Background After a cryptogenic stroke, long-term monitoring is recommended to start an anticoagulation therapy in patients with at least a documented paroxysm of subclinical atrial fibrillation (AF). Literature is sparse about the recurrence of AF (AF burden) after a cryptogenic stroke, but this might have significant implications in terms of therapeutic strategy. Methods This is a retrospective single-center study of 129 patients who received implantable loop recorders (ILRs), after a cryptogenic stroke, between March 2015 and March 2022. All patients were followed through remote monitoring for at least 6 months. The primary endpoint was AF detection; the secondary endpoints were the AF burden, the earliness (within or after 90 days from the ILR implant) of the first AF episode and if there was an association between these two variables. Results Mean age was 70.3 ± 10.4 years old (67 males, 51.9%); the mean value of left ventricular ejection fraction was 61% ± 5.8. Atrial fibrillation has been detected by ILR in 40.3% of patients (AF= 52 patients, NO AF= 77 patients) and each intracardiac electrogram was visually reviewed by two physicians. Median CHAD2S2-Vasc Score was 5 [4-6]; the median AF burden (assessed in 39 of the 52 patients) was 1.2% [0.1%-14.6%]; among these, 23 patients (59%) had the first episode within 90 days from the ILR implant versus 16 patients (41%) which experienced the first episode later than 90 days. AF burden was significantly higher in the first group (median 3.9% [1.2%-30.9%] vs 0.1% [0.03%-0.75%]; p=0.001). Of note the univariate analysis showed that both detection of the first AF episode within 90 days and echocardiographic findings of atrial disease (atrial dilation or diastolic dysfunction) were significantly associated with AF burden > 1% (about 7 hours for month) (respectively OR 16.5; 95% IC=3.34-81.21, p=0.001 and OR 4.5; 95% IC=1.2-17.5, p=0.03); at the multivariate analysis the significance was confirmed for the earliness of the first AF episode (OR 14.6; 95% IC=2.8-76.75, p=0.002). Conclusion In this small, retrospective study, AF was detected by ILR, after a cryptogenic stroke, in more than one third of patients. AF onset during the first 90 days might be a marker of a high AF burden and might highlight patients who could benefit from a rhythm control strategy of AF. Larger studies and clinical outcomes evaluation of these patients are required to confirm our results.

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An 80-year-old woman was electively hospitalized at our institution to undergo transcatheter aortic valve replacement (TAVR) for severe aortic valve stenosis symptomatic for exertional dyspnoea (NYHA III). At the admission she presented a normal electrocardiogram (EKG), a creatinine clearance (CrCl) of 36 ml/min, a normal size and hypertrophic left ventricle with a preserved ejection fraction (EF 70%). A pre-procedure coronary angiography was performed and showed absence of significant epicardic stenoses. A balloon-expandable valve (Edwards Sapien 26 mm) was successfully implanted via the trans-femoral access without intra-procedural complication and the patient was transferred to cardiology ward for monitoring; in the post-procedure, the patient complained of nausea and a feeling of vomiting, without other cardiologic symptoms; she had low blood pressure (BP 95/70 mmHg) with normal heart rate and oxygen saturation (Killip 1). An EKG was performed and showed a ST-elevation in antero-lateral leads, so a bed-side echocardiogram was performed showing a good function of TAVR but an ipo-akinesia of the left ventricle’s lateral wall. The patient was transferred to the Cath lab and at the emergent coronary angiography no clear epicardic stenoses were seen, with a diffuse narrowing of an early obtuse marginal (OM) branch and of the distal branches of circumflex artery, suggestive for a spasm, that was refractory to repeated nitroglycerine infusions. A clear mismatch between coronary angiogram findings and EKG was detected. Considering the hemodynamic compromise and symptoms persistence a percutaneous transluminal coronary angioplasty of OM was performed with a partial ST resolution. The patient was transferred to the Coronary Unit Care where an echocardiogram was repeated confirming the good function of TAVR but outlining the presence of a voluminous intramural haematoma (>30 mm of maximum diameter) with anterior, lateral and posterior wall akinesia and depressed left ventricle ejection fraction (EF 35%). A conservative management of the haematoma was chosen. The hospital stay was complicated by an acute pulmonary oedema, requiring non-invasive ventilation, a cardiogenic shock, requiring inotropic (dobutamine) support, and an acute renal failure (creatinine peak 2.9 mg/dl with CrCl of 15 ml/min) with anuria, requiring continuous renal replacement therapy for two days; she developed a left branch block with no complete atrioventricular block. The pre-discharged echocardiogram showed a partially organized moderate pericardial effusion (1.3 cm) and moderate mitral regurgitation. After six months, she was asymptomatic, with a significant improvement of functional status (NYHA II) and a stable renal function (CrCl > 30 ml/min); no more echocardiographic signs of pericardial effusion were shown but the persistence of akinesia of the postero-lateral- and anterior-wall with depressed left ventricle ejection fraction (EF 37%) and moderate-severe mitral regurgitation. The persistence of good result of TAVR (aortic mean gradient 9 mmHg, absence of peri-valvular leak) was confirmed. Intramural dissecting haematoma (IDH) is a rare complication of myocardial infarction, chest trauma and percutaneous interventions; it consists of a cavity filled with blood, with the integrity of both the outer wall (myocardium and pericardium) and the inner wall (myocardium and endocardium) and it can develop in the left ventricle free wall, the right ventricle and the interventricular septum. IDH’s formation may result from intra-myocardial vessels’ rupture in the interstitial space. Never understimate nausea as symptom: think about heart is challenging but mandatory!

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