Xiao-lin Luo

Sex-Related Differences in Outcomes After Transcatheter Aortic Valve Implantation A Systematic Review and Meta-analysis

Background—There were considerable discrepancies with regard to sex-related differences in complications and prognosis after transcatheter aortic valve implantation. Methods and Results—The Cochrane library and PubMed online databases were searched. Articles reporting sex-specific post–transcatheter aortic valve implantation complications and mortality were identified. Two authors selected studies and extracted data independently. Random- and fixed-effects models were used depending on between-study heterogeneity. There were 27 articles, a total of 9118 patients, enrolled in our systematic review and meta-analysis, including 4176 men and 4942 women. Pooled analyses suggested considerable sex-related differences in complications and early as well as midterm outcomes after transcatheter aortic valve implantation. The difference in the risk for heart block requiring permanent pacemaker implantation was noted to be significant only in the subgroup of the CoreValve-dominating studies (pooled risk ratio [RR, men versus women], 1.29; 95% confidence interval [CI], 1.13–1.47). Although men had significantly lower risks for major/life-threatening bleeding (pooled RR, 0.81; 95% CI, 0.68–0.96) and major vascular complications (pooled RR, 0.49; 95% CI, 0.37–0.66), they had poorer prognosis. In fact, male sex was associated with significantly higher risks for deaths at both 30 days (RR, 1.37; 95% CI, 1.07–1.76) and 1 year (RR, 1.30; 95% CI, 1.14–1.49). Conclusions—Although men had lower risks for major/life-threatening bleeding and major vascular complications after transcatheter aortic valve implantation, they had less favorable short-term and midterm survival.

Impact of Renal Dysfunction on Mid-Term Outcome after Transcatheter Aortic Valve Implantation: A Systematic Review and Meta-Analysis

Background There is conflicting evidence regarding the impact of preexisting renal dysfunction (RD) on mid-term outcomes after transcatheter aortic valve implantation (TAVI) in patients with symptomatic aortic stenosis (AS). Methods and results Forty-seven articles representing 32,131 patients with AS undergoing a TAVI procedure were included in this systematic review and meta-analysis. Pooled analyses were performed with both univariate and multivariate models, using a fixed or random effects method when appropriate. Compared with patients with normal renal function, mid-term mortality was significantly higher in patients with preexisting RD, as defined by the author (univariate hazard ratio [HR]: 1.69; 95% confidence interval [CI]: 1.50–1.90; multivariate HR: 1.47; 95% CI: 1.17–1.84), baseline estimated glomerular filtration rate (eGFR) (univariate HR: 1.65; 95% CI: 1.47–1.86; multivariate HR: 1.46; 95% CI: 1.24–1.71), and serum creatinine (univariate HR: 1.69; 95% CI: 1.48–1.92; multivariate HR: 1.65; 95% CI: 1.36–1.99). Advanced stage of chronic kidney disease (CKD stage 3–5) was strongly related to bleeding (univariate HR in CKD stage 3: 1.30, 95% CI: 1.13–1.49; in CKD stage 4: 1.30, 95% CI: 1.04–1.62), acute kidney injure (AKI) (univariate HR in CKD stage 3: 1.28, 95% CI: 1.03–1.59; in CKD stage 4: 2.27, 95% CI: 1.74–2.96), stroke (univariate HR in CKD stage 4: 3.37, 95% CI: 1.52–7.46), and mid-term mortality (univariate HR in CKD stage 3: 1.57, 95% CI: 1.26–1.95; in CKD stage 4: 2.77, 95% CI: 2.06–3.72; in CKD stage 5: 2.64, 95% CI: 1.91–3.65) compared with CKD stage 1+2. Patients with CKD stage 4 had a higher incidence of AKI (univariate HR: 1.70, 95% CI: 1.34–2.16) and all-cause death (univariate HR: 1.60, 95% CI: 1.28–1.99) compared with those with CKD stage 3. A per unit decrease in serum creatinine was also associated with a higher mortality at mid-term follow-up (univariate HR: 1.24, 95% CI: 1.18–1.30; multivariate HR: 1.19, 95% CI: 1.08–1.30). Conclusions Preexisting RD was associated with increased mid-term mortality after TAVI. Patients with CKD stage 4 had significantly higher incidences of peri-procedural complications and a poorer prognosis, a finding that should be factored into the clinical decision-making process regarding these patients.

The impact of smoking on clinical efficacy and pharmacodynamic effects of clopidogrel: a systematic review and meta-analysis

Context Previous findings regarding the relationship between smoking and clopidogrel effects were considerably discrepant. Objective To assess the impact of smoking on clinical and pharmacodynamic response to clopidogrel. Data sources Medline, EMBASE and the Cochrane Library through January 2013 were searched. Reference lists of pertinent literatures and abstracts of major cardiovascular conferences were screened. Study selection Clinical and laboratory studies, which reported major adverse cardiovascular events and on-clopidogrel platelet reactivity categorised by smoking status respectively, were selected. Data extraction Descriptive and quantitative data were extracted. The main analyses were performed under a random-effects model. For clinical studies, HR estimates were synthesised according to smoking status; for laboratory studies, standardised mean difference (SMD) of on-clopidogrel platelet reactivity and OR for high on-clopidogrel platelet reactivity were pooled. Heterogeneity was quantified by computing I2 statistic. Results Of the 1869 citations retrieved, seven clinical studies and 12 laboratory studies involving 111 132 patients with established cardiovascular disease and 6658 patients with acute coronary syndrome and/or stent deployment, respectively, were included for meta-analysis. Pooled clinical results showed that an intensified antiplatelet regimen involving clopidogrel was associated with 10% reduced risk for major adverse cardiovascular events among non-current smokers (HR 0.90; 95% CI 0.85 to 0.96), while this clinical benefit was enhanced by 2.9-fold among current smokers (HR 0.71; 95% CI 0.62 to 0.80). Pooled analysis of laboratory studies revealed that current smokers had significantly lower on-clopidogrel platelet reactivity (SMD −0.30; 95% CI −0.46 to −0.15) but, notably, there was considerable inter-study heterogeneity (I2 76.2%; p=0.000). The analysis based on four studies (n=1423) suggested a significantly lower odds of high on-clopidogrel platelet reactivity among current smokers than those among never smokers (OR 0.33; 95% CI 0.22 to 0.43). Conclusions Smoking appears to positively modify the relative clinical efficacy and pharmacodynamic effects of clopidogrel.

Subclassification of left ventricular hypertrophy based on dilation stratifies coronary artery disease patients with distinct risk.

A new 4‐tired classification of left ventricular hypertrophy (LVH) based on LV concentricity and dilation has been proposed; however, the association between the new categorization of LV geometry and outcomes in patients with coronary artery disease (CAD) is still unknown.

Heparin is Not Inferior to Bivalirudin in Percutaneous Coronary Intervention—Focusing on the Effect of Glycoprotein IIb/IIIa Inhibitor Use A Meta-Analysis

Our aim was to compare the efficacy and safety of bivalirudin (Biv) versus heparin (Hep) with or without similar usage rate of glycoprotein IIb/IIIa inhibitors (GPIs) during percutaneous coronary intervention (PCI). The PubMed and EMbase were searched. Randomized trials comparing Biv versus Hep were eligible for inclusion. With imbalanced GPI use, Biv had significantly lower major bleeding (pooled risk ratio [RR], 0.67; 95% confidence interval [CI], 0.54-0.83) without difference in mortality (pooled RR, 0.95; 95% CI, 0.80-1.14). With comparable GPI use, no significant difference was observed in major bleeding (pooled RR, 0.95; 95% CI, 0.82-1.10) and mortality (pooled RR, 1.13; 95% CI, 0.85-1.50). With no GPI use, Biv was associated with numerically higher mortality (pooled RR, 1.17; 95% CI, 0.83-1.65) without significant difference in major bleeding (pooled RR, 0.81; 95% CI, 0.64-1.02). In conclusion, when comparing different anticoagulants during PCI, the effect of GPIs should not be underestimated. Heparin as such was found noninferior to Biv.

Percutaneous coronary intervention compared with coronary artery bypass graft in coronary artery disease patients with chronic kidney disease: a systematic review and meta-analysis

Abstract Previous reports of percutaneous coronary intervention versus coronary artery bypass graft outcomes in coronary artery disease patients with chronic kidney disease (CKD) were inconsistent. We evaluated the optimal revascularization strategy for CKD patients. We searched Pub Med, EMBASE, and the Cochrane Central Register of Controlled Trials and scanned the references of relevant articles and reviews. All studies that compared relevant clinical outcomes between percutaneous coronary intervention and coronary artery bypass graft in CKD patients were selected. We defined short-term and long-term all-cause mortality as primary outcome, and long-term incidences of myocardial infarction and revascularization as secondary outcomes. A total of 2235 citations were retrieved, and 31 studies involving 99,054 patients, with 55,383 receiving percutaneous coronary intervention and 43,671 receiving coronary artery bypass graft, were included. In subgroup analyses of dialysis patients receiving percutaneous coronary intervention with stents versus coronary artery bypass graft, CKD patients with multivessel coronary disease, and CKD patients receiving drug-eluting stent versus coronary artery bypass graft, the pooled outcomes revealed that percutaneous coronary intervention possessed lower short-term mortality, but higher late revascularization risk. No significant differences in long-term mortality were observed between the two strategies in these subgroup analyses. In conclusion, in some specific clinical circumstances, CKD patients receiving percutaneous coronary intervention possessed lower short-term all-cause mortality, but higher long-term revascularization risk, than coronary artery bypass graft; long-term all-cause mortality was not different between the two strategies.

Inappropriate left ventricular mass and poor outcomes in patients with angina pectoris and normal ejection fraction.

Objectives Although inappropriate left ventricular mass has been associated with clustered cardiac geometric and functional abnormalities, its predictive value in patients with coronary artery disease is still unknown. This study examined the association of inappropriate left ventricular mass with clinical outcomes in patients with angina pectoris and normal ejection fraction. Participants and methods Consecutive patients diagnosed with angina pectoris whose ejection fraction was normal were recruited from 2008 to 2012. Inappropriate left ventricular mass was determined when the ratio of actual left ventricular mass to the predicted one exceeded 150%. The primary endpoint was a composite of all-cause death, nonfatal myocardial infarction, and nonfatal stroke. Clinical outcomes between the inappropriate and appropriate left ventricular mass group were compared before and after propensity matching. Results Of the total of 1515 participants, 18.3% had inappropriate left ventricular mass. Patients with inappropriate left ventricular mass had a higher composite event rate compared with those with appropriate left ventricular mass (11.2 vs. 6.6%, P=0.010). Multivariate Cox regression analyses showed that inappropriate left ventricular mass was an independent risk factor for adverse events (adjusted hazard ratio, 1.59; 95% confidence interval, 1.03–2.45; P=0.035). The worse outcome in patients with inappropriate left ventricular mass was further validated in a propensity matching cohort and patients with the traditional definition of left ventricular hypertrophy. Conclusion Inappropriate left ventricular mass was associated with an increased risk of adverse events in patients with angina pectoris and normal ejection fraction.

Percutaneous retrieval of a PICC fragment adherent to vascular wall 6 years after fracture

Considering that the deterioration of tricuspid regurgitation was caused by a fragment that lead to symptoms of dyspnea and fatigue, we prepared to retrieve the fragment. We punctured the two-side femoral vein and inserted 10F and 6F catheters into right and left side separately. We used the “trap method” to retrieve the fragment, that means we placed a 20 mm loop snare in the inferior vena cava beforehand, then passed the pigtail catheter through the snare to hook the fragment into the snare, and finally used the snare to grasp the fragment (Fig. 2A). However, we found that the fragment was adherent to the wall of inferior vena cava and could not be retrieved outside totally. We used another 5F guiding catheter to advance the fragment outside to dissect the adherent fragment from the wall of vein. This is called “catheter decollement” strategy (Fig. 2B). Finally, the fragment of catheter was successfully removed. Post-procedure inferior vena cava venography revealed no residual fragment or rupture/dissection of the inferior vena cava (Fig. 2C). After removal, we measured the polyurethane fragment, DOI: 10.5301/jva.5000546

Renal insufficiency and mortality in coronary artery disease with reduced ejection fraction.

BACKGROUND Despite strong evidence linking decreased estimated glomerular filtration rate (eGFR) to worse cardiovascular outcome, the impact of eGFR on mortality in coronary artery disease (CAD) patients with different left ventricular ejection fraction (EF) is not well defined. METHODS A retrospective cohort study. From Jul. 2008 to Jan. 2012, consecutive patients with CAD of West China Hospital were enrolled and were grouped into 3 eGFR categories: ≥90, 60-90, and <60mL/min/1.73m(2). Patients with EF≥50% or <50% were defined as preserved EF or reduced EF, respectively. The endpoints were all-cause mortality and cardiac mortality. RESULTS There are 2161 patients according to the inclusion criteria and follow-up requirement. The mean follow-up time was 30.97±11.70months. Cumulative survival curves showed that in patients with reduced EF, renal insufficiency significantly increases all-cause mortality and cardiovascular mortality in a graded fashion (mortality rate, moderate or severe vs. normal: 29.3% vs. 5.4%, p<0.001; cardiac mortality rate, moderate or severe vs. normal: 18.2% vs. 4.5%, p=0.001, respectively). Cox regression analysis showed that in CAD patients with reduced EF, moderate to severe renal insufficiency increased all-cause mortality by 6.10-fold (HR 6.10, 95% CI 2.50 to 14.87) and cardiac mortality by 4.10-fold (HR 4.10, 95% CI 1.51 to 11.13). Use of beta-blockers, angiotensin converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs), and statins was associated with decreased risk of mortality, but the use was lower in renal insufficiency patients, especially in combination of reduced EF. CONCLUSION This study has found that the effect of renal function on prognosis in patients with CAD is closely related to cardiac function. In patients with reduced EF, renal insufficiency accompanies the higher risks of all-cause mortality and cardiovascular mortality. A higher number of treatments from beta-blocker, ACEIs or ARBs, and statin therapy were associated with decreased risk of mortality, even in the combination of renal insufficiency or declining cardiac function.

Efficacy of transcatheter aortic valve implantation in patients with aortic stenosis and reduced LVEF. A systematic review.

BackgroundTranscatheter aortic valve implantation (TAVI) is safe and effective for patients with aortic stenosis (AS) who have a high operative risk. However, there is still debate on the effect of TAVI in AS patients with reduced left ventricular ejection fraction (REF). The objective of the review is to clarify the efficacy of TAVI and the impact of REF on the 30-day and midterm mortality in these patients.MethodsStudies on TAVI were searched in PubMed, Embase, and the Cochrane Library databases and were included in this review following predefined criteria. Data were extracted and pooled risk ratios (RR) were synthesized to explore the relationship between REF and 30-day plus midterm mortality.ResultsTwenty-eight studies comprising 14,099 patients were included in the analysis of the association of REF with the prognosis of patients after TAVI. An average increase in left ventricular ejection fraction of 8–10 % was observed among these patients after TAVI. REF was not related to the 30-day mortality [RR = 1.90, 95 % confidence interval (CI) = 0.80–4.47]; however, it was related to the midterm mortality (RR = 1.49, 95 %CI = 1.14–1.93) of patients undergoing TAVI. Patients with low-flow and low-gradient AS had a higher 30-day mortality (RR = 1.54, 95 %CI = 1.11–2.13) and midterm mortality rate (RR = 1.69, 95 %CI = 1.33–2.14) compared with AS patients without these characteristics. The mortality of TAVI patients was significantly lower than that of those undergoing conservative therapy, and was similar to that of patients undergoing surgical aortic valve replacement.ConclusionREF was not associated with 30-day mortality, but it was associated with the midterm mortality of TAVI patients. Patients with REF could benefit from TAVI compared with conservative therapy.ZusammenfassungHintergrundDie Transkatheter-Aortenklappenimplantation (TAVI) ist sicher und wirksam bei Patienten mit Aortenstenose (AS) und hohem Operationsrisiko. Jedoch ist die Wirksamkeit der TAVI bei AS-Patienten mit verminderter linksventrikulärer Ejektionsfraktion (LVEF) umstritten. Ziel der vorliegenden Übersicht war es, die Wirksamkeit der TAVI und die Auswirkungen einer verminderten LVEF auf die 30-Tage- und mittelfristige Mortalität bei diesen Patienten zu klären, MethodenEs wurde nach Studien zur TAVI in den Datenbanken PubMed, Embase und Cochrane Library gesucht. Diese Studien wurden nach vorher festgelegten Kriterien in die Auswertung einbezogen. Die Daten wurden extrahiert und die gepoolten relativen Risiken ermittelt, um die Beziehung zwischen einer verminderten LVEF und der 30-Tage- bzw. der mittelfristigen Mortalität zu untersuchen.ErgebnisseEs wurden 28 Studien mit 14.099 Patienten in die Auswertung eingeschlossen, um den Zusammenhang zwischen einer verminderten LVEF und der Prognose von Patienten nach TAVI zu ermitteln. Ein durchschnittlicher Anstieg von 8–10 % des LVEF wurde bei diesen Patienten nach TAVI festgestellt. Eine verminderte LVEF war nicht mit der 30-Tage-Mortalität assoziiert [RR = 1,90; 95 %-Konfidenzintervall (CI): 0,80–4,47], jedoch mit der mittelfristigen Mortalität (RR = 1,49; 95 %-KI: 1,14–1,93) der Patienten, bei denen eine TAVI erfolgte. Patienten mit niedrigem Fluss und niedrigem Gradienten der AS wiesen im Vergleich zu AS-Patienten ohne diese Merkmale eine höhere 30-Tage- (RR = 1,54; 95 %-KI: 1,11–2,13) und mittelfristige Mortalität auf (RR = 1,69; 95 %-KI: 1,33–2,14). Die Mortalität der TAVI-Patienten war deutlich niedriger als bei konservativer Therapie und ähnlich wie bei einer Aortenklappenersatzoperation.SchlussfolgerungEine verminderte LVEF war nicht mit der 30-Tage-Mortalität, aber mit der mittelfristigen Mortalität von TAVI-Patienten assoziiert. Patienten mit verminderter LVEF konnten gegenüber der konservativen Therapie von der TAVI profitieren.