Henri Roukoz

Comprehensive Meta-Analysis on Drug-Eluting Stents versus Bare-Metal Stents during Extended Follow-up

BACKGROUND Several observational reports have documented both increased and decreased cardiac mortality or Q-wave myocardial infarction with drug-eluting stents compared with bare-metal stents. METHODS We sought to evaluate the safety and efficacy of drug-eluting stents compared with bare-metal stents early after intervention (<1 year) and late (>1 year) among a broad population of patients, using a meta-analysis of randomized clinical trials. RESULTS We identified 28 trials with a total of 10,727 patients and a mean follow-up of 29.6 months. For early outcomes (<1 year), all-cause mortality for drug-eluting stents versus bare-metal stents was 2.1% versus 2.4% (risk ratio [RR] 0.91, [95% confidence interval (CI), 0.70-1.18]; P=.47), non-Q-wave myocardial infarction was 3.3% versus 4.4% (RR 0.78 [95% CI, 0.61-1.00]; P=.055), target lesion revascularization was 5.8% versus 18.4% (RR 0.28 [95% CI, 0.21-0.38]; P <.001), and stent thrombosis was 1.1% versus 1.3% (RR 0.87 [95% CI, 0.60-1.26]; P=.47). For late outcomes (>1 year), all-cause mortality for drug-eluting stents versus bare-metal stents was 5.9% versus 5.7% (RR 1.03 [95% CI, 0.83-1.28]; P=.79), target lesion revascularization was 4.0% versus 3.3% (RR 1.22 [95% CI, 0.92-1.60]; P=.16), non-Q-wave myocardial infarction was 1.6% versus 1.2% (RR 1.36 [95% CI, 0.74-2.53]; P=.32) and stent thrombosis was 0.7% versus 0.1% (RR 4.57 [95% CI, 1.54-13.57]; P=.006). CONCLUSIONS There was no excess mortality with drug-eluting stents. Within 1 year, drug-eluting stents appear to be safe and efficacious with possibly decreased non-Q-wave myocardial infarction compared with bare-metal stents. After 1 year, drug-eluting stents still have similar mortality, despite increased stent thrombosis. The reduction in target lesion revascularization with drug-eluting stents mainly happens within 1 year, but is sustained thereafter.

Cardiac resynchronization therapy in patients with minimal heart failure: a systematic review and meta-analysis.

OBJECTIVES The purpose of this study was to perform a systematic review and meta-analysis of prospective randomized clinical trials of cardiac resynchronization therapy (CRT) versus implantable cardioverter-defibrillator (ICD) in patients with reduced ejection fraction (EF), prolonged QRS interval, and New York Heart Association (NYHA) functional class I to II heart failure (HF). BACKGROUND In patients with advanced HF, CRT improves left ventricular (LV) function and reduces mortality and hospitalizations. Recent data suggest that patients with milder HF also benefit from CRT. METHODS A meta-analysis of 5 clinical trials including 4,317 patients with NYHA functional class I/II HF was performed. RESULTS Average age of patients was 65 years, and 80% were male. Frequency of all-cause mortality for CRT versus ICD was 8% versus 11.5% (risk ratio [RR]: 0.81; 95% confidence interval [CI]: 0.65 to 0.99, p = 0.04); for HF hospitalization, it was 11.6% versus 18.2% (RR: 0.68; 95% CI: 0.59 to 0.79, p < 0.001). Patients assigned to CRT had a significantly greater improvement in LVEF (+5.9% vs. +2.2%, p < 0.001) and LV volume than ICD patients. Among mildly symptomatic (NYHA functional class II) patients, CRT was associated with significantly lower mortality and HF hospitalization (RR: 0.73; 95% CI: 0.64 to 0.83), p < 0.001). In asymptomatic (NYHA functional class I) patients, HF hospitalization risk was lower (RR: 0.57; 95% CI: 0.34 to 0.97, p = 0.04) with CRT; however, there was no difference in mortality. Twelve asymptomatic HF patients needed to be treated with CRT to prevent 1 hospitalization. CONCLUSIONS Cardiac resynchronization therapy decreases all-cause mortality, reduces HF hospitalizations, and improves LVEF in NYHA functional class I/II HF patients. Although there was a reduction in HF hospitalization with CRT for asymptomatic (NYHA functional class I) patients, risks versus benefits have to be carefully considered in this subgroup.

Prognostic significance of FLT3 internal tandem duplication and tyrosine kinase domain mutations in acute promyelocytic leukemia: A systematic review

The fms-like tyrosine kinase 3 (FLT3) gene aberrations, internal tandem duplication (ITD) and tyrosine kinase domain (TKD) mutations, are frequent in acute promyelocytic leukemia (APL). To evaluate their prognostic significance, we performed a systematic review and meta-analysis. Eleven studies covering a total of 1063 subjects were included in this review. Incidence of ITD and TKD mutations was 12-38% and 2-20%, respectively. In 9 of 11 studies, ITD was associated with high WBC count at the time of diagnosis, which is a known prognostic indicator in APL. Patients with ITD had inferior 3-year overall survival compared to patients without ITD (risk ratio 1.42, 95% CI: 1.04-1.95). Similarly, ITD was also associated with adverse 3-year disease-free survival (risk ratio 1.48, 95% CI: 1.02-2.15). There were only two studies that evaluated the association of TKD mutation in APL; both showed a trend towards worse survival in patients with mutated TKD. In conclusion, FLT3 ITD is associated with high WBC at diagnosis in patients with APL. Although the available literature is limited to observational studies, our systematic review suggests that FLT3 mutations, especially ITD, can adversely affect overall survival and disease-free survival in APL.

Clinical ResearchCardiac Resynchronization TherapyCardiac Resynchronization Therapy in Patients With Minimal Heart Failure: A Systematic Review and Meta-Analysis

OBJECTIVES The purpose of this study was to perform a systematic review and meta-analysis of prospective randomized clinical trials of cardiac resynchronization therapy (CRT) versus implantable cardioverter-defibrillator (ICD) in patients with reduced ejection fraction (EF), prolonged QRS interval, and New York Heart Association (NYHA) functional class I to II heart failure (HF). BACKGROUND In patients with advanced HF, CRT improves left ventricular (LV) function and reduces mortality and hospitalizations. Recent data suggest that patients with milder HF also benefit from CRT. METHODS A meta-analysis of 5 clinical trials including 4,317 patients with NYHA functional class I/II HF was performed. RESULTS Average age of patients was 65 years, and 80% were male. Frequency of all-cause mortality for CRT versus ICD was 8% versus 11.5% (risk ratio [RR]: 0.81; 95% confidence interval [CI]: 0.65 to 0.99, p = 0.04); for HF hospitalization, it was 11.6% versus 18.2% (RR: 0.68; 95% CI: 0.59 to 0.79, p < 0.001). Patients assigned to CRT had a significantly greater improvement in LVEF (+5.9% vs. +2.2%, p < 0.001) and LV volume than ICD patients. Among mildly symptomatic (NYHA functional class II) patients, CRT was associated with significantly lower mortality and HF hospitalization (RR: 0.73; 95% CI: 0.64 to 0.83), p < 0.001). In asymptomatic (NYHA functional class I) patients, HF hospitalization risk was lower (RR: 0.57; 95% CI: 0.34 to 0.97, p = 0.04) with CRT; however, there was no difference in mortality. Twelve asymptomatic HF patients needed to be treated with CRT to prevent 1 hospitalization. CONCLUSIONS Cardiac resynchronization therapy decreases all-cause mortality, reduces HF hospitalizations, and improves LVEF in NYHA functional class I/II HF patients. Although there was a reduction in HF hospitalization with CRT for asymptomatic (NYHA functional class I) patients, risks versus benefits have to be carefully considered in this subgroup.

Safety and efficacy of the MitraClip® system for severe mitral regurgitation: a systematic review.

The MitraClip® system is a newer percutaneous device that has shown promising results but data on its safety and efficacy in low‐ and high‐surgical risk populations continues to evolve. We performed a systematic review of the published studies reporting the safety and efficacy of MitraClip® implantation for treatment of moderate to severe and severe mitral regurgitation (MR).

Hydroxychloroquine-Induced Cardiomyopathy A Case Report

Prolonged use of hydroxychloroquine (HCQ) has been implicated in the development of conduction disturbances and myocardial dysfunction.1 We report a case of cardiomyopathy after 10 years of HCQ therapy in a 66-year-old woman with systemic lupus erythematosus (SLE). A 66-year-old white woman with a 24-year history of SLE presented to our institution with decompensated heart failure. She had no cardiac history until 8 weeks before admission, when she presented to an outside hospital for new-onset heart failure. Other significant medical history included gout, dyslipidemia, hypertension, and SLE first diagnosed in 1986 complicated by World Health Organization class 4 lupus nephritis, diagnosed in 2001. She was taking HCQ (400 mg daily), prednisone (<5 mg/d), and …

Mortality prediction using a modified Seattle Heart Failure Model may improve patient selection for ventricular tachycardia ablation

BACKGROUND Catheter ablation is frequently used as a palliative option to reduce shock burden in patients with ventricular tachycardia (VT). A risk prediction tool that accurately predicts short-term survival could improve patient selection for VT ablation. OBJECTIVE The objective of the study is to assess utility of the Seattle Heart Failure Model (SHFM) to predict 6-month mortality in patients undergoing VT ablation. METHODS Data on patients who underwent VT ablation at 2 tertiary institutions were retrospectively compiled. The SHFM score at the time of ablation, including 2 added VT variables, was used to predict 6-month mortality. The predicted number of deaths was compared to the observed number to assess model calibration. Model discrimination of those who died within 6 months was assessed by both K- and C-statistics. RESULTS Mean age of the 243 patients was 63 ± 12 years; 89% were male. Mean SHFM score for the cohort was 1.3 ± 1.3. The Kaplan-Meier probability of death within 6 months was 14% (34 patients). The number of deaths estimated by the SHFM at 6 months was 31 (13%) giving a predicted to observed ratio of 0.91 (95% CI 0.64-1.30). The K-statistic for 6-month mortality predictions was 0.77 (95% CI 0.73-0.81), whereas the C-statistic was 0.84 (95% CI 0.78-0.92). Patients with an SHFM score ≥4.0 had an estimated positive predictive value of 80% (95% CI 28%-99%) for dying within 6 months of VT ablation. CONCLUSION The SHFM was well calibrated to a sample of patients who underwent VT ablation and provided good discrimination of short-term deaths. This model could be useful as a prognostic tool to improve patient selection for VT ablation.

Atrial arrhythmias after lung transplantation

Atrial arrhythmias are a common complication after lung transplant (LT), occurring in about 16-46% of LT patients early postoperatively, and in about 14% during longer-term follow-up. They have a significant impact on postoperative in-hospital length of stay and may have an impact on overall mortality. In this report, we review the incidence and risk factors of post lung transplant AA, their pathogenesis and their impact on short- and long-term outcomes. Pharmacological management options are reviewed. In brief, early atrial arrhythmias tend to be mostly atrial fibrillation and are treated acutely with a rate control strategy followed if needed by rhythm control for 4-6 weeks. Late atrial arrhythmias >6 months after LT tend to be more frequently organized atrial flutters amenable to ablation therapy. Long-term anticoagulation is controversial especially in patients with bilateral lung transplant who received surgical pulmonic vein isolation, however anticoagulation is still favored especially in single LT patients. More studies are needed to further document the pathophysiology of early versus late atrial arrhythmias and whether long-term anticoagulation is needed.

Efficacy and benefits of catheter ablation of ventricular premature complexes in patients younger and older than 65 years of age.

OBJECTIVES Catheter ablation of ventricular premature complexes (VPC) improves clinical status and systolic performance of the left ventricle (LV) in a certain subset of patients; however, whether or not VPC ablation is equally effective in younger (<=65 years) and older (>65 years) patients remains unclear. We aimed to assess the clinical benefits of catheter ablation of VPCs in elderly patients. STUDY DESIGN Fifty-one consecutive patients (66±10 years, 49 male) who underwent catheter ablation for symptomatic VPCs were included into the study. Twenty-seven patients were aged >65 years and 24 patients <=65 years. Frequency of VPCs per total heart beats by 24-hour Holter monitoring, LV ejection fraction (LVEF) and end-systolic diameters (LVEDD) were evaluated before and 6±3 months after ablation. RESULTS The pre-ablation 24-hour VPC burden and VPC number were significantly higher in patients >65 years compared to those <=65 years (31±15.3 vs. 21.9±12.6, p=0.04 and 34493±21226 vs. 23554±13792, p=0.026, respectively). At the follow-up after catheter ablation, the mean VPC burden had decreased to 9.1±10.3% (p<0.001) in patients >65 years and to 3.8±7.1 (p<0.001) in patients <=65 years. Mean LVEF showed a significant increase in both groups after ablation (43.4±10.4 vs. 51.5±8.2, p=0.005 for age >65 years and 40.8±13.2 vs. 49.5±11.8, p=0.003 for age <=65 years). The improvement in LVEF was accompanied by a significant decrease in LVEDD (p=0.032 for age >65 years and p=0.047 for <=65 years). CONCLUSION Catheter ablation is effective for treatment of frequent VPCs in all age groups.

Response to letter to the editor by Dr. Jastrzebski

Ann Noninvasive Electrocardiol 2011;16(4):416–417