Rama Dilip Gajulapalli

A systematic review on the safety of second-generation transcatheter aortic valves

AIMS To review the outcomes of studies and the safety of newer transcatheter aortic valves (THV). METHODS AND RESULTS All studies reporting on second-generation THV were identified and pooled using the systematic review guidelines. Twenty-four reports on 1,708 patients and eight THV were included in the analysis. The pooled 30-day event rate for mortality after transcatheter aortic valve implantation (TAVI) was 5.7% (95% CI: 4.0-7.8), myocardial infarction (MI) was 1.7% (95% CI: 1.1-2.6), stage 3 acute kidney injury (AKI) was 3.4% (95% CI: 2.0-5.6), life-threatening bleeding was 5.1% (95% CI: 3.3-7.8), major vascular complications was 4.9% (95% CI: 3.5-6.6%), major bleeding was 10.5% (95% CI: 5.1-20.4), major stroke was 2.4% (95% CI: 1.7-3.4), permanent pacemaker utilisation was 13.5% (95% CI: 10.8-16.9), and coronary obstruction was 1.2% (95% CI: 0.6%-2.4%). Moderate or severe aortic insufficiency (AI) after TAVI was 4.2% (95% CI: 2.0-8.5). The pooled 30-day mean gradient and effective orifice area (EOA) were 11.63 mmHg (95% CI: 10.19-13.07) and 1.60 cm2 (95% CI: 1.5-1.7), respectively. All estimates compare favourably to events reported for first-generation valves. CONCLUSIONS Our findings suggest that the new THV have a low risk of TAVI-related short-term complications.

Late Stroke: Comparison of Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Patients With Multivessel Disease and Unprotected Left Main Disease A Meta-Analysis and Review of Literature

Background and Purpose— Studies have suggested that the early excess risk of stroke in coronary artery bypass grafting (CABG) may be compensated for by a slow but progressive catch-up phenomenon in patients undergoing percutaneous coronary intervention (PCI). We therefore undertook this analysis to compare the temporal stroke risk between PCI and CABG in patients with unprotected left main stenosis and multivessel coronary artery disease. Methods— Studies of PCI versus CABG for unprotected left main stenosis and multivessel disease published between January 1994 (stent era) and July 2013 were identified using an electronic search and reviewed using meta-analytic techniques. Results— We selected 57 reports for the meta-analysis by applying the inclusion and exclusion criteria. The analysis was performed on 80 314 patient records. There was a significantly lower risk of cumulative stroke in patients undergoing PCI with stenting at 1 year (odds ratio [OR], 0.55; 95% confidence interval [CI], 0.42–0.71), 2 years (OR, 0.78; 95% CI, 0.66–0.92), 3 years (OR, 0.79; 95% CI, 0.67–0.92), 4 years (OR, 0.74; 95% CI, 0.56–0.97), and 5 years (OR, 0.79; 95% CI, 0.69–0.91). There was no significant difference in the incidence of stroke because of the small sample size (OR, 0.71; 95% CI, 0.46–1.08) at >5 years between PCI and CABG. Similar results were observed on subgroup analysis (multi-vessel coronary artery disease, unprotected left main, diabetics, and randomized trials) and for stroke within 30 days. Late stroke (stroke >30 days) was similar between the 2 groups. Conclusions— There is a significantly lower risk of stroke within 30 days and cumulative stroke with PCI as compared with CABG up to year 5. There is no late catch up of stroke in the PCI arm. The risk of stroke should be weighed in deciding between revascularization strategies.

Management of drug eluting stent in-stent restenosis: A systematic review and meta-analysis

The optimal management for coronary drug eluting stent in‐stent restenosis (DES ISR) is unclear. We performed a meta‐analysis of observational and randomized studies to compare the outcomes of management of DES ISR using DES, drug eluting balloon (DEB), or balloon angioplasty (BA).

Effect of early statin therapy on risk of atrial fibrillation after coronary artery bypass grafting with or without concomitant valve surgery.

Statins decrease postoperative atrial fibrillation (AF) if given before cardiac surgery. However, whether early administration of statins after surgery decreases the risk of postoperative AF is unknown. The association of early reinstitution of postoperative statin therapy within 48 hours to the occurrence of postoperative AF was studied in propensity-adjusted analyses of 200 consecutive patients in sinus rhythm who had undergone coronary artery bypass grafting with or without valve surgery. Postoperative AF occurred in 36 patients (18%). Of 52 patients who received a statin early after surgery, 4 (7.7%) developed AF compared to 32 (28%) of 148 patients who did not (p = 0.043). In the propensity-adjusted analyses, early postoperative statin treatment was associated with a significantly lower occurrence of AF (odds ratio 0.39, 95% confidence interval 0.15 to 0.99), irrespective of concomitant β-blocker therapy. The length of stay was shorter for the patients who received early postoperative statins (median 6.1 days, interquartile range 4 to 7, vs 7.8 days, interquartile range 5 to 8; p = 0.0031). In conclusion, of preoperative statin users undergoing coronary artery bypass grafting with or without valve surgery, early postoperative reinstitution of statins was associated with a lower occurrence of postoperative AF and a shorter length of stay. Early postoperative statin therapy might be a feasible and safe method of reducing postoperative AF.

Inflammatory bowel 'Cardiac' disease: Point prevalence of atrial fibrillation in inflammatory bowel disease population

Background/Aim: Proinflammatory markers such as interleukin (IL)-6 have been closely associated with atrial fibrillation (AF). These markers are characteristically elevated in chronic inflammatory bowel disease (IBD) and positively correlate with disease activity. Although IBD and AF have similar pathogenesis, there have been very limited studies looking at their association. The aim of this study is to determine the prevalence of AF in patients with IBD. Patients and Methods: Medical records of patients with biopsy proven IBD (n = 203, both in and outpatient) were retrospectively reviewed. One hundred and forty-one IBD patients with documentary evidence of electrocardiograms (ECGs) were included. The “Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA)” study, a large cross-sectional study (n = 1.89 million) done to evaluate the prevalence of AF among the US population, was our control population. All ECGs available till December 2010 for each IBD patient were reviewed carefully for evidence of AF. We studied the prevalence of AF among IBD population and compared it to that of control (ATRIA) population. Results: The prevalence of AF was significantly higher among IBD patients compared with the ATRIA study patients (11.3% vs 0.9%, P < 0.0001). Additionally, the IBD patient population were much younger compared with the controls (64.4 ± 10.7 vs 71.2 ± 12.2, P = 0.02). Conclusion: AF has an overall higher prevalence across all age groups in IBD compared with the subjects of ATRIA study, which could be due to the chronic inflammatory state of IBD. Further studies are needed to study the association in detail.

Transradial access mitigates bleeding benefit offered by bivalirudin over heparin in patients undergoing percutaneous coronary intervention: Insights from meta-analysis of randomized and observational studies

OBJECTIVE Recent randomized control trials (RCTs) showed conflicting efficacy and safety between bivalirudin and heparin during percutaneous coronary intervention (PCI). We aimed to perform an updated meta-analysis, including real-world and trial data to examine the factors affecting their risk-benefit ratio. METHODS We searched Medline, the Cochrane library, and meeting abstracts for studies comparing bivalirudin versus heparin during PCI. Random-effect meta-analyses for MACE (major adverse cardiovascular events), stent thrombosis (ST) and major bleeding were performed. p-Value <0.05 was considered statistically significant. RESULTS Meta-analysis of 20 RCTs and 31 observation studies (n=165,835) showed that bivalirudin and heparin were similar in the risk of MACE in RCTs (OR 1.05, 95% CI 0.97-1.13) and observational studies (OR 0.94, 95% 0.81-1.10). Major bleeding was lower with bivalirudin in both RCTs (OR 0.60, 95% CI 0.51-0.70) and observational studies (OR 0.56, 95% CI 0.47-0.68). However, in the metaregression analysis, every 10% increase of transradial access decreased the bleeding benefit of bivalirudin by 4.9% (p=0.046, adjusted for GPI and heparin loading dose). ST with bivalirudin was higher with ST-segment elevation myocardial infarction (STEMI) in RCTs (OR 1.51, 95% CI 1.15-1.99) but not in observational studies (p=0.65). CONCLUSIONS In this large meta-analysis, bivalirudin is associated with a lower risk of bleeding compared to heparin in both RCTs and observational studies, however, transradial PCI mitigated most of this bleeding benefit. Heparin should be the preferred agent in transradial PCI given its lower cost and comparable outcomes.

Optimal duration of dual antiplatelet therapy after drug eluting stent implantation: a network meta-analysis.

Objective: There has been much debate regarding the optimal duration of dual antiplatelet therapy (DAPT) cover after drug eluting stent (DES) implantation. We aimed to assess the relative benefits of shorter and longer durations of DAPT coverage. Methods: We performed a network meta-analysis (NMA) of all the randomized clinical trials (RCT) comparing different time durations of DAPT cover. Results: We included 11 unique trials with a total of 33,458 patients; the longest duration of follow-up was 48 months and the shortest was 3 months. NMA results demonstrated that compared with 12 months, longer DAPT of 30 months reduced the hazard ratio (HR) of stent thrombosis (HR, 0.29; 95% CrI, 0.17–0.49). There was no difference in mortality between shorter and longer durations of DAPT except for 30 vs. 48 months (HR, 0.48; 95% CrI, 0.23–0.98). Compared with 12 months, longer DAPT of 30 months reduced the risk of myocardial infarction (HR, 0.47; 95% CrI, 0.37–0.61). Results also demonstrated that compared with 12 months, a shorter-term DAPT reduced the risk of major bleeding (6 months: HR, 0.53; 95% CrI, 0.29–0.98), whereas longer-term DAPT increased the risk of major bleeding (30 months: HR, 1.61; 95% CrI, 1.21–2.15). Conclusion: As expected, bleeding was less in the shorter duration regimens, whereas the ischemic outcomes were better in the longer duration ones.

Post Operative Arrhythmias

Heart rhythm disturbances are being increasingly recognized during the postoperative period. While many are transient and short lived without altering the recovery phase after cardiac or non-cardiac surgery, they do have the potential to pose a threat to patient’s health, prolong hospital stay, and in a minority of patients may even cause death. Continuous monitoring is becoming the standard of care after surgery and therefore rhythm disturbances are being more frequently diagnosed during the postoperative recovery period. While cardiology consultation may be required, surgeons and anesthesiologists are often the first responders and are expected to be able to recognize the rhythm disturbance and treat them appropriately.

TAKOTSUBO CARDIOMYOPATHY (TCM) INCREASES RISK OF LETHAL ARRHYTHMIAS

Background: Takotsubo cardiomyopathy (TCM), although generally considered reversible, can be associated with significant mortality due to lethal arrhythmias. Repolarization abnormalities in TCM can lead to characteristic T-wave abnormalities & QT prolongation that place patients at increased risk

THE EFFECT OF VOLUME OVERLOADED STATE ON THE TRANSMURAL DISPERSION OF REPOLARIZATION IN A FAILING HEART

Volume overloaded state is suspected of increasing the risk of ventricular arrhythmias in congestive heart failure (CHF). The T peak to T end interval (Tpe) as measured on the surface electrocardiogram (EKG) is presumed to represent global dispersion of ventricular repolarization and has been shown