Dual antiplatelet therapy duration and stent type in patients with high bleeding risk: A systematic review and network meta-analysis.

BACKGROUND: It is uncertain whether the efficacy and safety of dual antiplatelet therapy (DAPT) in patients with high bleeding risk (HBR) vary according to DAPT duration and stent type (eg, durable polymer drug-eluting stents (DP-DESs), biodegradable polymer DESs (BP-DESs), or polymer-free drug-coated stents (PF-DCSs)). We aimed to study the stent type and DAPT duration appropriate for patients with HBR. METHODS: PubMed and EMBASE were searched until October 2023. Randomized controlled trials (RCTs) involving patients with HBR that compared standard DAPT (6-12 months) with DP- or BP-DES versus short DAPT (≤3 months) with DP- or BP-DES or PF-DCS or bare-metal stent (BMS) were identified. The primary efficacy outcome was major adverse cardiovascular events (MACEs), defined as cardiovascular death, myocardial infarction (MI), and stroke. The primary safety outcome was major bleeding. Secondary outcomes included MI and stent thrombosis (ST). We performed a network meta-analysis using a random effects model. RESULTS: Thirteen RCTs with a total of 19,418 patients with HBR were included. Compared to standard DAPT with DP-DES, short DAPT with BMS was associated with a higher risk of MACE and MI. For major bleeding, short DAPT strategies were associated with a lower risk than standard DAPT strategies (e.g. short DAPT with DP-DES vs standard DAPT with DP-DES; HR[95% CI]: 0.48[0.28-0.82]). Interestingly, the use of BP-DES was associated with a higher risk of ST than DP-DES (e.g. standard DAPT with BP-DES vs short DAPT with DP-DES; HR[95% CI]: 2.65[1.03-6.79]). CONCLUSIONS: In patients with HBR who underwent percutaneous coronary intervention, a short DAPT strategy with DP-DES should be used since it offers the best combination of efficacy and safety.

Systematic review and meta-analysis of the treatment strategies for coronary artery bypass graft patients with concomitant carotid artery atherosclerotic disease.

OBJECTIVE: Stroke is one of the devastating complications after coronary artery bypass graft (CABG). Underlying carotid artery atherosclerotic disease is reported to be an independent risk factor. The optimal treatment strategy for these patients remains under debate. METHODS: We aimed to perform a network meta-analysis to evaluate the safety and efficacy of additional carotid interventions for patients with concomitant carotid artery atherosclerotic disease who require CABG by comparing perioperative adverse event rates. All articles through February 2022 were searched using MEDLINE and EMBASE to identify studies that investigated outcomes of CABG only as well as additional staged vs combined carotid interventions by both carotid endarterectomy (CEA) and carotid artery stenting (CAS). RESULTS: Two randomized controlled trials and 23 observational studies were included, yielding a total of 32,473 patients who underwent combined CEA and CABG (n = 20,204), CEA and staged CABG (n = 6882), CABG and staged CEA (n = 340), CAS and CABG regardless of timing and sequences (n = 1224), and CABG only (n = 3823). No strategy showed a significant advantage over CABG only in all perioperative outcomes. CEA and staged CABG was associated with the lowest perioperative stroke/transient ischemic attack (TIA) rate, significantly lower compared with CAS and CABG (odds ratio [OR], 0.52; 95% confidence interval [CI], 0.36-0.76) as well as CABG and staged CEA (OR, 0.41; 95% CI, 0.23-0.74), but was also associated with the highest perioperative mortality (OR, 2.50; 95% CI, 1.67-3.85, vs CAS and CABG) and myocardial infarction rate (OR, 3.70 [95% CI, 1.16-12.5] and OR, 2.50 [95% CI, 1.35-4.55] vs CAS and CABG, vs combined CEA and CABG, respectively). CONCLUSIONS: CEA and staged CABG are associated with low perioperative stroke/transient ischemic attack rates with a tradeoff of higher mortality and myocardial infarction rate. No strategy showed a significant advantage over the CABG-only strategy in all perioperative outcomes, outlining the importance of a tailored approach and determining proper indications for carotid intervention in these patients.

Net clinical benefit of dual antiplatelet therapy in elderly patients with acute coronary syndrome: A systematic review and meta-analysis.

BACKGROUND: Contemporary dual antiplatelet therapy (DAPT) strategies, such as short-term DAPT or de-escalation of DAPT, have emerged as attractive strategies to treat patients with acute coronary syndrome (ACS). However, it remains uncertain whether they are suitable for elderly patients. METHODS: PubMed, Embase, and Cochrane CENTRAL databases were searched in September 2022. Randomized controlled trials (RCTs) investigating DAPT strategies, including standard (12 months), short-term, uniform de-escalation, and guided-selection strategies for elderly patients with ACS (age ≥ 65 years) were identified, and a network meta-analysis was conducted. The primary endpoint was the net clinical benefit outcome, a composite of major adverse cardiovascular events (MACEs: cardiovascular death, myocardial infarction, or stroke) and clinically relevant bleeding (equivalent to bleeding of at least type 2 according to the Bleeding Academic Research Consortium). The secondary outcomes were MACE and major bleeding. RESULTS: Sixteen RCTs with a combined total of 47,911 patients were included. The uniform de-escalation strategy was associated with an improved net clinical benefit compared with DAPT using potent P2Y12 inhibitors. The short-term DAPT strategy was associated with reduced risks of the primary outcome and major bleeding compared with DAPT using potent P2Y12 inhibitors, however, it was ranked as the least effective strategy for MACE compared with other DAPT strategies. CONCLUSIONS: Uniform de-escalation and short-term DAPT strategies may be advantageous for elderly patients, but need to be tailored based on individual bleeding and ischemic risks. Further RCTs of contemporary DAPT strategies specifically designed for elderly patients are warranted to confirm the findings of the present study.

Comparison of interventions for intermediate to high-risk pulmonary embolism: A network meta-analysis.

BACKGROUND: Multiple interventions, including catheter-directed therapy (CDT), systemic thrombolysis (ST), surgical embolectomy (SE), and therapeutic anticoagulation (AC) have been used to treat intermediate to high-risk pulmonary embolism (PE), but the most effective and safest treatment remains unclear. Our study aimed to investigate the efficacy and safety outcomes of each intervention. METHODS: We queried PubMed and EMBASE in January 2023 and performed a network meta-analysis of observational studies and randomized controlled trials (RCT), including high or intermediate-risk PE patients, and comparing AC, CDT, SE, and ST. The primary outcomes were in-hospital mortality and major bleeding. The secondary outcomes included long-term mortality (≥6 months), recurrent PE, minor bleeding, and intracranial hemorrhage. RESULTS: We identified 11 RCTs and 42 observational studies involving 157,454 patients. CDT was associated with lower in-hospital mortality than ST (odds ratio [OR] [95% confidence interval (CI)]: 0.41 [0.31-0.55]), AC (OR [95% CI]: 0.33 [0.20-0.53]), and SE (OR [95% CI]: 0.61 [0.39-0.96]). Recurrent PE in CDT was lower than ST (OR [95% CI]: 0.66 [0.50-0.87]), AC (OR [95% CI]: 0.36 [0.20-0.66]), and trended lower than SE (OR [95% CI]: 0.71 [0.40-1.26]). Notably, ST had higher major bleeding risks than CDT (OR [95% CI]: 1.51 [1.19-1.91]) and AC (OR [95% CI]: 2.21 [1.53-3.19]). By rankogram analysis, CDT presented the highest p-score in in-hospital mortality, long-term mortality, and recurrent PE. CONCLUSION: In this network meta-analysis of observational studies and RCTs involving patients with intermediate to high-risk PE, CDT was associated with improved mortality outcomes compared to other therapies, without significant additional bleeding risk.

Potent P2Y12 inhibitors versus Clopidogrel in elderly patients with acute coronary syndrome: Systematic review and meta-analysis.

BACKGROUND: Potent P2Y12 inhibitors reduce cardiovascular events but increase bleeding in patients presenting with acute coronary syndrome (ACS). Elderly patients are at increased risk of bleeding and whether the benefit-risk ratio of potent P2Y12 inhibitors remains favorable is not known. OBJECTIVES: To investigate the efficacy and safety of potent P2Y12 inhibitors versus clopidogrel in elderly patients with ACS. METHODS: PUBMED and EMBASE were searched through July 2020 for randomized control trials (RCTs) or subgroup analyses of RCTs investigating potent P2Y12 inhibitors (prasugrel or ticagrelor) or clopidogrel in elderly (age ≥ 65 years) patients with ACS. The primary outcome was major adverse cardiovascular events (MACE). RESULTS: Our search identified 9 RCTs with a total of 10,792 elderly patients. When compared with clopidogrel, potent P2Y12 inhibitors had similar risk of MACE (hazard ratio (HR): 0.94; 95%; confidence interval (CI) [0.85-1.06], P = .31, I2 = 9%), all-cause mortality (HR: 0.89; 95% CI [0.74-1.07], P = .22, I2 = 29%), reduced the risk of cardiovascular death (HR: 0.82; 95% CI [0.68-0.98], P = .03, I2 = 16%) but increased the risk of major bleeding (HR: 1.27; 95% CI [1.04-1.56], P = .02, I2 = 0%). In a subgroup analysis, ticagrelor reduced all-cause mortality (HR: 0.73; 95% CI [0.55-0.98]) and cardiovascular death (HR: 0.70; 95% CI [0.54-0.90]) compared with clopidogrel. CONCLUSIONS: Among elderly patients with ACS, potent P2Y12 inhibitors reduce cardiovascular death but increase bleeding with no difference in MACE or all-cause death when compared with clopidogrel. Further RCTs are needed to refine P2Y12 inhibitor selection for elderly patients with ACS.

Cardiovascular and renal outcomes with SGLT-2 inhibitors versus GLP-1 receptor agonists in patients with type 2 diabetes mellitus and chronic kidney disease: a systematic review and network meta-analysis.

BACKGROUND: Emerging evidence suggests that sodium-glucose cotransporter-2 (SGLT-2) inhibitors and glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are associated with decreased risk of cardiovascular and renal events in type 2 diabetes mellitus (DM) patients. However, no study to date has compared the effect of SGLT-2 inhibitors with that of GLP-1 RAs in type 2 DM patients with chronic kidney disease (CKD). We herein investigated the benefits of SGLT-2 inhibitors and GLP-1 RAs in CKD patients. METHODS: We performed a systematic literature search through November 2020. We selected randomized control trials that compared the risk of major adverse cardiovascular events (MACE) and a composite of renal outcomes. We performed a network meta-analysis to compare SGLT-2 inhibitors with GLP-1 RAs indirectly. Risk ratios (RRs) with corresponding 95% confidence intervals (CI) were synthesized. RESULTS: Thirteen studies were selected with a total of 32,949 patients. SGLT-2 inhibitors led to a risk reduction in MACE and renal events (RR [95% CI]; 0.85 [0.75-0.96] and 0.68 [0.59-0.78], respectively). However, GLP-1 RAs did not reduce the risk of cardiovascular or renal adverse events (RR 0.91 [0.80-1.04] and 0.86 [0.72-1.03], respectively). Compared to GLP-1 RAs, SGLT-2 inhibitors did not demonstrate a significant difference in MACE (RR 0.94 [0.78-1.12]), while SGLT-2 inhibitors were associated with a lower risk of renal events compared to GLP-1 RAs (RR 0.79 [0.63-0.99]). A sensitivity analysis revealed that GLP-1 analogues significantly decreased MACE when compared to placebo treatment (RR 0.81 [0.69-0.95]), while exendin-4 analogues did not (RR 1.03 [0.88-1.20]). CONCLUSIONS: In patients with type 2 DM and CKD, SGLT-2 inhibitors were associated with a decreased risk of cardiovascular and renal events, but GLP-1 RAs were not. SGLT-2 inhibitors significantly decreased the risk of renal events compared to GLP-1 RAs. Among GLP-1 RAs, GLP-1 analogues showed a positive impact on cardiovascular and renal outcomes, while exendin-4 analogues did not.

[The role of advance care planning and palliative care in new york city during COVID-19 pandemic].

New York City faced an explosive spread of Coronavirus disease 2019 (COVID-19), causing the city's death toll to spike owing to the high virulence of COVID-19. The health care system was on the verge of collapse. Advance care planning (ACP), informed assent, and palliative care played significant roles in supporting patient self-determination and dignity, facilitating decision making, and promoting better care. The importance of these strategies was revisited. Learning from the COVID-19 pandemic in New York City, it is anticipated that several approaches such as ACP and palliative intervention may attract more attention and become increasingly essential to the healthcare system in Japan.

Effect of renin-angiotensin system blockers on contrast-induced acute kidney injury in patients with normal or mild-to-moderate reduced kidney function undergoing coronary angiography: A systematic review and meta-analysis.

INTRODUCTION: Contrast-induced acute kidney injury (CI-AKI) is a major complication after coronary angiography (CAG) or percutaneous coronary intervention (PCI) and is associated with increased morbidity and mortality. It remains controversial whether renin-angiotensin system (RAS) blockers increase or decrease CI-AKI. In this meta-analysis, we investigated the association between RAS blockers and CI-AKI in patients with normal kidney function or mild-to-moderate chronic kidney disease (CKD). MATERIALS AND METHODS: We performed a systematic search of PubMed, EMBASE, clinicaltrials.gov, and the Cochrane Library up to December 2019 for studies that assessed the association between RAS blockers and CI-AKI events after CAG/PCI. The primary outcome was the development of CI-AKI. Odds ratios (ORs) with corresponding 95% confidence interval (CI) were synthesized. RESULTS: Five randomized controlled trials (RCTs) and five observational studies were included, accounting for a total of 7,420 patients. Unstratified, RAS blocker administration was significantly associated with an increased risk of CI-AKI (pooled OR = 1.63, 95% CI 1.19 - 2.25, p = 0.003). However, the effect was not observed in RCTs (pooled OR = 1.22, 95% CI 0.54 - 2.74, p = 0.63). Sensitivity analysis in observational studies showed significant association (pooled OR = 1.77, 95% CI 1.22 - 2.55, p = 0.003) with high heterogeneity and evidence of publication bias. CONCLUSION: In patients with relatively-preserved renal function, the association of RAS blockers with an increased risk of CI-AKI after contrast media exposure was inconclusive, as sensitivity analysis showed conflicting results and bias. Although this study did not demonstrate significant evidence, it indicated that clinicians need to be vigilant in assessing the potential risk for RAS blockers to cause CI-AKI in low-risk patients.

Late Survival Benefits of Concomitant Surgical Ablation for Atrial Fibrillation During Cardiac Surgery; A Systematic Review and Meta-Analysis.

Long-term survival benefits following surgical ablation for atrial fibrillation (AF) during cardiac surgery were not confirmed in previous randomized controlled trials or meta-analyses. This study aimed to investigate the long-term efficacy of surgical ablation in patients with AF. MEDLINE, EMBASE, and CENTRAL were searched to identify studies comparing concomitant surgical AF ablation with no surgical ablation during cardiac surgery. The primary outcome was long-term all-cause mortality. Secondary outcomes were stroke, heart failure rehospitalization, major bleeding, freedom from atrial fibrillation, and permanent pacemaker implantation during follow-up. To minimize confounding, only adjusted outcomes were used from observational studies. A total of 38 studies met the inclusion criteria. Of those, nine RCTs and 15 observational studies with 41,678 patients (surgical ablation, n = 19,125; no surgical ablation, n = 22,553) were analyzed for all-cause mortality, with a weighted median follow-up of 62.0 months. Surgical ablation was associated with decreased risks of long-term mortality (hazard ratio (HR): 0.78; 95% confidence interval (CI): 0.71 to 0.84), stroke (HR: 0.60; 95% CI: 0.48 to 0.76), heart failure rehospitalization (HR: 0.92; 95% CI: 0.87 to 0.96), and more freedom from AF during follow-up (relative risk: 1.93; 95% CI: 1.50 to 2.49), whereas surgical ablation was associated with a higher risk of permanent pacemaker implantation during follow-up (HR: 1.35; 95% CI: 1.03 to 1.77). There was no significant difference in major bleeding during follow-up between the two groups. In patients with AF undergoing cardiac surgery, surgical ablation was associated with decreased risks of long-term mortality, stroke, and heart failure rehospitalization than patients with untreated AF. Given that the survival benefits were predominantly observed in observational studies, further randomized trials are necessary to confirm these findings.

Comparing Anticoagulation Strategies for Venous Thromboembolism Associated With Active Cancer: A Systematic Review and Meta-Analysis.

Background: Current guidelines recommend several direct oral anticoagulant agents (DOACs) equally for managing cancer-associated venous thromboembolism (VTE). Objectives: The aim of this study was to assess the efficacy and safety of DOACs in patients with active cancer. Methods: Literature searches were conducted in PubMed, Embase, and Cochrane Central in November 2022. Randomized controlled trials investigating anticoagulation strategies (vitamin K antagonists, parenteral anticoagulation [eg, low-molecular weight heparin], and DOACs) for VTE in patients with active cancer were identified for network meta-analysis. The outcomes included recurrent VTE, recurrent pulmonary embolism, recurrent deep venous thrombosis, major bleeding, clinically relevant nonmajor bleeding (CRNMB), and a composite outcome of major bleeding or CRNMB. Pooled HRs and 95% CIs were estimated using either the HR or relative risk provided from each study. Random-effects models were used for all the analyses. Results: Seventeen randomized controlled trials involving 6,623 patients with active cancer were included. No significant differences were found among the DOACs for efficacy outcomes (recurrent VTE, pulmonary embolism, and deep venous thrombosis). In terms of major bleeding, apixaban was similarly safe compared with dabigatran and rivaroxaban but was associated with a decreased risk compared with edoxaban (HR: 0.38; 95% CI: 0.15-0.93). Regarding CRNMB, edoxaban was similarly safe compared with apixaban but was associated with a decreased risk compared with rivaroxaban (HR: 0.31; 95% CI: 0.10-0.91). Compared with parenteral anticoagulation, apixaban was associated with a reduced risk for recurrent VTE (HR: 0.60; 95% CI: 0.38-0.93) without increasing bleeding, edoxaban was associated with an increased risk for major bleeding or CRNMB (HR: 1.35; 95% CI: 1.02-1.79), and rivaroxaban was associated with an increased risk for CRNMB (HR: 3.76; 95% CI: 1.43-9.88). Conclusions: DOACs demonstrate comparable efficacy but exhibit different safety profiles. Apixaban may confer an antithrombotic benefit without an increased risk for bleeding, distinguishing it from other contemporary anticoagulation strategies in patients with active cancer and VTE.

Clinical outcomes of patients from older community hospitalized for heart failure in guideline-directed medical therapy era: Insights from the COMPASS-HF registry.

BACKGROUND: Despite strong recommendations in the latest guidelines for implementing guideline-directed medical therapy (GDMT) before discharge, there is a lack of data on the clinical characteristics and outcomes of older patients with heart failure (HF). Therefore, this study aimed to investigate the clinical characteristics and outcomes of patients with HF in a super-aging society during the GDMT era. METHODS AND RESULTS: In the COMPASS-HF study including 305 consecutive hospitalized patients, 177 with acute HF were identified through a medical record review. The mean age of the enrolled patients was 86.2 years, and 46.3 % were men. The mean simple GDMT score, which is recognized as a useful prognostic tool for Japanese patients with HF, was 5.0. The incidences of all-cause death and HF hospitalization were 46.5 % and 19.4 %, respectively. The incidences of all-cause death and cardiovascular death were significantly lower in the high simple GDMT score group (≥5 points) than in the low simple GDMT score group (≤4 points) (p = 0.049 and p = 0.044, respectively). However, no significant differences were noted in HF hospitalization and composite events (cardiovascular death and HF hospitalization) between the groups (p = 0.564 and p = 0.086, respectively). CONCLUSIONS: While GDMT was well-implemented in the older community, the mortality rate among hospitalized patients with HF remained high. Although GDMT appears to have reduced the HF hospitalization rate, further validation and development of an optimal predictive model for elderly patients with HF are essential. X (FORMERLY TWITTER): In the older community, although the short- and long-term mortality of hospitalized patients with HF is still high even in the GDMT era, the HF hospitalization rate is suppressed, probably due to GDMT. A simple GDMT score may also be useful for stratifying the prognosis of older patients with HF. #HeartFailure#Mortality#GDMT#Fantastic4.

Pseudoxanthoma Elasticum With Detailed Analyses of Coronary Artery Disease.

A 60-year-old woman with pseudoxanthoma elasticum (PXE) underwent thorough coronary artery disease assessments. Intravascular imaging tests suggested fragmented and calcified elastic fibers in the internal elastic lamina, suggesting a possible pathophysiology of coronary artery disease in PXE. Our case report would allow clinicians to acknowledge the clinical picture of PXE. (Level of Difficulty: Intermediate.).

P2Y12 Inhibitors for Non-ST-Segment Elevation Acute Coronary Syndrome: A Systematic Review and Network Meta-Analysis.

BACKGROUND: For patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS), prasugrel was recommended over ticagrelor in a recent randomized controlled trial, although more data are needed on the rationale. Here, the effects of P2Y12 inhibitors on ischemic and bleeding events in patients with NSTE-ACS were investigated. METHODS: Clinical trials that enrolled patients with NSTE-ACS were included, relevant data were extracted, and a network meta-analysis was performed. RESULTS: This study included 37,268 patients with NSTE-ACS from 11 studies. There was no significant difference between prasugrel and ticagrelor for any end point, although prasugrel had a higher likelihood of event reduction than ticagrelor for all end points except cardiovascular death. Compared with clopidogrel, prasugrel was associated with decreased risks of major adverse cardiovascular events (MACE) (hazard ratio [HR], 0.84; 95% CI, 0.71-0.99) and myocardial infarction (HR, 0.82; 95% CI, 0.68-0.99) but not an increased risk of major bleeding (HR, 1.30; 95% CI, 0.97-1.74). Similarly, compared with clopidogrel, ticagrelor was associated with a reduced risk of cardiovascular death (HR, 0.79; 95% CI, 0.66-0.94) and an increased risk of major bleeding (HR, 1.33; 95% CI, 1.00-1.77; P = .049). For the primary efficacy end point (MACE), prasugrel showed the highest likelihood of event reduction (P = .97) and was superior to ticagrelor (P = .29) and clopidogrel (P = .24). CONCLUSION: Prasugrel and ticagrelor had comparable risks for every end point, although prasugrel had the highest probability of being the best treatment for reducing the primary efficacy end point. This study highlights the need for further studies to investigate optimal P2Y12 inhibitor selection in patients with NSTE-ACS.

Selection of Vascular Closure Devices in Transcatheter Aortic Valve Replacement: Systematic Review and Network Meta-Analysis.

Various vascular closure devices (VCDs) are commonly used for percutaneous transcatheter aortic valve replacement (TAVR). However, superiority and safety profile among them remain unclear. We compared periprocedural complications among various VCDs in patients undergoing TAVR. PubMed and EMBASE were searched through January 2022 to identify clinical studies comparing any 2 VCDs of Prostar, Proglide and MANTA in patients who underwent TAVR. Studies using surgical cut-down or alternative access other than transfemoral approach were excluded. We analyzed the odds ratios (ORs) of vascular complications (VC), bleeding, acute kidney injury and all-cause mortality using a network meta-analysis. All outcomes were defined by Valve Academic Research Consortium 2 criteria. Two randomized controlled trials and 15 observational studies were identified, yielding a total of 11,344 patients including Prostar (n = 4499), Proglide (n = 5705), or MANTA group (n = 1140). The rates of major VC and life-threatening and major bleeding were significantly lower in Proglide compared to Prostar (OR [95 % CI] = 0.54 [0.32-0.89], 0.68 [0.52-0.90], and 0.49 [0.26-0.95], respectively). There was no significant difference in major VC and bleeding between Proglide and MANTA groups. Proglide was associated with a lower rate of acute kidney injury (0.56 [0.34-0.92]) and red blood cell transfusion (0.39 [0.16-0.98]) compared to Prostar. There was no significant difference in additional interventions and 30-day overall mortality among three groups. In this network meta-analysis of VCD in patients undergoing TAVR, MANTA and Proglide had comparable outcomes while Proglide appears superior to Prostar in terms of major VC and bleeding.

Systematic review and network meta-analysis of various nadir temperature strategies for hypothermic circulatory arrest for aortic arch surgery.

BACKGROUND: The optimal nadir temperature for hypothermic circulatory arrest during aortic arch surgery remains unclear. We aimed to assess and compare clinical outcomes of all three temperature strategies (deep, moderate, and mild hypothermia) using a network meta-analysis. METHODS: After literature search with MEDLINE and EMBASE through December 2021, studies comparing clinical outcomes with deep (<20°C), moderate (20-28°C), or mild (>28°C) hypothermic circulatory arrest were included. The outcomes of interest were perioperative mortality, stroke, transient ischemia attack (TIA), acute kidney injury (AKI), postoperative bleeding, operative time, and length of hospital stay. RESULTS: Twenty-four comparative studies were identified, including 6018 patients undergoing aortic arch surgery using hypothermic circulatory arrest (deep: 2,978, moderate: 2,525, and mild: 515). Compared to deep hypothermia, mild and moderate hypothermia were associated with lower mortality (mild vs. deep: odds ratio [OR] 0.50; 95% confidence interval (CI) 0.29-0.87, moderate vs. deep: OR 0.68; 95% CI 0.54-0.86). In addition, mild hypothermia was associated with lower stroke (OR 0.50; 95% CI 0.28-0.89), AKI (OR 0.36; 95% CI 0.15-0.88) and postoperative bleeding (OR 0.55; 95% CI 0.31-0.97) compared to deep hypothermia. There was no significant difference between mild and moderate hypothermia in mortality, AKI or bleeding occurrence, while mild hypothermia was associated with shorter operative time and hospital stay. There was no significant difference in TIA rate among three groups. CONCLUSIONS: Mild hypothermia was associated with overall more favorable clinical outcomes with comparable neurological complications compared to deep hypothermia. Furthermore, considering the shorter operative time and hospital stay compared with moderate hypothermia, mild hypothermia may be warranted when appropriate adjunctive cerebral perfusion is employed.

Ross Procedure Versus Mechanical Versus Bioprosthetic Aortic Valve Replacement: A Network Meta-Analysis.

Background The Ross operation appears to restore normal survival in young and middle-aged adults with aortic valve disease. However, there are limited data comparing it with conventional aortic valve replacement. Herein, we compared outcomes of the Ross procedure with mechanical and bioprosthetic aortic valve replacement (M-AVR and B-AVR, respectively). Methods and Results MEDLINE and EMBASE were searched through March 2022 to identify randomized controlled trials and propensity score-matched studies that investigated outcomes of patients aged ≥16 years undergoing the Ross procedure, M-AVR, or B-AVR. The systematic literature search identified 2 randomized controlled trials and 8 propensity score-matched studies involving a total of 4812 patients (Ross: n=1991; M-AVR: n=2019; and B-AVR: n=802). All-cause mortality was significantly lower in the Ross procedure group compared with M-AVR (hazard ratio [HR] [95% CI], 0.58 [0.35-0.97]; P=0.035) and B-AVR (HR [95% CI], 0.32 [0.18-0.59]; P<0.001) groups. The reintervention rate was lower after the Ross procedure and M-AVR compared with B-AVR, whereas it was higher after the Ross procedure compared with M-AVR. Major bleeding rate was lower after the Ross procedure compared with M-AVR. Long-term stroke rate was lower following the Ross procedure compared with M-AVR and B-AVR. The rate of endocarditis was also lower after the Ross procedure compared with B-AVR. Conclusions Improved long-term outcomes of the Ross procedure are demonstrated compared with conventional M-AVR and B-AVR options. These results highlight a need to enhance the recognition of the Ross procedure and revisit current guidelines on the optimal valve substitute for young and middle-aged patients.

Strategy of dual antiplatelet therapy for patients with ST-elevation myocardial infarction and non-ST-elevation acute coronary syndromes: A systematic review and network meta-analysis.

BACKGROUND: Various durations and de-escalation strategies of dual antiplatelet therapy (DAPT) after ST-elevation myocardial infarction (STEMI) or non-ST-elevation acute coronary syndromes (NSTE-ACS) have been tested in randomized controlled trials (RCT)s. However, evidence by specific ACS subtype is unknown. METHODS: PubMed, EMBASE, and Cochrane CENTRAL were searched in February 2023. RCTs on DAPT strategies included STEMI or NSTE-ACS patients with standard DAPT (12 months) with clopidogrel or potent P2Y12 inhibitors, short-term DAPT (≤6 months) followed by potent P2Y12 inhibitors or aspirin, unguided de-escalation from potent P2Y12 inhibitors to low-dose potent P2Y12 inhibitors or clopidogrel at one month, and guided selection with genotype or platelet function tests were identified. The primary outcome was the net adverse clinical events (NACE) defined as a composite of major adverse cardiovascular events (MACE) and clinically relevant bleeding events. RESULTS: Twenty RCTs with a combined total population of 24,745 STEMI and 37,891 NSTE-ACS patients were included. In STEMI patients, unguided de-escalation strategy was associated with a lower rate of NACE compared with standard DAPT using potent P2Y12 inhibitors (HR:0.57; 95% CI:0.34-0.96) without increased risk of MACE. In NSTE-ACS patients, unguided de-escalation strategy was associated with a lower rate of NACE compared with the guided selection strategy (HR:0.65; 95% CI:0.47-0.90), standard DAPT using potent P2Y12 inhibitors (HR:0.62; 95% CI:0.50-0.78) and standard DAPT using clopidogrel (HR:0.73; 95% CI:0.55-0.98) without increased risk of MACE. CONCLUSION: Unguided de-escalation strategy was associated with a reduced risk of NACE and may be the most effective DAPT strategy for STEMI and NSTE-ACS.

Short-Term DAPT and DAPT De-Escalation Strategies for Patients With Acute Coronary Syndromes: A Systematic Review and Network Meta-Analysis.

BACKGROUND: Short-term (≤6 months) dual antiplatelet therapy (DAPT) and DAPT de-escalation become attractive for patients with acute coronary syndrome. METHODS: A systemic search identified randomized controlled trials that included patients with acute coronary syndrome treated using (1) standard DAPT (12 months) with clopidogrel, prasugrel (standard/low dose), or ticagrelor; (2) extended DAPT (≥18 months); (3) short-term DAPT (≤6 months) followed by P2Y12 inhibitor or aspirin; (4) 12-month DAPT with unguided de-escalation from potent P2Y12 inhibitors to low-dose potent P2Y12 inhibitor or clopidogrel at 1 month; and (5) guided selection DAPT with genotype or platelet function tests. The primary efficacy outcome (major adverse cardiovascular events) was a composite of cardiovascular death, myocardial infarction, or stroke. The primary safety outcome was major or minor bleeding. RESULTS: This meta-analysis included 32 randomized controlled trials with 103 497 patients. While there were no differences in efficacy between short, unguided de-escalation and guided selection strategies, unguided de-escalation was associated with reduced risk of major adverse cardiovascular events compared with standard DAPT with clopidogrel or ticagrelor (hazard ratio [95% CI], 0.67 [0.49-0.93] and 0.68 [0.50-0.93]). Both short DAPT followed by P2Y12 inhibitor and unguided de-escalation were associated with reduced risks in safety compared with other strategies, including guided selection (hazard ratio [95% CI], 0.66 [0.47-0.93] and 0.48 [0.33-0.71]). Short DAPT followed by a P2Y12 inhibitor was associated with reduced risk of major bleeding and all-cause death compared with standard, extended DAPT (eg, versus DAPT with clopidogrel; hazard ratio [95% CI], 0.64 [0.42-0.97] and 0.60 [0.44-0.82]). By rankogram, unguided de-escalation strategy was the safest and most effective strategy in reducing major adverse cardiovascular events and major or minor bleeding while short DAPT followed by P2Y12 inhibitor was ranked the best for major bleeding and all-cause death. CONCLUSIONS: In patients with acute coronary syndrome, unguided de-escalation was associated with the lowest risk of major adverse cardiovascular events and major or minor bleeding outcomes, while short DAPT followed by P2Y12 inhibitor was associated with the lowest risk of major bleeding and all-cause death.

Prognostic value of right ventricular global longitudinal strain in patients with immunoglobulin light-chain cardiac amyloidosis.

Aims: Left ventricular (LV) global longitudinal strain (GLS) (LV-GLS) is a strong and independent predictor of outcomes in patients with immunoglobulin light-chain (AL) cardiac amyloidosis. This study was performed to investigate whether right ventricular (RV) GLS (RV-GLS) provides prognostic information in patients with AL amyloidosis. Methods and results: Among 74 patients who were diagnosed with AL cardiac amyloidosis at Kumamoto University Hospital from December 2005 to December 2022, 65 patients who had enough information for two-dimensional speckle tracking imaging and did not receive chemotherapy before the diagnosis of cardiac amyloidosis were retrospectively analysed. During a median follow-up of 359 days, 29 deaths occurred. In two-dimensional echocardiographic findings, LV-GLS, left atrium reservoir strain (LASr), and RV-GLS were significantly lower in the all-cause death group than in the survival group (LV-GLS: 8.9 ± 4.2 vs. 11.7 ± 3.9, P < 0.01; LASr: 9.06 ± 7.28 vs. 14.09 ± 8.32, P < 0.05; RV-GLS: 12.0 ± 5.1 vs. 16.8 ± 4.0, P < 0.01). Multivariable Cox proportional hazard analysis showed RV-GLS was significantly and independently associated with all-cause death in patients with AL cardiac amyloidosis (hazard ratio 0.85; 95% confidence interval, 0.77-0.94; P < 0.01). Receiver operating characteristic analysis showed that the area under the curve of RV-GLS for all-cause death was 0.774 and that the best cut-off value of RV-GLS was 14.5% (sensitivity, 75%; specificity, 72%). In the Kaplan-Meier analysis, patients with AL cardiac amyloidosis who had low RV-GLS (<14.5%) had a significantly higher probability of all-cause death (P < 0.01). Conclusion: RV-GLS has prognostic value in patients with AL cardiac amyloidosis and provides greater prognostic power than LV-GLS and LASr.

Revascularization strategies in patients with diabetes and stable ischemic heart disease: a systematic review and meta-analysis of randomized trials.

AIMS: The optimal treatment strategy comparing invasive revascularization versus optimal medical therapy (OMT) in patients with diabetes mellitus (DM) and stable ischemic heart disease (SIHD) still remains unclear. We aimed to investigate clinical outcomes of invasive revascularization (percutaneous coronary intervention, coronary artery bypass grafting or both) versus OMT in patients with DM and SIHD from updated published randomised-controlled trials (RCTs). METHODS: We conducted a comprehensive literature search through PubMed and EMBASE to investigate the effect of revascularization versus OMT for patients with DM and SIHD. The studies were limited to RCTs or their subgroup data for a meta-analysis. The outcomes of interest were major adverse cardiovascular events (MACE) in patients with DM and SIHD. RESULTS: Our search identified subgroup data with DM of four RCTs including a total of 5742 patients with SIHD. Our results showed that invasive revascularization was not associated with a decreased risk of MACE when compared to OMT [hazard ratio (95% confidence interval): 0.95 (0.85-1.05), P = 0.31; I2 = 0%]. CONCLUSION: Invasive revascularization was not associated with a decreased risk of MACE when compared with OMT.