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.

Prevalence of Neurovascular Microemboli After Transcatheter Aortic Valve Replacement.

Background: Neurolotic sequelae after transcatheter aortic valve replacement (TAVR) can cause significant morbidity and mortality. Transcranial Doppler (TCD) imaging can show real-time high intensity transient signals (HITS), which reflect active microembolization. Although it is well known that intraprocedural microembolism occurs, it is not known if this embolic phenomenon continues in the postprocedural period. We investigated whether microemboli occur post-TAVR and whether we could determine any clinical, procedural, or echocardiographic predictors. Methods: We evaluated HITS in 51 consecutive patients undergoing unprotected TAVR with low-, intermediate-, or high-risk Society of Thoracic Surgeons score. Patients were excluded if they did not have temporal windows for insonation of the middle cerebral artery or if they were not willing to participate. Primary outcomes of HITS 24 hours post-TAVR were observed using a Philips iU22 TCD. TCD was performed at 3 time points (pre-, peri-, and post-TAVR) for each patient, before, during, and 24 hours postprocedure. Results: While no HITS were detected in any of the patients preoperatively, all patients had HITS during the procedure. Interestingly, 56.8% had HITS 24 hours post-TAVR. One patient with HITS post-TAVR had a stroke 48 hours after TAVR. Conclusion: We observed a high prevalence of microemboli 24 hours post-TAVR. None of the predictors for intraprocedural microembolism seemed to play an important role for post-TAVR microemboli.

Procedural Feasibility and Peri-procedural Outcomes of Peripheral Endovascular Therapy via Transradial versus Transfemoral Access: A Systematic Review and Meta-Analysis.

OBJECTIVE: This systematic review and meta-analysis aimed to evaluate the safety and feasibility of transradial access for peripheral vascular interventions. DATA SOURCES: MEDLINE and Embase. REVIEW METHODS: MEDLINE and Embase databases were searched to June 2023 to identify studies investigating the outcomes of lower extremity, carotid, and visceral artery vascular interventions via transradial vs. transfemoral access. The primary outcome was procedural failure rate. Secondary outcomes were total access site complications, minor and major bleeding, stroke, access vessel occlusion, procedure time, fluoroscopy time, and contrast volume. RESULTS: Eight randomised controlled trials and 29 observational studies yielded a total of 70 882 patients treated via transradial (n = 2 616) vs. transfemoral access (n = 68 338). The overall failure rate was 2.3 ± 0.7%, and the transradial approach was associated with a statistically significantly higher procedural failure rate than the transfemoral approach (3.9 ± 0.7% vs. 1.0 ± 0.3%; odds ratio [OR] 3.07, 95% confidence interval [CI] 1.84 - 5.12; I2 = 32%; p < .001). Subgroup analysis showed the highest failure rate in lower extremity interventions with 12.4 ± 4.9% for transradial vs. 4.0 ± 1.2% for transfemoral access. Conversely, procedural complications were statistically significantly fewer with transradial access for total access site complications (OR 0.64, 95% CI 0.45 - 0.91; I2 = 36%; p = .010). Minor bleeding was statistically significantly less with the transradial approach (OR 0.52, 95% CI 0.31 - 0.86; I2 = 30%; p = .010), whereas major bleeding and stroke rates were similar. Transradial access had more access vessel occlusion than transfemoral access (1.9% ± 0.5% vs. < 0.1% ± 0.0%; p = .004), although most remained asymptomatic. Procedure time, fluoroscopy time, and contrast volume were all comparable. GRADE certainty was low to moderate in most outcomes. CONCLUSION: The transradial approach was associated with a higher procedural failure rate. Total access site complications and minor bleeding were lower with the transradial approach, albeit with more frequent access vessel occlusion. Transradial access may be a feasible and safe approach; however, appropriate patient selection is imperative.

Aortic Stenosis Management in Patients With Acute Hip Fracture.

The treatment of severe aortic stenosis (SAS) has evolved rapidly with the advent of minimally invasive structural heart interventions. Transcatheter aortic valve replacement has allowed patients to undergo definitive SAS treatment achieving faster recovery rates compared to valve surgery. Not infrequently, patients are admitted/diagnosed with SAS after a fall associated with a hip fracture (HFx). While urgent orthopedic surgery is key to reduce disability and mortality, untreated SAS increases the perioperative risk and precludes physical recovery. There is no consensus on what the best strategy is either hip correction under hemodynamic monitoring followed by valve replacement or preoperative balloon aortic valvuloplasty to allow HFx surgery followed by valve replacement. However, preoperative minimalist transcatheter aortic valve replacement may represent an attractive strategy for selected patients. We provide a management pathway that emphasizes an early multidisciplinary approach to optimize time for hip surgery to improve orthopedic and cardiovascular outcomes in patients presenting with HFx-SAS.

Safety of ultra-low contrast coronary angiography in patients with acute kidney injury.

BACKGROUND: Ultra-low contrast administration during coronary angiography has been previously shown to be feasible and safe among patients with stable chronic kidney disease. In the present study, we investigate the safety of ultra-low contrast coronary angiography in patients with pre-existing acute kidney injury (AKI). METHODS: The study was a retrospective single-center evaluation of hospitalized patients who had AKI and required coronary angiography. Ultra-low contrast use was defined as ≤18 mL of contrast media. RESULTS: The cohort consisted of a case series of eight inpatients with AKI who required coronary angiography. The mean age was 57 (±16) years and half were females. All patients had chronic kidney disease with a mean baseline estimated glomerular filtration rate of 34 (±17) mL/min/1.73 m2. The mean creatinine before angiography was 3 (±1) mg/dL and volume of contrast administered was 14 (±4) mL. One patient had a 0.1 mg/dL increase in creatinine during admission, and no patients had further AKI up to 1-week postprocedure. CONCLUSIONS: The current data suggest that ultra-low contrast coronary angiography can be safely performed in patients with pre-existing AKI The study should be viewed as hypothesis-generating due to its small sample size. A larger cohort is required to validate the results.

Outcomes for Patients With Chronic Limb-Threatening Ischemia After Direct and Indirect Endovascular and Surgical Revascularization: A Meta-Analysis and Systematic Review.

PURPOSE: The purpose of this review and meta-analysis is to determine the clinical outcome differences between patients with chronic limb-threatening ischemia who underwent direct versus indirect angiosome revascularization using either the surgical or endovascular approach. MATERIALS AND METHODS: The data sources used for article selection included PubMed, Embase/Medline, Cochrane reviews, and Web of Science (All studies were in English and included up to September 2023). All articles included were comparative in design, including retrospective, prospective, and randomized controlled trials that compared the clinical outcomes between direct and indirect angiosome-guided revascularization in chronic limb-threatening ischemia. A random-effects model was used to determine the measure of association between direct revascularization and amputation-free survival, wound healing, and overall survival. Publication bias was assessed with both Begg's and Egger's test, and heterogeneity was calculated using an I2. RESULTS: Data from 9 articles were analyzed and reported in this review. Direct revascularization was associated with improved amputation-free survival (odds ratio [OR]=2.632, confidence interval [CI]: 1.625, 4.265), binary wound healing (OR=2.262, CI: 1.518, 3.372), and overall survival (OR=1.757, CI: 1.176, 2.625). Time until wound healed was not associated with either direct or indirect revascularization (Standard Mean Difference [SMD]=-2.15, p=0.11). There was a low risk of bias across all studies according to the RoB 2.0 tool. CONCLUSION: Direct revascularization is associated with improved amputation-free survival, overall survival, and wound healing in chronic limb-threatening ischemic patients compared to the indirect approach. CLINICAL IMPACT: Preservation of the lower extremity is critical for preventing mortality and maintaining independence. The benefit of angiosome-guided revascularization for chronic limb-threatening ischemia remains controversial. The authors of this article aim to review the current literature and compare direct and indirect angiosome-guided intervention for preserving the lower extremity. Current findings suggest direct angiosome-guided intervention reduces amputation rates and improves survival; however, many trials neglect to address the multifactorial approach needed in wound care management.

Antithrombotic Therapy for Patients Undergoing Cardiac Electrophysiological and Interventional Procedures: JACC State-of-the-Art Review.

Electrophysiological and interventional procedures have been increasingly used to reduce morbidity and mortality in patients experiencing cardiovascular diseases. Although antithrombotic therapies are critical to reduce the risk of stroke or other thromboembolic events, they can nonetheless increase the bleeding hazard. This is even more true in an aging population undergoing cardiac procedures in which the combination of oral anticoagulants and antiplatelet therapies would further increase the hemorrhagic risk. Hence, the timing, dose, and combination of antithrombotic therapies should be carefully chosen in each case. However, the maze of society guidelines and consensus documents published so far have progressively led to a hazier scenario in this setting. Aim of this review is to provide-in a single document-a quick, evidenced-based practical summary of the antithrombotic approaches used in different cardiac electrophysiology and interventional procedures to guide the busy clinician and the cardiac proceduralist in their everyday practice.

Impact of VA-ECMO on Dynamic LV Outflow Obstruction After Transcatheter Aortic Valve Replacement.

Dynamic left ventricular outflow obstruction is a rare but severe complication of transcatheter aortic valve replacement. It presents as a paradoxical hemodynamic collapse after relieving the left ventricular afterload. Considering its unique pathophysiology, this entity dictates counterintuitive treatments. We describe a case of left ventricular outflow obstruction treated with venoarterial extracorporeal membrane oxygenation and discuss its management principles.

The mid-term effect of intravascular ultrasound on endovascular interventions for lower extremity peripheral arterial disease: A systematic review and meta-analysis.

OBJECTIVE: Intravascular ultrasound (IVUS) is an important adjunctive tool for patients with lower extremity peripheral arterial disease (PAD) undergoing endovascular therapy (EVT). The evidence regarding the advantages of IVUS use is evolving, and recent studies have reported conflicting results. We aimed to perform a meta-analysis to evaluate the efficacy of IVUS during angiography-guided EVT for patients with PAD. METHODS: MEDLINE and EMBASE were searched through April 2023 to identify studies that investigated the outcomes of IVUS with angiography-guided EVT vs angiography-alone-guided EVT. The primary outcome was restenosis/occlusion rate; secondary outcomes were target lesion revascularization, major amputation, and mortality. RESULTS: One randomized controlled trial and 14 observational studies, largely of moderate quality, were included, yielding a total of 708,808 patients with 709,189 lesions that were treated with IVUS-guided EVT (n = 101,405) vs angiography-alone (n = 607,784). Compared with angiography alone, IVUS-guided EVT was associated with a non-significant trend towards decreased restenosis/occlusion (relative risk [RR], 0.74; 95% confidence interval [CI], 0.54-1.00; I2 = 60%). Although the risk of target lesion revascularization and mortality were comparable (RR, 0.85; 95% CI, 0.65-1.10; I2 = 70%; RR, 1.01; 95% CI, 0.79-1.28; I2 = 43%, respectively), the use of IVUS was also associated with significantly lower risk of major amputation (RR, 0.74; 95% CI, 0.67-0.82; I2 = 47%). Subgroup analysis focusing on femoropopliteal disease demonstrated significantly higher patency (RR, 0.72; 95% CI, 0.52-0.98; I2 = 73%). However, superiority with major amputation was not observed. CONCLUSIONS: IVUS-guided EVT for PAD may possibly be associated with a lower major amputation rate compared with angiography alone-guided EVT, although the difference in patency remained an insignificant trend in favor of IVUS-guided EVT. Adjunctive use of IVUS during EVT may be beneficial, and further prospective studies are warranted to delineate this relationship and the applicability of this technology in routine practice.

A multidisciplinary approach for a patient with cardiogenic shock from pulmonary embolism with concomitant impending clot in transit trapped in PFO.

Impending paradoxical embolism (IPDE) is a right heart thrombus (RHT), in times of elevated pulmonary arterial pressure, that is trapped in a patent foramen ovale (PFO) Myers et al. (2010) (3). We present a case that highlights our multidisciplinary approach in a patient with IPDE with cardiogenic shock from pulmonary embolism (PE).

Comparison among various physiology and angiography-guided strategies for deferring percutaneous coronary intervention: A network meta-analysis.

BACKGROUND/PURPOSE: It is unclear whether coronary physiology or coronary angiography (CA)-guided strategy is the more preferable approach for deferring percutaneous coronary intervention (PCI). We sought to evaluate the clinical efficacy of various PCI strategies through a network meta-analysis of randomized controlled trials (RCTs). METHODS/MATERIALS: We searched multiple databases for RCTs investigating the impact of the following strategies for the purpose of determining whether or not to defer PCI: fractional flow reserve, instantaneous wave-free ratio, quantitative flow ratio (QFR), and CA. We conducted a network meta-analysis for trial-defined major adverse cardiovascular events (MACE), all-cause death, cardiovascular death, myocardial infarction (MI), target lesion revascularization (TLR), and stent thrombosis. We performed a subgroup analysis for those with acute coronary syndrome (ACS). RESULTS: Our search identified 12 eligible RCTs including a total of 13,177 patients. QFR-guided PCI was associated with reduced MACE, MI, and TLR compared with CA-guided PCI (relative risk (RR) 0.68; 95 % confidence interval (CI] [0.49 to 0.94], RR 0.58; 95 % CI [0.36 to 0.96], and RR 0.58; 95 % CI [0.38 to 0.91], respectively). There were no significant differences in any pairs for all-cause death, cardiovascular death, or stent thrombosis. QFR was ranked the best in most outcomes. In the subgroup analysis of the ACS cohort, there were no significant differences in MACE between any comparisons. CONCLUSIONS: QFR was associated with reduced MACE, MI, and TLR compared with CA, and ranked the best in most outcomes. However, this was not applied in the ACS cohort.

Comparison of Clinical Outcomes Among Various Percutaneous Coronary Intervention Strategies for Small Coronary Artery Disease.

It remains unclear which percutaneous coronary intervention (PCI) strategy is the most preferable in patients with small-vessel coronary artery disease (CAD). We sought to evaluate the clinical efficacy of various PCI strategies for patients with small-vessel CAD through a network meta-analysis of randomized controlled trials (RCTs). We searched multiple databases for RCTs investigating the efficacy of the following PCI strategies for small-vessel CAD (<3 mm in diameter): drug-coated balloons (DCB), early-generation paclitaxel-eluting stents and sirolimus-eluting stents (SES), newer-generation drug-eluting stents (DES), bare-metal stents (BMS), cutting balloon angioplasty, and balloon angioplasty (BA). The primary outcome was the trial-defined major adverse cardiovascular events (MACE), mostly defined as a composite of death, myocardial infarction, and revascularization. The secondary outcomes included each component of MACE and angiographic binary restenosis. We performed a sensitivity analysis for RCTs without BMS or first-generation DES. Our search identified 29 eligible RCTs, including 8,074 patients among the 8 PCI strategies. SES significantly reduced MACE compared with BA (hazard ratio 0.23, 95% confidence interval 0.10 to 0.54) with significant heterogeneity (I2 = 55.9%), and the rankogram analysis showed that SES was the best. There were no significant differences between DCB and newer-generation DES in any clinical outcomes, which was consistent in the sensitivity analysis. BMS and BA were ranked as the worst 2 for most clinical outcomes. In conclusion, SES was ranked as the best for reducing MACE. There were no significant differences in clinical outcomes between DCB and newer-generation DES. BMS and BA were regarded as the worst strategies for small-vessel CAD.

Acute Hemodynamic Compromise After Transcatheter Aortic Valve Replacement Due to Dynamic Left Ventricle Obstruction: A Systematic Review.

Acute hemodynamic compromise after transcatheter aortic valve replacement (TAVR) because of dynamic left ventricle (LV) obstruction (LVO), also known as suicide LV, is an infrequent but severe complication of TAVR that is poorly defined in previous studies. Understanding this complication is essential for its prompt diagnosis and optimal treatment. We conducted a systematic literature review using PubMed, Embase, Web of Science, and Medline databases for studies describing acute hemodynamic compromise after TAVR because of dynamic LVO or suicide LV. Each study was reviewed by 2 authors individually for eligibility, and a third author resolved disagreements. From a total of 506 studies, 25 publications were considered for the final analysis. The majority of patients with this condition were women demonstrating a hypertrophic septum, a small ventricle, and hyperdynamic contractility on pre-TAVR echocardiographic assessment. An intraventricular gradient before TAVR was found in half of the cases. Acute hemodynamic compromise after TAVR because of dynamic LVO manifested mainly as significant hypotension and occurred most often immediately after valve deployment. The LV outflow tract was the most common site of obstruction. Advanced therapies were required in nearly 65% of the cases. In conclusion, acute hemodynamic compromise after TAVR because of dynamic LVO occurred almost invariably in women. Echocardiography before TAVR may offer essential information to anticipate this complication. LV outflow tract obstruction appears to carry the highest risk of developing this phenomenon. Advanced therapies should be promptly considered as a bailout strategy in patients with hemodynamic collapse refractory to medical therapy.

Overview of SARS-CoV-2 infection and vaccine associated myocarditis compared to non-COVID-19-associated myocarditis: A systematic review and meta-analysis.

BACKGROUND: Previous literature suggests that both SARS-CoV-2 infection and COVID-19 mRNA vaccine are associated with myocarditis, in which the incidence is higher in the infection group. COVID-19 mRNA vaccine-related myocarditis is noted to have a more benign course. Despite these findings, there is a need for a larger population systematic review that compares the outcomes to pre-pandemic acute myocarditis to better understand the extent of the current post-COVID state. METHODS: We performed a literature search with PubMed and EMBASE and identified studies investigating COVID-19 and its vaccinated population, and the population prior to the pandemic (control group) who had myocarditis. We performed a one-group meta-analysis of the incidence, baseline demographics, and outcomes of myocarditis for each group. RESULTS: The incidence in the SARS-CoV-2 infection group was 2.76 per thousand (95% CI, 0.85-8.92), 19.7 per million (95% CI, 12.3-31.6) in the vaccine group, and 0.861 per million (95% CI, 0.04-16.7) in the control group. The majority of patients were male, with the highest proportion in the vaccine group. The mean age was the youngest in the vaccine group (24.8, 95% CI, 19.1-30.6). The vaccine group had the lowest mortality (2.0%, 95% CI, 1.3-2.7) followed by the control and the SARS-CoV-2 infection group. The vaccine group had the lowest proportion of immunoglobulin and glucocorticoid use, mechanical circulatory support, and cardiogenic shock. CONCLUSION: Our study showed favorable outcomes of myocarditis in patients with COVID-19 mRNA vaccination, despite a higher incidence than pre-COVID controls. Further studies with standardized myocarditis diagnostic criteria assessing long-term outcomes are necessary.

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.

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.

Use of Perioperative Extracorporeal Membranous Oxygenation in Pulmonary Endarterectomy Cases: A Systematic Review and Meta-Analysis.

Introduction: Pulmonary endarterectomy (PEA) is known to be a curative intervention for chronic thromboembolic pulmonary hypertension (CTEPH). Its complications include endobronchial bleeding, persistent pulmonary arterial hypertension, right ventricular failure, and reperfusion lung injury. Extracorporeal membranous oxygenation (ECMO) is a perioperative salvage method for PEA. Although risk factors and outcomes have been reported in several studies, overall trends remain unknown. We performed a systematic review and study-level meta-analysis to understand the outcomes of ECMO utilization in the perioperative period of PEA. Methods: We performed a literature search with PubMed and EMBASE on 11/18/2022. We included studies including patients who underwent perioperative ECMO in PEA. We collected data including baseline demographics, hemodynamic measurements, and outcomes such as mortality and weaning of ECMO and performed a study-level meta-analysis. Results: Eleven studies with 2632 patients were included in our review. ECMO insertion rate was 8.7% (225/2,625, 95% CI 5.9-12.5) in total, VV-ECMO was performed as the initial intervention in 1.1% (41/2,625, 95% CI 0.4-1.7) (Figure 3), and VA-ECMO was performed as an initial intervention in 7.1% (184/2,625, 95% CI 4.7-9.9). Preoperative hemodynamic measurements showed higher pulmonary vascular resistance, mean pulmonary arterial pressure, and lower cardiac output in the ECMO group. Mortality rates were 2.8% (32/1238, 95% CI: 1.7-4.5) in the non-ECMO group and 43.5% (115/225, 95% CI: 30.8-56.2) in the ECMO group. The proportion of patients with successful weaning of ECMO was 72.6% (111/188, 95% CI: 53.4-91.7). Regarding complications of ECMO, the incidence of bleeding and multi-organ failure were 12.2% (16/79, 95% CI: 13.0-34.8) and 16.5% (15/99, 95% CI: 9.1-28.1), respectively. Conclusion: Our systematic review showed a higher baseline cardiopulmonary risk in patients with perioperative ECMO in PEA, and its insertion rate was 8.7%. Further studies that compare the use of ECMO in high-risk patients who undergo PEA are anticipated.

Extracardiac Prothrombotic Effects of COVID-19.

COVID-19 infection triggers a heightened inflammatory response which in turn, increases thrombosis and thromboembolism. Microvascular thrombosis has been detected in various tissue beds which may account for some of the multi-system organ dysfunction associated with COVID-19. Additional research is needed to understand which prophylactic and therapeutic drug regimens are best for the prevention and treatment of thrombotic complications of COVID-19.

North American COVID-19 Myocardial Infarction (NACMI) Risk Score for Prediction of In-Hospital Mortality.

Background: In-hospital mortality in patients with ST-segment elevation myocardial infarction (STEMI) is higher in those with COVID-19 than in those without COVID-19. The factors that predispose to this mortality rate and their relative contribution are poorly understood. This study developed a risk score inclusive of clinical variables to predict in-hospital mortality in patients with COVID-19 and STEMI. Methods: Baseline demographic, clinical, and procedural data from patients in the North American COVID-19 Myocardial Infarction registry were extracted. Univariable logistic regression was performed using candidate predictor variables, and multivariable logistic regression was performed using backward stepwise selection to identify independent predictors of in-hospital mortality. Independent predictors were assigned a weighted integer, with the sum of the integers yielding the total risk score for each patient. Results: In-hospital mortality occurred in 118 of 425 (28%) patients. Eight variables present at the time of STEMI diagnosis (respiratory rate of >35 breaths/min, cardiogenic shock, oxygen saturation of <93%, age of >55 â€‹years, infiltrates on chest x-ray, kidney disease, diabetes, and dyspnea) were assigned a weighted integer. In-hospital mortality increased exponentially with increasing integer risk score (Cochran-Armitage χ2, P â€‹< â€‹.001), and the model demonstrated good discriminative power (c-statistic â€‹= â€‹0.81) and calibration (Hosmer-Lemeshow, P â€‹= â€‹.40). The increasing risk score was strongly associated with in-hospital mortality (3.6%-60% mortality for low-risk and very high-risk score categories, respectively). Conclusions: The risk of in-hospital mortality in patients with COVID-19 and STEMI can be accurately predicted and discriminated using readily available clinical information.