A. Bhat

Percutaneous transcatheter left atrial appendage closure devices: role in the long-term management of atrial fibrillation.

OBJECTIVE Atrial fibrillation remains the most common cardiac rhythmic disorder worldwide and is associated with significant health hazards, most notably an increase in the rate of cerebrovascular events. Stroke prevention in atrial fibrillation has traditionally been managed with warfarin therapy which is encumbered by risk of bleeding, drug administration logistics and interactions as well as issues of non-compliance. Occlusion of the left atrial appendage has recently been explored as an alternative method of stroke prevention. The aim of this article is to evaluate the history, efficacy and draw-backs associated with percutaneous left atrial appendage occlusion devices in the management of atrial fibrillation. METHODS The current literature and clinical experience was used to summarise the history and evaluate the efficacy of percutaneous left atrial appendage occlusion devices. RESULTS Percutaneous left atrial appendage occlusion devices are effective novel therapies for stroke prevention in atrial fibrillation, with proven reductions in thromboembolic events in comparison with placebo and non-inferiority with warfarin therapy. Pericardial effusions and embolic strokes are primary peri-procedural adverse reactions. The rates of adverse reactions reduce with operator experience. CONCLUSIONS Percutaneous left atrial appendage occlusion is an exciting and novel therapy of stroke prevention in atrial fibrillation. Whilst further trials and long-term data are required prior to widespread implementation of this procedure, trials so far have highlighted the clinical efficacy of the procedure.

Cardiac Vignette: Giant Left Atrial Appendage Aneurysm.

BACKGROUND The left atrial appendage (LAA) is a vestigial structure located in the postero-lateral aspect of the left atrium. Aneurysmal enlargement of the LAA is pathological and can predispose to adverse events, including myocardial infarction, atrial fibrillation and systemic thromboembolism. The condition is rare and usually isolated, occurring in the absence of other cardiac defects. In this cardiac vignette, we describe a case of giant left atrial appendage in a middle aged female presenting with chest pain and explore the natural history, different investigative modalities as well as issues in clinical management of this condition.

Myocardial Viability: From Proof of Concept to Clinical Practice

Ischaemic left ventricular (LV) dysfunction can arise from myocardial stunning, hibernation, or necrosis. Imaging modalities have become front-line methods in the assessment of viable myocardial tissue, with the aim to stratify patients into optimal treatment pathways. Initial studies, although favorable, lacked sufficient power and sample size to provide conclusive outcomes of viability assessment. Recent trials, including the STICH and HEART studies, have failed to confer prognostic benefits of revascularisation therapy over standard medical management in ischaemic cardiomyopathy. In lieu of these recent findings, assessment of myocardial viability therefore should not be the sole factor for therapy choice. Optimization of medical therapy is paramount, and physicians should feel comfortable in deferring coronary revascularisation in patients with coronary artery disease with reduced LV systolic function. Newer trials are currently underway and will hopefully provide a more complete understanding of the pathos and management of ischaemic cardiomyopathy.

An Update on Renal Artery Denervation and Its Clinical Impact on Hypertensive Disease

Hypertension is a globally prevalent condition, with a heavy clinical and economic burden. It is the predominant risk factor for premature cardiovascular and cerebrovascular disease, and is associated with a variety of clinical disorders including stroke, congestive cardiac failure, ischaemic heart disease, chronic renal failure, and peripheral arterial disease. A significant subset of hypertensive patients have resistant hypertensive disease. In this group of patients, catheter-based renal artery denervation has emerged as a potential therapy, with favourable clinical efficacy and safety in early trials. Additional benefits of this therapy are also being identified and include effects on left ventricular remodeling, cardiac performance, and symptom status in congestive cardiac failure. Utility of renal denervation for the management of resistant hypertension, however, has become controversial since the release of the Symplicity HTN-3 trial, the first large-scale blinded randomised study investigating the efficacy and safety of renal artery denervation. The aim of this paper is to evaluate the history, utility, and clinical efficacy of renal artery denervation technology, including an in-depth appraisal of the current literature and principal trials.