Right atrial fibromas are extremely rare in adults, as cardiac fibromas more commonly affect children and usually involve the ventricles. Accurate diagnosis and optimal management rely on a thorough assessment using advanced multimodality imaging techniques.
Background:Chronic thromboembolic pulmonary hypertension (CTEPH) is a complication of acute pulmonary embolism (PE) with an unknown incidence but estimated 10% mortality rate. While CTEPH is treatable, no consensus exists on structured surveillance after acute PE. Methods:We established a dedicated clinic within our pulmonary hypertension program to monitor patients evaluated by our PE response team. Patients were assessed 4 to 8 weeks and 3 months after acute PE and were offered right heart catheterization if imaging suggested CTEPH or persistent thromboemboli. We then conducted a retrospective review of outcomes. Results:Between July 2021 and December 2022, 80 of 185 (43%) patients evaluated by the PE response team completed both the baseline and 3-month follow-up assessments. Of these, 19 (24%) showed evidence of persistent thromboemboli on follow-up imaging. In 15 patients who completed right heart catheterization, CTEPH was confirmed in eight. Six of these patients with CTEPH underwent surgical thrombectomy, with complete resolution of pulmonary hypertension. All patients with CTEPH were alive at a median follow-up of 643 (range 487-737) days. Discussion:Our early experience shows that dedicated post-acute PE surveillance effectively identifies patients at risk for developing pulmonary hypertension, enabling timely diagnosis and treatment of CTEPH. Further evaluation is ongoing.
OBJECTIVE:Endovascular aneurysm repair (EVAR) is widely used for infrarenal abdominal aortic aneurysms, offering improved short-term outcomes compared with open repair. However, long-term durability is limited by the need for surveillance and reintervention, often related to sac growth and endoleak. Prophylactic sac embolization using shape memory polymer (SMP) plugs-a porous, bioabsorbable polyurethane scaffold designed to promote thrombosis and tissue ingrowth-has been evaluated in early feasibility studies. This study represents the first global, multicenter real-world analysis of SMP use during EVAR. METHODS:A multicenter, retrospective, two-arm computed tomography angiography (CTA)-based sac regression analysis was performed in 97 highly selected patients meeting prespecified eligibility criteria. Fifty-six patients underwent EVAR with prophylactic sac management (EVAR-PSM) using SMP between 2019 and 2023, including 31 treated prospectively in the abdominal aortic aneurysm-SHAPE early feasibility studies and 25 treated in real-world practice. Forty-one patients underwent standard EVAR between 2014 and 2019 at a single center and met identical inclusion/exclusion criteria, including aneurysm size thresholds, sac volume parameters, infrarenal stent grafts use within instructions for use, serial CTA availability, and exclusion of adjunctive branch vessel embolization. Sac regression (>10% volume reduction between 30-day and 1-year CTA) was assessed. Thrombus burden and patent accessory vessels were analyzed in all patients; packing density and plug proximity to accessory vessels were analyzed in the EVAR-PSM group. RESULTS:Hypertension was more prevalent in controls (98% vs 77%, P = .01), whereas prior myocardial infarction was less common (0% vs 17%, P = .01). In the treatment group, a mean of 59 plugs per patient were implanted, yielding a mean packing density of 129%. Sac regression >10% at 1 year occurred more frequently in the EVAR-PSM group (79% vs 51%, P < .01). Type II endoleak occurred in 40% vs 49% (P = .4), and secondary reintervention rates were similar (2.4% vs 1.8%, P < .90). No aneurysm ruptures occurred. One-year survival was similar between groups (100% vs 96%, P = .50). On multivariable analysis, SMP treatment was independently associated with sac regression (odds ratio: 4.13 [1.5-12.0], P < .01). Within the treatment group, shorter plug distance to patent branch vessels was independently associated with sac regression (odds ratio: 0.54 [0.30-0.71], P < .01), while packing density and thrombus burden were not. CONCLUSIONS:In this multicenter analysis of controlled and real-world data, prophylactic sac embolization with SMP was associated with significantly greater sac regression compared with standard EVAR. Effective sac remodeling appears influenced by plug proximity to branch vessels.
Importance Transcatheter aortic valve replacement (TAVR) is an established treatment option for many patients with severe symptomatic aortic stenosis; however, debris dislodged during the procedure can cause embolic stroke. The Sentinel cerebral embolic protection (CEP) device is approved for capture and removal of embolic material during TAVR but its efficacy has been debated. Objective To explore regional differences in the association of CEP utilization with stroke outcomes in patients undergoing TAVR. Design, Setting, and Participants This post hoc analysis of a prospective, postmarket, randomized clinical trial evaluating TAVR performed with or without the CEP took place at 51 hospitals in the US, Europe, and Australia from February 2020 to January 2022. Patients with symptomatic aortic stenosis treated with transfemoral TAVR were included. Randomization was stratified according to center, operative risk, and intended TAVR valve type. Patients were excluded if the left common carotid or brachiocephalic artery had greater than 70% stenosis or if the anatomy precluded placement of the CEP device. Data for this post hoc study were analyzed from August to October 2024. Intervention TAVR with or without CEP. Main Outcomes and Measures The primary end point was the rate of all stroke events at hospital discharge or 72 hours post-TAVR, whichever came first. Neurological examinations were performed at baseline and post procedure to identify stroke, disabling stroke, and other neurological outcomes. Results The Stroke Protection With Sentinel During Transcatheter Aortic Valve Replacement (PROTECTED TAVR) trial enrolled and randomized 3000 patients (1803 [60.1%] male; mean [SD] age, 78.9 [7.8] years): 1833 in the US cohort (TAVR alone: 919, TAVR with CEP: 914) and 1167 patients in the outside the US (OUS) cohort (TAVR alone: 580, TAVR with CEP: 587). Patients in the US cohort were younger, more predominantly male, had a lower prevalence of atrial fibrillation, and had a higher prevalence of bicuspid aortic valve, diabetes, and peripheral vascular disease compared with the OUS cohort. In the main trial, the incidence of stroke within 72 hours after TAVR or before discharge did not differ significantly between the CEP group and the control group, and there was no interaction by geographic region. In this post hoc analysis, patients treated with CEP in the US cohort exhibited a 50% relative risk reduction for overall stroke and a 73% relative risk reduction for disabling stroke compared to TAVR alone; a treatment effect on stroke risk reduction was not observed in the OUS cohort. Conclusion and Relevance The PROTECTED TAVR trial could not show that the use of CEP had a significant effect on the incidence of periprocedural stroke during TAVR. Although there was no significant interaction by geographic region, this exploratory post hoc analysis suggests a trend toward greater stroke reduction in the US cohort but not in the OUS cohort. These findings are hypothesis generating, and further research is needed to determine if regional differences in patient characteristics or procedural practices affect CEP efficacy. Trial Registration ClinicalTrials.gov Identifier: NCT04149535
