Mahesh Anantha Narayanan

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.

Fatal Case of Probable Invasive Aspergillosis after Five Years of Heart Transplant: A Case Report and Review of the Literature

Invasive fungal infections are very common in solid organ transplants and occur most frequently in the first three months after transplant. A 49-year-old female with a history of two remote heart transplants with the most recent one occurring 5 years ago was admitted for increasing shortness of breath, cough, and fever. Computerized tomography (CT) scan of the chest showed left lower lung ground-glass and tree-in-bud opacities. She was started on broad spectrum antibiotics along with ganciclovir and micafungin. Ganciclovir was added due to the patients past history of CMV infection and empiric fungal coverage with micafungin. Bronchoalveolar lavage (BAL) was performed as her respiratory status worsened and voriconazole was added for possible aspergillosis in combination therapy with micafungin. BAL galactomannan returned positive which was suggestive of aspergillosis. Patient worsened clinically and subsequently succumbed to cardiorespiratory arrest despite our best efforts. It is important to have a high degree of clinical suspicion for invasive aspergillosis in transplant patients even many years after transplant and initiate aggressive therapy due to poor outcomes.

Reversible Stress Cardiomyopathy Presenting as Acute Coronary Syndrome with Elevated Troponin in the Absence of Regional Wall Motion Abnormalities: A Forme Fruste of Stress Cardiomyopathy?

We present a case of reversible stress cardiomyopathy in a surgical patient, described here as a forme fruste due to its atypical features. It is important to recognize such unusual presentation of stress cardiomyopathy that mimics acute coronary syndrome. Stress cardiomyopathy commonly presents as acute coronary syndrome and is characterized by typical or atypical variants of regional wall motion abnormalities. We report a 60-year-old Caucasian male with reversible stress cardiomyopathy following a sternal fracture fixation. Although the patient had several typical features of stress cardiomyopathy including physical stress, ST-segment elevation, elevated cardiac biomarkers and normal epicardial coronaries, there were few features that were atypical, including unusual age, gender, absence of regional wall motion abnormalities, high lateral ST elevation, and high troponin-ejection fraction product. In conclusion, this could represent a forme fruste of stress cardiomyopathy.

Debranching of the arch in aortic aneurysms

We read with interest the surgical approach of Kondoh et al. [1] for the treatment of the distal arch aneurysm. They performed the elephant trunk procedure with undersized grafts instead of using the frozen elephant trunk technique with 10–20% oversized stent grafts. One month postoperative the residual ‘endoleak’ was 14% in Group 1, and 67% in Group 2. They performed an additional procedure in 77% of these patients. Although 92% of the patients were operated on electively, hospital mortality and cumulative mortality rates were 7.1 and 21.2%, respectively. They performed a two-staged elephant trunk technique in patients with the descending aortic diameter ≥35 mm. In more recent procedures, they started using endovascular techniques in the second stage. The technique of catching the graft with a snare (inserted by the endovascular technique) and pulling it inferiorly is a dangerous procedure that could easily cause a rupture of the fragile aorta, or distal embolism. When compared with the above technique, the frozen elephant trunk procedure or stent graft completion after the first elephant trunk open procedure appears to be safer. Landing a stent graft within the elephant Dacron segment either as a ‘frozen’ technique or at a later time is far more efficient and leads to fewer life-threatening complications [2]. While working at the level of the diseased arch or distal ascending aorta may be technically more demanding, suturing the four-branched arch graft to the sinotubular junction will compromise any future surgical interventions to the heart. In their technique, the distance between the coronary arteries and the arch branches is not sufficient for cross clamping of the aorta in reoperation. In the debranching procedure, suturing the branched graft 3–4 cm above the sinotubular junction will facilitate effective reoperation [3]. In conclusion, it is an interesting study. We thank the authors for sharing their experience. We think it is important to effectively obliterate the full aneurysm as early as possible, rather than wait for thrombosis to occur in a delayed fashion. The elephant trunk procedure combined with the endovascular technique is a safer alternative to the catheter pulling technique described by the authors.

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-156 Bivalirudin versus Heparin in Primary Percutaneous Coronary Intervention- a Meta analysis.

The safety and efficacy of bivalirudin in patients with primary percutaneous coronary intervention (PCI) remains controversial, with conflicting data from randomized trials. We performed a comprehensive meta analysis to compare bivalirudin to heparin, with and without routine GPIIb/IIIa inhibitors (

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