Yasser Al-khadra

Transcatheter Closure of Patent Foramen Ovale versus Medical Therapy after Cryptogenic Stroke: A Meta-Analysis of Randomized Controlled Trials

Background: Patent foramen ovale (PFO) with atrial septal aneurysm is suggested as an important potential source for cryptogenic strokes. Percutaneous PFO closure to reduce the recurrence of stroke compared to medical therapy has been intensely debated. The aim of this study is to assess whether PFO closure in patients with cryptogenic stroke is safe and effective compared with medical therapy. Method: A search of PubMed, Medline, and Cochrane Central Register from January 2000 through September 2017 for randomized controlled trails (RCT), which compared PFO closure to medical therapy in patients with cryptogenic stroke was conducted. We used the items “PFO or patent foramen ovale”, “paradoxical embolism”, “PFO closure” and “stroke”. Data were pooled for the primary outcome measure using the random-effects model as pooled rate ratio (RR). The primary outcome was reduction in recurrent strokes. Result: Among 282 studies, 5 were selected. Our analysis included 3,440 patients (mean age 45 years, 55% men, mean follow-up 2.9 years), 1,829 in the PFO closure group and 1,611 in the medical therapy group. The I2 heterogeneity test was found to be 48%. A random effects model combining the results of the included studies demonstrated a statistically significant risk reduction in risk of recurrent stroke in the PFO closure group when compared with medical therapy (RR 0.42; 95% CI 0.20–0.91, p = 0.03). Conclusion: Pooled data from 5 large RCTs showed that PFO closure in patients with cryptogenic stroke is safe and effective intervention for prevention of stroke recurrence compared with medical therapy.

Early Repolarization Found on Routine Electrocardiograms: Risk and Management

Early repolarization (ER) pattern is a prominent J point (end-QRS notch or slur) with an elevation ≥0.1 mV in two or more contiguous leads (excluding V1-V3) in a 12-lead electrocardiogram (ECG). Furthermore, the QRS duration is required to be <120 ms (measured in leads in which J point elevation

Risk of Left Atrial Enlargement in Obese Patients With Obesity-Induced Hypoventilation Syndrome vs Obstructive Sleep Apnea

Background: Obstructive sleep apnea (OSA) is a known risk factor for atrial fibrillation (AF) that is principally driven by left atrial enlargement. The impact of hypoventilation caused by obesity-induced hypoventilation syndrome (OHS) on left atrial diameter has not been examined. We investigated the association between OHS and left atrial diameter in obese patients. Methods: We performed a retrospective review of 210 consecutive medical records of patients diagnosed as obese (body mass index [BMI] >30 kg/m2) and as having OHS and OSA for the period January 2010 through December 2016 at St. Vincent Charity Medical Center in Cleveland, OH. Logistic regression analysis was performed for left atrial diameter ≥4 cm in 2 groups of patients: those with OHS+OSA and those with OSA alone. Results: A total of 104 obese patients with OHS+OSA and 106 obese patients with OSA alone were identified. Statistically significant differences were found in 6 demographic and baseline characteristics: median BMI, median left atrial diameter, history of type 2 diabetes mellitus, history of stroke, history of coronary artery disease, and history of congestive heart failure. The median left atrial diameter for the OHS+OSA and OSA alone groups was 4.45 cm and 4.20 cm, respectively (P = 0.014). Left ventricular ejection fraction <50% was found in 22% of the patients with OHS+OSA and in 21% of the patients with OSA alone (P = 0.777). Multivariate logistic regression analysis showed that patients in the OHS+OSA group had 2 times higher odds (odds ratio 2.151, 95% confidence interval 1.016-4.550, P = 0.045) of exhibiting a larger left atrial diameter vs patients in the OSA alone group. Conclusion: The results of this study indicate that OHS may be an independent risk factor for left atrial enlargement and may possibly contribute to AF development irrespective of left ventricular function.

The impact of mitral stenosis on outcomes of aortic valve stenosis patient undergoing surgical aortic valve replacement or transcatheter aortic valve replacement

BACKGROUNDnThe concomitant presence of mitral stenosis (MS) in the setting of symptomatic aortic stenosis represent a clinical challenge. Little is known regarding the outcome of mitral stenosis (MS) patients undergoing transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR). Therefore, we sought to study the outcome of MS patients undergoing aortic valve replacement (AVR).nnnMETHODnUsing weighted data from the National Inpatient Sample (NIS) database between 2011 and 2014, we identified patients who were diagnosed with MS. Patients who had undergone TAVR as a primary procedure were identified and compared to patients who had SAVR. Univariate and multivariate logistic regression analysis were performed for the outcomes of in-hospital mortality, length of stay (LOS), blood transfusion, postprocedural hemorrhage, vascular, cardiac and respiratory complications, permanent pacemaker placement (PPM), postprocedural stroke, acute kidney injury (AKI), and discharge to an outside facility.nnnRESULTSnA total of 4524 patients were diagnosed with MS, of which 552 (12.2%) had TAVR and 3972 (87.8%) had SAVR. TAVR patients were older (79.9 vs 70.0) with more females (67.4% vs 60.0%) and African American patients (7.7% vs 7.1%) (Pu2009<u20090.001). In addition, the TAVR group had more comorbidities compared to SAVR in term of coronary artery disease (CAD), congestive heart failure (CHF), chronic lung disease, hypertension (HTN), chronic kidney disease (CKD), and peripheral vascular disease (PVD) (Pu2009<u20090.001 for all). Using Multivariate logistic regression, and after adjusting for potential risk factors, TAVR patients had lower in-hospital mortality (7.9% vs 8.1% adjusted Odds Ratio [aOR], 0.615; 95% confidence interval [CI], 0.392-0.964, Pu2009=u20090.034), shorter LOS. Also, TAVR patients had lower rates of cardiac and respiratory complications, PPM, AKI, and discharge to an outside facility compared with the SAVR group.nnnCONCLUSIONnIn patients with severe aortic stenosis and concomitant mitral stenosis, TAVR is a safe and attractive option for patients undergoing AVR with less complications compared with SAVR.

Ultrasound-guided versus palpation-guided radial artery catheterization in adult population: A systematic review and meta-analysis of randomized controlled trials

Background The radial artery (RA) is routinely used for both hemodynamic monitoring and for cardiac catheterization. Although cannulation of the RA is usually undertaken through manual palpation, ultrasound (US)‐guided access has been advocated as a mean to increase cannulation success rates and to lower RA complications; however, the published data are mixed. We sought to evaluate the impact of US‐guided RA access compared with palpation alone on first‐pass success to access RA. Methods and Results Meta‐analysis of 12 randomized controlled trials comparing US‐guided with palpation‐guided radial access in 2,432 adult participants was done. Hemodynamic monitoring was the most common reason for RA catheterization. Only 2 randomized controlled trials evaluated patients undergoing cardiac catheterization. Ultrasound‐guided radial access was associated with increased first‐attempt success rate (risk ratio [RR] 1.35, 95% CI 1.16‐1.57]) and decreased failure rate (RR 0.52, 95% CI 0.32‐0.87). There were no significant differences in the risk of hematoma (RR 0.43, 95% CI 0.27‐1.06), the mean time to first successful attempt (mean difference 25.13 seconds, 95% CI −1.06 to 51.34) or to any successful attempt (mean difference −4.74 seconds; 95% CI −22.67 to 13.18) between both groups. Conclusions Ultrasound‐guided technique for RA access has higher first‐attempt success and lower failure rate compared with palpation alone, with no significant differences in access site hematoma or time to a successful attempt. These findings support the routine use of US guidance for RA access.