Concomitant left atrial appendage closure with left ventricular assist device surgery can reduce ischemic cerebrovascular accidents

Background

It remains unknown if concomitant left atrial appendage closure (LAAC) at the time of left ventricular assist device (LVAD) surgery can reduce ischemic cerebrovascular accidents.

Purpose

The purpose of this study is to assess the impact of LAAC at LVAD surgery on the incidence of ischemic cerebrovascular accidents.

Methods

Between January 2012 and November 2021, 310 patients underwent LVAD surgery with HeartMate II or III. Out of 310 patients, 98 patients (31.6%) underwent concomitant LAAC. The cohort was divided into two groups: patients with LAAC (Group A, n=98) and without LAAC (Group B, n=212). To minimize device bias, LVAD surgery with HeartWare HVAD device was excluded. The ischemic cerebrovascular accident was defined as ischemic stroke, hemorrhagic stroke or transient ischemic attack. We reviewed early and long-term clinical outcomes. The incidence of ischemic cerebrovascular accidents was compared between two groups using the Kaplan-Meier method. We also investigated if LAAC was associated with ischemic cerebrovascular accidents by Cox proportional hazards analysis.

Results

There were no significant differences in baseline characteristics between two groups including age (Group A: 55.0±12.3 years old, Group B: 56.9±14.1 years old, p=0.26), preoperative CHADS2 score (Group A: 2.40±1.1, Group B: 2.58±1.1, p=0.19) and history of atrial fibrillation (Group A: 42.9%, Group B: 42.5%, p=0.95). In-hospital mortality was not significantly different between the two groups (Group A: 7.1%, Group B: 12.3%, p=0.16). In terms of postoperative complications, there were no significant differences between two groups in requiring extracorporeal membrane oxygenation, re-exploration for bleeding and newly required hemodialysis. Median follow up period was 474 days. Thirty-five patients (11.2%) developed ischemic cerebrovascular accidents (5 patients in Group A and 30 patients in Group B). The rate of freedom from ischemic cerebrovascular accidents in Group A (94.1% at 500 days and 94.1% at 1500 days) was significantly higher than that in Group B (88.2% at 500 days and 77.4% at 1500 days; log rank=0.024). In a Cox proportional hazards regression analysis including LAAC, age, history of atrial fibrillation, diabetes mellitus and Heartmate 3 device implantation, LAAC was associated with reducing the incidence of ischemic cerebrovascular accidents (hazard ratio 0.37, 95% CI 0.13–0.89, p=0.02).

Conclusion

Concomitant LAAC at the time of LVAD surgery can reduce ischemic cerebrovascular accidents without increasing perioperative mortality and complications.

Funding Acknowledgement

Type of funding sources: None.

Intracardiac device associated interference with tricuspid valve apparatus on echocardiography: What can we learn from pathology?

Funding Acknowledgements

Type of funding sources: None.

Background

 New or worsening tricuspid regurgitation (TR) is associated with right-sided heart failure and worsened outcomes. Cardiac Implantable Electronic Devices (CIEDs), which are being implanted at growing rates worldwide, are increasingly being recognized as associated with TR occurrence related to interference with the tricuspid valve (TV) apparatus. Purpose: We sought to identify echocardiographic features in the right ventricle and TV that differentiate patients who have anatomically demonstrated interference with the TV on direct pathology inspection. 

Methods

 Explanted hearts from 44 consecutive patients undergoing orthotopic heart transplant (55 ±13 yrs, 68% men) with known implanted CIEDs were dissected to assess the presence (n = 18) or absence (n = 26) of CIED interference with the TV (Figure). Echocardiographic measurements performed prior to transplantation, including left and right ventricular (LV, RV) size and performance metrics as well as TR severity, were compared between both groups using non-parametric testing. 

Results

 Echocardiographic features of patients with and without anatomically demonstrated TV interference are shown in the Table. Although overall LV dimensions and volumes were not different between the two groups and LV ejection fraction was severely reduced in both groups, patients demonstrating CIED interference trended towards larger right atrial volumes (Table) and also larger RV and tricuspid annular sizes. Importantly, however, they were more than 4 times likely to have abnormal right ventricular function. Lastly, patients with tricuspid apparatus interference tended to have more significant TR, although these differences have not reached statistical significance (Table). 

Conclusion

 CIED interreference with tricuspid valve apparatus occurs frequently (41%) among patients with CIEDs, who undergo orthotopic heart transplantation. This may be associated with worsening TV function with subsequent changes in right atrial and ventricular geometry and function. In light of prior data showing poor outcomes with CIED associated TR, this study emphasizes the importance of non-invasive assessment of CIED interference with the tricuspid valve, in order to improve device placement and patient outcomes. Abstract Figure  Abstract Table

2422Outcome of histologically-proven fulminant versus acute non-fulminant myocarditis with left ventricular systolic dysfunction. Evidence from the International Registry on Acute Myocarditis

Background

Fulminant myocarditis (FM) is a form of acute myocarditis characterized by severe left ventricular (LV) dysfunction requiring inotropes and/or mechanical circulatory support. Based on a retrospective single-center study published in 2000, patients with FM were considered to have better outcomes than those affected by acute non-fulminant myocarditis (NFM) presenting with LV systolic dysfunction (LVSD). Recently, this tenet was challenged, though substantial disagreement still exists.

Purpose

Aim of the present study is to provide additional evidence on the outcome of FM and to ascertain if patient stratification based on the main histologic subtypes can provide additional prognostic information.

Methods

Two hundred and twenty patients (median age 42 years, 46.3% female) with histologically proven acute myocarditis (onset of symptoms <30 days) presenting with LVSD were included in a retrospective, international registry comprising 16 tertiary hospitals in the United States, Europe, and Japan. The primary endpoint was the occurrence of cardiac death or heart transplant (HTx) within 60 days from admission and at long-term follow-up.

Results

Patients with FM (N=165) had significantly higher rates of cardiac death and HTx compared with those with NFM (N=55), both at 60 days (28.0% vs. 1.8%, p=0.0001) and at 7-year follow up (47.7% vs. 10.4%, p<0.0001; Figure). At Cox-multivariate analysis, the histologic subtype emerged as a further variable affecting outcome in FM patients, with giant cell myocarditis having a significantly worse prognosis compared with eosinophilic and lymphocytic myocarditis both at 60 days (62.5% vs. 26.3% vs. 21.0%) and at 3 years (81.3% vs. 39.9% vs. 37.3%, overall p<0.0001). In a sub-analysis including only adults with lymphocytic myocarditis, the main endpoints occurred more frequently in FM compared with NFM both at 60 days (19.5% vs. 0%, p=0.005) and up to 7 years (41.4% vs. 3.1%, p=0.0004).

Outcome of FM vs NFM

Conclusions

The results of this international registry confirm that patients with FM have higher rates of cardiac death and HTx both in the short and long-term compared with patients with NFM. Furthermore, we provide evidence that the histologic subtype of FM carries independent prognostic value, highlighting the need for timely endomyocardial biopsy in this condition.

Acknowledgement/Funding

None

Role of the Nurse Counsellor in Managing Patients with the Hyperventilation Syndrome

A hyperventilation clinic was established specifically to deal with patients referred from the accident and emergency department with the hyperventilation syndrome. This was run by a staff nurse, who counselled the patients and taught abdominal breathing techniques and relaxation. In 30 patients so managed, 63% said their symptoms were much better or had completely gone and in only 6% was there no improvement; 43% had previously had more than one attendance at the A&E department, but following treatment only 2 patients represented during 5 months of follow up. The use of a nurse counsellor seems to be a simple and effective approach to managing these patients and considerably reduces both casualty and outpatient physician time.