 vs. 24.6 +/- 3.5 mm, p =0.03) and implanted deeper in the LAA (mean depth: 7.6 +/- 4.7 vs. 5.7 +/- 4.7 mm, p

Background As numbers and complexity of percutaneous coronary interventions are constantly increasing, optimal radiation protection is required to ensure operator safety. Suspended radiation protection systems (SRPS) and protective scatter radiation absorbing drapes (PAD) are novel methods to mitigate fluoroscopic scattered radiation exposure. The aim of the study was to investigate the effectiveness regarding radiation protection of a SRPS and a PAD in comparison with conventional protection. Methods A total of 229 cardiac catheterization procedures with SRPS (N = 73), PAD (N = 82) and standard radiation protection (N = 74) were prospectively included. Real-time dosimeter data were collected from the first operator and the assistant. Endpoints were the cumulative operator exposure relative to the dose area product [standardized operator exposure (SOE)] for the first operator and the assistant.Results For the first operator, the SRPS and the PAD significantly decreased the overall SOE compared to conventional shielding by 93.9% and 66.4%, respectively (P < 0.001). The protective effect of the SRPS was significantly higher compared to the PAD (P < 0.001). For the assistant, the SRPS and the PAD provided a not statistically significant reduction compared to conventional shielding in the overall SOE by 38.0% and 30.6%, respectively. Conclusions The SRPS and the PAD enhance radiation protection significantly compared to conventional protection. In most clinical scenarios, the protective effect of SRPS is significantly higher than the additional protection provided by the PAD., Clinical Research in Cardiology, 112 (5), ISSN:1861-0692, ISSN:1861-0684

Background Atrial fibrillation (AF) and chronic kidney disease (CKD) often coexist and share an increased risk of thromboembolic events. CKD concomitantly contributes to several pathophysiological changes predisposing towards a pro-haemorrhagic state. Objective To evaluate the impact of kidney function on peri-procedural complications and clinical outcomes in AF patients undergoing left atrial appendage occlusion (LAAO) with a Watchman device. Methods 2124 consecutive AF patients undergoing Watchman implantation at 8 different centers were categorized into CKD stage 1+2 (n=1089), CKD stage 3 (n=796), CKD stage 4 (n=170), CKD stage 5 (n=69) based on the estimated glomerular filtration rate at baseline. The primary efficacy endpoint included a composite of cardiovascular (CV) mortality, stroke, transient ischemic attack, peripheral thromboembolism (TE), and major bleeding. Results A non-significant higher incidence of major peri-procedural adverse events (1.7% vs. 2.3% vs. 4.1% vs. 4.3%) was observed with worsening baseline kidney function (p=0.14). The mean follow-up period was 13 ± 7 months [2226 patient-years (PY)]. In comparison to CKD stage 1+2 as a reference, the incidence of the primary endpoint was significantly higher in CKD stage 3 (log-rank p-value= 0.04), CKD stage 4 (log-rank p-value= 0.01), and CKD stage 5 (log-rank p-value= 0.001). A non-significant increase in event rates for stroke/TIA and clinically relevant bleeding was observed among the four groups. LAAO led to a TE risk reduction of 72%, 66%, 62%, and 41% in each group. The relative risk reduction in the incidence of major bleeding was 58%, 44%, 51%, and 52%, respectively. Conclusion Patients with moderate-to-severe CKD had a higher incidence of the primary composite endpoint. The relative risk reduction in the incidence of TE and major bleeding was consistent across CKD groups, irrespective of the very different risk profiles at baseline.

Despite maturing experience, transseptal puncture (TSP) remains a challenging part of percutaneous left atrial appendage closure (LAAC) and has inherent risks and safety concerns in accessing the left atrium (LA). The VersaCross radiofrequency (RF) system (Baylis Medical), a new RF-tipped pigtail wire-based TSP system, may facilitate LA access by serving as an exchange support wire once access is achieved. We retrospectively compared TSP safety and procedural efficiency in 10 consecutive LAAC cases using the VersaCross RF system to 10 cases using the conventional BRK1-XS mechanical needle (Abbott Vascular). The safety and time from femoral access to delivery of the device sheath were compared to the conventional workflow using BRK1-XS/SL1. We included consecutive 20 cases between July 2019 and November 2019 (12 with WATCHMAN (Boston Scientific, Natick, MA) and 8 with Amulet (St. Jude Medical, St Paul, MN)). Baseline patient characteristics and procedural details were similar in both groups (VersaCross RF system vs. conventional BRK1-XS mechanical needle). All cases were completed successfully with no procedural or in-hospital complications. VersaCross reduced time from femoral access to TSP [4.1 ± 2.5 min vs. 8.4 ± 4.0 min (p = 0.009)] and time from femoral access to delivery sheath access into LA [6.7 ± 2.4 min vs. 13.4 ± 5.4 min (p = 0.002)] compared to BRK1-XS. Combining a starter wire, transseptal needle and exchange guidewire in the VersaCross RF system enabled faster LA access, which potentially leads to efficient workflow. Further investigation with larger sample size is warranted to corroborate our findings.

Percutaneous left atrial appendage closure is increasingly performed for stroke prevention for patients with nonvalvular atrial fibrillation with contraindications to oral anticoagulation. The success and complication rates with left atrial appendage closure have dramatically improved with maturing experience, growing procedural familiarity, and preprocedural planning. Multimodality imaging involving cardiac computer tomography angiography, transesophageal echocardiography, or intracardiac echocardiography in conjunction with fluoroscopy has improved the efficacy, procedural success, and safety of left atrial appendage closure in recent years. Proceduralists need to familiarize themselves with the various modalities and understand their complimentary roles and their limitations.

PURPOSE: Cardiac computed tomography angiography (CCTA) is increasingly used for device surveillance after left atrial appendage closure (LAAC). While CT protocols with delayed scans are useful to diagnose thrombus in the LAA, an optimal protocol for post-procedural CCTA has not been established. Therefore, we assessed the role of delayed versus early scans for device surveillance. METHODS: We retrospectively reviewed patients who underwent LAAC at Vancouver General Hospital who had follow-up CCTAs using standard (early) and delayed scans. Scans were performed on Toshiba 320-detector (Aquilion ONE). Image quality was interpreted by 2 independent observers for anatomy, LAA contrast patency, and device-related thrombus (DRT) using VitreaWorkstation(TM). A Likert scale of 1–5 was used (1= poor quality, 5= excellent) for assessment. RESULTS: We included 27 consecutive LAAC patients (9 Amplatzer, 18 WATCHMAN) with mean age 76.0±7.7 years, mean CHADS(2) score 2.8±1.3, CHA(2)DS(2)-VASc score 4.4±1.6 and HAS-BLED score 3.4±1.0. Subjective quality assessments by both reviewers favored early scans for assessment of anatomy (reviewer 1: 4.63±0.63 [early] vs. 1.74±0.71 [delayed]; reviewer 2: 4.63±0.63 [early] vs. 1.89±0.64 [delayed]) and DRT (reviewer 1: 4.78±0.42 [early] vs. 3.11±1.16 [delayed]; reviewer 2: 4.70±0.47 [early] vs. 3.04±1.29 [delayed]). Inter-rater variability showed good correlation between reviewers (intraclass correlation 0.61–0.95). Mean LAA/LA attenuation ratios were significantly different between scans, with larger mean percent reduction of contrast opacification from LA to LAA in the early scans (57.0±36.6% reduction for early vs. 29.1±30.8% for delayed; p < 0.001). CONCLUSION: For CT device surveillance post-LAAC early phase imaging provides superior image quality objectively and subjectively compared with delayed scanning.

Subacute or late complications > 24 hours after left atrial appendage closure (LAAC) are infrequent. We therefore created a clinical pathway to enable safe same-day discharge (SDD) after LAAC. Patients were assessed for overall physical conditioning, lack of significant frailty and comorbidities limiting physical abilities, good home support, and patient preference. Of 78 LAACs performed, 24 patients (30.8%) were discharged the same day: 21 were transesophageal echocardiography guided and 3 intracardiac echocardiography guided. SDD clinical pathway patients were discharged 395.4 ± 56.6 minutes after leaving the procedural room. There were no clinical complications at 1 month or in long-term follow-up. SDD is safe and feasible after LAAC, following a dedicated clinical pathway and surveillance in carefully selected patients.

Spontaneous coronary artery dissection (SCAD) accounts for up to 4% of acute coronary syndromes (ACS) on coronary angiography and predominantly affects women (90%). SCAD most often occurs in patients with few or no conventional cardiovascular risk factors. This condition remains underdiagnosed due to a lack of awareness among health-care providers and misdiagnosis on coronary angiography. Areas covered: In this review, authors aim to summarize contemporary data on the etiology, morbidity and mortality risks, as well as management strategies in order to raise awareness. Expert opinion: The last decade of extensive research revealed that SCAD is not as rare as previously thought and needs to be in the differential diagnosis of all MI patients, especially in young to middle-aged women. Predisposing factors, such as fibromuscular dysplasia, and potential triggers like physical or emotional stresses, are frequently linked. Coronary angiography is the first-line diagnostic tool and should be performed meticulously because of more fragile vessel architecture to avoid iatrogenic dissections. If angiographic findings are uncertain, the use of intravascular imaging may be required. Conservative therapy is favored over revascularization unless patients have high-risk features. Recurrent cardiovascular events post-SCAD are frequent, and patients should be closely monitored after a SCAD event.

OBJECTIVES: To describe imaging assessment, procedural and follow-up outcome of patients undergoing left atrial appendage (LAA) occlusion (LAAO) using a "sandwich" technique.BACKGROUND: The presence of a LAA with chicken wing morphology constitutes a challenge that sometimes requires specific occlusion strategies like the "sandwich" technique. However, procedural and follow-up data focusing on this implanting strategy is scarce.METHODS: This multicenter study collected individual data from eight centers between 2012 and 2019. Consecutive patients with chicken-wing LAAs defined as an early (90°) who underwent LAAO with Amplatzer devices and using the "sandwich" technique were included in the analysis.RESULTS: Overall, 190 subjects were enrolled in the study. Procedures were done with the Amulet device (85%) and the Amplatzer Cardiac Plug (15%). Successful implantation was achieved in 99.5% with ≤1 partial recapture in 80% of cases. Single (46.2%) and dual antiplatelet therapy (39.4%) were the most used antithrombotic therapies after LAAO. In-hospital major adverse events rate was 1.5% with no deaths. One patient (0.5%) had cardiac tamponade requiring percutaneous drainage. With a mean follow-up of 19.6 ± 14.8 months, the mortality and stroke rates were 7.7%/year and 2.5%/year, respectively. Follow-up transesophageal echocardiography (TEE) at 2-3 months showed device-related thrombosis in 2.8% and peri-device leak ≥3 mm in 1.2% of patients.CONCLUSIONS: In a large series of patients with chicken wing LAA anatomies undergoing LAAO, the use of the "sandwich" technique was feasible and safe. Preprocedural imaging was a key-factor to determine specific measurements.

BACKGROUND Transseptal access for large sheaths may be encumbered by tissue resistance against the sheath-dilator stepped interface. The ExpanSure Large Access Transseptal Dilator (Baylis Medical) is designed as a single introducer and dilation device with a smooth sheath-dilator transition to support transseptal puncture. It may facilitate ease and efficiency of interatrial crossing. METHODS This study experimentally evaluated the crossing force of ExpanSure relative to a conventional 8.5 F Swartz SL1 transseptal sheath and dilator in a benchtop septum model. Its ability to reduce the subsequent crossing force of a 14 F WATCHMAN delivery sheath was also tested. The clinical use of ExpanSure, including procedure time, was then validated in a series of left atrial appendage closure (LAAC) procedures. RESULTS In a benchtop septum model (N = 12), less peak force (1.90 ± 0.08 N vs. 2.36 ± 0.09 N; p

Background: Patients with atrial fibrillation undergoing transcatheter aortic valve implantation (TAVI) have a worse prognosis than those in sinus rhythm. The bleeding risk associated with oral ant...

Spontaneous coronary artery dissection (SCAD) is an important cause of myocardial infarction (MI) in women with few or no conventional cardiovascular risk factors. Lack of awareness about this condition among healthcare providers had led to significant underdiagnosis and misdiagnosis in this relatively young patient population.The current review summarizes the contemporary data on cause, management strategies and outcomes of SCAD.SCAD is not as rare as previously thought, accounting for up to 4% of all acute coronary syndromes. It is frequently linked with predisposing factors, such as fibromuscular dysplasia or other vasculopathies, and is often triggered by physical or emotional stress. Due to more fragile vessel architecture, coronary angiography as the first-line diagnostic tool should be performed meticulously to avoid iatrogenic dissection. Intravascular imaging may be required if angiographic findings are uncertain. Unless patients have high-risk features such as ongoing ischemia, recurrent chest pains, left main artery dissection, ventricular arrhythmias, or hemodynamic instability, a conservative treatment strategy is favored over revascularization. Close monitoring is essential after a SCAD-event as recurrent cardiovascular events post-SCAD are frequent.

AIMS Device surveillance after left atrial appendage (LAA) closure (LAAC) is important to assess device positioning, peri-device leak (PDL) and device-related thrombus (DRT). There are limited data on the role of cardiac CT angiography (CCTA) after LAAC. We therefore sought to compare CCTA to transoesophageal echocardiography (TEE) in patients who successfully underwent LAAC. METHODS AND RESULTS We report our consecutive series of non-valvular atrial fibrillation patients who underwent LAAC and had CCTA and TEE post LAAC. Prospective cardiac-gated CCTA was performed with the Toshiba 320-detector or Siemens second-generation 128-slice dual-source scanner, and post-processing was performed with IMPAX 3D reformats. Glomerular filtration rate

Background: The horsepower not only of doctors&rsquo, cars correlates with personal income and social status. However, no clear relationship has previously been described between the horsepower of doctors&rsquo, cars and cardiovascular health or sexual dysfunction and/or satisfaction. Objective: Cross-sectional online survey to evaluate associations between self-reported horsepower of physicians&rsquo, cars and health aspects. Methods: Of 1877 physicians from the two University-Hospitals in Austria that were asked to participate in the study, 363 (37.7 &plusmn, 8.0 years, 208 (57.3%) men) were included into the final analysis. Results: Physicians that own a car with a stronger engine were significantly older, were more often male, had more often a leading position, had a higher monthly income (all p &lt, 0.001), had a higher scientific output (p = 0.030), and had hypercholesteremia more often (p = 0.009). They also tended to have a higher body mass index (p = 0.088), reported a higher maximum weight in previous years (p = 0.004) and less often reported regular healthy commuting to and from work (p = 0.010). No significant associations were found for self-reported physical fitness, smoking status, and arterial hypertension. In addition, sexual satisfaction and sexual dysfunction were also not related to horsepower in the whole population and the male subgroup. The findings essentially persisted after controlling for age. Conclusion: The horsepower of Austrian physicians&rsquo, cars correlates with senior position and increased cardiovascular risk. However, our data shows no relationship between sexual dysfunction or lack of sexual satisfaction and the horsepower of doctors&rsquo, cars.

Right ventricular systolic dysfunction is prognostic in various cardiovascular diseases. Right ventricular systolic function is not commonly assessed in the catheterization laboratory. Therefore, we developed a novel, reproducible method to measure right ventricular systolic function during selective coronary angiography. We analyzed the angiographic systolic translational motion and maximum speed of the right coronary artery (RCA) in 97 consecutive patients and compared it to the tricuspid annular plane systolic excursion (TAPSE) as measured by echocardiography. All measurements were performed by two independent operators on two occasions. Inter-observer variability and intra-observer variability were excellent for RCA motion distance and for RCA maximum speed. There was a significant correlation of the RCA motion distance and RCA maximum speed with the TAPSE measured by echocardiography (Pearson’s correlation for RCA distance: r = 0.59, p

Access to left atrial appendage closure (LAAC) in Canada is limited due to funding restrictions. This work aimed to assess Canadian clinical practice on patient selection, post-procedural antithrombotic therapy, and safety and/or efficacy with WATCHMAN implantation. All Canadian centers implanting

Transseptal access for delivery sheaths may encounter tissue resistance against the sheath-dilator interface, requiring tissue dilation or repuncture at a thinner part of the interatrial septum. The authors report the first clinical experience using a novel transseptal system with no sheath-dilator

Although rates of atrial septal defect (ASD) closure are stable, dramatic increases in the rates of patent foramen ovale (PFO) closure have placed greater demands on existing catheterization laboratory resources. The Vancouver PFO/ASD Clinical Pathway (Figure 1) was designed to facilitate same-day

Bei ausgepragtem Perikarderguss lasst sich in der Echokardiographie beobachten, wie sich das Herz im flussigkeitsgefullten Perikardbeutel hin und her bewegt, was als Swinging Heart umschrieben wird.