Satyanarayana R. Vaidya

Transcatheter Versus Surgical Aortic Valve Replacement in Patients With Lower Surgical Risk Scores: A Systematic Review and Meta-Analysis of Early Outcomes

BACKGROUNDnThe results from the PARTNER 2 trial showed the feasibility of transcatheter aortic valve replacement (TAVR) in intermediate surgical risk patients. Although low risk clinical trials will take time to conclude, some data has emerged comparing TAVR with surgical aortic valve replacement (SAVR) in lower risk patients.nnnMETHODSnA Medline search was conducted using standard methodology to search for studies reporting results comparing TAVR and SAVR. Studies were included if the overall mean Society of Thoracic Surgeons Score was less than 4% (or equivalent Euroscore). A meta-analysis comparing the 30-day risk of clinical outcomes between TAVR and SAVR in the lower surgical risk population was conducted.nnnRESULTSnA total of four studies, including one clinical trial and three propensity-matched cohort studies met the inclusion criteria. Compared to SAVR, TAVR had a lower risk of 30-day mortality (RR 0.67, 95% CI 0.41, 1.10), stroke (RR 0.60, 95% CI 0.30, 1.22), bleeding complications (RR 0.51, 95% CI 0.40, 0.67) and acute kidney injury (RR 0.66, 95% CI 0.47, 0.94). However, a higher risk of vascular complications (RR 11.72, 95% CI 3.75, 36.64), moderate or severe paravalvular leak (RR 5.04, 95% CI 3.01, 8.43), and permanent pacemaker implantations (RR 4.62, 95% CI 2.63, 8.12) was noted for TAVR.nnnCONCLUSIONnAmong lower risk patients, TAVR and SAVR appear to be comparable in short term outcomes. Additional high quality studies among patients classified as low risk are needed to further explore the feasibility of TAVR in all surgical risk patients.

Review of major registries and clinical trials of late outcomes after transcatheter aortic valve replacement.

The results of the Placement of AoRtic TraNscathetER Valves (PARTNER) 2 trial established the feasibility of transcatheter aortic valve replacement (TAVR) for intermediate surgical risk patients. The expansion of TAVR into the low-risk patient population will largely depend on its durability outcomes due to the high life expectancy in low-risk patients. Long-term follow-up results from low-risk clinical trials will take several years to be reported. Given this, we performed a systematic review of current long-term data to provide further insights into TAVR durability and long-term patient survival. We searched MEDLINE, Embase, Google Scholar, BIOSIS, and major conference abstracts for TAVR studies with follow-up of at least 4xa0years. Abstracts were retrieved and independently reviewed for eligibility. Final studies were selected irrespective of the type of TAVR valve, route of vascular access, or surgical risk profile. A total of 12xa0studies met the inclusion criteria. We reviewed data from these studies with emphasis on long-term survival and echocardiographic findings.

Meta‐analysis of transfemoral TAVR versus surgical aortic valve replacement

In the recently concluded PARTNER 2 trial, TF‐TAVR cohort was shown to have lower risks of death or disabling strokes as compared to SAVR, whereas the outcomes with transthoracic TAVR were comparable with SAVR.

Culprit versus multivessel coronary intervention in ST-segment elevation myocardial infarction: A meta-analysis of randomized trials

Background The 2015 American College of Cardiology/American Heart Association update on primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) recommended PCI of the non-infarct-related artery at the time of primary PCI (class IIb recommendation). Despite evidence supporting complete revascularization in STEMI, its benefit on mortality rates is uncertain. Methods We searched all available databases for randomized controlled trials comparing complete multivessel percutaneous coronary intervention (CMV PCI) with infarct-artery-only revascularization in patients with STEMI. Summary risk ratios and 95% confidence intervals (CIs) were calculated for both the efficacy and safety outcomes. Results Nine randomized controlled trials fulfilled the inclusion criteria, yielding 2991 patients. Follow-up periods ranged from 6 to 36 months. Compared with infarct-related artery-only PCI, CMV PCI was associated with significantly lower rates of major adverse cardiac events [relative risk (RR)=0.54, 95% CI=0.41–0.71; P<0.00001], cardiovascular mortality (RR=0.48, 95% CI=0.28–0.80; P=0.005), and repeat revascularization (RR=0.38, 95% CI=0.30–0.47; P<0.00001). Although, contrast-induced nephropathy and major bleed rates were comparable between both groups, CMV PCI failed to show any reduction in all-cause mortality (RR=0.75, 95% CI=0.53–1.07; P=0.11) and nonfatal myocardial infarction (RR=0.69, 95% CI=0.43–1.10; P=0.12). Conclusion Our results suggest that in patients with STEMI and multivessel disease, complete revascularization is safe, and is associated with reduced risks of major adverse cardiac events and cardiac death along with a reduced need for repeat revascularization. However, it showed no beneficial effect on all-cause mortality and nonfatal myocardial infarction.

Type 2 versus type 1 myocardial infarction: a comparison of clinical characteristics and outcomes with a meta-analysis of observational studies

BACKGROUNDnType 2 myocardial infarction (MI) is an imbalance between myocardial oxygen demand and supply, leading to myocardial ischemia. It is not due to plaque rupture, and is usually caused by a condition other than coronary artery disease (CAD). However, limited data are available comparing the prevalence of traditional coronary risk factors and mortality between type 1 and type 2 MI. We hypothesize that type 2 MI carries a higher mortality than type 1.nnnMETHODSnWe searched the databases of PubMed, EMBASE, CENTRAL, and MEDLINE for studies comparing type 1 MI with type 2 MI. The baseline variables were compared in each cohort. Summary risk ratios and 95% confidence intervals were calculated using the random effects model to compare mortality between the two groups.nnnRESULTSnThe included studies yielded 25,872 patients of whom 2,683 (10%) had type 2 MI. Compared to the type 1 cohort, the type 2 cohort had significantly higher inpatient (15% vs. 4.7%, P<0.00001), 30-day (17.6% vs. 5.3%, P<0.00001) and 1-yr mortality (27% vs. 13%, P<0.00001), as well as higher 30-day major adverse cardiovascular events (20% vs. 9%, P<0.0001). Operative stress (20%) was the most common trigger of type 2 MI, followed by sepsis (19%), arrhythmia (18.63%), heart failure (15%), and anemia (12%).nnnCONCLUSIONSnType 2 MI is a common entity and is more common in females, older age groups, and in patients with multiple comorbidities: it also tends to result in higher mortality.

Infarct related artery only versus complete revascularization in ST-segment elevation myocardial infarction and multi vessel disease: a meta-analysis

BACKGROUNDnThe 2015 American College of Cardiology Foundation/American Heart Association (ACCF/AHA) focused update on primary percutaneous coronary intervention (PCI) for patients with ST-segment elevation myocardial infarction (STEMI) only gives a class II b (weak) indication for non-infarct artery intervention at the time of primary PCI. Recent randomized controlled trials, however, suggest strong evidence supporting complete revascularization.nnnMETHODSnA systematic search was conducted in PUBMED, MEDLINE, EMBASE and Cochrane central register for randomized controlled trials comparing complete versus infarct artery (IRA) only revascularization in patients with STEMI. A meta-analysis was performed using the data extracted from each study. Summary risk ratios (RR) and 95% confidence intervals (CI) were calculated for five outcomes.nnnRESULTSnSix trials fulfilled the inclusion criteria yielding 1,792 patients. Follow up ranged from 6 months to 2.5 years. The incidence of major adverse cardiac events (MACE) was significantly lower in the complete revascularization group compared to the IRA only revascularization (13.8% vs. 25.1%, RR =0.51; 95% CI: 0.41-0.64, P<0.00001). It was attributed to significantly lower repeat revascularization rate in the complete revascularization group (8.2% vs. 18.9%, RR =0.41; 95% CI: 0.31-0.54, P<0.00001). This meta-analysis also showed a significant reduction in cardiovascular mortality (2.0% vs. 4.6%, RR =0.42; 95% CI: 0.24-0.74; P=0.003), non-fatal myocardial infarction (4.37% vs. 5.76%, RR =0.64; 95% CI: 0.34-1.20; P=0.16) and all-cause mortality rates [(4.6% vs. 6%), RR =0.75; 95% CI: 0.49-1.14, P=0.17] in the complete revascularization group, compared to the IRA revascularization group.nnnCONCLUSIONSnIn patients who present with STEMI, complete revascularization is associated with lower rates of MACE and cardiovascular deaths as compared to revascularization of the IRA alone. Even though the outcomes of all-cause mortality and nonfatal re-infarction rates were lower in the complete revascularization group, they were not significant.

Repair of Coronary Artery Perforation Into the Left Ventricle Using Graftmaster Stent Graft After Complicated Percutaneous Coronary Intervention of Myocardial Bridge

A myocardial bridge (MB) is a band of heart muscle that lies on the top of a coronary artery, instead of underneath it. This leads to tunneling of coronary artery through this segment of the myocardium which can be mechanically compressed during systole, also known as myocardial bridging. Although usually asymptomatic, it can be associated with exertional angina, acute coronary syndrome, cardiac arrhythmia or even sudden cardiac death. The utilization of percutaneous coronary intervention (PCI) of the bridged segment to ameliorate vessel compression and normalize blood flow is limited due to concerns of complications, particularly restenosis and perforation. Although conventional management of coronary perforation includes prolonged balloon dilation and reversal of anticoagulation, stent grafting of these perforations is not uncommonly utilized. We report a case of a patient with symptomatic MB who underwent a PCI of the bridging segment of the left anterior descending (LAD) coronary arterywhich was complicated with a perforation into the left ventricle. As patient became symptomatic, the perforation was emergently repaired using a Graftmaster® RX coronary stent graft system (Abbott Vascular) with complete alleviation of symptoms and successful radiographic resolution. J Med Cases. 2017;8(3):77-80 doi: https://doi.org/10.14740/jmc2750w