Janani Baskaran

Early versus late surgical intervention or medical management for infective endocarditis: A systematic review and meta-analysis

Objective Infective endocarditis is associated with high morbidity and mortality and optimal timing for surgical intervention is unclear. We performed a systematic review and meta-analysis to compare early surgical intervention with conservative therapy in patients with infective endocarditis. Methods PubMed, Cochrane, EMBASE, CINAHL and Google-scholar databases were searched from January 1960 to April 2015. Randomised controlled trials, retrospective cohorts and prospective observational studies comparing outcomes between early surgery at 20 days or less and conservative management for infective endocarditis were analysed. Results A total of 21 studies were included. OR of all-cause mortality for early surgery was 0.61 (95% CI 0.50 to 0.74, p<0.001) in unmatched groups and 0.41 (95% CI 0.31 to 0.54, p<0.001) in the propensity-matched groups (matched for baseline variables). For patients who had surgical intervention at 7 days or less, OR of all-cause mortality was 0.61 (95% CI 0.39 to 0.96, p=0.034) and in those who had surgical intervention within 8–20 days, the OR of mortality was 0.64 (95% CI 0.48 to 0.86, p=0.003) compared with conservative management. In propensity-matched groups, the OR of mortality in patients with surgical intervention at 7 days or less was 0.30 (95% CI 0.16 to 0.54, p<0.001) and in the subgroup of patients who underwent surgery between 8 and 20 days was 0.51 (95% CI 0.35 to 0.72, p<0.001). There was no significant difference in in-hospital mortality, embolisation, heart failure and recurrence of endocarditis between the overall unmatched cohorts. Conclusion The results of our meta-analysis suggest that early surgical intervention is associated with significantly lower risk of mortality in patients with infective endocarditis.

What is the optimal approach to a non- culprit stenosis after ST-elevation myocardial infarction — Conservative therapy or upfront revascularization? An updated meta-analysis of randomized trials ☆

BACKGROUND Non-culprit percutaneous coronary intervention (PCI) during a ST-segment elevation myocardial infarction (STEMI) remains controversial. We performed a meta-analysis of the published literature comparing a strategy of complete revascularization (CR) with culprit or target vessel revascularization (TVR)-only after STEMI in patients with multi-vessel disease. METHODS We searched PubMed/Medline, Cochrane, EMBASE, Web of Science, CINAHL, Scopus and Google-scholar databases from inception to March-2016 for clinical trials comparing CR with TVR during PCI for STEMI. Mantel-Haenszel risk ratio (MH-RR) with 95% confidence intervals (CI) for individual outcomes was calculated using random-effects model. RESULTS A total of 7 randomized trials with 2004 patients were included in the final analysis. Mean follow-up was 25.4months. Major adverse cardiac events (MACE) (MH-RR: 0.58, 95% CI: 0.43-0.78, P<0.001), cardiac deaths (MH-RR: 0.42, 95% CI: 0.24-0.74, P=0.003) and repeat revascularization (MH-RR: 0.36, 95% CI: 0.27-0.48, P<0.001) were much lower in the CR group when compared to TVR. However, there was no significant difference in the risk of all-cause mortality (0.84, 95% CI: 0.57-1.25, P=0.394) or recurrent MI (MH-RR: 0.66, 95% CI: 0.34-1.26, P=0.205) between the two groups. CR appeared to be safe with no significant increase in adverse events including stroke rates (MH-RR: 2.19, 95% CI: 0.59-8.12, P=0.241), contrast induced nephropathy (MH-RR: 0.73, 95% CI: 0.34-1.57, P=0.423) or major bleeding episodes (MH-RR: 0.72, 95% CI: 0.34-1.54, P=0.399). CONCLUSIONS CR strategy in STEMI patients with multivessel coronary artery disease is associated with reduction in MACE, cardiac mortality and need for repeat revascularization but with no decrease in the risk of subsequent MI or all-cause mortality. CR was safe however, with no increase in adverse events including stroke, stent thrombosis or contrast nephropathy when compared to TVR.

Surgical Repair of Moderate Ischemic Mitral Regurgitation—A Systematic Review and Meta-analysis

Introduction Moderate mitral regurgitation (MR) of ischemic etiology has been associated with worse outcomes after coronary artery bypass grafting (CABG). Studies comparing concomitant mitral valve replacement/repair (MVR/Re) with CABG and standalone CABG have reported conflicting results. We performed a systematic review and meta‐analysis of the published literature. Patients and Methods We searched using PubMed, Cochrane, EMBASE, CINAHL, and Google scholar databases from January 1960 to June 2016 for clinical trials comparing CABG to CABG + MVR/Re for moderate MR. Pooled risk ratio or mean difference (MD) with 95% confidence intervals (CI) for individual outcomes were calculated using random effects model and heterogeneity was assessed using Cochranes Q‐statistic. Results A total of 11 studies were included. Mean follow‐up was 35.3 months. All‐cause mortality (Mantel‐Haenszel [MH] risk ratio [RR]: 0.96, 95% CI: 0.75‐1.24, p = 0.775), early mortality (MH RR: 0.65, 95% CI: 0.39‐1.07, p = 0.092), and stroke rates (MH RR 0.65, 95% CI: 0.21‐2.03, p = 0.464) were similar between CABG and CABG + MVR/Re groups. Adverse event at follow‐up was lower with CABG (MH RR: 0.90, 95% CI: 0.61‐1.32, p = 0.584). MD of change from baseline in left ventricular (LV) end‐systolic dimension (MD: − 2.50, 95% CI: − 5.21 to − 0.21, p = 0.071) and LV ejection fraction (MD: 0.48, 95% CI: − 2.48 to 3.44, p = 0.750) were not significantly different between the groups. Incidence of moderate MR (MH RR: 3.24, 95% CI: 1.79‐5.89, p < 0.001) was higher in the CABG only group. Conclusion Addition of MVR/Re to CABG in patients with moderate ischemic MR did not result in improvement in early or overall mortality, stroke risk, or intermediate markers of LV function when compared with CABG alone.

Ivabradine in the treatment of systolic heart failure - A systematic review and meta-analysis

AIM To perform a systematic-review and meta-analysis to compare outcomes of ivabradine combined with beta-blocker to beta-blocker alone in heart failure with reduced ejection fraction (HFrEF). METHODS We searched PubMed, Cochrane, EMBASE, CINAHL and Web of Science for trials comparing ivabradine + beta-blocker to beta-blocker alone in HFrEF. We performed a systematic-review and meta-analysis of published literature. Primary end-point was combined end point of cardiac death and hospitalization for heart failure. RESULTS Six studies with 17671 patients were included. Mean follow-up was 8.7 ± 7.9 mo. Combined end-point of heart failure readmission and cardiovascular death was better in ivabradine + beta-blocker group compared to beta-blocker alone (RR: 0.93, 95%CI: 0.79-1.09, P = 0.354). Mean difference (MD) in heart rate was higher in the ivabradine + beta-blocker group (MD: 6.14, 95%CI: 3.80-8.48, P < 0.001). There was no difference in all cause mortality (RR: 0.98, 95%CI: 0.89-1.07, P = 0.609), cardiovascular mortality (RR: 0.99, 95%CI: 0.86-1.15, P = 0.908) or heart failure hospitalization (RR: 0.87, 95%CI: 0.68-1.11, P = 0.271). CONCLUSION From the available clinical trials, ivabradine + beta-blocker resulted in a significantly greater reduction in HR coupled with improvement in combined end-point of heart failure readmission and cardiovascular death but with no improvement in all cause or cardiovascular mortality. Given the limited evidence, further randomized controlled trials are essential before widespread clinical application of ivabradine + beta-blocker is advocated for HFrEF.

Bivalirudin versus heparin in percutaneous coronary intervention—a systematic review and meta-analysis of randomized trials stratified by adjunctive glycoprotein IIb/IIIa strategy

Background Bivalirudin has been shown to be associated with less major bleeding than heparin in patients undergoing percutaneous coronary intervention (PCI); but the confounding effect of concomitant glycoprotein IIb/IIIa inhibitors (GPI) limits meaningful comparison. We performed a systematic review and meta-analysis to compare bivalirudin to heparin, with and without adjunctive GPI in PCI. Methods We searched PubMed, Cochrane, EMBASE, CINAHL and WOS from January 2000 to December 2017 for clinical trials comparing bivalirudin to heparin, with and without adjunctive GPI during PCI. Cochranes Q statistics were used to determine heterogeneity. Random effects model was used. Results Twenty-six comparison groups (22 original studies and 4 subgroup analyses) with 53,364 patients were included. Mean follow-up was 192±303 days. There was no difference between the two groups in all-cause mortality [risk ratio (RR: 0.93; 95% CI: 0.82-1.05, P=0.260), target vessel revascularization (TVR) (RR: 1.17; 95% CI: 0.93-1.46, P=0.174) or stroke (RR: 0.91; 95% CI: 0.71-1.18, P=0.490). Major bleeding was lower in the bivalirudin group with concomitant GPI in one or both arms (RR: 0.64; 95% CI: 0.53-0.77, P<0.001) and without (RR: 0.71; 95% CI: 0.51-0.99, P=0.041) provisional or routine GPIs. Bivalirudin appeared to have a higher risk of stent thrombosis (RR: 1.32; 95% CI: 1.04-1.68, P=0.022) and a trend towards more myocardial infarction (RR: 1.12; 95% CI: 0.98-1.28, P=0.098) though without statistical significance. However, exclusion of studies with GPI showed no difference in stent thrombosis or myocardial infarction with bivalirudin. Conclusions Bivalirudin is associated with less major bleeding compared to heparin, regardless of GPI use. The lower anticoagulant effect of bivalirudin is linked with higher stent thrombosis and a trend towards more MI, however a confounding effect of GPI use in the heparin arm cannot be excluded.

Late-onset pulmonary arterial hypertension in repaired D-transposition of great arteries: an uncommon complication

Late-onset pulmonary arterial hypertension (PAH) is a rare but fatal complication in patients with childhood surgical repair of dextro-transposition of great arteries (D-TGA), especially with the Mustard and Senning procedures. The pathogenic mechanisms of PAH in patients with repaired D-TGA are not well understood and treatment is not standardized. In this manuscript, we present a case of late-onset PAH in an adult D-TGA patient after Mustard repair and discuss the pathogenic mechanisms, diagnosis, and treatment of pulmonary hypertension in repaired D-TGA.

TCT-203 Dual versus triple anti thrombotic therapy in Acute Coronary Syndromes - A meta analysis

nos: 202 227 TCT-202 Interaction between choice of anticoagulation, antiplatelet therapy and access site on mortality and bleeding after percutaneous coronary intervention: Insights from the California NCDR registry Femi Philip, Stina Anderson, Suresh Ram, William Bommer UC Davis, Sacramento, CA, 95864, California, United States; Department of Mechanical Engineering, Stanford University; University of Louisville; ASCARDIO BACKGROUND The aim of this study was to evaluate the optimal combination of anticoagulation strategy, access site and short term safety and efficacy outcomes in a contemporary population undergoing percutaneous coronary intervention (PCI). METHODS We evaluated 248100 patients receiving PCI at 258 sites utilizing the ACC NCDR CathPCI Registry between 2009 to 2014. Patient presentation, PCI access site, PCI medication, bleeding, transfusion, cerebrovascular accident, rates of coronary artery bypass grafting and death were collected and analyzed using SAS. Patients were divided into high risk status (HRS) (cardiogenic shock, needed an IABP or emergent salvage PCI) or low risk status (LRS). Composite cardiovascular events (CCE) included a composite of death, need for transfusion and bleeding events) were recorded. RESULTS A total of 248113 PCI procedures were performed, most used a transfemoral approach (TFA) (91%), heparin was used in the majority (51%), GPI was used in a small number (13%) and the P2Y12 agent of choice was clopidogrel (90%). In the HRS and LRS subset, mortality, bleeding and CCE rates were significantly lower with transradial approach (TRA) vs. TFA irrespective of GPI use. Additionally, recurrent myocardial infarction and CVA rates were the same in the TFA vs. TRA groups irrespective of GPI. In the HRS and LRS subsets, TRA with bivalirudin use was associated with significantly lower mortality, bleeding and CCE events rates irrespective of GPI or P2Y12 use. Additionally, recurrent myocardial infarction and CVA rates were the no different with the use of bivalirudin vs. heparin in the HRS or LRS irrespective of GPI use. CONCLUSION In contemporary PCI, TRA with the use of bivalirudin with P2Y12 and irrespective of GPI use was associated with the optimal balance of safety and efficacy in both HRS and LRS subsets. CATEGORIES CORONARY: PCI Outcomes TCT-203 Dual versus triple anti thrombotic therapy in Acute Coronary Syndromes A meta analysis Mahesh Anantha Narayanan, Nagarjuna Gujjula, Dixitha Anugula, Yogesh N.V. Reddy, Janani Baskaran, Ganesh Raveendran University Hospital Iceland, Roseville, Minnesota, United States; Road clinic; CHI Health Creighton University Medical Center; LIV Hospital; Henry Ford Health System; University of Minnesota, Saint Paul, Minnesota, United States BACKGROUND In patients requiring long term anti coagulation, there is lack of consensus on optimal antiplatelet and anti thrombotic therapy in acute coronary syndrome (ACS). We performed a meta analysis to compare dual anti platelet therapy (DAPT) or dual therapy (DT) with triple therapy (TT) in ACS. METHODS We searched 6 databases until June 2016 for clinical trials comparing DAPT (aspirin and clopidogrel) or DT (aspirin/clopidogrel with warfarin) versus TT (aspirin, clopidogrel and warfarin) in ACS using Random effects model. RESULTS Thirty-two studies including 2 RCTs with 37,939 patients were included. Mean follow up was 14 months and mean age 70.5 years. There was no difference in Major Adverse Cardiac Events (MACE)(Mantel Haenszel(MH)risk ratio(RR):1.10,95%CI:0.951.27,p1⁄40.214) but Major Bleeding (MB) rates were lower in the DAPT/ DT group compared to TT (MHRR:0.50,95%CI:0.37-0.69,p1⁄40.001). Inclusion of only RCTs showed significantly lower rates of MACE (MHRR:0.60,95%CI:0.40-0.91,p1⁄40.015) and MB in the DAPT /DT group (MHRR:0.44,95%CI:0.62-1.20,p1⁄40.001). We analyzed 7 studies that used only TIMI bleeding score; MB was still lower in DAPT/DT group (MHRR:0.54,95%CI:0.32-0.91,p1⁄40.020). Analysis of studies comparing only DT to TT showed no benefit to TT with no difference in MB and MACE. CONCLUSION Patients on DAPT/DT have lower rates of MB compared to TT. MACE were lower with DAPT/DT when analysis was restricted to only RCTs. Thus, TT cannot be recommended for patients with ACS J O U R N A L O F T H E A M E R I C A N C O L L E G E O F C A R D I O L O G Y , V O L . 6 8 , N O . 1 8 , S U P P L B , 2 0 1 6 B83 requiring anticoagulation due to increase in MB and potentially an increase in MACE. Further large scale randomized trials are essential. CATEGORIES CORONARY: Acute Coronary Syndromes TCT-204 Optimal duration of dual antiplatelet therapy (DAPT) after second generation drug-eluting stent (DES) implantation in elderly patients: the SECURITY-ELDERLY substudy Luca Angelo Ferri, Alaide Chieffo, Gennaro Giustino, Arian Frasheri, Roberto Garbo, Monica Masotti-Centol, Neus Salvatella, Juan Francisco Oteo Dominguez, Luigi Steffanon, Giuseppe Tarantini, Patrizia Presbitero, Alberto Menozzi, Edoardo Pucci, Josepa Mauri, Gennaro Sardella, Antonio Colombo San Raffaele Hospital / Vita-Salute University, Milan, Milan, Italy; San Raffaele Scientific Institute, Milan, Italy; The Icahn School of Medicine at Mount Sinai Hospital, New York City, New York, United States; S Antonio Abate Hospital, Trapani, Italy; Unknown, Torino, Italy; Vancouver General Hospital; AMC; Unknown, Madrid, Spain; Hesperia Hospital, Bologna, Italy; Policinico Universitario, Padova, Padua, Italy; Istituto Clinico Humanitas, Rozzano-Milan, Italy; Azienda Ospedaliero Universitaria di Parma, Parma, Modena, Italy; Hofstra Northwell School of Medicine; UNT Health Science Center; Policlinico Umberto I University, Rome, Italy; San Raffaele Scientific Institute, Milan, Italy BACKGROUND The randomized SECURITY trial (NCT00944333) showed non-inferiority of 6 vs 12 month DAPT after DES implantation in a low-risk population treated with percutaneous coronary intervention (PCI). We aim to assess the outcome of elderly ( 75 year old) in comparison to younger patients (<75 year old) and the association between DAPT duration and outcome in elderly patients enrolled in the SECURITY trial. METHODS In this subanalysis from the SECURITY trial, all elderly (EP) were compared to younger (YP) patients. The primary endpoint (PE) was a composite of cardiac death (CD), myocardial infarction (MI), stroke, definite/probable stent thrombosis, BARC 3/5 bleeding at 12 months. The secondary endpoint (SE) was a composite of CD, MI, stroke, any bleeding at 24 months. RESULTS Of the 1399 patients enrolled, 279 (19.9%) were elderly. Elderly were associated with a higher incidence of the primary (6.8% vs 3.7%, p1⁄40.02) and secondary (9.7% vs 4.6%, p<0.001) end points in comparison with younger patients, with similar rate of bleeding (1.2% vs 0.9%, p1⁄40.8). Between EP, we observed a trend towards an increase in the primary end point occurrence in the 6 month group (9.4% vs 4.3%, p1⁄40.08), with similar rate of bleeding events (see Figure 1 and Table 1). >75 year old patients (n[279) 6 month DAPT (n[139) 12 month DAPT (n[140) p (log-rank)

TCT-186 Delayed versus immediate stenting strategy in ST segment elevation myocardial infarction - A meta analysis.

TCT-185 Influence of total ischemic time on clinical outcomes and efficacy of manual thrombus aspiration during primary percutaneous coronary intervention for ST-segment elevation myocardial infarction: Analysis from the POST trial Ji-Hoon Jang, Dong-Kie Kim, Pil Sang Song, Doo-Il Kim, Joo-Yong Hahn Inje University Haeundae Paik Hospital, Busan, Korea, Republic of; Inje University Haeundae Paik Hospital, Busan, Korea, Republic of; INJE, Busan, Korea, Republic of; Inje University Haeundae Paik Hospital; Samsung Medical Center, Seoul, Korea, Republic of

Complete versus target vessel revascularization in ST-elevation myocardial infarction—analysis of results from published meta-analysis of randomized controlled trials

We thank Weng et al . for their interest in our recent paper where we performed an updated meta-analysis of the benefits of non-culprit revascularization during an ST elevation myocardial infarction (STEMI) (1). The authors used trial sequence analysis (TSA) to further explore the results of our meta-analysis. The results of their TSA (2) confirmed the lower incidence of major adverse cardiac events and repeat revascularization among patients undergoing non-culprit lesion intervention. They also hypothesized that our finding of similar all-cause mortality may be a type II error (false negative) and the demonstration of lower myocardial infarction may be a type 1 error (false positive).

Malignant Course of Anomalous Left Coronary Artery Causing Sudden Cardiac Arrest: A Case Report and Review of the Literature.

Sudden cardiac arrest has been reported to occur in patients with congenital anomalous coronary artery disease. About 80% of the anomalies are benign and incidental findings at the time of catheterization. We present a case of sudden cardiac arrest caused by anomalous left anterior descending artery. 61-year-old African American female was brought to the emergency department after sudden cardiac arrest. Initial EKG showed sinus rhythm with RBBB and LAFB with nonspecific ST-T wave changes. Coronary angiogram revealed no atherosclerotic disease. The left coronary artery was found to originate from the right coronary cusp. Cardiac CAT scan revealed similar findings with interarterial and intramural course. Patient received one-vessel arterial bypass graft to her anomalous coronary vessel along with a defibrillator for secondary prevention. Sudden cardiac arrest secondary to congenital anomalous coronary artery disease is characterized by insufficient coronary flow by the anomalous left coronary artery to meet elevated left ventricular (LV) myocardial demand. High risk defects include those involved with the proximal coronary artery or coursing of the anomalous artery between the aorta and pulmonary trunk. Per guidelines, our patient received one vessel bypass graft to her anomalous vessel. It is important for clinicians to recognize such presentations of anomalous coronary artery.