Giuseppe Santarpia

Efficacy and Safety of Non-Vitamin K Antagonist Oral Anticoagulants versus Vitamin K Antagonist Oral Anticoagulants in Patients Undergoing Radiofrequency Catheter Ablation of Atrial Fibrillation: A Meta-Analysis

Background Use of the non-vitamin K antagonist oral anticoagulants (NOACs) is endorsed by current guidelines for stroke prevention in patients with atrial fibrillation (AF). However efficacy and safety of NOACs in patients undergoing catheter ablation (RFCA) of AF has not been well established yet. Objectives To perform a meta-analysis of all studies comparing NOACs and vitamin K antagonist oral anticoagulants (VKAs) in patients undergoing RFCA. Data Sources Studies were searched for in PubMed and Google Scholar databases. Study Eligibility Criteria Studies were considered eligible if: they evaluated the clinical impact of NOACs versus VKAs; they specifically analyzed the use of anticoagulants during periprocedural phase of RFCA; they reported clinical outcome data. Study Appraisal and Synthesis Methods 25 studies were selected, including 9881 cases. The summary measure used was the risk ratio (RR) with 95% confidence interval (CI). The random-effects or the fixed effect model were used to synthesize results from the selected studies. Results There was no significant difference in thromboembolic complications (RR 1.39; p=0.13). Bleeding complications were significantly lower in the NOACs-treated arm as compared to VKAs (RR=0.67, p<0.001). Interestingly, a larger number of thromboembolic events was found in the VKAs-treated arm in those studies where VKAs had been interrupted during the periprocedural phase (RR=0.68; p=ns). In this same subgroup a significantly higher incidence of both minor (RR=0.54; p=0.002) and major bleeding (RR=0.41; p=0.01) events was recorded. Conversely, the incidence of thromboembolic events in the VKAs-treated arm was significantly lower in those studies with uninterrupted periprocedural anticoagulation treatment (RR=1.89; p=0.02). Limitations As with every meta-analysis, no patients-level data were available. Conclusions and Implications The use of NOACs in patients undergoing RFCA is safe, given the lower incidence of bleedings observed with NOACs. On the other side, periprocedural interruption of VKAs and bridging with heparin is associated with a higher bleeding rate with no significant benefit on onset of thromboembolic events.

Impact of increased transmitral gradients after undersized annuloplasty for chronic ischemic mitral regurgitation

BACKGROUND Recent studies have demonstrated that undersized ring mitral annuloplasty (URMA) for chronic ischemic mitral regurgitation (CIMR) can induce iatrogenic mitral stenosis. The impact of this functional mitral stenosis on clinical and echocardiographic results is not well established. METHODS 125 consecutive URMA for CIMR were dichotomized according to postoperative mean trans-mitral gradient (Δp) into Group A (61 patients, >5 mm Hg) and Group B (64 patients, ≤5 mm Hg). Echocardiographic, clinical and functional outcomes were prospectively recorded and compared. RESULTS There were no hospital deaths. Intensive-care and hospital length of stay were comparable in the 2 groups (p=N.S.). Twenty-three months of actuarial survival was 73.2 ± 8.0%, without inter-group differences (log-rank p=0.627), actuarial freedom from congestive heart failure was 71.4 ± 5.6%, freedom from hospitalization was 59.8 ± 7.7%, without inter-group differences (p=0.497 and 0.393 respectively), and actuarial freedom from recurrent CIMR was 62.7 ± 10.4%, without group-difference (p=0.259), respectively. Both groups showed progressive improvement of NYHA (Time p=0.0001), with reduced diuretics (p=0.0001), and without inter-group differences (Group Time p=0.894 and 0.397 respectively). Both groups showed a constant improvement of left ventricular end-systolic diameters, ejection fraction, CIMR-grade, tricuspid insufficiency grading, indexed left ventricular mass, systolic pulmonary arterial pressure, and tricuspid annular plane systolic excursion (Time p=0.0001 for all), without intergroup differences (p=N.S. for all). However, left ventricular end-diastolic diameters were better remodeled in Group A (Group Time p=0.037), together with a higher mean trans-mitral Δp and a lower coaptation depth (Group Time p=0.0001 and 0.05 respectively). Left atrial diameter was ameliorated in Group B, but remained unchanged in Group A (p=0.168). CONCLUSIONS URMA cures CIMR. The induction of mild mitral stenosis did not affect clinical, functional and echocardiographic outcomes.

Neurohormonal and Echocardiographic Results After CorCap and Mitral Annuloplasty for Dilated Cardiomyopathy

BACKGROUND Restrictive mitral annuloplasty (RMA) can be an effective treatment for functional mitral regurgitation in congestive heart failure (CHF). Passive cardiac restraint is another surgical approach, but the midterm results are not well characterized. METHODS Thirty patients with functional mitral regurgitation were prospectively randomized to RMA alone or cardiac restraint with the CorCap Cardiac Support Device (Acorn Cardiovascular Inc, St. Paul, MN) and RMA. Clinical, echocardiographic, New York Heart Association (NYHA) functional class, Short Form 36-Item Health Survey (SF-36) quality of life scores, and N-terminal pro-B-type natriuretic peptide (NT-proBNP) results were analyzed. RESULTS No hospital deaths or device-related complications occurred. The two groups had comparable morbidity (p = 0.34). Echocardiography showed a trend towards a slightly better functional improvement during follow-up in CorCap plus RMA patients (between groups, p = 0.001). Both groups showed improved results for SF-36, NYHA, and NT-pro.BNP; however, CorCap plus RMA patients had significantly better SF-36 at discharge (p = 0.003), postoperative NYHA (p = 0.05), and NT-pro.BNP (p = 0.001). Survival (p = 0.46), freedom from CHF (p = 0.23), and rehospitalization (p = 0.28) were comparable. Patients in whom CHF developed after postoperative day 1 had higher NT-pro.BNP values (p = 0.001 at all time-points). CONCLUSIONS Adjunctive application of CorCap with RMA correlated with better NT-pro.BNP at short-term follow-up together with slightly improved echocardiographic and functional results. This deserves further evaluation at midterm and long-term follow-up. Reduction of NT-pro.BNP at follow-up may be suggested as a prognostic index.

The Brugada Syndrome ― From Gene to Therapy ―

It is almost a quarter of century that a pioneering work of 2 researchers named Brugada brought the entire scientific community to understanding the molecular, clinical, and electrophysiological aspects of a distinctive syndrome. It affects mainly young adults with syncope and/or sudden cardiac death caused by polymorphic ventricular tachycardia or ventricular fibrillation in the absence of any sign of cardiac degeneration or alteration. Although the involvement of the epicardial layer of the right ventricular outflow tract, and the requirement of pharmacologic challenge for unveiling concealed forms, have been fully characterized, many areas of uncertainties remain to be elucidated, such as the unpredictable usefulness of programmed ventricular stimulation, the role of radiofrequency catheter ablation for reducing ST-segment elevation, and the value of risk stratification in patients diagnosed with upper displacement of right precordial leads. How much Brugada syndrome is an intense field of research is witnessed by 4 different consensus committees that took place in a relatively short period of time considering the recent discovery of this intricate arrhythmogenic disease. The main focus of this review is to describe the milestones in Brugada syndrome from its first phenotypic and genotypic appraisals to recent achievements in electrical therapies proposed for the management of this fascinating rhythm disturbance that, despite new diagnostic and therapeutic learnings, still predisposes to sudden cardiac death.

Clinical Usefulness of a Mobile Application for the Appropriate Selection of the Antiarrhythmic Device in Heart Failure

Appropriate selection of implantable cardioverter defibrillator (ICD) or cardiac resynchronization therapy (CRT) device can be challenging in patients with left ventricular (LV) dysfunction. In this setting, limited information exists about the role of medical applications in helping physicians to choose the most useful device.

123I-mIBG imaging predicts functional improvement and clinical outcome in patients with heart failure and CRT implantation

I-metaiodobenzylguanidine (mIBG) Echocardiography Myocardial imaging Adrenergic nervous system Cardiac resynchronization therapy (CRT)

Should We Maintain Anticoagulation after Successful Radiofrequency Catheter Ablation of Atrial Fibrillation? The Need for a Randomized Study

Background Atrial fibrillation (AF) is associated with a high risk of thromboembolic stroke and oral anticoagulation therapy (OAT) is able to reduce the rate of ischemic events. Nevertheless, the actual benefit of prolonged OAT after successful radiofrequency catheter ablation (RFCA) is not clear yet. Methods Scientific investigations were assumed suitable if they assessed the clinical significance of the use of anticoagulation versus no anticoagulation in AF patients undergoing successful RFCA. The odds ratio (OR) with 95% confidence interval (CI) was used as the study summary measure. Results At meta-analysis, the rate of total thromboembolic events was not significantly different between the groups (OR 1.83, 95% CI 0.69–4.88; p = 0.221), while a lower incidence of total bleeding events in patients not treated with OAT was found (OR 6.5, 95% CI 1.93–21.86; p = 0.002). Conclusion This meta-analysis raises doubts about the net clinical benefit (NCB) of a long-term prophylactic OAT in patients with AF underwent to successful RFCA. In fact, despite similar rate of thromboembolic events, the apparent increase in bleeding risk suggests caution in prolonging OAT after RFCA. However, the lack of prospective randomized studies does not allow a comprehensive appraisal of this issue. Thus, we propose the design of a novel prospective randomized trial to evaluate the NCB of prolonged OAT after successful RFCA of AF.

Tips and tricks to implant a MitraClip in a patient with previous surgical closure of atrial septal defect

Percutaneous edge-to-edge mitral valve repair using the MitraClipdevicehasevolvedasanewtoolfortreatmentofmitralvalveregurgita-tion (MVR). The first randomized controlled trial (EVEREST II) com-pared the standard surgical repair/replacement of mitral valve versuspercutaneous repair by MitraClip and demonstrated its superior safetycomparedtosurgicalprocedure,withinferiorefficacyinMVRreduction,but similar improvements in clinical outcomes at 4 years follow-up [1].The guidelines [2,3] on the management of valvular heart disease, pub-lished in 2012 and 2014, suggested to consider percutaneous edge-to-edge mitral valve repair in patients with symptomatic severe MR, con-sidered inoperable or at high surgical risk by “heart team” and thathave a reasonable life expectancy (Class IIb). Percutaneous edge-to-edge mitral valve repair by MitraClip device using trans-septal leftheartcatheterization[4] isbecomingafirst-line treatmentfor function-alMR,whenanatomicalfeaturesaresuitable.Infact,thesepatientsusu-ally show a higher surgical risk and hospital mortality and a longerhospital stay than degenerative MR [5].We describea rarecaseof a61-year-oldmanwithsevere functionalMR, idiopathic dilatative cardiomyopathy and low ejection fraction(30%), in which the MitraClip implantation was very demanding. Healso had arterial hypertension, chronic renal failure on dialysis, moder-ate pulmonary hypertension and previous surgical closure of atrialseptum defect with direct suture. He underwent to automatedcardioverter defibrillator implantation in primary prevention and wasreferred to our hospital for a severe MVR in functional Class IV NYHA.The patients anterior chest wall revealed a well healed sternotomyscar. The results of his laboratory analysis, including metabolic profileand complete blood count, were normal, with the exception of serumcreatinineandpro-BNPlevelsthatwereelevated.TheECGshowednor-mal sinus rhythm at 78 bpm. The trans-thoracic echocardiogramshowedanincreased diameter of theleft atrium and ventricle with dif-fuse hypokinesia and severe reduction of left ventricular systolic func-tion (Simpson ejection fraction 30%); thickening of the mitral valveleaflets, annulus and subvalvular apparatus and increased diameters oftherightsectionswithslightreductionofrightventricularsystolicfunc-tion (TAPSE 14mm). The color-Doppler demonstrated a severe MR (jetarea 11 cm