Nelson Wang

Periprocedural effects of statins on the incidence of contrast-induced acute kidney injury: A systematic review and trial sequential analysis

BACKGROUND Contrast-induced acute kidney injury (CI-AKI) is a potential complication in coronary angiography (CAG) and percutaneous coronary interventions (PCI). Prior randomized controlled trials (RCTs) have suggested that statins may play a role in reducing rates of CI-AKI, however it is not clear how firm the current evidence is. OBJECTIVES The aim of this study was to conduct a meta-analysis and trial sequential analysis to determine the effects of statins in lowering CI-AKI rates in CAG and PCI. METHODS A systematic literature search was performed to include all RCTs comparing statins (treatment arm) versus low-dose statins or placebo (control arm) as pretreatment for CAG and/or PCI. A traditional meta-analysis and several subgroup analyses were conducted using traditional meta-analysis with relative risk (RR), trial sequential analysis, and meta-regression analysis. RESULTS 14 RCTs met our inclusion criteria giving a total of 2992 statin treated (49.6%) and 3041 control patients (50.4%). There was a significant reduction in CI-AKI in the statin group compared to controls (3.7% vs 8.3%, RR, 0.46; p=<0.00001). Trial sequential analysis using a relative risk reduction threshold of 20%, power 80% and type 1 error of 5%, indicated that the evidence is firm. A greater risk reduction in CI-AKI in the statin group significantly correlated with higher estimated glomerular filtration rate (eGFR; p=0.003) CONCLUSIONS: The present trial sequential analysis provides support for statins in reducing the incidence of CI-AKI in patients undergoing CAG/PCI. This effect appeared to be greater in patients with higher eGFR.

Transcatheter valve-in-valve implantation versus reoperative conventional aortic valve replacement: a systematic review

Transcatheter valve-in-valve (VIV) implantation for degenerated aortic bioprostheses has emerged as a promising alternative to redo conventional aortic valve replacement (cAVR). However there are concerns surrounding the efficacy and safety of VIV. This systematic review aims to compare the outcomes and safety of transcatheter VIV implantation with redoes cAVR. Six databases were systematically searched. A total of 18 relevant studies (823 patients) were included. Pooled analysis demonstrated VIV achieved significant improvements in mean gradient (38 mmHg preoperatively to 15.2 mmHg postoperatively, P<0.001) and peak gradient (59.2 to 23.2 mmHg, P=0.0003). These improvements were similar to the outcomes achieved by cAVR. The incidence of moderate paravalvular leaks (PVL) were significantly higher for VIV compared to cAVR (3.3% vs. 0.4%, P=0.022). In terms of morbidity, VIV had a significantly lower incidence of stroke and bleeding compared to redo cAVR (1.9% vs. 8.8%, P=0.002 & 6.9% vs. 9.1%, P=0.014, respectively). Perioperative mortality rates were similar for VIV (7.9%) and redo cAVR (6.1%, P=0.35). In conclusion, transcatheter VIV implantation achieves similar haemodynamic outcomes, with lower risk of strokes and bleeding but higher PVL rates compared to redo cAVR. Future randomized studies and prospective registries are essential to compare the effectiveness of transcatheter VIV with cAVR, and clarify the rates of PVLs.

The effect of N-acetylcysteine on the incidence of contrast-induced kidney injury: A systematic review and trial sequential analysis

BACKGROUND There have been a myriad of studies investigating the effectiveness of N-acetylcysteine (NAC) in the prevention of contrast induced nephropathy (CIN) in patients undergoing coronary angiography (CAG) with or without percutaneous coronary intervention (PCI). However the consensus is still out about the effectiveness of NAC pre-treatment due to vastly mixed results amongst the literature. OBJECTIVES The aim of this study was to conduct a meta-analysis and trial sequential analysis to determine the effects of pre-operative NAC in lowering the incidence of CIN in patients undergoing CAG and/or PCI. METHODS A systematic literature search was performed to include all randomized controlled trials (RCTs) comparing NAC versus control as pretreatment for CAG and/or PCI. A traditional meta-analysis and several subgroup analyses were conducted using traditional meta-analysis with relative risk (RR), trial sequential analysis, and meta-regression analysis. RESULTS 43 RCTs met our inclusion criteria giving a total of 3277 patients in both control and treatment arms. There was a significant reduction in the risk of CIN in the NAC treated group compared to control (OR 0.666; 95% CI, 0.532-0.834; I2=40.11%; p=0.004). Trial sequential analysis, using a relative risk reduction threshold of 15%, indicates that the evidence is firm. CONCLUSIONS The results of the present paper support the use of NAC in the prevention of CIN in patients undergoing CAG±PCI. Future studies should focus on the benefits of NAC amongst subgroups of high-risk patients.

Hybrid coronary revascularization versus coronary artery bypass surgery: Systematic review and meta-analysis☆

0.61; 95% CI, 0.24–1.58; I 2 = 0%; P = 0.31) or postoperative MACCE (RR, 0.78; 95% CI, 0.34–1.78; I 2 = 0%; P = 0.55), with no significant heterogeneity detected (Fig. 1). From data of 1664 patients, 30-day mortality rates of hybrid and CABG approaches were comparable (RR, 0.88; 95% CI, 0.34–2.33; I 2 = 0%; P = 0.80). Postoperative myocardial infarction (RR, 0.67; 95% CI, 0.49–0.93; I 2 =0 %; P= 0.01) and blood transfusions (RR, 0.54; 95% CI, 0.40–0.74; I 2 =

Transcatheter aortic valve implantation (TAVI) versus sutureless aortic valve replacement (SUAVR) for aortic stenosis: a systematic review and meta-analysis of matched studies

BACKGROUND With improving technologies and an increasingly elderly populations, there have been an increasing number of therapeutic options available for patients requiring aortic valve replacement. Recent evidence suggests that transcatheter aortic valve implantation (TAVI) is one suitable option for high risk inoperable patients, as well as high risk operable patients. Sutureless valve technology has also been developed concurrently, with facilitates surgical aortic valve replacement (SUAVR) by allow resection and replacement of the native aortic valve with minimal sutures and prosthesis anchoring required. For patients amenable for both TAVI and SUAVR, the evidence is unclear with regards to the benefits and risks of either approach. The objectives are to compare the perioperative outcomes and intermediate-term survival rates of TAVI and SUAVR in matched or propensity score matched studies. METHODS A systematic literature search was performed to include all matched or propensity score matched studies comparing SUAVR versus TAVI for severe aortic stenosis. A meta-analysis with odds ratios (OR) and mean differences were performed to compare key outcomes including paravalvular regurgitation and short and intermediate term mortality. RESULTS Six studies met our inclusion criteria giving a total of 741 patients in both the SUAVR and TAVI arm of the study. Compared to TAVI, SUAVR had a lower incidence of paravalvular leak (OR =0.06; 95% CI: 0.03-0.12, P<0.01). There was no difference in perioperative mortality, however SUAVR patients had significantly better survival rates at 1 (OR =2.40; 95% CI: 1.40-4.11, P<0.01) and 2 years (OR =4.62; 95% CI: 2.62-8.12, P<0.01). CONCLUSIONS The present study supports the use of minimally invasive SUAVR as an alternative to TAVI in high risk patients requiring aortic replacement. The presented results require further validation in prospective, randomized controlled studies.

Robot-assisted Hybrid Coronary Revascularisation: Systematic Review

BACKGROUND Hybrid coronary revascularisation (HCR) for multi-vessel coronary artery disease combines surgical bypass grafting for the left anterior descending (LAD) coronary artery and percutaneous coronary intervention (PCI) for non-LAD coronary arteries. The present systematic review was conducted to assess the available evidence on robotic-assisted HCR and explore the potential advantages and disadvantages it proposes. METHODS A comprehensive search from six electronic databases was performed for studies reporting outcomes for robotic-assisted hybrid coronary revascularisation. Eight studies were identified from six electronic databases amenable for qualitative assessment and pooled quantitative analysis. RESULTS There were no in-hospital deaths reported. Pooled myocardial infarction rates was 1.2% (range 0-3.7%), pooled strokes was 0.8% (range: 0-1.7%), freedom from reintervention was 92.5% (range 70.4-100%), and freedom from angina was 92.9% (range 74.3-100%). LITA patency ranged from 89-100%, while hospital stay ranged from 4-8.1 days. CONCLUSIONS The current data suggests potentially acceptable mortality and complication rates, when patients are carefully selected and operated on by expert cardiovascular teams. However, due to the heterogeneous nature of the evidence and lack of long-term outcomes, this promising technique warrants future comparative and randomised studies before becoming a part of mainstay coronary interventions.

Effect of Preoperative Anemia on the Outcomes of Anterior Cervical Discectomy and Fusion

Study Design: Retrospective cohort study. Objective: Preoperative anemia has been associated with an increased need for blood transfusions and postoperative complications. The effects of anemia on the outcomes of anterior cervical discectomy and fusion (ACDF) have not been explored. The present study aimed to evaluate the association between preoperative anemia and 30-day complications following ACDF surgery. Methods: Data from the American College of Surgeons National Surgical Quality Improvement Program (2005-2012) was used. Preoperative anemia was defined as hematocrit <39% for males and <36% for females. A bivariate analysis was performed on demographic and perioperative variables. Multivariable logistic regression models were employed, adjusting for patient variables, to identify independent risk factors for complications. Results: A total of 3500 patients were included of which 444 (12.7%) were anemic patients. Multivariate analysis was used to quantify the predictive power of anemia on key postoperative outcomes, while controlling for the other statistically significant. Preoperative anemia was found to be a statistically significant predictor of any complication (odds ratio [OR] = 1.853; 95% confidence interval [CI] = 1.17-2.934; P = .0086), pulmonary complications (OR = 3.269; 95% CI = 1.745-6.126; P = .0002), intraoperative blood transfusion (OR = 4.364; 95% CI = 1.48-12.866; P = 0.0076), return to operating theatre (OR = 2.655; 95% CI = 1.539-4.582; P = .0005), and length of hospital stay more than 5 days (OR = 2.151; 95% CI = 1.499-3.085; P < .0001). Conclusion: Preoperative anemia appears to be a significant predictor of perioperative complications, reoperation, and extended length of hospital stay in patients undergoing elective ACDF. Future studies should explore outcomes of treatment of preoperative anemia prior to surgery to determine the optimal management strategy.

Implantable cardioverter defibrillator therapy in hypertrophic cardiomyopathy: an updated systematic review and meta-analysis of outcomes and complications

BACKGROUND Since the introduction of the implantable cardioverter-defibrillator (ICD) in patients with hypertrophic cardiomyopathy (HCM), the incidence of sudden cardiac death (SCD) has been significantly reduced. Given its widespread use, it is important to identify the outcomes associated with ICD use in patients with HCM. The present paper is a systematic review and meta-analysis of the rates of appropriate and inappropriate interventions, mortality, and device complications in HCM patients with an ICD. METHODS We conducted a systematic review and meta-analysis on 27 studies reporting outcomes and complications after ICD implantation in patients with HCM. ICD interventions, device complications, and mortality were extracted for analysis. RESULTS A total of 3,797 patients with HCM and ICD implantation were included (mean age, 44.5 years; 63% male), of which 83% of patients had an ICD for primary prevention of SCD. The cardiac mortality was 0.9% (95% CI: 0.7-1.3) per year and non-cardiac mortality was 0.8% (95% CI: 0.6-1.2) per year. Annualized appropriate intervention rate was 4.8% and annualized inappropriate intervention was 4.9%. The annual incidence of lead malfunction, lead displacement and infection was 1.4%, 1.3%, and 1.1%, respectively. CONCLUSIONS ICD use in patients with HCM produces low rates of cardiac and non-cardiac mortality, and an appropriate intervention rate of 4.8% per year. However, moderate rates of inappropriate intervention and device complications warrant careful patient selection in order to optimize the risk to benefit ratio in this select group of patients.

Post-dilation in transcatheter aortic valve replacement: A systematic review and meta-analysis

OBJECTIVES The aim of this study was to perform a meta-analysis to compare the outcomes of patients undergoing TAVR with and without balloon post-dilation (PD). BACKGROUND PD is a commonly used technique in TAVR to minimize paravalvular regurgitation (PVR), albeit supported by little evidence. METHODS Systematic review and meta-analysis of 6 studies comparing 889 patients who had PD compared to 4118 patients without PD. RESULTS Patients undergoing PD were more likely male (OR 1.92; 95% CI, 1.41-2.61; P < 0.001) and to have coronary artery disease (OR 1.31; 95% CI, 1.03-1.68; P = 0.03) than those patients not requiring PD. There were no significant differences in 30-day mortality (OR 1.24; 95% CI, 0.88-1.74; P = 0.22) and myocardial infarction (OR 0.93; 95% CI, 0.46-1.90; P = 0.85). Patients undergoing TAVR did not have higher 1-year mortality rates (OR 0.98; 95% CI, 0.61-1.56; P = 0.92). The incidence of stroke was significantly greater in patients with PD (OR, 1.71; 95% CI, 1.10-2.66). PD was able to reduce the incidence of moderate-severe PVR by 15 fold (OR 15.0; 95% CI, 4.2-54.5; P < 0.001), although rates of moderate-severe PVR were still higher after PD than patients who did not require PD (OR 3.64; 95% CI, 1.96-6.75; P < 0.001). CONCLUSIONS PD significantly improves rates of PVR, however careful patient selection is needed to minimize increased risk of strokes.

Predictors of successful chronic total occlusion percutaneous coronary interventions: a systematic review and meta-analysis

Objective The aim of this study was to identify positive and negative predictors of technical and clinical success for percutaneous coronary intervention (PCI) of chronic total occlusions (CTO). Methods We conducted a systematic review and meta-analysis of studies published between 2000 and 2016 analysing rates of CTO PCI success with respect to demographic and angiographic characteristics. Crude ORs and 95% CIs for each predictor were calculated using a random effects model. Predictors of technical and clinical success were assessed among 28 demographic and 31 angiographic variables. Clinical success was defined as technical success without major adverse cardiac events. Results A total of 61 studies, totalling 69 886 patients were included in this analysis. The major demographic characteristics associated with a 20% or greater reduction in the odds of technical and clinical success were a history of myocardial infarction, PCI, coronary artery bypass grafting, stroke/transient ischaemic attack and peripheral vascular disease. Angiographic factors were generally stronger predictors of reduced technical and clinical success. Those associated with >20% odds reduction included non-left anterior descending CTOs, multivessel disease, presence of bridging collaterals, moderate-to-severe calcification, >45 degree vessel bending, tortuous vessel, blunt stump and ostial lesions. Of these, novel predictors included prior PCI, prior stroke, peripheral vascular disease, presence of multivessel disease and bridging collaterals. Conclusion The present study has identified strong negative predictors for clinical success for CTO PCI, which will aid in patient selection for this procedure.