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Objective: comparison of general anesthesia (GA) and intravenous conscious sedation during left atrial appendage occlusion (LAAO).Materials and Methods. The study included 120 patients from LAAO Register at the National Medical Research Center of Cardiology, who were divided into GA (n = 100) and intravenous sedation (n = 20) groups. In-hospital outcomes were assessed, as well as outcomes and data of transesophageal echocardiography (TEE) at 45 days and 6 months.Results. 3 patients required intraoperative conversion of the anesthetic method to GA. The duration of the procedure, the time of fluoroscopy, the amount of contrast medium, and the technical success did not differ signifcantly between the two groups. The incidence of in-hospital complications in the GA group was 10%, and 15% in the intravenous sedation group (p = 0.453). There were no statistically signifcant differences between the groups in long-term outcomes and TEE data after 45 days and 6 months.Conclusion. Combined intravenous sedation with local anesthesia is an effective and fairly safe method of anesthesiological support for implantation of the occluder of the left atrial auricle. It can be used in patients with a high risk of GA, with predictable difculties of tracheal intubation, as well as if the patient wishes accordingly. The limitations of the use of intravenous sedation in combination with local anesthesia are anatomical variants of SFM that are difcult for occluder implantation, as well as the patient's low tolerance to ECG in consciousness.

Atrial fbrillation is one of the most common cardiac arrhythmias, which is dangerous for its complications. This article presents the most common risk factors for the development of arrhythmias: obesity, hypertension, diabetes, smoking and others. The analysis of modifable risk factors will enable to elaborate preventive measures and reduce the incidence of atrial fbrillation.

Bacground. Obstructive sleep apnea-hypopnea syndrome (OSAHS) is associated with increased incidence and progression of atrial fibrillation (AF). Experimental studies indicate that OSAHS can modify the cardiac extracellular matrix (ECM). However, significant mechanisms of cardiac remodeling in AF patients with OSAHS have not been uncovered. The aim: to evaluate the impact of OSAHS on serum levels of tissue inhibitor of matrix metalloproteinase-1(TIMP-1) and hypoxia-inducible factor-1α (HIF-1α) in AF patients with ischemic heart disease (IHD) and/or arterial hypertension (AH), suffering from OSAHS. Material and methods. We examined 140 non-valvular AF patients with IHD and/or AH. Cardiorespiratory monitoring was conducted in the studied subjects and they were divided into 2 groups according to the presence of OSAHS: group 1 – non-OSAHS patients; group 2 – patients with OSAHS. Serum levels of TIMP-1 and HIF-1α were assayed using commercially available ELISA kit. Results. The patients with OSAHS had higher levels of TIMP-1 and HIF-1α than non-OSAHS patients (p

Objective: Catheter ablation combined with left atrial appendage closure (LAAC) has emerged as a promising strategy for atrial fibrillation (AF) patients at high risk for stroke or with contraindications for oral anticoagulants (OACs). But the evidence for the long-term safety and efficacy of a combined procedure using cryoballoon ablation (CBA) with LAAC is still insufficient.Methods: From October 2015 to December 2017, a total of 76 consecutive non-valvular, drug-refractory AF patients who underwent a combined procedure of CBA and LAAC are included. Peri- and post-procedural safety and efficacy were evaluated through scheduled follow-ups and transesophageal echocardiography (TEE).Results: A total of 74 patients (97.4%) underwent the combined procedure and achieved instant pulmonary vein isolation and satisfactory LAAC. With a mean follow-up time of 23.7 ± 11.0 months, the recurrence of atrial arrhythmia was recorded in 35 patients (48.0%). In addition, a survival analysis shows a non-significant higher recurrence in persistent AF (p = 0.48). The overall OAC withdrawal rate was 97.2%, and one patient (1.4%) had a lethal hemorrhagic stroke while on single antiplatelet therapy. For safety concerns, the overall mortality was 2.7%, which resulted from one case of myocardial infarction on OAC and one hemorrhagic stroke, as mentioned. No other major hemorrhagic events occurred. Among the 72 patients (94.7%) who underwent TEE, one patient (1.4%) had device-related thrombosis and one patient (1.4%) had prominent residual flow (over 3 mm). Both were prescribed long-term OACs without severe complications occurring.Conclusions: Combining CBA with LAAC in a single procedure achieved considerable long-term safety and efficacy, providing a promising strategy for AF management.

Data on thrombus resolution and clinical outcome data after a therapy of LAA thrombus with novel oral anticoagulants (NOACs) are scarce. In this single-center study, we retrospectively analyzed 78 patients diagnosed with a solid LAA thrombus by transesophageal echocardiography (TEE). We assessed baseline clinical and echocardiographic characteristics, the anticoagulatory regimens and outcomes of patients with (responders) and without (non-responders) thrombus resolution. Mean age was 76.1 ± 8.3 years, patients were male in 57.7% and presented with a high risk for thromboembolism (CHA2DS2-VASc: 4.3 ± 1.1). At thrombus diagnosis, 44.9% patients were treated with a NOAC, while 41.0% were under therapy with a VKA. Complete thrombus resolution was achieved after a mean of 116 ± 79 days in a total of 51.3% of patients, 35.9% showed a reduction of thrombus size, whereas 12.8% showed no changes in thrombus dimensions. There was no statistically significant difference in the rate of LAA thrombus resolution between VKA and NOACs (41.2 vs. 57.1%, p = 0.18). However, in cases in which only the therapy with a NOAC led to complete thrombus resolution, the time needed was significantly shorter than with VKA (81 ± 38 vs. 129 ± 46 days, p = 0.03). Regarding safety outcomes, no differences in bleeding or thromboembolism were observed between patients with and without thrombus resolution. In this registry, approximately 85% of LAA thrombi were diagnosed in patients with ongoing OAC. Thrombus resolution was observed in nearly 50% of cases. Although there was no difference in the rate of LAA thrombus resolution between VKA and NOACs, the resolution time was shorter in patients prescribed a NOAC.

COVID-19 outbreak had a major impact on the organization of care in Italy, and a survey to evaluate provision of for arrhythmia during COVID-19 outbreak (March–April 2020) was launched. A total of 104 physicians from 84 Italian arrhythmia centres took part in the survey. The vast majority of participating centres (95.2%) reported a significant reduction in the number of elective pacemaker implantations during the outbreak period compared to the corresponding two months of year 2019 (50.0% of centres reported a reduction of > 50%). Similarly, 92.9% of participating centres reported a significant reduction in the number of implantable cardioverter-defibrillator (ICD) implantations for primary prevention, and 72.6% a significant reduction of ICD implantations for secondary prevention (> 50% in 65.5 and 44.0% of the centres, respectively). The majority of participating centres (77.4%) reported a significant reduction in the number of elective ablations (> 50% in 65.5% of the centres). Also the interventional procedures performed in an emergency setting, as well as acute management of atrial fibrillation had a marked reduction, thus leading to the conclusion that the impact of COVID-19 was disrupting the entire organization of health care, with a massive impact on the activities and procedures related to arrhythmia management in Italy. Electronic supplementary material The online version of this article (10.1007/s11739-020-02487-w) contains supplementary material, which is available to authorized users.

Arterial and venous thromboembolism are both more common in older adults. The use of anticoagulants, the mainstay to prevent thromboembolism, requires consideration of the balance between risk and benefit. Such consideration is even more important in the very elderly in whom the risk of anticoagulant-related bleeding and thrombosis are higher. This review will focus on the challenges of implementing and managing anticoagulant therapy in older patients in an era when the options for anticoagulants include not only vitamin K antagonists (VKAs), but also direct-acting oral anticoagulants (DOACs).

The pharmacological stimulation of GLP-1 receptors is associated with an increase in heart rate. A pooled analysis of patient-level data from phase III trials with albiglutide revealed a significant increase in the risk of atrial fibrillation. Aim of the present meta-analysis is to summarize all available evidence on the effects of individual GLP-1 receptor agonists (RA), and of the whole class, on the incidence of atrial fibrillation. A Medline search for GLP-1 RA (exenatide, liraglutide, lixisenatide, albiglutide, dulaglutide, or semaglutide) was performed, collecting all randomized clinical trials with a duration ≥12 weeks, enrolling patients with type 2 diabetes and comparing a GLP-1 RA with placebo or any other non-GLP-1 RA drug. Of the 113 trials fulfilling the inclusion criteria, 19 did not report information on atrial fibrillation, whereas 63 reported zero events in all treatment groups. In the remaining trials (enrolling 17,966 and 15,305 patients in GLP-1 RA and comparator arms, respectively, 55.3% women, with a mean age of 57.0 ± 3.8 years), treatment with GLP-1 RA was not associated with a significant increase in the incidence of atrial fibrillation [Mantel–Haenszel OR (95% CI) 0.87 (0.71–1.05), p = 0.15]. In conclusion, available data suggest that GLP-1 RA is not associated with atrial fibrillation, with the only possible exception of albiglutide. Newly onset atrial fibrillation deserves to be investigated as an event of special interest in future trials with GLP-1 RA.

L atrial (LA) stunning after cardioversion of atrial fibrillation (AF) has been reported during spontaneous conversion to sinus rhythm.1 This observation suggest that atrial stunning is a function of underlying arrhythmia and not of the mode of cardioversion. It is known that AF causes atrial dilation, and progressive LA enlargement occurs when AF becomes chronic.2 Recently, it has been shown that multiple factors contribute to LA enlargement, including the presence and persistence of arrhythmia.3 Many reports suggest that if sinus rhythm is restored then dilation may regress.4 The Framingham Study showed a relation between LA size and the risk of stroke in men and the risk of death in both genders.5–7 Previous studies have suggested that N-terminal atrial natriuretic peptide (NANP) levels are elevated in patients with AF.8,9 It is unclear whether AF rather than LA dilation,10 hemodynamic impairment,11 or another hormonal alteration, can result in the elevation of N-ANP levels.8 The present report evaluates the changes in LA size and function after spontaneous cardioversion of AF and their relation to N-ANP. • • • Hemodynamically stable patients referred for cardioversion for nonrheumatic AF between September 1997 and March 2000 were considered for inclusion in this investigation. The initial study group included 202 consecutive patients; 98 patients spontaneously recovered sinus rhythm within 48 hours from the onset of arrhythmia and were selected for the study (Group A). The study population included 57 men and 41 women of mean age 60 16 years; patients were compared with 98 ageand gender-matched control subjects (mean age 61 16 years) who underwent pharmacologic cardioversion within 48 hours from the onset of arrhythmia (Group B). Patients received intravenous propafenone 2 mg/kg of body weight; the drug was dissolved in 100 ml of 5% glucose and infused over 30 minutes. Exclusion criteria were: atrial flutter, valvular stenosis, valvular prosthesis, significant valvular insufficiency, atrial and/or left ventricular thrombosis, spontaneous echo contrast, patent foramen ovale or an atrial septal aneurysm, or decreased LV function (ejection fraction 45%). No patients received long-term therapy with antiarrhythmic drugs. Demographic and clinical characteristics of the patients are listed in Table 1. Clinical records included age, gender, time and circumstances of the onset of symptoms related to AF, and the duration of AF estimated from the initial onset of symptoms until the time of the in-hospital conversion. The protocol was approved by the Ethical Committee of our university and all patients signed an informed consent form. The initial Doppler echocardiographic study was performed during AF and after cardioversion (mean 3 1.5 hours). A complete monoand 2-dimensional color Doppler echocardiogram was performed in each patient using a commercial Hewlett-Packard echocardiograph (Andover, Massachusetts) with a 2.5-MHz probe. LA function was assessed using these parameters: (1) transmitral pulsed Doppler recorded from the apical 4-chamber view with the sample volume positioned between the tips of the mitral leaflets; peak early filling (E) and atrial filling (A) velocities; and From the Departments of Cardiology and Biomedics, University of Modena and Reggio Emilia, Modena, Italy. Dr. Mattioli’s address is: Department of Cardiology, University of Modena, Via del pozzo, 71, 41100 Modena, Italy. E-mail: mattioli.annavittoria@ unimo.it. Manuscript received December 17, 2002; revised manuscript received and accepted March 3, 2003. TABLE 1 Demographics and Clinical Characteristics

Atrial fibrillation (AF), the most common cardiac arrhythmia, confers a 5-fold risk of stroke that increases to 17-fold when associated with mitral stenosis. At this time, the most effective long-term solution to protect patients from stroke and thromboembolism is oral anticoagulation, either with vitamin K antagonists (VKAs) or a novel oral anticoagulant (NOAC). Despite the significant benefits they confer, both VKAs and NOACs are underused because of their increased potential for bleeding, and VKAs are underused because of their narrow therapeutic range, need for regular international normalized ratio checks, and interactions with food or medications. In patients with nonvalvular AF, approximately 90% of strokes originate from the left atrial appendage (LAA); in patients with rheumatic mitral valve disease, many patients (60%) have strokes that originate from the left atrium itself. Surgical LAA amputation or closure, although widely used to reduce stroke risk in association with cardiac surgery, is not currently performed as a stand-alone operation for stroke risk reduction because of its invasiveness. Percutaneous LAA closure, as an alternative to anticoagulation, has been increasingly used during the last decade in an effort to reduce stroke risk in nonvalvular AF. Several devices have been introduced during this time, of which one has demonstrated noninferiority compared with warfarin in a randomized controlled trial. This review describes the available technologies for percutaneous LAA closure, as well as a summary of the published trials concerning their safety and efficacy in reducing stroke risk in AF.