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  • Case reports br Discussion RV perforation is


    Case reports
    Discussion RV perforation is a rare but serious complication of PPM and ICD implantation. It is diagnosed when at least the tip of a passive fixation lead or the screw of an active fixation lead passes through the myocardium and extends into the pericardial cavity [1]. This complication may develop acutely (i.e., less than 24h) after device implantation or in a subacute or chronic fashion [2].
    Conflict of interest
    Introduction Cardiac arrhythmia is a major source of chest discomfort, lightheadedness, dyspnea, and presyncope, occasionally leading to syncope, osthole failure, and death. In particular, atrial fibrillation (AF) is the most frequently encountered sustained cardiac arrhythmia [1]. Even if individuals with AF or atrial flutter (AFL) do not have symptoms initially, they may develop tachycardia-induced ventricular dysfunction, followed by heart failure due to non control of the ventricular rate. AF also confers an increased risk of ischemic stroke and systemic thromboembolism due to the formation of atrial thrombi in the left atrial appendages (LAA) [1,2]. In patients with a recent occurrence of AF or AFL, the termination of the arrhythmias can reasonably be expected to have an impact on the clinical outcome. Electrical cardioversion (ECV) is used to restore the sinus rhythm in patients with arrhythmia such as AF and AFL. The efficacy of conversion to sinus rhythm in patients with symptomatic AF is known; it improves the patients’ hemodynamics, functional status, and quality of life. However, ECV is associated with a thromboembolic risk after conversion to sinus rhythm. In non-anticoagulated patients, there is a 5–7% risk of thromboembolic complications such as ischemic stroke and systemic embolism [3,4]. If anticoagulation therapy such as those using vitamin K antagonists (VKAs) is adequate, the risk of thromboembolic events by cardioversion, including both electric and pharmacological methods is reduced to 0.5–1.6% [5,6]. As an alternative to oral anticoagulation therapy using the VKA oral anticoagulant warfarin—which has been administered for decades—non-VKA oral anticoagulants (NOACs) were recently developed and are available for ordinary clinicians. NOACs were reported to have several advantages over warfarin: a lower risk of intracranial hemorrhage, the lack of a need to frequently check the international normalized ratios (INRs), and their quicker action [7]. Posthoc analyses of phase III trials have found new NOACs: dabigatran, rivaroxaban, and apixaban to be as safe and effective as VKA treatment in the setting of cardioversion [8–10]. However, this finding has not been confirmed in a real-world clinical practice. In the present study, we estimated the efficacy and safety of NOACs in patients with AF and AFL who underwent ECV in a real-world setting, in comparison with warfarin therapy.
    Material and methods
    Results Overall, the mean age of the patients was 65.7 ±10.3 years (range, 32–86 years); 63% (n=257) were male, and 37% (n=149) were female. AF was observed in 87.5% (n=355) of the patients, and AFL was observed in 12.5% (n=51). The basal clinical characteristics of the VKA and NOACs groups are shown in Table 1. AF patients accounted for 86.4% and 89.3% of the VKA and NOACs groups, respectively. There were no significant between-group differences in age, gender, features of atrial arrhythmia, or the CHA2DS2-VASc score. However, the CHADS2 and HAS-BLED scores were significantly higher in the VKA group than in the NOACs group (P=0.029 and P=0.001, respectively). Anti-platelets were prescribed significantly more often in the VKA group than in the NOAC group (P=0.004). Complete TEE findings were available in 66.1% and 73.2% of the VKA and NOACs patients, respectively. As shown in Table 2, there were also no significant differences between the two groups for LAD, LVEF, LAA flow velocity, or the spontaneous echo contrast grade measurements through echocardiographic and Doppler findings.