Saurabh Gaba

Comparison of Approaches to Revascularization in Patients With Multivessel Coronary Artery Disease Presenting With ST-Segment Elevation Myocardial Infarction: Meta-analyses of Randomized Control Trials.

Background Significant controversy exists regarding the best approach for nonculprit vessel revascularization in patients with multivessel coronary artery disease presenting with ST‐segment elevation myocardial infarction. We conducted a systematic investigation to pool data from current randomized controlled trials (RCTs) to assess optimal treatment strategies in this patient population. Methods and Results A comprehensive search of SCOPUS from inception through May 2015 was performed using predefined criteria. We compared efficacy and safety outcomes of different approaches by categorizing the studies into 3 groups: (1) complete revascularization (CR) versus culprit lesion revascularization (CL) at index hospitalization, (2) CR at index hospitalization versus staged revascularization (SR) of nonculprit vessels at a separate hospitalization, and (3) comparison of SR versus CL. Eight eligible RCTs met the inclusion criteria: (1) CR versus CL (6 RCTs, n=1727) (2) CR versus SR (3 RCTs, n=311), and (3) SR versus CL (1 RCT, n=149). We observed significantly lower rates of major adverse cardiovascular events, revascularization, and repeat percutaneous coronary interventions among patients treated with CR and SR compared with a CL approach (P<0.05). The rates of all‐cause mortality, cause‐specific mortality, major bleeding, reinfarction, stroke, and contrast‐induced nephropathy did not differ in the CR arm compared with the CL arm. The rates of these outcomes were similar in the CR and SR arms. Conclusion Results suggest that CR and SR compared with CL reduce major adverse cardiovascular event and revascularization rates primarily by lowering repeated percutaneous coronary intervention rates. We did not observe any increase in the rate of adverse events while using a CR or SR strategy compared with a CL approach. Current guidelines discouraging CR need to be reevaluated, and clinical judgment should prevail in treating multivessel coronary artery disease patients with ST‐segment elevation myocardial infarction as data from larger RCTs accumulate.

Incremental Value of Live/Real Time Three-Dimensional Transthoracic Echocardiography over Two-Dimensional Echocardiography in Hypertrophic Cardiomyopathy with Mid-Ventricular Obstruction and Apical Aneurysm

We describe a case of hypertrophic cardiomyopathy with mid‐left ventricular obstruction and apical aneurysm containing thrombi where live/real time three‐dimensional transthoracic echocardiography provided incremental value over two‐dimensional echocardiography in assessing the findings.

Two- and live/real time three-dimensional transthoracic echocardiographic assessment of infective endocarditis of a valved pulmonary conduit.

We describe the use of a nonstandard left infraclavicular approach in making the diagnosis of an infected valved conduit with two‐dimensional transthoracic echocardiography. The patient was an adult with tetralogy of Fallot and pulmonary atresia who had undergone multiple surgical repair procedures. The initial diagnosis of infective endocarditis was made by transesophageal echocardiography. Both techniques demonstrated a single, large vegetation in the conduit. Live/real time three‐dimensional transthoracic echocardiography, on the other hand, provided further information by demonstrating several additional vegetations in the conduit and more comprehensively assessed their size by enabling measurement of their azimuthal dimensions and volumes. The patient was treated with antibiotics with complete resolution of the vegetations.

Incremental value of three-dimensional transesophageal echocardiography over the two-dimensional technique in percutaneous closure of aortic paraprosthetic regurgitation.

We describe 2 patients with significant aortic paraprosthetic regurgitation who underwent percutaneous closure where live/real time three‐dimensional transesophageal echocardiography provided incremental value over two‐dimensional transesophageal echocardiography.

GPIIB/IIIA INHIBITORS USE IMPROVES OUTCOMES AFTER ASPIRATION THROMBECTOMY IN PATIENTS WITH ST ELEVATION MYOCARDIAL INFARCTION: A METAREGRESSION ANALYSIS

results: Metaregression of 13 RCTs showed that studies with higher GpIIb/IIIa inhibitor use had higher mortality benefit with TA, compared with studies with lower GpIIb/IIIa inhibitor use (0.07 reduction in log-relative risk per 10% increase in GpIIb/IIIa inhibitor use, p=0.047, Figure). A second metaregression to evaluate the association between the prevalence of GpIIb/IIIa inhibitors use in the TA arm minus the prevalence of GpIIb/IIIa inhibitors use in control arm and all-cause mortality with use of TA showed that studies with higher proportion of GpIIb/IIIa inhibitors use in TA arm (than control arm in the same study) showed a higher mortality benefit with TA (0.09 reduction in log-relative risk for every percent higher GpIIb/IIIa inhibitors use in the TA arm, compared with the control arm, p=0.02).

A COMPARATIVE META-ANALYSIS FOR LONG-TERM STROKE IN PATIENTS RECEIVING EDWARDS-SAPIEN VERSUS COREVALVE

Stroke has emerged as an ominous complication after transcatheter aortic valve replacement. While short-term stroke risk of this procedure has been studied, long-term stroke risk with different valve types is not defined. We performed a comprehensive meta-analysis to compare long-term risk of two

META-ANALYSIS OF RANDOMIZED CONTROL TRIALS (RCTS) COMPARING PERCUTANEOUS LEFT ATRIAL APPENDAGE (WATCHMAN DEVICE) CLOSURE VERSUS ADJUSTED DOSE WARFARIN FOR STROKE PROPHYLAXIS IN NON-VALVULAR ATRIAL FIBRILLATION

Recent RCTs indicate non-inferiority of percutaneous left atrial appendage (LAA) closure compared to warfarin for stroke prevention. The use of percutaneous devices remains controversial due to concerns for complications. We sought to pool the published data to compare LAA closure vs warfarin.

COMPLETE VERSUS CULPRIT LESION REVASCULARIZATION DURING PRIMARY PERCUTANEOUS INTERVENTION (PCI) WITH ST-ELEVATION MYOCARDIAL INFARCTION (STEMI): A COMPREHENSIVE META-ANALYSIS OF RANDOMIZED CONTROL TRIALS

Patients with multi-vessel coronary artery disease (CAD) presenting with STEMI, generally undergo primary PCI, which is limited to treating the culprit lesion (CL) rather than complete revascularization (CR). The results from available randomized control trials (RCTs) are conflicting. We performed a