Daniel Garcia

Incidence of cardiovascular events and gastrointestinal bleeding in patients receiving clopidogrel with and without proton pump inhibitors: an updated meta-analysis.

Background Dual antiplatelet therapy is the standard of care after coronary stent placement but increases the bleeding risk. The effects of proton pump inhibitors (PPIs) on clopidogrel metabolism have been described, but the clinical significance is not yet definitive. We aimed to do an updated meta-analysis comparing outcomes in patients receiving clopidogrel with and without PPIs. Methods We systematically searched PubMed, Scopus and the Cochrane Central Register of Controlled Trials for randomised controlled trials (RCTs) and controlled observational studies in patients taking clopidogrel stratified by concomitant PPI use. Heterogeneity was examined with the Cochran Q test and I2 statistics; p values inferior to 0.10 and I2 >25% were considered significant for heterogeneity. Results We included 39 studies with a total of 214u2005851 patients, of whom 73u2005731 (34.3%) received the combination of clopidogrel and a PPI. In pooled analysis, all-cause mortality, myocardial infarction, stent thrombosis and cerebrovascular accidents were more common in patients receiving both drugs. However, among 23u2005552 patients from eight RCTs and propensity-matched studies, there were no significant differences in mortality or ischaemic events between groups. The use of PPIs in patients taking clopidogrel was associated with a significant reduction in the risk of gastrointestinal bleeding. Conclusions The results of our meta-analysis suggest that PPIs are a marker of increased cardiovascular risk in patients taking clopidogrel, rather than a direct cause of worse outcomes. The pharmacodynamic interaction between PPIs and clopidogrel most likely has no clinical significance. Furthermore, PPIs have the potential to decrease gastrointestinal bleeding in clopidogrel users.

Percutaneous Pulmonary Valve Implantation : Present Status and Evolving Future

Due to recurrent right ventricular outflow tract (RVOT) dysfunction, patients with complex congenital heart disease of the RVOT traditionally require multiple surgical interventions during their lifetimes. Percutaneous pulmonary valve implantation (PPVI) has been developed as a nonsurgical alternative for the treatment of right ventricular to pulmonary artery stenosis or pulmonary regurgitation. PPVI has been shown to be a safe and effective procedure in patients with dysfunctional surgical RVOT conduits. In this population, PPVI has the potential to improve symptoms, functional capacity, and biventricular hemodynamics. However, limitations to the anatomical substrate and size of the RVOT currently restrict PPVI eligibility to less than one-quarter of patients with RVOT dysfunction. The current review discusses contemporary practices in PPVI, evidence supporting the procedure, and future technologies and developments in the field.

Chagas Cardiomyopathy is Associated With Higher Incidence of Stroke: A Meta-analysis of Observational Studies

BACKGROUNDnChagas disease (CD) has been associated with an elevated risk of stroke, but current data are conflicting and prospective controlled studies are lacking. We performed a systematic review and meta-analysis examining the association between stroke and CD.nnnMETHODSnPubmed, Embase, Cochrane Central, Latin American database, and unpublished data were searched with the use of the following terms: (Chagas OR American trypanosomiasis) AND (dilated OR ischemic OR idiopathic OR nonChagasic OR stroke OR cerebrovascular). We included studies that reported prevalence or incidence of stroke in a CD group compared with a non-CD control group. Odds ratios (ORs) and their 95% confidence intervals (CIs) were computed with the use of a random-effects model.nnnRESULTSnA total of 8 studies and 4,158 patients were included, of whom 1,528 (36.7%) had CD. Risk of stroke was elevated in the group of patients with CD (OR 2.10, 95% CI 1.17-3.78). Similar results were observed in a subanalysis of cardiomyopathy patients (OR 1.74, 95% CI 1.02-3.00) and in sensitivity analysis with removal of each individual study. Furthermore, exclusion of studies at higher risk for bias also yielded consistent results (OR 1.70, 95% CI 1.06-2.71). Subanalysis restricted to studies that included patients with the indeterminate form found no significant difference in the stroke prevalence between CD and non-CD patients (OR 3.10, 95% CI 0.89-10.77).nnnCONCLUSIONSnCD is significantly associated with cerebrovascular events, particularly among patients with cardiomyopathy. These findings underline the need for prospective controlled studies in patients with Chagas cardiomyopathy to ascertain the prognostic significance of cerebrovascular events and to evaluate the role of therapeutic anticoagulation in primary prevention.

Vertebral osteomyelitis caused by Mycobacterium abscessus.

Mycobacterium infection caused by non-tuberculous mycobacterial (NTBM) organisms is becoming more common. Although NTBM osteomyelitis is unusual, it can occur in otherwise healthy individuals, but it is also associated with immunocompromised states, such as steroidal therapy and AIDS, and may be observed following trauma. Mycobacterium avium is reported to be the most common causative agent, and Mycobacterium abscessus has only been described in two cases. We report the case of a 44-year-old man with history of hepatitis C diagnosed with osteomyelitis of the thoracic spine caused by M abscessus. We present a literature review of NTBM osteomyelitis and a discussion of its diagnosis and treatment.

Lymphocytic interstitial pneumonia as a manifestation of SLE and secondary Sjogren's syndrome.

A 47-year-old woman with systemic lupus erythematosus (SLE) diagnosed at age of 35years was admitted for dyspnoea, substernal chest pain, dry mucosas and difficulty in swallowing. Physical examination revealed vesicular breath sounds bilaterally. Laboratory work showed antinuclear antibody (ANA) (speckled pattern, 1:40), positive anti-Sjogren’s syndrome antigen (SSA) and antisingle side band (SSB) and negative double-strand DNA (dsDNA), with normal C3,C4,C50. A high-resolution chest CT scan demonstrated multiple bronchial cysts and diffuse interstitial infiltrates. Surgical lung biopsy revealed emphysematous changes and mild lymphocytic infiltrate around the bronchioles compatible with lymphocytic interstitial pneumonia diagnosis. This case illustrates a patient with primary SLE overlapped by initial manifestations of secondary Sjogren’s syndrome (SS) presenting with associated autoimmune interstitial lung disease. Antibody markers, high-resolution chest CT scan and surgical lung biopsy were essential in evaluating this patient, confirming the interstitial lymphocytic infiltration of the lung. Primary SS (pSS) is the most commonly associated disease to lung interstitial pneumonia (LIP) (25%). High-resolution chest CT scan demonstrates areas of ground-glass attenuation, suggestive of interstitial disease. Surgical lung biopsy shows pathologic increase of mature lymphocyte cells and histiocytes. Most of the cases have a benign presentation and shortly relapse. Superimposed infection, pulmonary fibrosis and lymphoma develop in less than 20% of cases. Corticosteroids are the primary therapy. While pSS is commonly associated with interstitial lung involvement, secondary Sjogrens syndrome (sSS) is only rare. It has been described the initial sSS presentation by Sica symptoms development only, and our case is the first report of LIP presentation as initial manifestation of sSS. Our patient remained stable after corticosteroids and hydoxychloroquine therapy and no progression of disease after 6u2005months follow-up.

Device stratified comparison among transfemoral, transapical and transubclavian access for Transcatheter Aortic Valve Replacement (TAVR): A meta-analysis

a Department of Internal Medicine/Cardiology, University of Miami/Jackson Memorial Hospital, Miami, FL, United States b Department of Cardiology, Ochsner Medical Center, New Orleans, LA, United States c Department of Cardiology, Baylor College of Medicine, Houston, TX, United States d Department of Cardiology, Columbia College of Physicians and Surgeons, St. Lukes Hospital, New York, NY, United States

The Prevalence of Atrial Fibrillation and Conduction Abnormalities in Chagas' Disease: A Meta-Analysis.

Chagas’ disease (CD) has been associated with atrial fibrillation (AF) and electrocardiographic (ECG) conduction defects. However, prior studies have shown conflicting results. We performed a meta‐analysis comparing the prevalence of AF and conduction abnormalities between CD and non‐CD patients.

Left main coronary embolization after direct current cardioversion for persistent atrial flutter in the absence of detectable intracardiac thrombi.

We report a case of left main coronary embolization after direct current cardioversion in the absence of detectable intracardiac thrombi by pre-procedure comprehensive transesophageal echocardiographic assessment [(1)][1]. Although it is considered a rare event, in patients with post-cardioversion

A rare native mitral valve endocarditis successfully treated after surgical correction.

Mycobacterium abscessus and Kocuria species are rare causes of infections in humans. Endocarditis by these agents has been reported in only 11 cases. M. abscessus is a particularly resistant organism and treatment requires the association of antibiotics for a prolonged period of time. We report a case of native mitral valve bacterial endocarditis due to M. abscessus and Kocuria species in a 48-year-old man with a history of intravenous drug use. The case was complicated by a perforation of the posterior mitral valve leaflet, leading to surgical mitral valve replacement. Cultures from the blood and mitral valve disclosed M. abscessus and Kocuria species. The patient was treated for 6u2005months with clarithromycin, imipenem and amikacin, with resolution of symptoms. Repeated blood cultures were negative. Acid-fast staining should be done in subacute endocarditis in order to identify rapidly growing mycobacteria.

HYBRID AND STAGED PULMONARY VEIN ISOLATION WITH LEFT ATRIAL APPENDAGE CLOSURE FOR RHYTHM CONTROL AND PREVENTION OF THROMBOEMBOLISM IN ATRIAL FIBRILLATION

The combination of left atrial appendage (LAA) occlusion with pulmonary vein isolation (PVI), either as a hybrid or staged procedure, may provide rhythm control and reduce the thromboembolic risk in patients with AF. However, proximity of the LAA closure device and ablation targets raises the