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Transcatheter Aortic Valve Implantation (TAVI) in Patients With Bicuspid Aortic Valve Stenosis – Systematic Review and Meta-Analysis

BACKGROUND Transcatheter aortic valve implantation (TAVI) is a feasible interventional technique for severe aortic stenosis in patients who are deemed inoperable or at high surgical risk. There is limited evidence for the safety and efficacy of TAVI in patients with bicuspid aortic valves (BAV), the most common congenital valve abnormality. In many TAVI trials, patients with BAV have been contraindicated due to concerns surrounding abnormal valve geometry, leading to malfunction or malpositioning. A systematic review and meta-analysis was conducted in order to assess the current evidence and relative merits of TAVI in aortic stenosis patients with BAV. METHOD From six electronic databases, seven articles including 149 BAV and 2096 non-BAV patients undergoing TAVI were analysed. RESULTS Between the BAV and no-BAV cohorts, there was no difference in 30-day mortality (8.3% vs 9.0%; P=0.68), post-TAVI mean peak gradients (weighted mean difference, 0.36 mmHg; P=0.55), moderate or severe paravalvular leak (25.7% vs 19.9%; P=0.29), pacemaker implantations (18.5% vs 27.9%; P=0.52), life-threatening bleeding (8.2% vs 13.9%; P=0.33), major bleeding (20% vs 16.8%; P=0.88), conversion to conventional surgery (1.9% vs 1.2%; P=0.18) and vascular complications (8.6% vs 10.1%; P=0.32). CONCLUSIONS Preliminary short and mid-term pooled data from observation studies suggest that TAVI is feasible and safe in older patients with BAV. While future randomised trials are not likely, larger adequately-powered multi-institutional studies are warranted to assess the long-term durability and complications associated with TAVI in older BAV patients with severe aortic stenosis.

Systematic Review of Defibrillation Threshold Testing at De Novo Implantation

Background—Recent results from the largest multicenter randomized trial (Shockless IMPLant Evaluation [SIMPLE]) on defibrillation threshold (DFT) testing suggest that while shock testing seems safe, it does not reduce the risk of failed shocks or prolong survival. A contemporary systematic review of DFT versus no-DFT testing at the time of implantable cardioverter–defibrillator implantation was performed to evaluate the current evidence and to assess the impact of the SIMPLE study. Methods and Results—Electronic searches were performed using 6 databases from their inception to March 2014. Relevant studies investigating implant DFT were identified. Data were extracted and analyzed according to predefined clinical end points. Predefined outcomes for interrogation were all-cause mortality, composite end point of implantable cardioverter–defibrillator efficacy (arrhythmic deaths and ineffective shocks), and composite safety end point (the sum of complications recorded at 30 days). Meta-analysis was performed including 13 studies and 9740 patients. No significant differences between DFT versus no-DFT cohorts were found in terms of all-cause mortality (risk ratio, 0.90; 95% confidence interval, 0.71–1.15; P=0.41), composite efficacy outcome (risk ratio, 1.24; 95% confidence interval, 0.65–3.37; P=0.51), and 30-day postimplant complications (risk ratio, 1.18; 95% confidence interval, 0.87–1.60; P=0.29). No significant difference was found in the trends observed when the results of the SIMPLE study were excluded or included. Conclusions—This systematic review of contemporary data suggests a modest average effect of DFT, if any, in terms of mortality, shock efficacy, or safety. Therefore, DFT testing should no longer be compulsory during de novo implantation. However, DFT testing may still be clinically relevant in specific patient populations.

Early hemodynamic performance of the third generation St Jude Trifecta aortic prosthesis: A systematic review and meta-analysis

OBJECTIVE The Trifecta aortic prosthesis is a latest-generation trileaflet stented pericardial valve designed for supra-annular placement in the aortic position. Robust clinical evidence and long-term follow-up data for this new prosthesis are lacking; a systematic review was conducted to assess current evidence. METHODS A comprehensive search from 6 electronic databases was performed, with time period parameters dating from database inception to January 2014. Results utilizing Trifecta prosthesis for aortic valve replacement (AVR) were identified. RESULTS A total of 13 studies with 2549 patients undergoing AVR with this prosthesis were included in this review. The mean proportion of patients with aortic stenosis was 82.4%, with a mean gradient of 47.4 mm Hg, and a pooled effective orifice area (EOA) of 0.74 cm(2). Valve sizes of 21 mm and 23 mm were implanted in 71.3% of patients. The pooled rates of 30-day mortality, cerebrovascular accidents, and acute kidney injuries were 2.7%, 1.9%, and 2.6%, respectively. After implantation, the pooled mean gradient decreased to 9.2 mm Hg, whereas discharge EOA increased to 1.8 cm(2), compared with preoperative parameters. Among included studies with significant heterogeneity detected, most patients had satisfactory patient-prosthesis mismatch, with 2.7% having severe mismatch. CONCLUSIONS The present systematic review demonstrated that short-term AVR with this prosthesis provided excellent early safety and hemodynamic outcomes with acceptable mean gradients and EOA. Long-term follow-up and randomized controlled trials are warranted to confirm the early results.

Hepatic resection for malignant liver tumours in the elderly: a systematic review and meta-analysis: Liver resection for malignant tumours in the elderly

The number of elderly patients undergoing hepatic resection for surgical treatment of benign and malignant cancers is increasing. However, there is limited clinical data on the complications and long‐term survival rates associated with liver surgery in the elderly patients (≥70 years) versus younger patients for malignant liver conditions.

Response to Re: Hepatic resection for malignant liver tumours in the elderly: a systematic review and meta‐analysis

It is with great respect that I reflect on the comments made by Kehlet and Su’a and Hill on our paper. The limitations highlighted by these experts are acknowledged along with the value of their perspectives. Our intention was to provoke thought and stimulate discussion in an area of interest for those who perform colorectal surgery. The intention was also to be honest about what happens in many units, but it is not openly discussed (D’Souza, pers. comm., 2015). The science referenced provides a clear picture. The greater challenge, however, lies in wider translation of the science. Under ideal circumstances, we would be able to do things differently, but in the meantime, we do the best we can, respecting the wisdom of those who lead and guide.