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Background: Coronary embolism (CE) is an uncommon cause of non-atherosclerotic acute myocardial infarction (AMI). Although atrial fibrillation (AF) is the main cause of CE, evidence of clinical, biochemical, echocardiographic, angiographic findings and outcomes of AF CE is lacking., Methods: We retrospectively analyzed 85 consecutive patients with CE that was diagnosed based on criteria encompassing clinical, angiographic and diagnostic imaging findings. We classified patients according to AF CE or non-AF CE., Results: Forty-five patients presented with AF CE (53%). Patients with AF CE were older (76 ± 12 vs. 63 ± 14 years; p < 0.001) and had more often chronic kidney disease (24% vs. 5%; p = 0.01). AF CE had lower estimated glomerular filtration rate at admission (59 ± 18 vs. 77 ± 16 ml/min/1.73 m 2 ; p < 0.001) and higher brain natriuretic peptide levels (512 ± 417 vs. 210 ± 479 pg/ml; p = 0.02). Coronary arteriography revealed a higher incidence of coronary artery obstruction in the AF CE group (73% vs. 38%; p = 0.001) without differences in interventional management. The AF CE group showed higher left atrial volume index (LAVI) (42 ± 15 vs. 25 ± 12 ml/m 2 ; p < 0.001) and showed lower left atrium ejection fraction (LAEF) (32 ± 17 vs. 49 ± 17%; p = 0.001). In the multivariable analysis AF CE (OR 10 [95% CI 1.04-95; p = 0.046]) and LAEF (OR 0.94 [95% CI 0.88-0.99; p = 0.02]) were associated with worse in-hospital outcomes. Moreover, in the multivariable analysis, prior stroke (OR 12.5 [95% CI 1.1-137; p = 0.04]) and LAVI (OR 1.1 [95% CI 1.03-1.14; p = 0.003]) were independently associated with worse long-term outcomes., Conclusion: AF CE has specific characteristics compared to non-AF-CE and it is associated with more in-hospital events. Furthermore, atrial cardiopathy is associated with worse in-hospital and long-term outcomes in this setting., (© 2024 Wiley Periodicals LLC.)

The management of embolic acute limb ischaemia commonly involves determining aetiology and performing emergency invasive procedures. This detailed study aimed to determine the impact of manipulation of anticoagulation in the aetiology of emboli in acute limb ischaemia and determine the efficacy of primary anticoagulation therapy vs. invasive interventions. Material and methods: Data collection was conducted at a single institution on a cohort of patients presenting consecutively with embolic acute limb ischaemia over one year. Two groups were compared, one receiving anticoagulation as primary therapy with those undergoing invasive treatment as the internal comparison group. Results: A likely haematological causation was identified in 22 of 38 presentations, related to interruption of anticoagulation in cardiac conditions, the majority atrial fibrillation (n=12), or hypercoagulable states (n=10). Limb salvage was pursued in 36 patients employing anticoagulation (n=19) or surgical embolectomy (n=17) as the primary therapy in upper and lower limbs (n=17 vs n=19 respectively). Despite delays often well beyond six hours and a range of ischaemic severity in both groups, 35 of 36 patients achieved full or substantive restoration of function with improved perfusion. Regarding anatomical distribution of arterial disease and therapy, three patients with multi-level disease proceeded to embolectomy following anticoagulation. Embolectomy was undertaken most often for proximal emboli and more profound paralysis. Conclusions: Anticoagulation and coagulopathy are commonly implicated in the aetiology of arterial emboli, with omission of effective anticoagulation in atrial fibrillation being associated in almost 1/3 of presentations. Whilst more profound limb paralysis and proximal or multi-level disease tended to be managed surgically, primary anticoagulation therapy alone or with a secondary embolectomy was effective across the spectrum of ischaemia severity and despite significant delays beyond guideline recommendations.

Background: Stroke remains one of the most serious complications in atrial fibrillation (AF) patients and has been linked to disturbances of the autonomic nervous system., Objective: The purpose of this study was to test the hypothesis that impaired cardiac autonomic function might be associated with an enhanced stroke risk in AF patients., Methods: A total of 1922 AF patients who were in either sinus rhythm (SR group; n = 1121) or AF (AF group; n = 801) on a 5-minute resting electrocardiographic (ECG) recording were enrolled in the study. Heart rate variability triangular index (HRVI), standard deviation of normal-to-normal intervals, root mean square root of successive differences of normal-to-normal intervals, mean heart rate, 5-minute total power, and power in the high-frequency, low-frequency, and very-low-frequency ranges were calculated. Cox regression models were constructed to examine the association of heart rate variability (HRV) parameters with the composite endpoint of stroke or systemic embolism., Results: Mean age was 71 ± 8 years in the SR group and 75 ± 8 years in the AF group. Thirty-seven patients in the SR group (3.4%) and 60 patients in the AF group (8.0%) experienced a stroke or systemic embolism during follow-up of 5 years. In patients with SR, HRVI <15 was the strongest HRV parameter to be associated with stroke or systemic embolism (hazard ratio 3.04; 95% confidence interval 1.3-7.0; P = .009) after adjustment for multiple confounders. In the AF group, no HRV parameter was found to be associated with the composite endpoint., Conclusion: HRVI measured during SR on a single 5-minute ECG recording is independently associated with stroke or systemic embolism in AF patients. HRV analysis in SR may help to improve risk stratification in AF patients., Competing Interests: Disclosures Dr Beer reports grants from the Swiss National Foundation of Science, The Swiss Heart Foundation, and Bayer; and lecture fees from Sanofi Aventis and Amgen, to the institution outside the submitted work. Dr Blum has received research grants from the Swiss National Science Foundation and the Swiss Heart Foundation, all for work outside the submitted study. Dr Bonati has received an unrestricted research grant from AstraZeneca; consultancy or advisory board fees or speaker honoraria from Amgen, Bayer, Bristol-Myers Squibb, and Claret Medical; and travel grants from AstraZeneca and Bayer, outside the submitted work. Dr Conen received consultancy fees from Roche Diagnostics and Trimedics; and speaker fees from Servier and BMS/Pfizer, outside the submitted work. Dr Kühne received personal fees from Daiichi Sankyo and grants from the Swiss National Science Foundation, Swiss Heart Foundation, Foundation for CardioVascular Research Basel, Bayer, Pfizer, Boston Scientific, BMS, Biotronik, and Daiichi Sankyo, outside the submitted work. Dr Krisai has speaker fees from BMS/Pfizer, outside the submitted work. Dr Müller reports fellowship and training support from Biotronik, Boston Scientific, Medtronic, Abbott/St. Jude Medical, and Biosense Webster; speaker honoraria from Biosense Webster, Medtronic, Abbott/St. Jude Medical, AstraZeneca, Daiichi Sankyo, Biotronik, MicroPort, Novartis, Zoll, and Bristol Myers Squibb; consultant fees from Biosense Webster, Medtronic, Abbott/St. Jude Medical, and Biotronik, outside the submitted work. Dr Moschovitis has received advisory board and/or speaker fees from Astra Zeneca, Bayer, Boehringer Ingelheim, Daiichi Sankyo, Gebro Pharma, Novartis, and Vifor, outside the submitted work. Dr Osswald received research grants from the Swiss National Science Foundation and Swiss Heart Foundation, Foundation for CardioVascular Research Basel, and F. Hoffmann-La Roche Ltd.; and educational and speaker grants from F. Hoffmann-La Roche Ltd., Bayer, Novartis, Sanofi, AstraZeneca, Daiichi-Sankyo, and Pfizer, outside the submitted work. Dr Reichlin has recieved research grants from the Swiss National Science Foundation, the Swiss Heart Foundation, and the sitem insel support funds; speaker/consulting honoraria or travel support from Abbott/SJM, Astra Zeneca, Brahms, Bayer, Biosense-Webster, Biotronik, Boston-Scientific, Daiichi Sankyo, Farapulse, Medtronic, Pfizer-,BMS and Roche; and support for his institution’s fellowship program from Abbott/SJM, Biosense Webster, Biotronik, Boston Scientific, and Medtronic for work, outside the submitted study. Dr Zuern has received funding from the “Freiwillige Akademische Gesellschaft Basel”; and personal fees from Cardiomatics, outside the submitted work. All other authors have no conflicts of interest to disclose., (Copyright © 2024 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

We describe the case of a male heavy machinery operator who presented from work with a rapidly evolving spinal cord syndrome. Spinal MRI revealed thoracic vertebral body and cord infarction and evolving mild disc prolapse attributed to fibrocartilaginous disc embolism (FCDE). FCDE should be considered as one of the aetiological mechanisms of acute spinal cord infarction in pile-driver/heavy machinery operators, especially in association with adjacent vertebral body infarction and intervertebral disc prolapse. Magnetic resonance imaging (MRI) changes may evolve, warranting early follow-up MRI in appropriate cases., Competing Interests: Declaration of competing interest The authors declare the following financial support: Dominick McCabe reports that grant support for his Vascular Neurology Research Programme was provided by The Meath Foundation, Ireland; The Adelaide Health Foundation, Ireland; The Vascular Neurology Research Foundation, Ireland; and the Enterprise Ireland-Innovation Partnership Programme. Dominick McCabe reports that unrestricted educational grant funding for his Vascular Neurology Research Programme was provided by Werfen, Barcelona, Spain; Sysmex Ireland-UK and Siemens, Germany; SINNOWA, China; and by Acquis BI Technology, Ireland. None of the above charities or funding bodies had any influence on the design or content of this manuscript, or had any influence on the decision to submit the final manuscript for publication. The other authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

The use of left atrial appendage occlusion (LAAO) devices have gained prominence as an alternative to long-term anticoagulation therapy in patients with atrial fibrillation at risk of stroke and high risk of bleeding. While these devices have shown efficacy in reducing stroke risk, there have been reported cases of embolization of the Watchman device. There are very few cases of successful percutaneous retrieval of embolized Watchman devices from the left ventricle (LV), as many of these cases require open heart surgery for safe removal. We are presenting a case of an 80-year-old male whose Watchman device embolized to the LV and was entrapped on the LV papillary muscle that was then successfully retrieved via percutaneous methods, which shows the percutaneous options remain a viable strategy to retrieve LAAO devices from the LV., (© 2024 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.)

Background: The prevalence and impact of coronary emboli (CE) in patients with ST-segment-elevation myocardial infarction (STEMI) and atrial fibrillation (AF) have not been specifically studied. The objective was to describe the clinical characteristics and outcomes of patients with AF and CE in a large series of patients with STEMI., Methods and Results: We investigated 2292 consecutive patients with STEMI and among them 225 patients with AF: 46 patients with a STEMI related to CE (group A) and 179 patients with a STEMI related to an atherosclerotic cause (group B). Compared with the 2067 patients without AF and CE (group C), patients with AF and CE were older (73 versus 59 years, P <0.05), more likely to be female (43% versus 22%, P <0.05), and presented more frequently with cardiogenic shock at admission (26% versus 9%, P <0.05). The baseline characteristics of patients with AF (group A versus B) did not differ significantly according to STEMI pathogenesis. In the unadjusted analysis, the 45-day mortality was higher in patients with CE and AF (group A versus group C: 20% versus 4%; P <0.05 and group A versus group B: 20% versus 8%, P =not significant); this trend persisted at 2-year follow-up (group A versus group C: 24% versus 6%; P <0.05 and group A versus group B: 24% versus 17%, P =not significant). After stabilized inverse exposure probability weighting adjustment, a higher 45-day mortality rate was confirmed in patients with CE and AF (group A versus group C: 18% versus 5%, P <0.05)., Conclusions: In patients presenting with STEMI and AF, CE was associated with excess early mortality., Registration: URL: clinicaltrials.gov. Identifier: NCT05679843.

A 63-year-old man was admitted to the hospital for nausea, vomiting, and right flank pain. He was found to have septic emboli in multiple organs secondary to aortic valve endocarditis. He was started on broad-spectrum antibiotics and underwent valve replacement. Blood cultures from admission were negative, but a blood polymerase chain reaction (PCR) test for fastidious difficult-to-culture pathogens showed a positive result for Tropheryma whipplei. Valve histopathological evaluation confirmed Tropheryma whipplei endocarditis. He was treated with intravenous penicillin followed by oral trimethoprim-sulfamethoxazole. A high index of suspicion for causes of culture-negative endocarditis needs to be maintained when blood cultures are negative despite clear evidence of endocarditis especially with large vegetation sizes and other complications such as septic emboli. Multiple imaging modalities are available to assist with diagnosis including transthoracic and transesophageal echocardiogram as well as cardiac computed tomography. A blood PCR test can identify the implicated pathogen in a more expeditious manner compared to valve histopathological evaluation. Treatment is complex and usually requires surgical intervention and prolonged antimicrobial therapy., (© 2024. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Primary heart tumors are rare, with atrial myxomas being the most common type. Atrial myxomas can lead to embolisms, heart obstruction, and systemic symptoms. Herein, we report a case of 72-year-old woman who presented with a left atrial myxoma at the atrial septal defect occluder, a new acute cerebral infarction, and MINOCA (myocardial infarction with no obstructive coronary atherosclerosis). Left atrial myxoma is a common primary cardiac tumor; however, left atrial myxomas arising after percutaneous atrial septal defect occlusion are rare. Additionally, the patient presented with a new case of multiple systemic emboli. The patient underwent surgical resection of a left atrial myxoma, occluder, and left atrium, and atrial septal repair, and was discharged with good recovery for outpatient follow-up. The possibility of a cardiac tumor, especially an atrial myxoma, which can lead to a series of complications, should be considered at the closure site after percutaneous atrial septal closure. Therefore, active surgical treatment and long-term follow-up are warranted in such cases.

Aims: The Edoxaban Low-Dose for Elder Care Atrial Fibrillation Patients (ELDERCARE-AF) trial showed that edoxaban at a very low dosage (VLD) of 15 mg/day was more effective than a placebo at preventing stroke/systemic embolism without significantly increasing the risk of serious bleeding. We aimed to compare the effectiveness and safety for VLD non-vitamin K antagonist oral anticoagulants (NOACs) [edoxaban 15 mg o.d., dabigatran 110 or 150 o.d., apixaban 2.5 mg o.d., or rivaroxaban 10 mg (without the diagnosis of chronic kidney disease) or <10 mg o.d.] vs. regular-dosage (RD) NOACs (edoxaban 60/30 mg o.d. or other labeling-dosage NOACs) among a real-world cohort of elderly atrial fibrillation (AF) population similar to the ELDERCARE-AF cohort., Methods and Results: In this nationwide retrospective cohort study from Taiwan National Health Insurance Research Database (NHIRD), we identified a total of 7294 and 4151 consecutive AF patients aged 80 years or older with a CHADS2 (congestive heart failure, hypertension, age 75 years or older, diabetes mellitus, previous stroke/transient ischemic attack (2 points) score ≥2 who met the enrollment criteria (generally similar to ELDERCARE-AF) taking VLD and RD NOACs from 1 June 2012 to 31 December 2019, respectively. Propensity-score stabilized weighting (PSSW) was used to balance covariates across study groups. Patients were followed up from the first date of prescription for NOACs until the first occurrence of any study outcome, death, or until the end date of the study period (31 December 2020). After PSSW, VLD NOAC was associated with a comparable risk of ischemic stroke/systemic embolism and major bleeding but a higher risk of major adverse limb events (MALEs) requiring lower limb revascularization or amputation [hazard ratio (HR): 1.54, 95% confidential interval (CI): 1.09-2.18; P = 0.014), venous thrombosis (HR: 3.75, 95% CI: 1.56-8.97; P = 0.003), and all-cause mortality (HR: 1.21, 95% CI: 1.15-1.29; P <0.001) compared with RD NOACs. VLD NOACs showed worse outcomes in most net clinical outcome (NCO) benefits. The main result was consistent based on on-treatment analysis or accounting for death as a competing risk. In general, the advantage of NCOs for the RD NOACs over VLD NOACs persisted in most high-risk subgroups, consistent with the main analysis (P for interaction > 0.05)., Conclusion: Use of VLD NOACs was associated with a greater risk of arterial and venous thrombosis, death as well as the composite outcomes, when compared with that of RD NOAC in high-risk elderly AF patients at increased bleeding risk. Thromboprophylaxis with RD NOAC is still preferable over VLD NOAC for the majority of elderly AF patients at increased bleeding risk., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: Atrial fibrillation (AF) is one of the most frequent causes of stroke. Several randomized trials have shown that prolonged monitoring increases the detection of AF, but the effect on reducing recurrent cardioembolism, ie, ischemic stroke and systemic embolism, remains unknown. We aim to evaluate whether a risk-adapted, intensified heart rhythm monitoring with consequent guideline conform treatment, which implies initiation of oral anticoagulation (OAC), leads to a reduction of recurrent cardioembolism., Methods: Find-AF 2 is a randomized, controlled, open-label parallel multicenter trial with blinded endpoint assessment. 5,200 patients ≥ 60 years of age with symptomatic ischemic stroke within the last 30 days and without known AF will be included at 52 study centers with a specialized stroke unit in Germany. Patients without AF in an additional 24-hour Holter ECG after the qualifying event will be randomized in a 1:1 fashion to either enhanced, prolonged and intensified ECG-monitoring (intervention arm) or standard of care monitoring (control arm). In the intervention arm, patients with a high risk of underlying AF will receive continuous rhythm monitoring using an implantable cardiac monitor (ICM) whereas those without high risk of underlying AF will receive repeated 7-day Holter ECGs. The duration of rhythm monitoring within the control arm is up to the discretion of the participating centers and is allowed for up to 7 days. Patients will be followed for at least 24 months. The primary efficacy endpoint is the time until recurrent ischemic stroke or systemic embolism occur., Conclusions: The Find-AF 2 trial aims to demonstrate that enhanced, prolonged and intensified rhythm monitoring results in a more effective prevention of recurrent ischemic stroke and systemic embolism compared to usual care., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objective: To explore the diagnostic value of age-adjusted d-dimer cut-off for the acute pulmonary embolism(APE). Methods: Computed Tomography Pulmonary Angiography (CTPA) was performed for the diagnosis of 367 cases of suspected APE, and enzyme-linked immunosorbent assay (ELISA) was used to detect D-dimer concentration. The sensitivity, specificity, accuracy, negative prediction value and positive predictive value between age-adjusted D-dimer cut-off [(age× 10) μg/L] and traditional cut-off (500μg/L) was compared. Results: 367 suspected APE patients, 64 cases was confirmed with the detection rate of 17.4％. The concentration of D-dimer in APE patients was (2108.5± 335.9) μg/L, was significantly higher than(486.8± 65.2) μg/L in non APE patients (t=27.61, P＜0.05). The concentration of D-dimer in APE patients more than 60 year-old was (2931.8± 509.4) μg/L, was significantly higher than (1806.1± 319.6) μg/L in patients less than 60 year-old (t=1 0.77, P＜0.05). The specificity, coincidence rate, positive predictive value and area under the curve (AUC) of age-adjusted D-dimer cut-off in the diagnosis of APE were significantly increased than those of traditional D-dimer cut-off (P＜0.05). While there was no significant difference on sensitivity, negative predictive value between two cut-offs(P＞0.05). Conclusions: The D-dimer concentration was increased with the increase of age, age-adjusted D-dimer cut-off could improve the efficiency of the diagnosis of APE, reduce the missed diagnosis, it was especially suitable for the patients more than 50 years old. [ABSTRACT FROM AUTHOR]

Background: The CRP/albumin ratio (CAR), a new inflammatory marker, is associated with adverse outcomes in various cardiovascular diseases. We evaluated the effectiveness of CAR in predicting embolic events in patients diagnosed with infective endocarditis (IE). Methods: A total of 145 patients with IE were included in the study and categorized into two groups according to the presence of embolic events. We retrospectively analyzed the patients' clinical, laboratory and echocardiographic data. Results: CRP (94.2 vs 63.3; p < 0.001) and CAR (25.8 vs 15.1; p < 0.001) values were significantly higher in patients who experienced embolic events. Multivariate analysis showed that a high CAR value (odds ratio: 1.030; 95% CI: 1.000-1.060; p = 0.041) was an independent predictor of embolic events in patients with IE. Conclusion: The CAR is a cheap and easily accessible marker that can predict the development of embolic events in patients diagnosed with IE.

Emboli caused by cardiac myxomas mostly occur in the cardiovascular or cerebrovascular systems and rarely in the lower extremity vasculature. We introduce the rare case of a patient with left atrial myxoma (LAM) whose right lower extremity (RLE) suffered from acute ischemia due to tumor fragments, along with a review of the relevant literature, and highlight the clinical characteristics of LAM. An 81-year-old female presented with acute ischemia of RLE. Color Doppler ultrasound showed no blood flow signal far from the RLE femoral artery. Computed tomography angiography showed an occlusion of the right common femoral artery. A transthoracic echocardiogram revealed a left atrial mass. Femoral artery embolectomy was performed under local anesthesia, followed by thoracotomy with tumor resection under general anesthesia on postoperative day seven. The tumor was pathologically confirmed as an atrial myxoma. A literature search of the PubMed database returned 58 cases of limb ischemia due to LAM, and the conclusions drawn from the statistical analysis were that emboli from LAM occurred most commonly in the aortoiliac and bilateral lower limb vasculature and were rarely associated with upper extremity and atrial fibrillation. Multisystem embolism is characteristic of cardiac myxoma. The removed embolus should be examined pathologically for signs of a cardiac myxoma. Lower-limb embolisms should be promptly diagnosed and treated to avoid osteofascial compartment syndrome.

Valve embolization is a catastrophic complication of mitral valve-in-valve and valve-in-ring procedures and occurs due to inadequate ventricular positioning, undersizing, or insufficient anchoring. Emergent cardiac surgery to retrieve the embolized valve is usually required for overt embolization. In the situation described herein, a decision was made to attempt to deploy a second valve at a proper depth to anchor the embolized valve and prevent further migration. This case highlights the technique of deploying a second valve to anchor the embolized valve if valve migration has occurred with minimal movement.

Background: Our aim was to analyze the incidence of P-wave abnormalities in embolic and non-embolic strokes, and evaluate its clinical usefulness for predicting stroke etiology., Methods: We included 376 consecutive patients hospitalized for acute ischemic stroke from January 2015 to September 2021. Among the patients in sinus rhythm at admission, 31 had ischemic stroke due to atrial fibrillation (AF)-related embolism, 59 had embolic stroke of unknown source (ESUS), and 143 had non-embolic stroke. P-wave abnormalities were defined as 1. P-wave axis abnormality (PWAA); 2. P-wave terminal force in V 1 (PTFV1) ≤ -4000 μV*ms; 3. advanced inter-atrial block (A-IAB)., Results: The prevalence of each type of abnormality was consistently lower in patients with non-embolic stroke than in those with AF-related embolism (AF-related vs. ESUS vs. non-embolic; PWAA, 45% vs. 20% vs. 14%; PTFV1, 36% vs. 37% vs. 15%; and A-IAB, 55% vs. 31% vs. 13%, respectively). The identification of at least one type of P-wave abnormality improved the sensitivity compared to using a single abnormality parameter (sensitivity 72%, specificity 62%), while at least two types of abnormality had low sensitivity, but high specificity (sensitivity 29%, specificity 95%). Multivariate regression analysis revealed that identification of at least one type of P-wave abnormality was independently associated with embolic stroke (odds ratio 3.11, 95%CI 1.46-6.63)., Conclusions: The incidence of each type of P-wave abnormality was significantly lower in patients with non-embolic stroke. A combination of PWAA, PTFV1, and A-IAB parameters could be useful for distinguishing embolic from non-embolic stroke., Competing Interests: Declaration of Competing Interest None., (Copyright © 2022 Elsevier B.V. All rights reserved.)

A 31-year-old male with acute blurred vision and respiratory distress occurring three days after a penile filler injection was found to have outer plexiform layer hyperreflectivity on optical coherence tomography (OCT), consistent with paracentral acute middle maculopathy (PAMM). He was diagnosed with diffuse bilateral pneumonitis and silicone embolism syndrome requiring inpatient management. Following systemic stabilization, his vision and OCT findings improved. PAMM may be associated with silicone embolism syndrome in the presence of acute central scotomas and minimal retinal findings. Penile filler injections could contribute to retinal vaso-occlusion via an embolic process. PAMM may be self-limited and result in functional vision. [ Ophthalmic Surg Lasers Imaging Retina 2022;53:635-638.] .

Objectives: Scarce data exist on noncerebrovascular peripheral embolism (NCPE) patients undergoing transcatheter patent foramen ovale (PFO) closure. The objectives of this study were to determine the clinical and procedural characteristics, and long-term outcomes of patients with NCPE undergoing transcatheter PFO closure., Methods: This was a multicenter study including 1136 consecutive patients who underwent PFO closure after a thromboembolic event. Patients were divided into 2 groups according to the type of event leading to PFO closure, ie, cerebrovascular event (CVE, n = 1099 [96.7%]) and NCPE (n = 37 [3.3%]). The median follow-up was 3 years (interquartile range, 1-8), with follow-up complete in 98%., Results: Patients in the NCPE group exhibited higher rates of prior or concomitant pulmonary embolism (29.7% vs 3.4%; P&lt;.001), and prior myocardial infarction (24.3% vs 1.8%; P&lt;.001). Most NCPE events were located in the limbs (41%), followed by coronary (27%) and renal/splenic/mesenteric arteries (12%). PFO closure was successful in all patients, with a low complication rate (&lt;1%) in both groups. NCPE patients were more frequently treated with anticoagulation following PFO closure (63% vs 13%; P&lt;.001). There were no differences between NCPE and CVE groups in death (0 per 100 patient years vs 0.4 per 100 patient-years; P=.53) or cerebrovascular events (1.3 per 100 patient-years vs 0.4 per 100 patient-years; P=.15) at follow-up., Conclusions: Patients with NCPE events undergoing PFO closure exhibited differential baseline characteristics compared with patients with CVEs; limbs and coronary arteries were the most frequent NCPE location. PFO closure results and long-term outcomes were similar to their CVE counterparts, with a very low rate of recurrent thromboembolic events. Further studies are needed in this population.

Background: Embolic stroke of undetermined source (ESUS) encompasses diverse embologenic mechanisms, which transesophageal echocardiography (TEE) is critical to detect. Specific markers related to each embolic source in ESUS is not fully studied. We focused on D-dimer levels, and explored the association of D-dimer with potential embolic sources (PES) identified on TEE in ESUS., Methods: Consecutive patients with ESUS were included in this study. Clinical characteristics including D-dimer levels were compared between ESUS patients with and without TEE, and among none of, one, and at least two PES in ESUS patients undergoing TEE. Factors related to elevation of D-dimer were analyzed., Results: A total of 211 patients (age, 69.3 ± 13.2 years; 149 males) with ESUS were enrolled. Of these, 115 received TEE, displaying significantly younger age and lower D-dimer levels than patients without TEE (P < 0.05), and 20 (17%), 61 (53%), and 34 (30%) patients were classified into none of, one, and ≥ two PES, respectively. On multiple logistic regression analysis, D-dimer levels were related to one PES (odds ratio [OR]: 9.01; 95% confidence interval [CI]: 1.00-81.51; P = 0.050) and PES ≥ two (OR: 9.76; 95% CI: 1.07-88.97; P = 0.043). Right-to-left shunt (RLS) with deep venous thrombosis (DVT)(OR: 13.94; 95% CI: 1.77-109.99; P = 0.012) and without DVT (OR: 3.90; 95% CI: 1.20-12.70; P = 0.024) were associated with elevation of D-dimer., Conclusions: D-dimer levels were higher in patients with PES. Among PES, RLS, with and without DVT, were associated with increase of D-dimer in ESUS., (© 2022. The Author(s).)

Several trials have shown that paclitaxel drug-coated balloons (DCBs) significantly reduce restenosis rates. However, some reports have shown distal embolisms occurring after DCBs. No study has analyzed the clinical outcomes of patients with DCB-induced distal embolism. This study aimed to investigate the clinical outcomes of DCB-induced distal embolism in patients with femoropopliteal artery disease. Between February 2018 and April 2019, consecutive patients (n = 32) who presented with de novo femoropopliteal artery disease and underwent endovascular therapy using DCB were retrospectively reviewed in a single-center study. Patients were divided into two groups based on whether distal embolism was detected using laser doppler flowmetry (DEL group) or not (non-DEL group). Baseline characteristics and 1-year clinical outcomes were compared between the groups. DEL was found in 44% of limbs (DEL group: n = 15, non-DEL group: n = 19). Below-the-knee arterial runoff ≤ 1 (p = 0.033), popliteal lesion (p = 0.044), ambulation difficulty (p = 0.021), and previous history of coronary artery disease (p = 0.013) were identified as predictive factors of DEL. Procedural factors, reference vessel diameter, lesion length, and total drug amount were not predictive of DEL. The overall target lesion restenosis (TLR) rate was 17.4% (n = 5). The TLR rate was not significantly different between the DEL and non-DEL groups (13.3% vs. 15.8%, p = 0.55). Severe calcification was the only significant factor for TLR (4.2% vs. 40.0%, p = 0.02). Among patients with femoropopliteal disease, there was no difference in 1-year clinical outcome between patients who underwent DEL and those who did not., (© 2021. The Author(s).)

In this work, the use of hyperpolarized (HP)3He for in vivo intravascular imaging on animal is reported. To overcome the problem of the low solubility of helium in blood, we propose an approach based on helium encapsulation in lipid-based carrier agents. The mean diameter of the3He microbubbles. measured equal to 3.0 ±0.2 µm, makes it possible to conduct in vivo studies. In vitro spectroscopy yielded a longitudinal relaxation time T1 equal to 90 s and an apparent transverse relaxation time T 2 * of 4.5 ms. Angiographie imaging (venous and cardiac cavity visualization), as well as lung perfusion imaging, were demonstrated in rats using intravenous injections of microbubble suspensions. Suitable signal and spatial resolution were achieved. The potential of this technique for lung perfusion assessment was assessed using an experimental animal embolism model. Lung perfusion defects and recovery towards a normal perfusion state were visualized. This study was completed with the demonstration of a new ventilation-perfusion lung exploration method based entirely on HP3He. [ABSTRACT FROM AUTHOR]

Complete heart block, aortic root abscess and aortic valve regurgitation are well-recognized complications of infective endocarditis of the aortic valve. Splenic abscess and aorto-cavitary fistula are rarer phenomena and are indicative of calamitous infection. The authors present the case of an otherwise healthy 61-year-old man presenting with a 2-month history of non-specific symptoms, who developed suppurative endocarditis with a fistulating aortic root abscess, combined with severe sepsis, splenic embolization and complete heart block. Staphylococcus lugdunensis was the causative bacterium identified. The combination of these sequelae in the same patient is sparsely reported, is exceedingly rare and carries a significant risk of mortality.

A 26-year-old male patient presented with left-sided pneumonia, endocarditis of the tricuspid and pulmonary valves and a pulmonary artery embolism. In 2004 a Ross operation was performed because of congenital aortic valve stenosis. There was an elevation of the antibody titer for Coxiella burnetii, the pathogen of Q fever. Under antibiotic treatment with levofloxacin and doxycycline there was an improvement of the symptoms and a normalization of the inflammation parameters. The treatment of the endocarditis was successful., (© 2021. The Author(s).)

Spinal cord infarction (SCI) occurs rarely and is characterized by abrupt onset of neck or back pain and neurologic deterioration. Fibrocartilaginous embolism (FCE) of the spinal cord is a rare but possible cause of acutely progressive spinal cord symptoms. Here, we report the case of an older woman who developed acute paraplegia with SCI on the 10th day after thoracic spine surgery. Although definitive FCE diagnosis can be confirmed only histologically, the characteristic clinical and radiological features were highly suggestive of FCE. Furthermore, 40 clinically suspected cases of FCE are reviewed.

Background: Acute lower limb ischemia (ALI) is a limb and life-threatening condition whose treatment largely depends on the underlying cause. The clinical distinction between the main causes may have changed over the years because of changes in the epidemiology of this syndrome. The objective of this study was to determine the clinical pattern associated with the main causes of ALI in a contemporary series of cases., Methods: We retrospectively reviewed all consecutive ALI cases admitted to a tertiary hospital between 2007 and 2019. ALI secondary to other conditions than embolism or NAT were excluded. The association between clinical variables and the ALI cause was assessed with multiple logistic regressions and the discriminative power of the resulting clinical predictive scores with the area under the ROC curve., Results: The study group included 243 patients (mean age 77.2 years; 52.7% male), of which 140 (57.6%) were caused by an arterial embolism and 103 (42.4%) by a NAT. Among these latter, 78 (75.7%) were related to an atherosclerotic NAT and 25 (24.3%) to a complicated popliteal aneurysm. Independent risk factors associated with embolism included atrial fibrillation (OR 10.26, 95% CI 5.1 - 20.67) or female gender (OR 5.44, 95% CI 2.76 - 10.71), but not the severity of the episode or the presence of contralateral pulses. Those related to a NAT included a previous symptomatic peripheral arterial disease (OR 2.68, 95% CI 1.35 - 5.35) and seeking consultation more than 24 hours after the beginning of symptoms (OR 2.57, 95% CI 1.32 - 5), but not a higher rate of other vascular risk factors. Among patients with NAT, previous intermittent claudication (OR 8.34, 95% CI 2.42 - 28.72) and >24 hs delay of arrival of the patient (OR 4.78, 95% CI 1.48 - 15.43) were more frequent among those related to an atherosclerotic NAT, whereas higher hemoglobin levels (OR 1.60, 95% CI 1.21 - 2.11) and non-significantly the history of tobacco smoking (OR 2.95, 95% CI 0.84 - 10.36) among those with a popliteal aneurysm-related NAT. The discriminative power of the two clinical models resulting from these predictive variables for differentiating embolism from NAT and atherosclerosis-related NAT from popliteal aneurysm-related NAT was excellent (0.86 and 0.85, respectively)., Conclusion: Certain clinical features appear to be no longer useful in the distinction between embolism and NAT, while others may help in the differential diagnosis between atherosclerotic and popliteal aneurysm-related NAT. Surgeons must be aware of possible changes in the presentation of ALI because time constraints are frequent and clinical data remain essential., (Copyright © 2021. Published by Elsevier Inc.)

The errors in the following list appeared in the article entitled "Systematic Immune-Inflammation Index Predicts Embolic Eventsin Infective Endocarditis" by Wangling Hu, Guanhua Su, Wanyue Zhu, Enqing Zhou, and Xinxin Shuai (Vol. 63, 510-516, 2022).

Arterial thrombotic events in younger patients without a readily apparent etiology present significant diagnostic and management challenges. We present a structured approach to diagnosis with consideration of common causes, including atherosclerosis and embolism, as well as uncommon causes, including medications and substances, vascular and anatomic abnormalities, systemic disorders, and thrombophilias. We highlight areas of management that have evolved within the past 5 years, including the use of dual-pathway inhibition in atherosclerotic disease, antithrombotic therapy selection in embolic stroke of undetermined source and left ventricular thrombus, the role of closure of patent foramen ovale for secondary stroke prevention, and the thrombotic potential of coronavirus disease 2019 infection and vaccination. We conclude with a representative case to illustrate the application of the diagnostic framework and discuss the importance of consideration of bleeding risk and patient preference in determining the appropriate management plan., (Copyright © 2021 by The American Society of Hematology.)

Introduction: Charlson Comorbidity Index (CCI) is commonly used in outcome studies to adjust for patient comorbid conditions but has not been specifically validated for use in acute embolic lower limb ischaemia (AELLI)., Objectives: The aim of this study was to access whether a high CCI score unadjusted (CCIu) and adjusted (CCIa) by age relates to major amputation and mortality after a first episode of AELLI., Methods: The last 100 patients presenting with the first event of AELLI submitted to embolectomy at our Vascular Surgery Department were retrospectively evaluated. Patient characteristics, pre- and post-operative period variables were collected and CCIu and CCIa calculated. Survival predictors were analyzed using Cox regression. The area under the curve of the receiver operating characteristic curves was calculated to validate and determine the discriminating ability of CCIu and CCIa in predicting amputation rate and 30-day mortality. Youden index was used to determine the critical value. Survival analysis was performed with Kaplan-Meier method and differences between survival curves were tested with Log-Rank test. A P value of <0.05 was considered statistically significant., Results: The mean age was 80.03±10.776 years and the mean follow-up 19.28±7.929 months. Amputation rate was 16%, 30-day mortality 21% and long-term mortality 42%. Patients with CCIu≥3 compared with patients with CCIu<3 had higher amputation rate (37.5% vs. 1.7%; OR:35.400), 30-day mortality (47.5% vs. 3.3%; OR:35.400) and global mortality (P=0.00). Also, patients with CCIa≥6 compared with patients with CCIa<6 had higher amputation rate (34.1% vs. 1.8%; OR:28.488), 30-day mortality (47.7% vs. 0.0%) and global mortality (P=0.00). Multivariate analysis showed that both CCIu and CCIa were independent predictors of amputation rate and 30-day mortality., Conclusion: CCIu and CCIa have proven to be good predictors of amputation rate and survival, thus being a valuable prognostic factor in patients presenting with the first event of AELLI., (Copyright © 2021. Published by Elsevier Inc.)

Background: Accumulating data suggest blood biomarkers could inform stroke etiology., Objective: The purpose of this study was to investigate the performance of multiple blood biomarkers in elucidating stroke etiology with a focus on new-onset atrial fibrillation (AF) and cardioembolism., Methods: Between January and December 2017, information on clinical and laboratory parameters and stroke characteristics was prospectively collected from ischemic stroke patients recruited from the National University Hospital, Singapore. Multiple blood biomarkers (N-terminal pro-brain natriuretic peptide [NT-proBNP], d-dimer, S100β, neuron-specific enolase, vitamin D, cortisol, interleukin-6, insulin, uric acid, and albumin) were measured in plasma. These variables were compared with stroke etiology and the risk of new-onset AF and cardioembolism using multivariable regression methods., Results: Of the 515 ischemic stroke patients (mean age 61 years; 71% men), 44 (8.5%) were diagnosed with new-onset AF, and 75 (14.5%) had cardioembolism. The combination of 2 laboratory parameters (total cholesterol ≤169 mg/dL; triglycerides ≤44.5 mg/dL) and 3 biomarkers (NT-proBNP ≥294 pg/mL; S100β ≥64 pg/mL; cortisol ≥471 nmol/l) identified patients with new-onset AF (negative predictive value [NPV] 90%; positive predictive value [PPV] 73%; area under curve [AUC] 85%). The combination of 2 laboratory parameters (total cholesterol ≤169 mg/dL; triglycerides ≤44.5 mg/dL) and 2 biomarkers (NT-proBNP ≥507 pg/mL; S100β ≥65 pg/mL) identified those with cardioembolism (NPV 86%; PPV 78%; AUC 87%). Adding clinical predictors did not improve the performance of these models., Conclusion: Blood biomarkers could identify patients with increased likelihood of cardioembolism and direct the search for occult AF., (Copyright © 2021 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Although rare, retinal artery cholesterol emboli (Hollenhorst plaques) post angioplasty can be a severe event that can cause irreversible visual disturbances, usually taking place during or following the procedure. However, as the number of procedures continues to increase, interventional radiologists or cardiologists who perform coronary catheterization should be cognizant of its possible delayed occurrence, as in the case presented herein.

Endovascular treatment of strokes caused by large vessel occlusion enables the histopathological investigation of the retrieved embolus, possibly providing a novel opportunity to contribute to the diagnostic workup of etiology and to define secondary prevention measures in strokes with uncertain genesis. We aimed to develop a classification rule based on pathophysiological considerations and adjustment to reference thrombi for distinction between cardiac and arteriosclerotic emboli and to validate this classification rule on a patient cohort. From 125 patients with stroke due to large vessel occlusion and thrombectomy, 82 patients with known etiology (55 cardioembolic and 27 arterioembolic strokes) were included. The corresponding emboli were histologically evaluated by two raters blinded to the etiology of stroke by means of a novel classification rule. Presumed etiology and classification results were compared. Agreement concerning cardiac emboli was 72.2% (95% CI: 58.4-83.5) for rater I and 78.2% (95% CI: 65.0-88.2) for rater II. Agreement concerning arteriosclerotic emboli was 70.4% (95% CI: 49.8-86.3) for rater I and 74.1% (95% CI: 53.7-88.9) for rater II. Overall agreement reached 71.6% (95% CI: 60.5-81.1) for rater I and 76.8% (95% CI: 66.2-85.4) for rater II. Within the limits of generally restricted accuracy of histological evaluations, the classification rule differentiates between cardiac and arteriosclerotic emboli of acute ischemic stroke patients. Further improvement is needed to provide valuable complementary data for stroke etiology workup.

Introduction: There have been 30 clinically suspected cases and 41 histopathologically confirmed cases of fibrocartilaginous embolism (FCE) reported in the literature. FCE often has a poor prognosis and is estimated to represent 5.5% of spinal cord infarctions, but may be more common than initially presumed given underdiagnosis due to its vague clinical presentation., Case Presentation: We report two cases, a 15-year-old male and a 15-year-old female, whose clinical history, examination, and imaging findings were consistent with spinal cord infarction secondary to FCE., Discussion: These cases were unique given our patients' neurologic improvement; however, the commonly held assumption of poor prognosis may in part be fueled by the preferential case ascertainment via biopsy on autopsy. These cases highlight the importance of recognizing rare causes of spinal cord pathology and considering FCE in the differential diagnosis of acute myelopathy.

Background:  AVERROES, a randomized controlled trial in high-risk patients with atrial fibrillation, unsuitable for vitamin K antagonist therapy, demonstrated efficacy and safety of apixaban compared with aspirin. At the conclusion of the double-blind phase, an open-label extension was initiated to allow study participants to receive apixaban until it became locally available. This study reports outcomes of patients on apixaban during the open-label extension., Methods:  Rates of stroke or systemic embolism, hemorrhagic stroke, major bleeding, and other outcomes during the open-label extension are reported., Results:  Of the 5,599 participants enrolled in AVERROES, 3,275 (58.5%) received apixaban during the open-label extension. Median (interquartile range) follow-up in the open-label extension was 3.0 (2.5-3.5) years. The rate of stroke or systemic embolism during the open-label extension was 1.0% per year, and the annual rates of hemorrhagic stroke and major bleeding were 0.3 and 1.2%, respectively. After adjustment for imbalances in patient variables, event rates in patients on apixaban during the open-label extension were similar to those of patients receiving apixaban during AVERROES. Additional analyses in all patients who received apixaban, at any time from the start of AVERROES to the end of the open-label extension, were performed. This cohort ( n  = 4,414) showed annual event rates of 1.1% for stroke or systemic embolism, 0.3% for hemorrhagic stroke, and 1.2% for major bleeding., Conclusion:  During the open-label extension, annual rates of stroke or systemic embolism, hemorrhagic stroke, and major bleeding remained as low as those observed during apixaban treatment in AVERROES. These data support the long-term efficacy and safety of apixaban in patients with atrial fibrillation., Competing Interests: A.P.B. reports travel support to attend a scientific meeting from St. Jude Medical/Abbott, outside the submitted work. J.W.E. reports grants and personal fees from Bristol-Myers Squibb/Pfizer, during the conduct of the study; grants and personal fees from Astra Zeneca, grants and personal fees from Bayer, grants and personal fees from Boehringer Ingelheim, grants and personal fees from Bristol-Myers Squibb/Pfizer, grants and personal fees from Daiichi Sankyo, grants and personal fees from Eli Lilly, grants and personal fees from Glaxo Smith Kline, grants and personal fees from Janssen, grants and personal fees from Sanofi Aventis, outside the submitted work. S.Y. reports grants from Bristol-Myers Squibb/Pfizer, during the conduct of the study; grants and personal fees from Bayer, grants and personal fees from Boehringer Ingelheim, outside the submitted work. S.H.H. reports personal fees from Bristol-Myers Squibb/Pfizer, during the conduct of the study; personal fees from Bayer Healthcare, personal fees from Boehringer Ingelheim, personal fees from Daiichi Sankyo, personal fees from Medtronic, personal fees from St. Jude Medical/Abbott, personal fees from Zoll, outside the submitted work. A.K. is an employee of Bristol-Myers Squibb. H.B. has nothing to disclose. K.B. has nothing to disclose. J.S.H. reports grants and personal fees from Bristol-Myers Squibb/Pfizer, grants and personal fees from Medtronic, grants and personal fees from Boston Scientific, personal fees from Servier, outside the submitted work. S.J.C. reports grants and personal fees from Bristol-Myers Squibb/Pfizer, during the conduct of the study; grants and personal fees from Portola Pharmaceuticals, grants and personal fees from Bristol-Myers Squibb/Pfizer, grants and personal fees from Bayer, grants and personal fees from Daiichi Sankyo, grants and personal fees from Boehringer Ingelheim outside the submitted work. Open Access support was provided by the Apixaban, Bristol Myers Squibb and Pfizer Alliance., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)