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Background: PFO is more common in cases with cryptogenic stroke compared to cases with no stroke or stroke of identified etiology. Several randomized controlled trials (RCTs) comparing PFO closure with medical therapy have been published with controversial findings. Methods: PubMed, Embase and Cochrane library databases were searched for RCT comparing PFO closure with medical therapy including antiplatelet therapy (aspirin or clopidogrel or combination) or anticoagulation. We identified 5 trials, including 3627 cases. The mean duration of follow-up was 4 years. Relative risk (RR) and 95% confidence intervals (CI) were calculated using fixed and random-effects models.Results: There was a significant reduction in the incidence of stroke among the PFO closure group compared to medical therapy group, 2.0 versus 4.2%, RR 0.48; 95% CI (0.3, 0.7), p < 0.001. The incidence of AF was higher in the PFO closure group compared to medical therapy group, 4.2 versus 0.7%, respectively, RR 5.9, 95% CI (3, 11), p < 0.001. After exclusion of oral anticoagulants cases (19%), analysis showed a lower incidence of stroke in the PFO closure group (2%) compared to antiplatelet therapy (5.2%), RR 0.4; 95% CI (0.3, 0.6), p < 0.001. There was no significant difference between both groups in the incidence of transient ischemic attacks or all-cause deaths.Conclusion: PFO closure results in a significant reduction in the recurrence of ischemic stroke compared to medical therapy alone, primarily antiplatelet, among cases with PFO and cryptogenic stroke. [ABSTRACT FROM AUTHOR]

The development of a new generation of non-vitamin K oral anticoagulants represents a potential breakthrough in the management of patients with thrombotic diseases, disorders and conditions. While a large and growing body of evidence from large-scale clinical trials and registries supports a favorable safety profile, having a means to rapidly reverse their anticoagulant effects represents an unmet need among practicing clinicians. Several targeted reversal agents are currently in development and the early results are promising. Idarucizumab is a monoclonal antibody that can immediately and specifically reverse dabigatran. Andexanet alfa is a recombinant modified factor Xa that can bind and reverse oral and parenteral factor Xa inhibitors, including rivaroxaban, apixaban and edoxaban, and low molecular weight heparin. Aripazine is a small molecule that can reverse the action of factor Xa inhibitors and possibly dabigatran as well through non-covalent binding and charge–charge interactions. [ABSTRACT FROM AUTHOR]

Introduction The optimal duration of dual antiplatelet therapy ( DAPT) after drug-eluting stent implantation ( DES) is not certain. The AHA/ ACC guidelines recommend 12 months of DAPT based on observational trials. Recently, several large randomized controlled trials ( RCT) suggested a noninferiority of shorter duration of DAPT and other trials showed a benefit from extended duration of DAPT after 12 months of DES implantation. Methods PubMed databases were searched for RCTs comparing the continued use of DAPT to shorter duration of DAPT (aspirin alone) for variable durations beyond 3 months of DES implantation. Our analysis was limited to trials with clinical outcomes. Odds ratio ( OR) and 95% confidence intervals ( CI) were calculated using fixed and random-effects models. Subgroup analyses were performed for second generation DES and for trials comparing 12 months of DAPT vs. earlier interruption or longer duration of DAPT. Results We identified 10 RCTs including 32,136 subjects randomized to continued use of DAPT vs. aspirin alone for variable durations after 3 months of DES implantation. There was no significant heterogeneity among studies (Q test P > 0.1). Compared to shorter DAPT, longer DAPT resulted in a significant reduction in stent thrombosis (0.3% vs. 0.7%, P < 0.01) and myocardial infarction (1.3% vs. 2%, P < 0.01), and a significant increase in major bleeding (0.8% vs. 0.4%, P < 0.01). There was no difference in cardiac deaths or stroke. All-cause deaths were slightly lower with shorter DAPT compared to longer DAPT ( OR 0.8, 95% CI 0.7 to 0.99, P = 0.04). A small number of subjects were included between 3 and 6 months after DES implantation. Conclusion DAPT continued beyond 6 months after second generation DES implantation decreases stent thrombosis and myocardial infarction, but increases major bleeding and all-causes mortality compared to shorter DAPT (aspirin alone). There was no difference in cardiac mortality or stroke. [ABSTRACT FROM AUTHOR]

Surgical Treatment of Atrial Fibrillation Atrial fibrillation (AF) is the most common chronic arrhythmia in the adult population. Ablation lines have largely replaced the historical and challenging cut and sew techniques. Surgical ablation of AF is commonly performed in cases with other indications for cardiac surgery and less commonly as a stand-alone therapy. Pulmonary vein isolation is the cornerstone of this procedure. Extended left atrial ablation lines may increase efficacy in cases with longstanding persistent or permanent AF. Additional efficacy by adding right atrial ablation is controversial but is often performed in cases undergoing right atrial or atrial septal surgery. Left atrial volume reduction is recommended in cases with large left atria and AF undergoing another cardiac surgery. Arrhythmia recurrence is not uncommon after surgical ablation of AF and varies among studies due to heterogeneity in patient population, lesion set and endpoints. Freedom from AF recurrence was 65-87% at 12 months and 58-70% at 2 years follow-up. Long-term monitoring is recommended due to an increased prevalence of asymptomatic recurrences. The strongest predictors of AF recurrence are longstanding or persistent AF and a large left atrium. The most common mechanisms of recurrence are pulmonary vein reconnection, nonpulmonary vein triggers, and gaps in the ablation lines. About 20% of atrial tachyarrhythmia recurrences are atrial flutter or atrial tachycardia. There are not enough data in the surgical literature to support withdrawal of anticoagulation after surgical AF ablation. Patients selected for stand-alone surgical ablation usually have low risk profiles and low postoperative mortality rates (0.2%). [ABSTRACT FROM AUTHOR]

This review aims to clarify the underlying risk of arrhythmia associated with the use of macrolides and fluoroquinolones antibiotics. Torsades de pointes (TdP) is a rare potential side effect of fluoroquinolones and macrolide antibiotics. However, the widespread use of these antibiotics compounds the problem. These antibiotics prolong the phase 3 of the action potential and cause early after depolarization and dispersion of repolarization that precipitate TdP. The potency of these drugs, as potassium channel blockers, is very low, and differences between them are minimal. Underlying impaired cardiac repolarization is a prerequisite for arrhythmia induction. Impaired cardiac repolarization can be congenital in the young or acquired in adults. The most important risk factors are a prolonged baseline QTc interval or a combination with class III antiarrhythmic drugs. Modifiable risk factors, including hypokalemia, hypomagnesemia, drug interactions, and bradycardia, should be corrected. In the absence of a major risk factor, the incidence of TdP is very low. The use of these drugs in the appropriate settings of infection should not be altered because of the rare risk of TdP, except among cases with high-risk factors. [ABSTRACT FROM AUTHOR]

Background Trials to maintain sinus rhythm in patients with atrial fibrillation (AF) and refractory symptoms have been complicated by lack of success or intolerance of medications. Experience with minimally invasive AF surgery is relatively new, and early results have been promising. However, the study populations and techniques were heterogeneous, and the follow-up periods were short in many series. Methods We present a single center experience through a retrospective review of medical records of patients who had minimally invasive AF surgery. Results The surgical techniques addressed several possible mechanisms of AF and causes of recurrence, including pulmonary vein isolation, underlying substrates modification, ligament of Marshall interruption, ganglion plexus ablation, and left atrial appendage exclusion. Thirty-three cases were identified. The mean duration of follow-up was 23.2 months, and 58.6% were maintained in a sinus rhythm and were off antiarrhythmic drugs at the end of the follow-up period. Cases with persistent AF had a lower success rate. Conclusion Results with minimally invasive surgery are suboptimal at two years of follow-up, particularly for patients with persistent AF. doi: 10.1111/jocs.12092 (J Card Surg 2013;28:315-320) [ABSTRACT FROM AUTHOR]

A letter to the editor is presented concerning a research study about telemetry monitoring in elderly patients hospitalized with pneumonia and who are at risk for cardiovascular diseases.

We report a case of pulmonary vein stenosis following a standalone minimally invasive surgical ablation for atrial fibrillation. The etiology, diagnosis, and management of this complication are the subject of this review. doi: 10.1111/jocs.12579 (J Card Surg 2015;30:619-621) [ABSTRACT FROM AUTHOR]

A letter to the editor is presented which is concerned with antibiotic-induced cardiac arrhythmia in elderly patients.

The management of coronary thrombus is not well defined. Current therapies include medical management with anticoagulation, antiplatelet, and thrombolytic therapies or revascularization with percutaneous coronary interventions including mechanical thrombectomy, and coronary artery bypass grafting surgery. In this report, we present a patient with significant left main coronary artery thrombus burden with advanced cirrhosis and recent esophageal variceal bleeding who was successfully treated with conservative medical management. [ABSTRACT FROM AUTHOR]

We compared live/real time three-dimensional transesophageal echocardiography (3D TEE) with real time two-dimensional transesophageal echocardiography (2D TEE) in the assessment of individual mitral valve (MV) segment/scallop prolapse and associated chordae rupture in 18 adult patients with a flail MV undergoing surgery for mitral regurgitation. 2D TEE was able to diagnose the prolapsing segment/scallop and associated chordae rupture correctly in only 9 of 18 patients when compared to surgery. In three of these, 2D TEE diagnosed an additional segment/scallop not confirmed at surgery. In the remaining nine patients, surgical findings were missed by 2D TEE. On the other hand with 3D TEE, the prolapsed segment/scallop and associated ruptured chords correlated exactly with the surgical findings in the operating room in 16 of 18 patients. The exceptions were two patients. In one, 3D TEE diagnosed prolapse and ruptured chordae of the A3 segment and P3 scallop, while the surgical finding was chordae rupture of the A3 segment but only prolapse without chordae rupture of the P3 scallop. In the other patient, 3D TEE diagnosed prolapse and chordae rupture of P1 scallop and prolapse without chordae rupture of the A1 and A2 segments, while at surgery chordae rupture involved A1, A2, and P1. This preliminary study demonstrates the superiority of 3D TEE over 2D TEE in the evaluation of individual MV segment/scallop prolapse and associated ruptured chordae. [ABSTRACT FROM AUTHOR]

Introduction: MINOCA (Myocardial Infarction in non-obstructive coronary artery disease) is a recently described infarct subtype. There are few data that examine CAD (Coronary artery disease), extent MI size and type, and treatment differences at hospital discharge compared to MIOCA (Myocardial Infarction in obstructive coronary artery disease), or sex-specific MINOCA attributes of coronary anatomy and infarct size. Hypothesis: CAD extent, MI size and type, and guideline recommended treatment at hospital discharge are similar in MINOCA and MIOCA pts. Clinical characteristics of MINOCA pts are similar in men and women. Method: Single tertiary-center cohort study of consecutive pts that had coronary angiography for acute MI between 2005 and 2015. MI type at presentation (STEMI vs NSTEMI), MI size (peak cardiac troponin value (cTn) and ejection fraction (EF)) and gender differences in the MINOCA pts were examined. MINOCA was defined by absence of obstructive CAD >50% (n=87) and MIOCA by presence of stenosis ≥50% (n=1611) Result: Among 1,698 cases with acute MI, 87 had MINOCA (5.1%). MINOCA pts were younger, more often had NSTEMI, lower peak cTn values, and greater EF than MIOCA pts. Interestingly, frequency of multi-vessel disease involvement was similar in both groups. At hospital discharge, MINOCA pts less frequently received beta blockers or angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB) therapy; 30-day re-admission rates were similar (Table). Women with MINOCA (n=41) had smaller MI's (peak cTn 14 vs 72 ng/ml; p<0.001), higher EF (53% vs 46.5% p=0.002) than the women with MIOCA (n=358) and were significantly less likely to be diabetic, hypertensive or hyperlipidemic. When the 87 MINOCA pts were examined, sex comparisons revealed women were older than men (60 vs 52 yrs., p<0.001), had lower mean peak cTn values (14.2 vs 29 ng/ml, p<0.001), greater EF (56% vs 48%, p=0.02) and more single vessel disease than men (73.2% vs 10.6%, p<0.0001). Conclusion: On average, MI size is smaller in MINOCA than MIOCA pts, and there are sex-related differences in clinical presentation, CAD extent and MI size. Re-admission rates are similar but MINOCA pts are less likely to receive guideline recommended medical therapy at discharge. [ABSTRACT FROM AUTHOR]