Large papillary fibroelastoma of right atrium, an unusual case of respiratory distress in a young man

Background Papillary fibroelastomas are rare but benign cardiac tumour that are often found on cardiac valvular surfaces. Their clinical manifestations ranging from clinically asymptomatic to substantial complications that are usually secondary to systemic embolism. Multiple theories have been proposed to explain the pathophysiology of its formation. Case presentation We reported a rare case of large papillary fibroelastoma in the right atrium of a young gentleman which was complicated with pulmonary embolism. Transthoracic echocardiography identified a large pedunculated mass measuring 3.4cmX3.4cmX2cm in right atrium with stalk attached to interatrial septum. The intracardiac mass was resected surgically, which revealed papillary fibroelastoma in histology examination. Conclusion Differential diagnosis of intracardiac masses requires clinical information, laboratory tests and imaging modalities including echocardiography. Incidentally discovered papillary fibroelastomas are treated on the basis of their sizes, site, mobility and potential embolic complications. Due to the embolic risk inherent to intraacardiac masses, surgical resection represents an effective curative protocol in treating both symptomatic and asymptomatic right sided and left sided papillary fibroelastomas, with excellent long term postoperative prognosis.

A Rare Case of Papillary Fibroelastoma Involving The Tricuspid Valve. A single Center experience over a period of 22 years (1999-2021)

Background and aim Papillary fibroelastoma (PFE) represents only 16% of the benign cardiac tumor and approximately 15% of these are located on tricuspid valve. Materials and Methods Over a period of 22 years (1999-2021) we observed 75 pts with cardiac tumors at our Center over 9650 pts operated on. Most of them were mixoma but in 10 cases histology showed a PFE. We describe a rare case (1/75 of cardiac tumors) of a tricuspid valve PFE in a 69-year-old patient. Trans-thoracic echocardiography demonstrated a mobile mass (20 x 10 mm), adhering to the atrial side of the septal leaflet of the tricuspid valve. In consideration of the mobility of the mass and the consequent high embolic risk, surgical removal was made. Patient underwent surgery through a median sternotomy on CPBP. A “gelatinous” mass adhering to the tricuspid leaflet was found and completely removed. The postoperative course was uneventful. The pathological evaluation confirmed the diagnosis of PFE. Conclusions PFE of the tricuspid valve is rare entities being in most cases found incidentally. In our experience the incidence of this tumor in this location is 1/10000 cases of cardiac surgery. Although most patients are asymptomatic, surgical treatment is nevertheless recommended in consideration of the high embolic risk.

Can we use the CHA2DS2VASc score in Atrial Flutter?

Funding Acknowledgements Type of funding sources: None. Introduction CHA2DS2VASc score is a well stablished prognostic score in atrial fibrillation population. However, considering patients with isolated atrial flutter no prognostic score are defined, regarding the embolic risk of this population. Purpose To evaluate the capacity of CHA2DS2VASc score to predict cardiovascular death and major adverse cardiovascular events (MACE) in flutter patients (pts). Methods Single-center retrospective study of pts submitted to CTA between 2015 and 2019, comprising two groups: I – pts with lone AFL; II – patients with AFL and prior AF. Clinical records were analyzed to determine the occurrence of MACE during the long-term follow up, defined as death (of cardiovascular or unknown cause), stroke, clinically relevant bleed or hospitalization due to heart failure or arrhythmic events. CHA2DS2VASc score was categorized into 3 groups: 0-1; 2-3; >4. Kaplan Meier survival curves were used to estimate the risk of events and the groups were compared using uni- and multivariate Cox regression analyses. Results A total of 476 pts (66 ± 12 years, 80% males) underwent CTA: group I – 284 pts (60%), II – 192 pts (40%). Baseline characteristics were similar between groups, except for age with group I pts being older (68 ± 12, 64 ± 11, p < 0.01). The mean baseline CHA2DS2VASc was 2.3 ± 1.5 and the median post-CTA follow-up was 2.8 year. Considering global population, CHA2DS2VASc score was an independent predictor of cardiovascular death (OR: 1.49 95%CI 1.09-1.79, p = 0.08) and was a predictor of MACE even after adjustment for the diagnose of prior AF (OR 1.88, 95% IC 1.094-3.249, p = 0.022). Considering only the pts in group I CHA2DS2VASc score was a predictor of MACE (OR 3.03, 95% CI 1.112-8.278, p = 0.03) after adjustment for sex and age. Regarding the different MACE components, the score was a predictor of stroke (OR 4.45, IC 1.66-13.39, p = 0.04). In flutter pts CHA2DS2VASc score did not predict cardiovascular death. Conclusions In our population CHA2DS2VASc score was able to predict MACE events and stroke in patients with isolated atrial flutter. This suggests that in the future CHA2DS2VASc score could be applied to establish embolic risk in atrial flutter. Abstract Figure.

Ibrutinib in patients with atrial fibrillation – the challenge of thromboembolic prophylaxis

Ibrutinib is a novel drug used in haematological malignancies. Its use is associated with an increased risk of atrial fibrillation (AF), which, in turn, exposes patients to embolic risk, including stroke. Reducing this risk requires anticoagulant therapy which is a matter of concern in the context of the increased bleeding risk of patients with haematological malignancies. In this context the presence of thrombocytopenia related to haematological disorder, ibrutinib-anticoagulants and ibrutinib-platelets interactions contribute to the amplification of the problem. The correct assessment of the thrombosis vs. haemorrhage balance represents a significant challenge for the clinician. In this paper we discuss practical issues related to anticoagulation in patients treated with ibrutinib and incident AF.

Low Embolic Risk from Short Duration Atrial Fibrillation following Anatomic Lung Resection

Objectives There is no consensus regarding the merits of anticoagulation following short duration atrial arrhythmia and anatomic lung resection. We hypothesized that the risk of embolic event following episodes of atrial fibrillation (AF) lasting less than 48 hours is low and even with an elevated CHA2DS2-VASC score should not incur the risk of long-term full dose anticoagulation contrary to recommendations. Design & Intervention A retrospective review was performed of a prospectively maintained database of all patients undergoing anatomic lung resection at a single institution from 2014 to 2019. Patients who had new onset post-operative atrial fibrillation (POAF) were queried as to their co-morbidities, the length of arrhythmia, discharge with anticoagulation, and any post-operative embolic events. Main Outcome Measures There were 565 patients who underwent anatomic lung resection. 40 patients (7.1%) developed new POAF that lasted a median of one day. In 32 patients (80%), POAF lasted for less than 48 hours. There were 28 males and 12 females, median age of 73 years. These patients underwent segmentectomy (2/40), lobectomy (24/40) and pneumonectomy (14/40). Twenty-nine patients were discharged home without anticoagulation. Median follow-up was 22 month (range 1.3 – 62.8 month). Two patients had embolic events and these two were discharged home without anticoagulation. The overall incidence rate of thromboembolic events was 3.2% per person year. Conclusions Our data suggest that the risk of arterial embolic events is low in patients with new, short duration atrial fibrillation post anatomical lung resection. Anticoagulation may not be necessary in these patients and can be given selectively.

Abstract P617: Ischemic Strokes in Patients With Atrial Fibrillation: The Neuro-AFib Study

Background: An estimated 150,000 atrial fibrillation (AF) patients suffer an ischemic stroke (IS) annually in the US. Understanding the frequency/causes of underuse and failures of current FDA-approved preventive methods in patients with known AF may reduce stroke risk and related death/disability. Methods: The Neuro-AFib study is a multicenter effort geared toward elucidating the causes and consequences of IS and hemorrhagic stroke (HS) in a contemporary AF cohort. The retrospective phase of the study is underway, aiming to obtain detailed clinical, laboratory and multimodal neuro- and cardiac imaging data from ~9,000 AF patients admitted to 30 US academic stroke centers with an IS or HS between 1/2018-12/2019. Clinical data of IS admissions from 12 sites will be discussed. Disability is defined as a modified Rankin Score (mRS) 3-5, outcomes are from the time of hospital discharge. Results: A total of 3944 AF patients presented with an IS, mean age was 76.8 + 12, and 50.2% were female. AF was diagnosed prior to IS in 78% of patients. Data on prestroke antithrombotic usage, embolic risk scores, clinical stroke severity and outcomes are presented in the FIGURE. Conclusions: Preliminary results from the Neuro-AFib study show high rates of underuse of approved stroke prevention measures (54%) and anticoagulant failures (46%) that result into IS even in known AF patients. Relatively high rates of pre-stroke AF detection failures were also noted (22%). Death/disability rates were high in all of these AF-related IS patients ( > 69%). Detailed data collection focused on imaging and lab markers of stroke risk from this contemporary cohort will be ready to be presented during ISC 2021.

Prognostic value of pro-adrenomedullin and copeptin in acute infective endocarditis

Background Infective endocarditis (IE) is a life-threatening disease whose prognosis is often difficult to predict based on clinical data. Biomarkers have been shown to favorably affect disease management in a number of cardiac disorders. Aims of this retrospective study were to assess the prognostic role of procalcitonin (PCT), pro-adrenomedullin (pro-ADM) and copeptin in IE and their relation with disease characteristics and the traditional biomarker C-reactive protein (CRP). Methods We studied 196 patients with definite IE. Clinical, laboratory and echocardiography parameters were analyzed, with a focus on co-morbidities. PCT, pro-ADM and copeptin were measured on stored plasma samples obtained on admission during the acute phase of the disease. Results Pro-ADM and copeptin were significantly higher in older patients and associated with prior chronic kidney disease. Pro-ADM was an independent predictor of hospital mortality (OR 3.29 [95%C.I. 1.04–11.5]; p = 0.042) whilst copeptin independently predicted 1-year mortality (OR 2.55 [95%C.I. 1.18–5.54]; p = 0.017). A high PCT value was strictly tied with S. aureus etiology (p = 0.001). CRP was the only biomarker associated with embolic events (p = 0.003). Conclusions Different biomarkers correlate with distinct IE outcomes. Pro-ADM and copeptin may signal a worse prognosis of IE on admission to the hospital and could be used to identify patients who need more aggressive treatment. CRP remains a low-cost marker of embolic risk. A high PCT value should suggest S. aureus etiology.

The Multifaceted Interplay between Atrial Fibrillation and Myocardial Infarction: A Review

This review was conducted to emphasize the complex interplay between atrial fibrillation (AF) and myocardial infraction (MI). In type 1 (T1) MI, AF is frequent and associated with excess mortality. Moreover, AF after hospital discharge for T1MI is not rare, suggesting the need to improve AF screening and to develop therapeutic strategies for AF recurrence. Additionally, AF is a common trigger for type 2 MI (T2MI), and recent data have shown that tachyarrhythmia or bradyarrhythmia could be a causal factor in, respectively, 13–47% or 2–7% of T2MI. In addition, AF is involved in T2MI pathogenesis as a result of severe anemia related to anticoagulants. AF is also an underestimated and frequent cause of coronary artery embolism (CE), as a situation at risk of myocardial infarction with non-obstructive coronary arteries. AF-causing CE is difficult to diagnose and requires specific management. Moreover, patients with both AF and chronic coronary syndromes represent a therapeutic challenge because the treatment of AF include anticoagulation, depending on the embolic risk, and ischemic heart disease management paradoxically includes antiplatelet therapy.

What do we do about atrial high rate episodes?

Atrial high rate episodes (AHREs) are defined as asymptomatic atrial tachyarrhythmias detected by cardiac implantable electronic devices with atrial sensing, providing automated continuous monitoring and tracings storage, occurring in subjects with no previous clinical atrial fibrillation (AF) and with no AF detected at conventional electrocardiogram recordings. AHREs are associated with an increased thrombo-embolic risk, which is not negligible, although lower than that of clinical AF. The thrombo-embolic risk increases with increasing burden of AHREs, and moreover, AHREs burden shows a dynamic pattern, with tendency to progression along with time, with potential transition to clinical AF. The clinical management of AHREs, in particular with regard to prophylactic treatment with oral anticoagulants (OACs), remains uncertain and heterogeneous. At present, in patients with confirmed AHREs, as a result of device tracing analysis, an integrated, individual and clinically-guided assessment should be applied, taking into account the patients’ risk of stroke (to be reassessed regularly) and the AHREs burden. The use of OACs, preferentially non-vitamin K antagonists OACs, may be justified in selected patients, such as those with longer AHREs durations (in the range of several hours or ≥24 h), with no doubts on AF diagnosis after device tracing analysis and with an estimated high/very high individual risk of stroke, accounting for the anticipated net clinical benefit, and informed patient’s preferences. Two randomized clinical trials on this topic are currently ongoing and are likely to better define the role of anticoagulant therapy in patients with AHREs.