No abstract

Background:The role of left atrial appendage occlusion (LAAO) for atrial fibrillation patients that during oral anticoagulant therapy (OAC) suffer from ischemic events or present LAA sludge, and the best postinterventional anticoagulant regimen, need to be defined. We present our experience with a hybrid approach of LAAO+ lifelong OAC therapy in this cohort of patients.Methods: Out of 425 patients treated with LAAO, 102 underwent LAAO because, despite OAC, suffered from ischemic events or presented with LAA sludge. Patients without high bleeding risk were discharged with the aim of maintaining lifelong OAC.This cohort was then matched to a population who underwent LAAO in primary ischemic events prevention. The primary endpoint was the composite of all-cause death and major adverse cardiovascular events consisting of ischemic stroke, systemic embolism (SE), and major bleeding.Results: Procedural success was 98%, and 70% of patients were discharged with anticoagulant therapy. After a median follow-up of 47.2 months, the primary endpoint occurred in 27 patients (26%). At multivariate analyses, coronary artery disease (OR 5.1, CI 1.89-14.27, p = .003) and OAC at discharge (OR 0.29, CI 0.11-0.80, p = .017) were associated with the primary endpoint. After propensity score matching, no significant difference was found in the survival free from the primary endpoint according to the indication for LAAO (p = .19). Conclusions:In this high-ischemic risk cohort, LAAO + OAC seem a long-term safe and effective therapeutical approach, with no difference in the survival free from the primary endpoint according to the indication for LAAO in a matched cohort.

Funding Acknowledgements Type of funding sources: None. Background. Postoperative atrial fibrillation (POAF) is the most common arrhythmic complication following cardiac surgery. It may occur between the second and fourth postoperative days as acute POAF, or within 30 days as subacute POAF (sPOAF). The incidence varies from 15% to 60%, with the highest rates observed in patients undergoing valvular surgery. POAF is associated with longer hospital stay and higher thromboembolic risk, which consistently increase patients’ morbidity and mortality. Identification of high-risk categories may allow optimization of in-hospital prevention and treatment, possibly improving clinical outcomes. Aim of the study. The aim of this study was to assess the incidence of sPOAF and to identify possible predictors in patients performing Cardiovascular Rehabilitation (CR) after Cardiac Surgery (CS). Methods. A single-centre retrospective study was performed on 383 post-cardiac surgery patients hospitalised in our CR Unit for inpatient rehabilitation. The entire population was on sinus rhythm at the admission in CR and continuous monitoring with 12-lead ECG telemetry was performed during the hospital stay. We calculated the incidence of sPOAF and then evaluated the predictive value of the following variables: anamnestic data, type of cardiac intervention, clinical course in both CS and CR Unit, laboratory parameters including baseline neutrophil-to-lymphocyte ratio (NLR). Results. Median age was 65 years (63% male). sPOAF was documented in 122 cases (31.9%). Patients developing sPOAF were older [median age 69 (63-76) vs. 61 (51-70); p < 0.001)], more frequently underwent complex surgical procedures (50% vs. 36%; p = 0.009) and were known for previous episodes of atrial fibrillation (27.9% vs. 11.2%; p < 0.001). On the first day after surgery (T1), sPOAF group showed higher values of glycemia [median 155 (126.5–186.8) vs. 129 (106.5–164); p < 0.001] and troponin T [median 721.5 (470.1–1084.3) vs. 488 (301.6-776.2); p < 0.001]. The multivariate analysis identified advanced age (OR 1.04, 95% CI 1.01-1.08; p = 0.023), acute POAF in the Cardiac Surgery Unit (OR 3.51, 95% CI 1.62-7.59; p = 0.001), baseline NLR (OR 1.46, 95% CI 1.10-1.93; p = 0.008) and T1-troponin > 552 ng/L (OR 4.16 95% CI 1.50-11.53; p = 0.006) as independent risk predictors of sPOAF during the CR period. Conclusions. sPOAF is common after cardiac surgery occurring in 31.9% of patients during CR. Age, acute POAF, baseline NLR and elevated troponin T on the first postoperative day were shown predictors of increased sPOAF risk. Recognition of new predictors of POAF could be helpful to better stratify patients, improving management strategies and outcomes.

BackgroundPercutaneous left atrial appendage occlusion (LAAO) presents many technical complex features, and it is often performed under the intraprocedural surveillance of a product specialist (PS). Our aim is to assess whether LAAO is equally safe and effective when performed in high-volume centers without PS support.MethodsIntraprocedural results and long-term outcome were retrospectively assessed in 247 patients who underwent LAAO without intraprocedural PS monitoring between January 2013 and January 2022 at three different hospitals. This cohort was then matched to a population who underwent LAAO with PS surveillance. The primary end point was all-cause mortality at 1 year. The secondary end point was a composite of cardiovascular mortality plus nonfatal ischemic stroke occurrence at 1 year.ResultsOf the 247 study patients, procedural success was achieved in 243 patients (98.4%), with only 1 (0.4%) intraprocedural death. After matching, we did not identify any significant difference between the two groups in terms of procedural time (70 ± 19 min vs. 81 ± 30 min, p = 0.106), procedural success (98.4% vs. 96.7%, p = 0.242), and procedure-related ischemic stroke (0.8% vs. 1.2%, p = 0.653). Compared to the matched cohort, a significant higher dosage of contrast was used during procedures without specialist supervision (98 ± 19 vs. 43 ± 21, p < 0.001), but this was not associated with a higher postprocedural acute kidney injury occurrence (0.8% vs. 0.4%, p = 0.56). At 1 year, the primary and the secondary endpoints occurred in 21 (9%) and 11 (4%) of our cohort, respectively. Kaplan–Meier curves showed no significant difference in both primary (p = 0.85) and secondary (p = 0.74) endpoint occurrence according to intraprocedural PS monitoring.ConclusionsOur results show that LAAO, despite the absence of intraprocedural PS monitoring, remains a long-term safe and effective procedure, when performed in high-volume centers.

Background Postoperative atrial fibrillation (POAF) is the most frequent arrhythmic complication following cardiac surgery (occurring in up to one third of patients). It may develop between the second and fourth postoperative days (acute POAF) as well as later, within 30 days after surgery (subacute). Episodes of atrial fibrillation in the subacute phase (sPOAF) are associated with an increase in morbidity, length of hospital stay and several complications both in the mid- and long- term. Therefore, POAF is not just an acute event but it may impact on long term clinical outcomes. Aim of the study The aim of this study was to identify the clinical predictors of postoperative atrial fibrillation in the subacute phase (sPOAF) in patients performing Cardiovascular Rehabilitation (CR) after cardiac surgery. Materials and methods A retrospective study was conducted on 737 post-surgical valvular patients (median age 62 years; 55,4% male) hospitalised in our Unit for in-patient CR program. During all the hospital stay patients received continuous monitoring with 12-lead ECG telemetry. We evaluated the predictive value of anamnestic data, the type of cardiac surgery intervention, the clinical course in the Cardiac Surgery Unit and in the CR Unit, the 6 minutes-walking tests (6MWT) parameters and main blood tests on sPOAF onset. Results SPOAF was documented in 170 patients (23,1%). Those who developed sPOAF were older [median 66 (56–74) years vs median 61 (50–70) years; p<0,001), had a history of atrial fibrillation prior to surgery (29,4% vs 16,2%; p<0,001), had a worse functional result at the 6MWT at the admission in CR Unit [median 250 (180–320) vs median 275 (210–370); p=0,015], had higher values of neutrophil-lymphocite ratio at baseline [median 2,33 (1,84–3,27) vs median 2,17 (1,64 - 2,87); p=0,027] when compared to those who did not develop POAF. At the multivariable logistic regression analysis, the occurrence of POAF in the acute phase (OR 2,916; 95% CI 2,011–4,228; p<0,001), advanced age (OR 1,027; 95% CI 1,01–1,044; p=0,002), previous history of atrial fibrillation (OR 1,652; 95% CI 1,068–2,555; p=0,024), higher values of NLR at baseline (OR 1,144; 95% CI 1,028–1,272; p=0,013) and mitral valve surgery (OR 1,632, 95% CI 1,075–2,480; p=0,022) were found to be independent predictors of sPOAF after cardiac surgery. Conclusions Atrial fibrillation is a common complication after cardiac surgery with great clinical relevance. Advanced age, previous history of AF, higher values of NLR at baseline, mitral valve surgery and the occurrence of POAF in the acute phase were shown to be predictors of sPOAF in a cardiac surgery population during the rehabilitation period. Funding Acknowledgement Type of funding source: None