Percutaneous left atrial appendage closure reduces cost of care independent of the institutional cumulative caseload in patients with non-valvular atrial fibrillation

Background

Data on the impact of the cumulative percutaneous left atrial appendage closure (LAAC) caseload on cardiovascular outpatient and hospitalisation costs are limited.

Methods

The present single-institution analysis includes patients treated consecutively from the beginning of our LAAC experience in January 2012 until December 2016. Pre- and post-LAAC costs for hospitalisation and ambulatory visits were included.

Results

A total of 676 patients underwent percutaneous LAAC (using the Watchman device): 49 (2012), 78 (2013), 211 (2014), 210 (2015), and 129 (2016). LAAC procedural costs were stable over the years (overall median €9639; 2012: €9630; 2013: €10,003; 2014: €9841; 2015: €9394; 2016: €9530; p = 0.8) and there was no correlation between cumulative caseload and procedural costs (p = 0.9). Although annualised cardiovascular management costs after LAAC were lower than before LAAC (median difference between pre-LAAC and post-LAAC yearly costs: €727; 2012: €235; 2013: €1187; 2014: €716; 2015: €527; 2016: €1052; p = 0.5 among years analysed) from the beginning of the cumulative procedural experience, a significant reduction in costs was observed only from 2014 onwards. Institutional cumulative LAAC caseload and year of procedure were not related to the amount of reduction in the costs for cardiovascular care.

Conclusion

LAAC led to cost-of-care savings from the beginning of our institutional procedural experience.

Sex differences in treatment strategy for coronary artery aneurysms: Insights from the international Coronary Artery Aneurysm Registry

Introduction

Sex disparities exist in coronary artery disease (CAD) in terms of risk profile, clinical management and outcome. It is unclear if differences are also present in coronary aneurysms, a rare variant of CAD.

Methods

Patients were selected from the international Coronary Artery Aneurysm Registry (CAAR; ClinicalTrials.gov: NCT02563626), and differences between groups were analysed according to sex. The CAAR database is a prospective multicentre registry of 1565 patients with coronary aneurysms (336 females). Kaplan-Meier method was used for event-free survival analysis for death, major adverse cardiac events (MACE: composite endpoint of death, heart failure and acute coronary syndrome) and bleeding.

Results

Female patients were older, were more often hypertensive and less frequently smoker. They were treated conservatively more often compared to male patients and received significantly less frequently aspirin (92% vs 88%, p = 0.002) or dual antiplatelet therapy (DAPT) (67% vs 58%, p = 0.001) at discharge. Median DAPT duration was also shorter (3 vs 9 months, p = 0.001). Kaplan-Meier analysis revealed no sex differences in death, MACE or bleeding during a median follow-up duration of 37 months, although male patients did experience acute coronary syndrome (ACS) more often during follow-up (15% vs 10%, p = 0.015).

Conclusions

These CAAR findings showed a comparable high-risk cardiovascular risk profile for both sexes. Female patients were treated conservatively more often and received DAPT less often at discharge, with a shorter DAPT duration. ACS was more prevalent among male patients; however, overall clinical outcome was not different between male and female patients during follow-up.

Actual management costs of patients with non-valvular atrial fibrillation treated with percutaneous left atrial appendage closure or oral anticoagulation

Background

Left atrial appendage closure (LAAC) is a safe and efficacious alternative to oral anticoagulation (OAC) therapy in patients with non-valvular atrial fibrillation (AF) who are at high risk for both stroke and bleeding. Data on cost-effectiveness of LAAO are limited and existing studies on the topic are based on simulation model approaches rather than on real-world costs.

Purpose

To compare actual management costs in patients with non-valvular AF treated with LAAC or OAC only.

Methods

Percutaneous LAAC was performed only in patients with at least one cerebral thromboembolic event, one major bleeding episode while under OAC, and with absolute contraindication to prolonged OAC. AF patients undergoing percutaneous LAAC were matched with AF patients treated with OAC only. Matching variables were gender, age, and Diagnosis Related Groups (DRG) clinical complexity level. Costs for cardiovascular outpatient clinic visits and hospitalizations were derived from the actual medical claims and reimbursement records. Data were prospectively collected and retrospectively analyzed.

Results

Between 1/2012 and 12/2016, 8478 patients with non-Valvular AF were referred to our institution: 7801 (92%) were managed with OAC only and 677 (8%) with LAAC. A total of 559 patients (279 per group) were matched. Mean age was 74.9±7.5 years, 244 were female (43.7%), and mean DRG clinical complexity level was 1.8±1.1.

Median annualized management cost before LAAC was €3110 (IQR €1281–8127). Median hospitalization cost for LAAC was €9601 (IQR: €9393–10007). After a mean follow-up of 4.5±1.4 years, median annualized management cost was €1297 (€607–2735) in patients with sole OAC and €1013 (IQR €0–4770) in patients after LAAC (p=0.003). Undergoing LAAC was the strongest independent determinant to reduce follow-up management costs (linear regression: beta = −0.335; CI: −1.09 to −0.682; p<0.0001). Estimated 3-year survival was similar in the LAAC (92%) and OAC patients (90%) (p=0.7).

Conclusion

LAAC significantly reduces management costs of patients with non-valvular AF. In patients referred for percutaneous LAAC, the drastic reduction in management costs following LAAC justifies the procedural costs. In spite of their complex comorbid profile, LAAC patients show a follow-up survival rate similar to those of patients solely treated with OAC. Management costs of patients solely on OAC are significantly higher than management costs of patients after LAAC. Future studies are necessary to investigate the potential net economic and clinical benefit of LAAC in patients that are treated with OAC only.

Funding Acknowledgement

Type of funding sources: None.

2020 ESC Guidelines on acute coronary syndrome without ST-segment elevation : Recommendations and critical appraisal from the Dutch ACS and Interventional Cardiology working groups

Recently, the European Society of Cardiology (ESC) has updated its guidelines for the management of patients with acute coronary syndrome (ACS) without ST-segment elevation. The current consensus document of the Dutch ACS working group and the Working Group of Interventional Cardiology of the Netherlands Society of Cardiology aims to put the 2020 ESC Guidelines into the Dutch perspective and to provide practical recommendations for Dutch cardiologists, focusing on antiplatelet therapy, risk assessment and criteria for invasive strategy.

Guidelines for the management of myocardial infarction/injury with non-obstructive coronary arteries (MINOCA): a position paper from the Dutch ACS working group

Patients with myocardial infarction and non-obstructive coronary arteries (MINOCA), defined as angiographic stenosis <50%, represent a conundrum given the many potential underlying aetiologies. Possible causes of MINOCA can be subdivided into coronary, myocardial and non-cardiac disorders. MINOCA is found in up to 14% of patients presenting with an acute coronary syndrome. Clinical outcomes including mortality, and functional and psychosocial status, are comparable to those of patients with myocardial infarction and obstructive coronary arteries. However, many uncertainties remain regarding the definition, clinical features and management of these patients. This position paper of the Dutch ACS working group of the Netherlands Society of Cardiology aims to stress the importance of considering MINOCA as a dynamic working diagnosis and to guide the clinician in the management of patients with MINOCA by proposing a clinical diagnostic algorithm.

Non-HACEK Gram-negative bacillus endocarditis

PATIENTS AND METHODS

Retrospective analysis of clinical data using 26 diagnosed non-HACEK Gram-negative infective endocarditis cases from nine hospitals in Turkey.

RESULTS

Mean age of patients was 53 (28-84) years, with a 23% case fatality. Nineteen (73%) of the 26 patients had at least one predisposing factor. The presence of a central venous catheter was the most common predisposing factor (7/26 patients). Pseudomonasaeruginosa (7/26 patients) and Escherichiacoli (7/26 patients) were the most common pathogens. The median duration of the antibiotic therapy was 42 days (range 3-84 days). Surgical procedures were performed in 10 patients. The case fatality was similar in patients who did or did not undergo surgery (20% vs. 25%).

2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: comments from the Dutch ACS working group

On behalf of the Dutch ACS working group, we discuss the most important changes in recommendations in the 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation relevant for both the general and interventional cardiologist.

Bilateral dacryocystocele with an intranasal cyst as the cause of respiratory distress in a newborn

A congenital dacryocystocele with an intranasal cyst is an uncommon lesion that is usually treated by ophthalmologists, although sometimes an otorhinolaryngologist is consulted first because of nasal obstruction. The nasal cavity is narrow in newborns and can easily be obstructed, even by small lesions. Prolapse or expansion of the cyst into the nose may lead to respiratory distress and difficulty in feeding, since newborns are obligate nose breathers. Here we report a case of bilatera dacryocystocele with intranasal extension in a 3-day-old female infant. The infant presented with respiratory distress and episodic desaturation and was managed successfully by bilateral endoscopic marsupialization of the intranasal cysts. This case report discusses the diagnosis and management and reviews the relevant literature. These finding suggest tha congenital dacryocystocele with an intranasal cyst must be considered in the differential diagnosis of newborns suffering from nasal respiratory difficulty.

An unusual cause of necrosis and nasal septum perforation after septoplasty: Enterobacter cloacae

A 20-year-old man with nasal obstruction underwent septoplasty due to nasal septal deviation. Nasal packs were inserted at the end of surgery and removed 48 hours after surgery. Twenty-four hours after removal of nasal packs, there was necrosis in both sides of septal mucosa and in bilateral inferior turbinates. Nasal swab culture was performed from both nasal cavities. Enterobacter cloacae was isolated from samples. Two weeks after surgery, nasal septum perforation was unavoidable. To our knowledge, this is the first case in literature describing septal mucosal necrosis caused by this pathogen after septoplasty. Mucosal necrosis and perforation as septoplasty complications should be kept in mind, the result of causes both common and, as in the present case, unusual.

Acute pontine infarction after percutaneous coronary intervention: a very rare but devastating complication

A 64-year-old man suffering from an acute posterior wall myocardial infarction underwent primary percutaneous coronary intervention. After several aspiration attempts, tirofiban infusion and pre- and post-dilatation, a bare-metal stent was successfully implanted in the culprit right coronary artery. While the patient did not show any neurological symptoms before or during the procedure, he exhibited hemiplegia and loss of spontaneous speech. Additional magnetic resonance imaging showed an extensive brain stem infarction. This is the first report of a brain stem infarction as a complication of percutaneous coronary intervention.

Comparison of colistin-carbapenem, colistin-sulbactam, and colistin plus other antibacterial agents for the treatment of extremely drug-resistant Acinetobacter baumannii bloodstream infections

The purpose of this investigation was to compare the efficacy of colistin-based therapies in extremely drug-resistant Acinetobacter spp. bloodstream infections (XDR-ABSI). A retrospective study was conducted in 27 tertiary-care centers from January 2009 to August 2012. The primary end-point was 14-day survival, and the secondary end-points were clinical and microbiological outcomes. Thirty-six and 214 patients [102 (47.7%): colistin-carbapenem (CC), 69 (32.2%): colistin-sulbactam (CS), and 43 (20.1%: tigecycline): colistin with other agent (CO)] received colistin monotherapy and colistin-based combinations, respectively. Rates of complete response/cure and 14-day survival were relatively higher, and microbiological eradication was significantly higher in the combination group. Also, the in-hospital mortality rate was significantly lower in the combination group. No significant difference was found in the clinical (p = 0.97) and microbiological (p = 0.92) outcomes and 14-day survival rates (p = 0.79) between the three combination groups. Neither the timing of initial effective treatment nor the presence of any concomitant infection was significant between the three groups (p > 0.05) and also for 14-day survival (p > 0.05). Higher Pitt bacteremia score (PBS), Acute Physiology and Chronic Health Evaluation II (APACHE II) score, Charlson comorbidity index (CCI), and prolonged hospital and intensive care unit (ICU) stay before XDR-ABSI were significant risk factors for 14-day mortality (p = 0.02, p = 0.0001, p = 0.0001, p = 0.02, and p = 0.01, respectively). In the multivariable analysis, PBS, age, and duration of ICU stay were independent risk factors for 14-day mortality (p < 0.0001, p < 0.0001, and p = 0.001, respectively). Colistin-based combination therapy resulted in significantly higher microbiological eradication rates, relatively higher cure and 14-day survival rates, and lower in-hospital mortality compared to colistin monotherapy. CC, CS, and CO combinations for XDR-ABSI did not reveal significant differences with respect to 14-day survival and clinical or microbiological outcome before and after propensity score matching (PSM). PBS, age, and length of ICU stay were independent risk factors for 14-day mortality.

Pelvic and retroperitoneal hydatid cysts superinfected with Brucella sp. and review of infected hydatid cysts

Hydatid disease is a zoonotic infection resulting from the tissue infestation of the larval stage of the parasite Echinococcus granulosus. Hydatid cysts superinfected with pyogenic organisms have been reported previously. Brucellosis is more prevalent in people with close contact to animals and those consuming fresh milk or fresh milk products. Although these two disorders have some similar epidemiological features, we did not encounter any hydatid cyst cases superinfected with Brucella species (sp.) in a search of medical literature (Pubmed). Here, we present a case of hydatid cyst disease superinfected with Brucella and review the literature on other hydatid cyst cases superinfected with pyogenic organisms. We conclude that in regions where brucellosis and hydatid cysts are endemic, cysts may be infected with Brucella sp.

TLR2 and TLR4 in ischemia reperfusion injury

Ischemia reperfusion (I/R) injury refers to the tissue damage which occurs when blood supply returns to tissue after a period of ischemia and is associated with trauma, stroke, myocardial infarction, and solid organ transplantation. Although the cause of this injury is multifactorial, increasing experimental evidence suggests an important role for the innate immune system in initiating the inflammatory cascade leading to detrimental/deleterious changes. The Toll-like Receptors (TLRs) play a central role in innate immunity recognising both pathogen- and damage-associated molecular patterns and have been implicated in a range of inflammatory and autoimmune diseases. In this paper, we summarise the current state of knowledge linking TLR2 and TLR4 to I/R injury, including recent studies which demonstrate that therapeutic inhibition of TLR2 has beneficial effects on I/R injury in a murine model of myocardial infarction.

The role of versican isoforms V0/V1 in glioma migration mediated by transforming growth factor-beta2

Versican is a large chondroitin sulphate proteoglycan produced by several tumour cell types, including high-grade glioma. The increased expression of certain versican isoforms in the extracellular matrix (ECM) plays a role in tumour cell growth, adhesion and migration. Transforming growth factor-β2 (TGF-β2) is an important modulator of glioma invasion, partially by remodeling the ECM. However, it is unknown whether it interacts with versican during malignant progression of glioma cells. Here, we analysed the effect of TGF-β2 on the expression of versican isoforms. The expression of versican V0/V1 was upregulated by TGF-β2 detected by quantitative polymerase chain reaction and immunoprecipitation, whereas V2 was not induced. Using time-lapse scratch and spheroid migration assays, we observed that the glioma migration rate is significantly increased by exogenous TGF-β2 and inhibited by TGF-β2-specific antisense oligonucleotides. Interestingly, an antibody specific for the DPEAAE region of glycosaminoglycan-β domain of versican was able to reverse the effect of TGF-β2 on glioma migration in a dose-dependent manner. Taken together, we report here that TGF-β2 triggers the malignant phenotype of high-grade gliomas by induction of migration, and that this effect is, at least in part, mediated by versican V0/V1.

An imbalance between Smad and MAPK pathways is responsible for TGF-beta tumor promoting effects in high-grade gliomas

The transforming growth factor-beta (TGF-beta) plays a pivotal role in the pathobiology of human gliomas: during carcinogenesis, it turns from a tumor suppressor to a tumor promoter. The traditional Smad pathway and the more recently discovered MAPK pathway are the most important pathways for TGF-beta related intracellular signal transduction mediating differential pathobiological effects. In this study, we investigated the effects of TGF-beta2 and the TGF-beta2 antisense phosphorothioate oligodeoxynucleotide (PTO) AS-11 on the functionality of both the Smad and MAPK pathways in high-grade gliomas. We aimed to correlate the imbalance between the pathways with differences in the behaviour of high-grade glioma cells. Gene and protein expression studies were used to detect levels of members of the Smad and MAPK pathways under regulation of TGF-beta2 and AS-11. Proliferation and migration assays were functional readouts for effects caused by these regulating tools. Gene arrays were used to detect yet unknown regulators of these functional effects. The Smad pathway was functional in the tested cell lines. Exogenous TGF-beta2 inhibited proliferation but enhanced migration. Smad 2 mRNA expression and activation were significantly reduced by incubation with AS-11. K-ras was reduced both in gene arrays and quPCR under treatment with AS-11, but there was no influence of K-ras down-regulation on the activity of ERK. Ubiquitination-related genes also were specifically down-regulated with AS-11. Our results indicate the involvement of K-ras in TGF-beta signaling in high-grade gliomas. ERK, which is a member of the MAPK pathway, was not influenced and seems to be activated through RAS independent cascades in glioma. These results suggest that combined antagonization of the TGF-beta and MAPK pathways might be a promising approach for glioma therapy. An imbalance between these two pathways might be responsible for TGF-beta switching to a tumor promoter protein in high-grade gliomas.