Characterization of “Super-Responders” to Cryoballoon Ablation

Background: Pulmonary Veins Isolation (PVI) is the cornerstone in the treatment of atrial fibrillation. Recurrence rate is common in the long-term followup (FU); nevertheless, some patients maintain Sinus Rhythm (SR) for more than 5 years after the index ablation. The aim of this study is characterize this kind of patients so called “super-responders”. Methods: This is a retrospective single-center study including all patients summited for cryo-balloon ablation in our hospital from January 2011 to September 2020. We investigated clinical, electrocardiographic, echocardiographic variables and those linked to the ablation procedure. A univariate and multivariate logistic regression was performed. Results: During this period, 422 patients underwent PVI; however, 193 were excluded: 21 lost in the FU, 30 got radiofrequency ablation and 142 did not reach a minimum 5 years FU. Of the 229 finally included, 85 (group 1) did not have any recurrence during the follow-up, in front of 144 (group 2) with AF recurrences. In the multivariate analysis the p wave duration: OR: 0.92; 95% CI (0.89-0.94); p <0.001, BMI kg/m²: OR: 0.74; 95% CI (0.65-0.85); p <0.001, a temperature <-40°C in all the targeted veins: OR: 3.52; 95% CI (1.45-8.54); p=0.005 and SR on the ablation index day OR: 7.29; 95% CI (1.53-34.71); p=0.012, maintained statistical significance. Conclusions: In our series the p wave duration, BMI, the presence of SR the ablation index day and achieving a temperature <-40°C in all the targeted veins, resulted as protective factors to maintain SR in the long term follow-up. An adequate selection of patients probably could improve results and optimize resources.

Day-Case Patent Foramen Ovale Closure Under Transthoracic Echocardiography and Fluoroscopic Guidance: A Safe and Cost-Effective Approach as Compared to Conventional Hospitalization

Background: Transcatheter Patent Foramen Ovale (PFO) is recommended as a therapy in secondary prevention of cryptogenic stroke. The aim of this study was to report one-year French single-center experience in PFO closure under sole Transthoracic Echocardiography (TTE) and fluoroscopy guidance performed as a day-case procedure versus a 3-day hospitalization. Methods: In 2018, all consecutive patients undergoing PFO closure for stroke were retrospectively included: 108 patients as a day-case procedure (group 1) versus 20 patients performed under a 3-day hospitalization (group 2). A comparison was performed between Occlutech and Amplatzer PFO devices and the impact on hospitalization costs was studied. Results: Occluders included Occlutech (n=81), Amplatzer (n=43), Lifetech (n=2) and PFM (n=2) PFO devices. Implantation succeeded in all. In-group 1, hospital discharge was delayed in only 3 cases. At one-month, 5 patients had Atrial Fibrillation (AF) and 91 patients (84%) had no residual shunt. In-group 2, hospital discharge was delayed in 4 patients. At one month, 1 patient had AF and no shunt was observed in 80%. In the comparative study, no significant statistical difference could be observed between Amplatzer and Occlutech devices. The one-day strategy leaded to a positive balance of 1825 euros per procedure in 2018, with a difference of 3785 euros with group 2. Conclusion: Our experience suggests that day-case PFO closure under fluoroscopy and TTE guidance is safe and effective in the majority of patients leading to a cost reduction and no increased risk of embolization.

Evaluation of Efficacy and Determining Various Factors Associated with the Effective Use of Vitamin-K Antagonist Therapy in the Indian Population

Aim: To assess the efficacy of Vitamin K antagonist to maintain stable INR in a tertiary care hospital. Methodology: All the patients who are on Vitamin K antagonists therapy for more than 6 months before the initiation of the study were included. Data, which include demographics, Personal history, medical history, medication history, Dietary habits, laboratory data (INR), and other relevant data, are collected. The laboratory results are further evaluated using the Rosendaal method and Time in Therapeutic Range, which was obtained which is evaluated, for assessing the use of medication, and other correlations were further made. Results and Discussion: The study showed a mean TTR of 25.638%, the mean TTR above and below the therapeutic range is 19.23% (±17.14), 55.11% (±29.64) respectively, this represents that the patients in the sample population are at higher risk of developing a new clot during the therapy with VKA, various chronic conditions such as Diabetes mellitus, the use of NSAIDs, PPI also showed a statistically significant difference on the patients TTR. Conclusion: Despite patients being therapeutically anticoagulated, based on the available data, many patients in the study population are at high risk of developing complications of anticoagulants and also the development of new clots even during the treatment, there are not many reports of TTR measurement in INDIAN population, The use of Vitamin K Antagonist comes with many limitations, many Newer Oral Anticoagulants (NOAC) can be used in patients as they are proven to be providing better control of TTR.

When Can a Pulmonary Embolism and Deep Vein Thrombosis Patient Fly Safely Again on Airplane? A Case Report

There was no recommendation in the current guidelines for how long after the pulmonary embolism (PE) attack the patient can fly again safely on an airplane. A 45 years old female was admitted to our hospital because of deep vein thrombosis and acute PE. Due to persistent leg swelling and afraid of recurrent PE for long distance flights, this patient received four weeks anticoagulant therapy before flying. Eventually, she flew back safely. This report describes our preliminary experience for managing this patient with deep vein thrombosis and PE.

The Effects of Combined Same Session Aerobic and Resistance Training on Physical Performance in Coronary Artery Disease Patients: Protocol Comparison

Aerobic training is included to cardiac rehabilitation programs together with resistance training. The effects of combined aerobic and resistance training performed in a same session with different protocols on peak aerobic capacity (VO2peak) and maximal dynamic strength (1RM: one repetition maximum) are not well known. We compared the effectiveness of two different combined aerobic and resistance training programs for 12 weeks performed three times in a week in stable Coronary Artery Disease (CAD) patients (n=30) who had previously performed aerobic training only. The patients were randomized to High Volume- Low Intensity Group (HLG) or Low Volume-High Intensity Group (LHG). Both groups performed laboratory controlled aerobic exercise first (60min, 80% of lactate threshold) followed by six major muscle group resistance exercises (HLG: 30-35% of 1RM, 3 sets, 12 repetitions) or (LHG: 60-70% of 1RM, 3 sets, 6 repetitions). VO2peak remained at the baseline level for whole study group (23 ± 6 vs. 24 ± 7 ml·kg-1·min-1, p=0.380) and the responses did not differ between the HLG and LHG (p=0.891). Muscle strength increased when analyzed as one group for both upper (Push Up; 24 ± 8 vs. 30 ± 7 kg, p <0.0001) and lower body (Leg Extension; 20 ± 6 vs. 27 ± 6 kg, p <0.0001) with no difference between subgroups (p=0.240 and p=0.504, respectively). As conclusion, combined aerobic and resistance training in the same training session for 12 weeks improved maximal strength independently of the intensity of resistance training. These results highlight the importance of regular resistance training, even at moderate intensity, for CAD patients in terms of physical performance and independent living.

Recurrent Episodes of ST-Elevation Myocardial Infarction in a 19-Year-Old Male with Fontan Circulation

We describe a case of a 19-year-old male with history of single ventricle physiology status post-Fontan procedure at the age of two who developed thromboembolic phenomena involving his splenic, renal and coronary arteries resulting in multiple infarcts and recurrent in-hospital acute ST-Segment Elevation Myocardial Infarction (STEMI) treated by emergent Percutaneous Coronary Intervention (PCI). This case highlights multiple aspects and challenges of managing young patients with congenital heart disease.

An Unusual Case of Pannus Formation - A Late Postoperative Complication of a Prosthetic Valve Replacement Causing Severe Cardiomyopathy

There are several well-known long-term complications following prosthetic valve replacement. Pannus formation is one of the rare complications whose estimated incidence varies between 0.3% and 1.3% per patient-year [1]. The exact etiology of pannus formation is unknown but histopathologically, pannus formation is due to fibroelastic hyperplasia that variably occurs after valve implantation [2]. The rarity and acute coronary syndrome like clinical presentation makes pannus formation a clinically important diagnosis during initial presentation. Workup preferably includes Transthoracic Echocardiography (TEE) with or without CT angiography. Management includes urgent or emergent surgical excision of the pannus with or without re-replacement of the aortic valve [1]. We present a 66-year-old female who presented with typical angina symptoms along with diffuse ischemic EKG changes five years after aortic valve replacement surgery with Trifecta Bioprosthesis due to severe aortic stenosis with Non-ST Elevation Myocardial Infarction (NSTEMI). Coronary angiography done on admission showed left main ostial stenosis of 90-95 % in proximity to the aortic valve prosthesis. A Transthoracic Echocardiogram (TTE) revealed an ejection fraction of 30-35 % with global hypokinesia but did not suggest any valve dysfunction. CT angiogram was done the next day which revealed a noncalcified plaque (pannus) greater than 75% occlusion in the left main in proximity of the aortic valve. Despite expedited care and surgical evaluation, unfortunately the patient decompensated in the surgical operating room and did not survive.

Myocardial Infarction and Three-Vessel Coronary Artery Disease as Presenting Features of Granulomatosis with Polyangiitis: A Case Report with Review of Literature

Chagas disease is a systemic infection due to Trypanosoma cruzi, a parasitic protozoan. Trypanosoma cruzi is endemic in Latin America; however, the prevalence has been increasing in the United States. The infection is mostly vector-borne secondary to triatomine or “kissing” bug bites. However, the infection can also spread via organ transplantation, blood transfusion, or transplacentally resulting in congenital manifestations. Chronic Chagas disease can cause cardiac or gastrointestinal complications that may be irreversible if left untreated. Major cardiac complications include dilated cardiomyopathy, arrhythmias, sudden cardiac death, and thromboembolism.