Background: Approximately 25% of strokes are cryptogenic in origin and identifying atrial fibrillation (AF) as an etiologic factor in this situation has major therapeutic implication. Standard Holter ECG has a low sensitivity for AF detection in this patient group.
Aim: To assess the diagnostic yield of prolonged ambulatory noninvasive ECG telemonitoring for AF detection in cryptogenic stroke or transitory ischemic attack (TIA) patients.
Methods and Results: We prospectively included 36 patients (mean age 53 ± 15 years, 17% women) with cryptogenic stroke or TIA in the previous 3 months and without previously documented episodes of AF. We employed a validated ECG telemonitoring system (TEMEO). The median monitoring period was 22 days, ranging from 13 to 36 days. AF was detected in 10 patients (27%): in 7 patients (70%) AF episodes lasted <30 sec and in the other 3 episodes of absolute arrhythmia were longer. AF runs were asymptomatic in 6 of the patients with arrhythmia detection (60%). The mean time from initiation of telemonitoring to AF detection was 10 days, ranging from 2 to 29 days.
Anticoagulation therapy for secondary prevention of stroke and systemic embolism was initiated in all of the patients with AF detected during telemonitoring.
Conclusion: ECG telemonitoring after cryptogenic stroke or TIA results in AF detection in at least one in every four patients. Considering the important therapeutic implication of this finding we believe that prolonged ECG monitoring should become the standard of care in this patient group.
Aims: Paravalvular regurgitation (PVR) post transcatheter aortic valve implantation (TAVI) is associated with poor survival however considerable variability exists between incidences of PVR in current literature. The primary aim of this study was to establish the incidence of PVR post-procedure, at 6-months and 1-year following TAVI. The secondary aims of this study were to review the impact of moderate to severe PVR on mortality and examine strategies employed to reduce PVR.
Methods: PubMed searches included articles detailing paravalvular leak rates post TAVI
published between 2002 and 2013. A systematic review and meta-analysis of current literature to identify PVR incidence at three time points was performed using the random effects model of DerSimonian and Laird. A total of 19 studies were identified. For post procedure to 30 days, six months and one year; 7,652, 3,340 and 3,673 patients were included in the analysis of incidence of PVR.
Results: The pooled analysis of PVR incidence was 8.21, 10.2 and 10.98% in each group
respectively. Moderate-severe PVR is associated with an increased risk of mortality
in all studies reviewed. Management strategies include balloon valvuloplasty, transcatheter aortic valve implantation-in-transcatheter aortic valve (TAVI-in-TAV), valve repositioning and the use of occlusion devices.
Conclusion: Moderate-severe PVR occurs in approximately one in ten patients directly following TAVI and does not appear to change significantly in the first year. A number of feasible strategies can be employed to treat PVR. Consideration should be given to the development of early-intervention management algorithms for this patient cohort in order to improve survival post TAVI.