Importance of Risk Reassessment in Patients With Atrial Fibrillation in Guidelines: Assessing Risk as a Dynamic Process

The appropriate use of oral anticoagulants (OACs) for prevention of stroke in atrial fibrillation (AF) relies on the convenient and accurate stroke risk-prediction scheme: namely, the CHA₂DS₂-VASc score. As patients with AF would become older and accumulate more comorbidities, their risks—for example, as reflected by the CHA₂DS₂-VASc scores—are not static and could increase over time. The available data demonstrated that follow-up and Δ CHA₂DS₂-VASc scores perform better than the baseline CHA₂DS₂-VASc score in the prediction of ischemic stroke. Approximately 90% of initially low-risk patients would have a Δ CHA₂DS₂-VASc score ≥ 1 before the occurrence of ischemic stroke. Apart from risk of stroke, the risk of bleeding for patients with AF is also highly dynamic. For example, the accuracies of the follow-up or Δ Hypertension, Abnormal Renal and Liver Function, Stroke, Bleeding, Labile INR, Elderly, Drugs or Alcohol (HAS-BLED) score in the prediction of major bleeding was significantly higher than that of the baseline HAS-BLED score. Most importantly, the risks of stroke and major bleeding were higher within several months after patients had changes (increases) in their stroke- or bleeding-risk scores. Therefore, risk profiles of patients with AF should be reassessed regularly so that OACs could be prescribed in a timely manner once patients are no longer at low risk for stroke, and modifiable risk factors for bleeding could be corrected. More efforts are necessary to incorporate clear and easy-to-follow recommendations about risk reassessment into the guidelines to improve AF patient care.     

Vascular Plugging for the Enlarging Pulmonary Arteriovenous Malformation in a Patient With Idiopathic Pulmonary Artery Hypertension

The coexistence of idiopathic pulmonary artery hypertension with pulmonary arteriovenous malformation (PAVM) is challenging because although the PAVM causes hypoxia and polycythemia with potential thrombotic complications, closing the PAVM increases pulmonary artery pressure. We report on a lady with PAVM and idiopathic pulmonary artery hypertension who, within 2 years of diagnosis, had an ischemic stroke, PAVM enlargement from 20 × 20 × 30 mm to 30x × 40 × 40 mm and oximetry decrease to 90%. Transcatheter occlusion of PAVM with a vascular plug was successful. A year later, she had no flow via the PAVM and systemic oximetry improved to 97%, but pulmonary vascular resistance increased to 1.5-fold of baseline.     

Epicardial Adipose Tissue Is Associated With Left Atrial Dysfunction in People Without Obstructive Coronary Artery Disease or Atrial Fibrillation

Background

Epicardial adipose tissue (EAT) is a metabolically active visceral fat depot. Although EAT volume is associated with the incidence and burden of atrial fibrillation (AF), its role in subclinical left atrial (LA) dysfunction is unclear. This study aims to evaluate the relationships between EAT volumes, LA function, and LA global longitudinal strain.

Sinus Venosus Interatrial Communication,Anomalous Pulmonary Venous Return,Pulmonary Artery Aneurysm With Left Main Compression: Complex Case With Complex Management

A young female patient was referred for pulmonary arterial hypertension (PAH). Catheterization revealed a large sinus venosus interatrial communication (SVIAC), partial anomalous pulmonary venous return (PAPVR), pulmonary vascular resistance (PVR) 15 Wood units, and bidirectional shunting. She was then put on target medication for PAH. Two years later, she had angina and underwent computed tomography examination, which showed pulmonary arterial aneurysm compressing the left main coronary. Coronary stenting was performed, which successfully relieved the compression and angina. Meanwhile, PVR lowered to 3.5 Wood units after medical therapy. Surgical correction for SVIAC and PAPVR was done successfully 5 years after diagnosis.     

Feasibility and Reliability of Nonexpert POCUS for Cardiovascular Preparticipation Screening of Varsity Athletes: The SHARP Protocol

Background

Point of care ultrasound (POCUS) is a potential adjunctive cardiovascular preparticipation screening modality for young competitive athletes. A novel cardiac POCUS screening protocol, Screening the Heart of the Athlete Research Program (SHARP), was developed for nonexpert examiners to assess common structural etiologies associated with sudden cardiac arrest/death (SCA/D).

Transcatheter Aortic Valve Replacement for Severe Aortic Regurgitation With Acute Refractory Cardiogenic Shock

From January 2013 to January 2017, 686 consecutive patients were referred to our centre for transcatheter aortic valve replacement, including 5 subjects with severe aortic regurgitation and acute refractory cardiogenic shock. These patients were contraindicated for surgical treatment by the heart team because of high surgical risk (median logistic EuroSCORE: 74.6/Society of Thoracic Surgeons score: 37.9). The success rate of valve implantation was 100% through transfemoral access with self-expandable devices. The observed 30-day mortality rate was 20%. Hence, the transcatheter aortic valve replacement procedure might represent a successful and life-saving intervention for treatment of patients with severe aortic regurgitation who present with acute refractory cardiogenic shock.