Mohamad Soud

Transcatheter Closure of Patent Foramen Ovale versus Medical Therapy after Cryptogenic Stroke: A Meta-Analysis of Randomized Controlled Trials

Background: Patent foramen ovale (PFO) with atrial septal aneurysm is suggested as an important potential source for cryptogenic strokes. Percutaneous PFO closure to reduce the recurrence of stroke compared to medical therapy has been intensely debated. The aim of this study is to assess whether PFO closure in patients with cryptogenic stroke is safe and effective compared with medical therapy. Method: A search of PubMed, Medline, and Cochrane Central Register from January 2000 through September 2017 for randomized controlled trails (RCT), which compared PFO closure to medical therapy in patients with cryptogenic stroke was conducted. We used the items “PFO or patent foramen ovale”, “paradoxical embolism”, “PFO closure” and “stroke”. Data were pooled for the primary outcome measure using the random-effects model as pooled rate ratio (RR). The primary outcome was reduction in recurrent strokes. Result: Among 282 studies, 5 were selected. Our analysis included 3,440 patients (mean age 45 years, 55% men, mean follow-up 2.9 years), 1,829 in the PFO closure group and 1,611 in the medical therapy group. The I2 heterogeneity test was found to be 48%. A random effects model combining the results of the included studies demonstrated a statistically significant risk reduction in risk of recurrent stroke in the PFO closure group when compared with medical therapy (RR 0.42; 95% CI 0.20–0.91, p = 0.03). Conclusion: Pooled data from 5 large RCTs showed that PFO closure in patients with cryptogenic stroke is safe and effective intervention for prevention of stroke recurrence compared with medical therapy.

Beyond Beck's Triad: A Rare Cause of Cardiac Tamponade and Hemoptysis

Background: Primary cardiac angiosarcoma (CAS) is a rare tumor with a dismal prognosis. Many patients present with noncardiac symptoms related to metastatic disease that could delay the diagnosis and deteriorate the outcome. Case Report: A 36-year-old male presented with hemoptysis. Initial imaging and biopsies were inconclusive, but a repeat transthoracic echocardiogram to evaluate the patients pericardial effusion showed a mass inferior to the right atrium and invading the wall. Biopsy results from 3 different sites confirmed the diagnosis of CAS. However, the patients course was complicated with respiratory failure that ultimately led to his death. Autopsy demonstrated CAS involving the full thickness of the right atrium and pericardial tissue, with a diffuse metastatic process involving the lung, brain, and stomach. Conclusion: The case highlights the importance of having an increased level of suspicion for cardiac malignancy among young patients presenting with noncardiac symptoms.

Trauma-Induced Conduction Disturbances

Background: Electrical disturbances following blunt cardiac injuries are rare but can be caused by electrical or structural damage to the heart. We present the case of a patient who had conduction abnormalities following blunt traumatic injury that were incidentally detected on telemetry. Case Report: A 64-year-old female with no history of cardiac disease was brought to the emergency department after a motor vehicle collision that resulted in chest wall bruising. The patient was found to have L-spine fractures and was admitted for observation. During her hospitalization, the patient had multiple episodes of heart block. A temporary pacemaker was inserted because of the recurrent episodes, and a dual-chamber permanent pacemaker was placed on day 4 of her hospitalization. Conclusion: Heart block as a consequence of blunt cardiac injury is rare; however, it needs to be recognized as early as possible. Permanent pacemaker placement is usually indicated for patients with prolonged or recurrent episodes.

Should Ultrasound Guidance Be Routinely Used for Femoral Artery Access

ABSTRACT Ultrasound-guided femoral artery access should always be utilized as it has been shown to significantly reduce vascular complications, number of arterial access attempts, accidental venipunctures, and time to access. Despite the increased adoption of transradial access, the conventional femoral artery cannulation remains the primary route for performing peripheral angiography and cardiac catheterization in the setting of high-risk interventional procedures requiring mechanical hemodynamic support. Similarly, with the expansion of structural heart interventions such as transcatheter aortic valve replacement and mitral valve interventions, femoral access has been increased especially for large-bore sheaths.

Minimally invasive intervention of radial artery pseudoaneurysm using percutaneous thrombin injection

A 67-year-old woman with severe mitral regurgitation, underwent coronary angiography for pre-operative evaluation prior to mitral valve surgery via right radial artery (RA) which showed normal coronaries. TR bandR was applied for haemostasis; however, a small haematoma developed, and this prompted to keep the TR BandR for a longer period. The following morning, patient complained of right forearm pain. Exam revealed a pulsatile mass over the access site (Supplementary material online, Video S1). Arterial duplex showed a large RA pseudoaneurysm (PSA) emanating from the right RA and measuring 26.5 14.4 mm (Panel A and B, Supplementary material online, Video S2). Treatment options were explored including surgical repair. However, patient opted for percutaneous endovascular intervention (PEI) using thrombin injection into PSA. After usual sterilization, lidocaine 2% was used to anaesthetize the right carpus. Under direct ultrasound guidance, a 21-gauge spinal needle was inserted into the PSA cavity and positioned just above the neck of the PSA. Six hundred (600) units of thrombin was injected, and this successfully thrombosed-off the PSA with no untoward complications. Complete cessation of flow into the PSA was confirmed by ultrasound duplex (Panel C and D, Supplementary material online, Video S3). Repeated arterial duplex in the clinic 2 months later showed smaller, and completely thrombosed PSA (20.0 14.0 mm in size) with no flow into it (Panel E, Supplementary mate rial online, Video S4). Radial artery access has lower rate of vascular complications compared with femoral access (0.6% vs. 1.5%). Pseudoaneurysm is rare (incidence< 0.1%), but serious complication that should be managed surgically, or percutaneously using ultrasound-guided direct thrombin injection.

How soon should patients with infective endocarditis be referred for valve surgery

Refer sooner rather than later if the patient has heart failure, uncontrolled infection, or embolic risk.

Impact of statins preloading before PCI on periprocedural myocardial infarction among stable angina pectoris patients undergoing percutaneous coronary intervention: A meta-analysis of randomized controlled trials

It has been shown that statins preloading, before percutaneous coronary intervention (PCI), may reduce the risk of cardiovascular outcomes for acute coronary syndrome patients. Nevertheless, the effect of such pretreatment among patients with stable angina pectoris (SAP) is still debatable. We performed a systematic review and updated meta-analysis of the literature to evaluate the efficacy of short-term statins preloading on periprocedural myocardial infarction (PMI) incidence and mortality after PCI. We included 13 randomized control trials that examined statins preloading in adult patients with SAP undergoing PCI. While the use of preloading statins significantly reduced PMI, the benefit of statins pretreatment on long-term mortality was not statistically significant. SHORT SUMMARY: High dose statins preloading prior to elective PCI was associated with a significant reduction in PMI in SAP patients. The mortality benefit of such intervention will need to be addressed by further large randomized studies. The routine use of statins in stable patients before PCI should be considered if no contraindications are present.

Dual Antiplatelet Therapy Versus Single Antiplatelet Therapy After Transaortic Valve Replacement: Meta-Analysis

BACKGROUNDnThe current guidelines recommend empirical therapy with DAPT of aspirin and clopidogrel for six months after TAVR. This recommendation is based on expert consensus only. Giving the lack of clear consensus on treatment strategy following TAVR. Goal of this meta-analysis is to assess the efficacy and safety of mono-antiplatelet therapy (MAPT) versus dual antiplatelet therapy (DAPT) following transcatheter aortic valve replacement (TAVR).nnnMETHODS AND MATERIALSnWe performed a meta-analysis from randomized clinical trials (RCTs) and prospective studies that tested DAPT vs. MAPT for all-cause mortality and major bleeding of 603 patients. The primary efficacy outcomes were 30u202fdays mortality and stroke. The primary safety outcomes were major bleeding and major vascular complications.nnnRESULTSnWe included 603 patients from 4 studies. The use of MAPT was associated with similar mortality rate (5.9% vs. 6.6%; RRu202f=u202f0.92; 95% CI 0.49-1.71; Pu202f=u202f0.68) and stroke rate compared with DAPT (1.3% vs. 1.3%; RR 1.04; 95% CI 0.27 to 4.04; Pu202f=u202f0.81). There was no difference in major vascular complication (4.2% vs. 8.9%; RR 0.52; 95% CI 0.23 to 1.18; Pu202f=u202f0.17) or minor vascular complication (4.2% vs. 7.3%; RR 0.58; 95% CI 0.25 to 1.34; Pu202f=u202f0.14). However, MAPT was associated with significantly less risk of major bleeding (4.9% vs. 14.5%; RR 0.37; 95% CI 0.20 to 0.70; Pu202f<u202f0.01) but no difference in minor bleeding (4.2% vs. 3.6%; RR 1.16; 95% CI 0.43 to 3.10; Pu202f=u202f0.85).nnnCONCLUSIONnMAPT use after TAVR is associated with lower rates of major bleeding compared with DAPT with no significant difference in mortality, stroke or vascular complications.

Ultrasound-guided versus palpation-guided radial artery catheterization in adult population: A systematic review and meta-analysis of randomized controlled trials

Background The radial artery (RA) is routinely used for both hemodynamic monitoring and for cardiac catheterization. Although cannulation of the RA is usually undertaken through manual palpation, ultrasound (US)‐guided access has been advocated as a mean to increase cannulation success rates and to lower RA complications; however, the published data are mixed. We sought to evaluate the impact of US‐guided RA access compared with palpation alone on first‐pass success to access RA. Methods and Results Meta‐analysis of 12 randomized controlled trials comparing US‐guided with palpation‐guided radial access in 2,432 adult participants was done. Hemodynamic monitoring was the most common reason for RA catheterization. Only 2 randomized controlled trials evaluated patients undergoing cardiac catheterization. Ultrasound‐guided radial access was associated with increased first‐attempt success rate (risk ratio [RR] 1.35, 95% CI 1.16‐1.57]) and decreased failure rate (RR 0.52, 95% CI 0.32‐0.87). There were no significant differences in the risk of hematoma (RR 0.43, 95% CI 0.27‐1.06), the mean time to first successful attempt (mean difference 25.13 seconds, 95% CI −1.06 to 51.34) or to any successful attempt (mean difference −4.74 seconds; 95% CI −22.67 to 13.18) between both groups. Conclusions Ultrasound‐guided technique for RA access has higher first‐attempt success and lower failure rate compared with palpation alone, with no significant differences in access site hematoma or time to a successful attempt. These findings support the routine use of US guidance for RA access.

Coronary Artery Aneurysm With Thrombosis After Implantation of a Bioresorbable Coronary Artery Scaffold

A 33-year-old man presented with non–ST-segment elevation myocardial infarction (NSTEMI), received a 2.5 mmxa0× 28.0 mm bioresorbable scaffold (Absorb, Abbott Vascular, Santa Clara, California) into the left circumflex coronary artery after pre-dilation ([Figuresxa01A and 1B][1]). Thirteen months