BACKGROUND:The left atrial appendage (LAA) is the predominant site of thrombus formation in atrial fibrillation. Current percutaneous LAA occlusion devices require permanent implants. A catheter-based, non-implant mechanical inversion strategy may offer an alternative approach to stroke prevention. OBJECTIVES:To assess the feasibility of vacuum-assisted catheter-based inversion of the LAA using transseptal aspiration in a swine model. METHODS:A 59-kg domestic swine underwent transseptal access via the right femoral vein under fluoroscopy, transesophageal echocardiography (TEE), and intracardiac echocardiography (ICE). A 22-F aspiration catheter was advanced into the left atrium and positioned at the LAA apex. Negative pressure was generated manually with a 60-mL syringe attached to the aspiration port, and sequential suction-traction maneuvers were performed to induce LAA inversion. Procedural feasibility, hemodynamic stability, imaging changes, and gross pathology were assessed. RESULTS:LAA suction and inversion were feasible. Sequential negative pressure applications resulted in complete inversion, confirmed by multiplane TEE. A mild, non-hemodynamically significant pericardial effusion occurred. Necropsy showed focal apex injury consistent with catheter stiffness and suction forces. CONCLUSIONS:Catheter-based vacuum-assisted LAA inversion was technically feasible in this acute swine experiment. However, chronic survival studies are required to evaluate durability of inversion, tissue healing, thrombogenicity, and long-term safety before clinical translation can be considered.

Background The left atrial appendage (LAA) is the primary source of thrombus formation in atrial fibrillation. Mechanical exclusion of the LAA using occlusion devices can prevent embolic stroke but requires permanent implants and may lead to device-related complications. Mechanical inversion of the LAA represents a potential non-implant alternative, but whether this can be achieved using a fully percutaneous, catheter-based approach is unknown. Objectives To evaluate the feasibility of catheter-based, vacuum-assisted LAA inversion using a transseptal aspiration system in a large-animal model. Methods A 59-kg domestic swine underwent transseptal access via the right femoral vein under fluoroscopy, transesophageal echocardiography (TEE), and intracardiac echocardiography (ICE). A 22-F aspiration catheter was advanced into the left atrium and positioned at the LAA apex. Negative pressure was generated manually with a 60-mL syringe attached to the aspiration port, and sequential suction–traction maneuvers were performed to induce LAA inversion. Procedural feasibility, hemodynamic stability, imaging changes, and gross pathology were assessed. Results Transseptal access, catheter positioning, and suction delivery were feasible. Complete LAA inversion into the left atrium was achieved after four suction attempts and confirmed by TEE. A mild pericardial effusion developed, likely related to contact between the stiff catheter tip and the thin appendage wall, but it was not hemodynamically significant. Necropsy demonstrated a discolored ring consistent with localized tissue injury and a small perforation at the LAA apex. Conclusions This first-in-animal feasibility study demonstrates that vacuum-assisted catheter-based inversion of the LAA is technically achievable using current-generation aspiration systems. Although preliminary safety limitations were identified, the findings support further refinement of dedicated, atraumatic aspiration catheters and justify chronic survival and design-optimization studies. A catheter-based, non-implant LAA inversion strategy may represent a future alternative for stroke prevention in patients with atrial fibrillation.

Introduction: Sepsis is one of the oldest and most elusive syndromes in Medicine.The clinical manifestations of sepsis are highly variable, depending on the initial site of infection, the causative organism, the pattern of acute organ dysfunction, the underlying health status of the patient, and the interval before initiation of treatment.Aim of this study: To observe the clinical and laboratory profile of patients with sepsis & severe sepsis as well as hospital mortality at the end of the 1 st week.Method: It was hospital based cross sectional, observational study and was carried out in the Department of Medicine, Dhaka Medical College Hospital (DMCH) during the period of January 2015 to December 2015.Patients admitted in the intensive care unit (ICU) of DMCH, who fulfilled the criteria of sepsis or severe sepsis and aged more than 14 Years, among them 100 patients were enrolled in the study.Data from each patient was collected in structured data sheets.Finally, all data compiled and statistical analysis was carried out by using IBM SPSS Statistics 22.0 (IBM Inc, Chicago, Illinois, USA).Result: Among 100 patients, 35% were in sepsis group and 65% were in severe sepsis group.Fever was present in 97.1% cases, Heart rate > 90 beats/min in 82.9%, Tachypnea in 37.1%, edema 5.7%, Hyperglycemia in 25.7%, Arterial hypoxemia in 22.9%, Leukocytosis in 88.65% and Plasma C-reactive protein was 94.3%.Sepsis induced arterial hypotension was 40%, Hyperlactataemia was 44.6%, Acute oliguria was 18.5%, Acute lung injury with Pao2/Fio2 < 200 in the presence of pneumonia as infection source was 16.9%, Creatinine > 2.0 mg/dL was 23.1%, Serum bilirubin > 2 mg/dL was in 7.7%, Thrombocytopenia was 38.5% and Coagulopathy was 21.5%.Correlation of GCS score at seventh day with initial AMT score appeared to be particularly strong (Rs = 0.663, P<0.001).Blood Culture was positive in 8.2% only.Whereas Throat Swab culture is positive in 83.3% cases.Systemic hypotension (P=0.004),Hyperlactataemia (P=<0.001),Thrombocytopenia (P=0.020),Coagulation abnormalities (P=<0.001)differed significantly between survivor and non-survivor group.The female mortality was more (27.27%) in severe sepsis group.Conclusion: This study will help the caregiver doctor to think in a systematic way for avoiding diagnostic delay and also highlights comparative values of different clinical and laboratory parameters.Statistical models can be developed based on similar clinical and laboratory variables that may help to develop criteria to predict different outcomes.

Background Percutaneous closure (LAAC) of the left atrial appendage (LAA) is an efficacious preventive procedure for patients with non-valvular atrial fibrillation (NVAF) and considerable bleeding risk. We sought to systematically review the available LAAC data on the novel occluder device LAmbre™. Methods For this systematic review, a search of the literature was conducted by 3 independent reviewers, reporting the safety and therapeutic success of LAAC in patients being treated with a LAmbre™. Publications reporting the safety and therapeutic success of LAAC using LAmbre™ in n > 5 patients were included. Results The literature search retrieved n = 10 publications, encompassing n = 403 NVAF patients treated with a LAmbre™ LAAC, with relevant data regarding safety and therapeutic success of the procedure. The mean CHA 2 DS 2 -VASc Score was 4.0 + 0.9, and the mean HAS-BLED score was 3.4 + 0.5. The implantation success was 99.7%, with a mean procedure time of 45.4 ± 18.7 min, and a fluoroscopy time of 9.6 ± 5.9 min, and a contrast agent volume of 96.7 ± 0.7 ml. The anticoagulation regimen was switched to DAPT post procedure in the majority of the patients (96.8%). Partial and full recapture were done in 45.5% and in 25.6%, respectively. Major complications were reported in 2.9%, with 0.3% mortality, 1.7% pericardial tamponade, 0.3% stroke, and 0.6% major bleeding complications; no device embolization was observed. During follow up at 6 or 12 months, major adverse cardiovascular events were reported in 3.3%: Stroke or TIA in 1.7%, thrombus formation on the device in 0.7%, and residual flow > 5 mm in 1.0%. In some publications, the favorable implantion properties of the LAmbre™ for difficult anatomies such as shallow or multilobular LAA anatomies were described. Conclusions This systematic review on the LAmbre™ LAA-occluder including n = 403 NVAF patients demonstrates an excellent implantion success rate, promising follow-up clinical data, and favorable properties for also challenging LAA anatomies,. While its design seems to be helpful in preventing device embolization, pericardial tamponade may not be substantially reduced by the LAmbre™ as compared with other established LAAC devices. Further larger prospective multicenter registries and randomized trials are needed to scrutinize the value of the LAmbre™ compared with established LAAC devices.

Background Hemodynamic monitoring is an integral part of a cardiac catheterization procedure; however it is prone to many distortions, including damping and resonance [1]. Objectives We sought to compare damping ratio, ascending aortic pressure waveform and invasive blood pressure between Manifold and ACIST CVi® devices in subjects undergoing cardiac catheterization. Methods This prospective randomised, single-blind, cross-over study was conducted in 81 adults subjects (mean age 59.2 ± 12, 24% females) undergoing cardiac catheterization. The fast-flush test [2] was performed at the beginning of the procedure with both Manifold and ACIST. The square wave was analysed to calculate the damping coefficient. Data analyzed by JMP Pro (SAS for Windows, Version 13) p < 0.05 considered significant. Results The mean damping ratio was 0.63 ± 0.11 (range 0.34–0.95) with Manifold vs. 0.94 ± 0.25 (range 0.53–2.1) with ACIST, mean difference 0.30, p < 0.0001. The pressures were significantly different between the two devices; systolic –2.85 ( p < 0.05); diastolic –5.2 ( p < 0.0001) and mean pressure 3.5 ( p < 0.01), mmHg. The inter-device BP difference showed a wide scatter; systolic, –24 to +67; diastolic, –44 to +25 and mean pressure, –24 to +54 mmHg. Conclusions To the best of our knowledge, this is the first study comparing a manual haemdynamic monitoring system to an automated one commonly used in the cardiac cath lab. The Manifold meets the international recommendations for accurate haemodynamic monitoring, compared with an overdamped ACIST which also underestimated pressures in our study. Manifold may be the preferred device for haemodynamic monitoring, particularly patients haemodynamically unstable, with cardiomyopathies and valvular heart disease.

Background Alcohol septal ablation (ASA) is an established interventional treatment for hypertrophic obstructive cardiomyopathy (HOCM) patients with drug refractory symptoms. This study investigated the prognostic value of cardiopulmonary exercise test (CPET) in relation to the late clinical outcome. Methods Twenty-one (21) HOCM patients underwent CPET before and 3 months after ASA and were followed yearly thereafter. Clinical success was considered to be a decrease of >= 1 (New York Heart Association or Canadian Cardiovascular Society) functional class. Cardiopulmonary exercise test parameters [maximal oxygen uptake (PeakVO(2)), % predicted VO2 (PeakVO(2)%), oxygen uptake at anaerobic threshold (AT), maximal workload (W), % predicted W (W%), ventilation (VE), % predicted VE (VE%), ventilation to maximal carbon dioxide production slope (VE/VCO2), % predicted maximal heart rate (HR%), and maximal systolic blood pressure (SBP)] were compared before and 3 months after ASA. Results After follow-up of 29 +/- 13 months, 16 patients had a good clinical results (clinical responders), while five did not improve (clinical non-responders). The CPET parameters did not change in non-responders, while clinical responders showed significant improvement in VO2, VO2%, W, VE/VCO2, VE, VE%, as well as an increase in HR% and SBP at 3 months. Conclusions The data confirmed a good association between the improvement in CPET parameters and the clinical results 3 months after ASA. This may therefore serve as an early marker of HOCM-ASA treatment success.

Although the incidence of acute myocardial infarction and in-hospital mortality after ST-elevation myocardial infarction (STEMI) has declined substantially in countries that have established primary percutaneous coronary interventions (pPCI) over the past two decades, coronary artery disease remains a major cause of morbidity and mortality worldwide. We aimed to examine whether the direct transfer of STEMI patients to the cardiac catheterization laboratory (CCL) had a prognostic effect on in-hospital mortality in patients who underwent pPCI after STEMI.

Treatment of left ventricular outflow tract (LVOT) obstruction in hypertrophic obstructive cardiomyopathy (HOCM) with septal reduction, either with myectomy or alcohol septal ablation, is aiming to reduce the LVOT gradient and improve symptoms in patients who are refractory to or do not tolerate medical treatment. Apart from contributing to the evolution to heart failure, LVOT obstruction is considered a risk factor for sudden cardiac death (SCD). Both septal reduction treatments have been proven effective in reducing symptoms and seem to improve survival, which has been shown equal to the expected in the normal population. SCD is probably reduced after septal reduction, implying that LVOT obstruction is a major factor predisposing to ventricular tachyarrhythmias. Although available algorithms for SCD stratification have not been tested in patients after septal reduction treatments, effective treatment improves SCD risk profile substantially. Furthermore, high-risk patients with already implanted implantable cardioverter defibrillators (ICDs) before septal reduction show very low appropriate ICD shock rate after effective treatment. It should be noted, however, that the best outcomes for septal myectomy or ablation have been reported in HOCM patients treated in high-volume centres, which substantiates the need to refer patients to centres with high procedural expertise.

Takotsubo syndrome (TTS) is an acute and mostly reversible cardiomyopathy that mimics an acute coronary syndrome with left ventricular (LV) systolic dysfunction without relevant obstructive coronary artery disease. Its prevalence is probably underestimated and reaches 1.2–2% in patients with acute coronary syndrome undergoing coronary catheterization. Although supraphysiological epinephrine levels have been associated with TTS, the detailed pathophysiology is incompletely understood. Chest pain is the most common clinical presentation; however, cardiac decompensation, cardiogenic shock, and sudden cardiac death due to ventricular fibrillation may also be the first clinical manifestations. Patients are mostly postmenopausal women, in whom the condition is commonly associated with emotional triggers; however, men have a higher prevalence of TTS being associated with physical triggers, which has a worse prognosis compared with TTS associated with emotional triggers. As a diagnosis of exclusion, TTS has no single definitive diagnostic test. According to the distribution of LV wall motion abnormalities, various morphological subtypes have been identified. The final diagnosis depends on cardiac imaging with left ventricular angiography during acute heart catheterization, as well as on echocardiography and cardiac magnetic resonance. Most patients recover completely, albeit several factors have been associated with worse prognosis. Management is based on observational data, while randomized multicenter studies are still lacking. This review provides a general overview of TTS and focuses on the hypothesized pathophysiology, and especially on current practices in diagnosis, prognosis, and treatment.

Amyloidosis is caused by extracellular deposition of insoluble abnormal fibrils constituted by misfolded proteins, which can modify tissue anatomy and hinder the function of multiple organs including the heart. Amyloidosis that can affect the heart includes mostly systemic amyloidosis (amyloid light chain, AL) and transthyretin amyloidosis (ATTR). The latter can be acquired in elderly patients (ATTRwt), or be inherited in younger individuals (ATTRm). The diagnosis is demanding given the high phenotypic heterogeneity of the disease. Therefore, “red flags,” which are suggestive features giving support to diagnostic suspicion, are extremely valuable. However, the lack of broad awareness among clinicians represents a major obstacle for early diagnosis and treatment of ATTR. Furthermore, recent implementation of noninvasive diagnostic techniques has revisited the need for endomyocardial biopsy (EMB). In fact, unlike AL amyloidosis, which requires tissue confirmation and typing for diagnosis, ATTR can now be diagnosed noninvasively with the combination of bone scintigraphy and the absence of a monoclonal protein. Securing the correct diagnosis is pivotal for the newly available therapeutic options targeting both ATTRm and ATTRwt, and are directed to either stabilization of the abnormal protein or the reduction of the production of transthyretin. The purpose of this article is to review the contemporary aspects of diagnosis and management of transthyretin amyloidosis with cardiac involvement, summarizing also the recent therapeutic advances with tafamidis, patisiran, and inotersen.

Transcatheter alcohol septal ablation (ASA) treatment of symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM) is based on the existence and degree of intraventricular obstruction. Patients with significant gradient and symptoms who do not respond to optimal medical therapy are eligible to gradient reduction through a surgical (septal myectomy) or a transcatheter (alcohol septal ablation) septal reduction. The latter encompasses occlusion of a septal branch perfusing the hypertrophied septum, which is involved in the generation of obstruction, by injecting ethanol into the supplying septal branch(es). ASA has been established as a highly effective and safe method and has outnumbered the surgical gold standard. Although the technique is straightforward, patient selection and some technical details may influence the efficacy and safety of the procedure. The technique is based on echocardiographic contrast guidance, which allows accurate target septal branch selection and optimisation of the result. Published long-term results from high-volume centres have confirmed the effectiveness of ASA and have shown excellent survival, which is comparable to that in the general population. Choice and performance of the surgical or interventional treatment should be implemented in highly specialised centres in terms of a heart-team approach, taking notice of anatomic characteristics as well as comorbidities. Involvement of all cases in international registries may reveal the individual merits and indications for the surgical and interventional treatment in HOCM.

Acute myocardial infarction (AMI) is the main cause of global and in-hospital mortality in patients with cardiovascular diseases. We aimed to examine the association between the coronary artery involved and the in-hospital mortality in patients who underwent primary percutaneous coronary intervention (pPCI) after ST segment elevation myocardial infarction (STEMI).