Ali Osama Malik

Comparison of Irrigation versus No Irrigation during Burr Hole Evacuation of Chronic Subdural Hematoma.

Objective To compare the results of the use of irrigation versus no irrigation during burr hole evacuation of chronic subdural hematoma (CSDH). Methodology The study was a retrospective chart review of those patients who underwent burr hole evacuation of CSDH during a period of 5 years. Cases were divided into two groups based on the use of irrigation during surgery. A subdural drain was placed in all patients (i.e., in both the irrigation and no-irrigation groups) and removed 24 to 48 hours postoperatively. Results The total sample size was 56, of which 34 patients were in the irrigation group and 22 in the no-irrigation group. Recurrence rate was 17.6% in the irrigation group and 9.1% in the no-irrigation group (p = 0.46). Systemic complications were predominantly cardiac related in the no-irrigation group compared with respiratory complications in the irrigation group. The irrigation group had a mortality rate of 5.9% compared with 4.5% in the no-irrigation group (p = 0.66). Conclusion No statistically significant difference was found between the two groups in terms of recurrence or mortality.

Beta-blockers do not provide survival benefit in a population with angiographic coronary artery disease without myocardial infarction or reduced ejection fraction: A meta-analysis

BACKGROUND While beta-blockers have been widely used for patients with stable coronary artery disease (CAD), some concerns have been raised that beta blockers do not have survival benefit in this population. We conducted a meta-analysis to determine the effects of beta blockers on all-cause and cardiac mortality in adults with CAD without previous myocardial infarction (MI) or reduced ejection fraction. METHODS A systematic search of PubMed, Web of Science, Medline/Ovid and Google Scholar through March 2016 identified 4 studies that reported angiographic CAD without previous myocardial infarction or reduced ejection fraction. Fixed-effects pooled odds ratios and 95% confidence intervals of all-cause and cardiac mortality were estimated. We used the Grading of Recommendations Assessment, Development, and Evaluation system to assess overall quality of evidence. RESULTS A total of 17,397 patients were analyzed. In both all-cause and cardiac mortality analysis, no serious limitation was identified. Beta-blockers were not associated with reductions in all-cause mortality (odds ratios=0.910, 95% confidence intervals 0.797-1.039, p=.163) or cardiac mortality (odds ratio=0.926, 95% confidence interval 0.773-1.110, p=.407). CONCLUSION Beta-blockers do not provide any survival benefit in patients with angiographic CAD without history of MI or reduced ejection fraction.

Subvalvular aortic stenosis: a review of current literature

Subvalvular aortic stenosis (SAS) is one of the common adult congenital heart diseases, with a prevalence of 6.5%. It is usually diagnosed in the first decade of life. Echocardiography is the test of choice to diagnose SAS. Surgical correction is the best treatment modality, and the prognosis is usually excellent. In this review, we describe the pathophysiology, diagnosis, prognosis, and management of SAS with a focus on different pathophysiologic mechanisms, diagnostic approach, and prognosis of the disease by reviewing the current literature.

Resource utilization for transfemoral transcatheter aortic valve replacement: An international comparison

Transfemoral transcatheter aortic valve replacement (TF‐TAVR) has enjoyed a rapid diffusion in the US and Europe, but the procedure is resource intensive.

Significance of inferior wall ischemia in non-dominant right coronary artery anatomy

AIM To investigate the relationship of inferior wall ischemia on myocardial perfusion imaging in patients with non-dominant right coronary artery anatomy. METHODS This was a retrospective observational analysis of consecutive patients who presented to the emergency department with primary complaint of chest pain. Only patients who underwent single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) were included. Patients who showed a reversible defect on SPECT MPI and had coronary angiography during the same hospitalization was analyzed. Patients with prior history of coronary artery disease (CAD) including history of percutaneous coronary intervention and coronary artery bypass graft surgerys were excluded. True positive and false positive results were identified on the basis of hemodynamically significant CAD on coronary angiography, in the same territory as identified on SPECT MPI. Coronary artery dominance was determined on coronary angiography. Patients were divided into group 1 and group 2. Group 1 included patients with non-dominant right coronary artery (RCA) (left dominant and codominant). Group 2 included patients with dominant RCA anatomy. Demographics, baseline characteristics and positive predictive value (PPV) were analyzed for the two groups. RESULTS The mean age of the study cohort was 57.6 years. Sixty-one point seven percent of the patients were males. The prevalence of self-reported diabetes mellitus, hypertension and dyslipidemia was 36%, 71.9% and 53.9% respectively. A comparison of baseline characteristics between the two groups showed that patients with a non-dominant RCA were more likely to be men. For inferior wall ischemia on SPECT MPI, patients in study group 2 had a significantly higher PPV, 32/42 (76.1%), compared to patients in group 1, in which only 3 out of the 29 patients (10.3%) had true positive results (P value < 0.001 Z test). The difference remained statistically significant even when only patients with left dominant coronary system (without co-dominant) were compared to patients with right dominant system (32/40, 76.1% in right dominant group, 3/19, 15.8% in left dominant group, P value < 0.001 Z test). There was no significant difference in mean hospital stay, re-hospitalization, and in-hospital mortality between the two groups. CONCLUSION The positive predictive value of SPECT MPI for inferior wall ischemia is affected by coronary artery dominance. More studies are needed to explain this phenomenon.

ST-segment elevation myocardial infarction, systems of care. An urgent need for policies to co-ordinate care in order to decrease in-hospital mortality

BACKGROUND Regional trends for ST-segment elevation myocardial infarction (STEMI) treatment is not known in the state of Nevada. HYPOTHESIS Great disparity exists for treatment for STEMI in different geographical areas of Nevada. There is a great potential to improve treatment and outcomes of STEMI patients in the State of Nevada. METHODS Admissions to non-federal hospitals in the state of Nevada, using 2011 to 2013 discharge data from the Nevada State Inpatient Data Base (acquired from Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality), were analyzed. Outpatient-onset STEMI patients were identified. The state of Nevada was divided into three divisions based on population densities, defined as population per square mile. Division A included counties with population density of <50 per square mile, Division B included counties with population density of 50 to 200 per square mile, and Division C included counties with population density of >200 per square mile. Trends in use of STEMI-related therapies and the impact on in-hospital mortality rates were compared. RESULTS Almost 20% of the patients with outpatient-onset STEMI do not get any STEMI-related therapy and have significantly higher mortality rate. Patients from Division A do not have direct access to percutaneous coronary intervention (PCI) centers. These patients receive less STEMI-related therapies. Low-volume PCI centers had equivalent mortality rates for STEMI patients who got PCI, compared to high-volume PCI centers. CONCLUSIONS Policies must be created and processes streamlined so all STEMI patients in Nevada receive appropriate treatment.

Management of Symptomatic Severe Aortic Stenosis in Patient With Very Severe Chronic Obstructive Pulmonary Disease

Transcatheter aortic valve replacement (TAVR) is a viable option for patients with severe chronic obstructive pulmonary disease (COPD) who are deemed inoperable or high risk for surgery. We sought to determine outcomes of patients with severe aortic stenosis (AS) and severe COPD referred for aortic valve replacement (AVR). One hundred thirty-one patients with severe AS and severe COPD (GOLD criteria) were evaluated at our center between 2008 and 2013 and were divided retrospectively into 4 groups: 1-medical management, 2-balloon aortic valvuloplasty, 3-surgical aortic valve replacement (SAVR), and 4-TAVR. Baseline, clinical, and echo data were recorded. Primary outcome was cardiovascular death. From the study cohort, 54 (41.2%), 29 (22.1%), 21 (16.0%), and 27 (20.6%) were included in groups 1-4, respectively; the age was 74.9 ± 8.8, 76.2 ± 8.8, 78.8 ± 7.4, and 82.8 ± 6.8 years, respectively (P < 0.01). There was no significant difference between the groups for hypertension, diabetes, aortic valve area or gradients, forced expiratory volume in first second, right ventricular systolic pressure, ejection fraction, and Society of Thoracic Surgeons predicted risk of mortality score. At 3 ± 1.5 years, death occurred in 87%, 97%, 47.7%, and 51.8% of patients in groups 1-4, respectively. Heart failure readmissions occurred in 43%, 42%, 9.6%, and 14.8% of patients in groups 1-4, respectively. When SAVR and TAVR groups were compared, there was no significant difference in survival (P = 0.719) or heart failure readmissions (P = 0.19). In patients with severe or very severe COPD and severe AS, replacing the severely stenotic aortic valve by either SAVR or TAVR improves survival and reduces rehospitalization compared with medical therapy or balloon aortic valvuloplasty.

PREDICTORS OF TREATMENT AND OUTCOMES IN PATIENTS WITH ST SEGMENT ELEVATION MYOCARDIAL INFARCTION IN THE STATE OF NEVADA

Multiple factors can effect treatment and outcomes for ST segment elevation myocardial infarction (STEMI). We studied the characteristics and variables associated with treatment and outcomes of patients who received STEMI care in the state of Nevada. This is a retrospective study of STEMIs from