Clinical outcomes and the impact of valve morphology for transcatheter aortic valve replacement in bicuspid aortic valves: A systematic review and meta-analysis.

BACKGROUND: Bicuspid aortic valve (BAV) is present in approximately 0.5%-2% of the general population, causing significant aortic stenosis (AS) in 12%-37% of affected individuals. Transcatheter aortic valve replacement (TAVR) is being considered the treatment of choice in patients with symptomatic AS across all risk spectra. AIM: Aim Our study aims to compare TAVR outcomes in patients with BAV versus tricuspid aortic valves (TAV). METHODS: A comprehensive literature search was performed in PubMed, Web of Science, and Cochrane trials. Studies were included if they included BAV and TAV patients undergoing TAVR with quantitative data available for at least one of our predefined outcomes. Meta-analysis was performed by the random-effects model using Stata software. RESULTS: Fifty studies of 203,288 patients were included. BAV patients had increased 30-day all-cause mortality (odds ratio [OR] = 1.23 [1.00-1.50], p = 0.05), in-hospital stroke (OR = 1.39 [1.01-1.93], p = 0.05), in-hospital and 30-day PPI (OR = 1.13 [1.00-1.27], p = 0.04; OR = 1.16 [1.04-1.13], p = 0.01) and in-hospital, 30-day and 1-year aortic regurgitation (AR) (OR = 1.48 [1.19-1.83], p < 0.01; OR = 1.79 [1.26-2.52], p < 0.01; OR = 1.64 [1.03-2.60], p = 0.04). Subgroup analysis on new-generation valves showed a reduced 1-year all-cause mortality (OR = 0.86 [CI = 0.75-0.98], p = 0.03), despite higher in-hospital and 30-day PPI (OR = 0.1.21 [1.04-1.41], p = 0.01; OR = 1.17 [1.05-1.31], p = 0.01) and in-hospital AR (OR = 1.62 [1.14-2.31], p = 0.01) in the BAV group. The quality of included studies was moderate-to-high, and only three analyses presented high heterogeneity. CONCLUSION: TAVR is associated with comparable outcomes in patients with BAV and TAV. Careful selection of BAV cases by preprocedural assessment of valve anatomy and burden of calcification, pre- and post-procedural dilation, and implementing newer generations of valves may improve the safety and efficacy of TAVR in BAV patients.

Comparative Safety and Effectiveness of Loading Doses of P2Y12 Inhibitors in Patients Undergoing Elective PCI: a Network Meta-analysis.

PURPOSE: Effective platelet inhibition prior to elective percutaneous coronary intervention (PCI) reduces the risk of ischemic complications. Newer P2Y12 inhibitors are preferred agents over clopidogrel for patients presenting with the acute coronary syndrome. However, the comparative efficacy and safety of them over clopidogrel in elective PCI is unclear. We performed a network meta-analysis to compare the safety and efficacy of loading strategies of P2Y12 inhibitors in patients undergoing elective PCI. METHODS: We conducted a systematic review of randomized controlled trials (RCT) up to June 2021 to compare the safety and effectiveness of different loading strategies of P2Y12 inhibitors before elective PCI. The endpoints of interest were overall mortality, rates of myocardial infarction (MI), stroke, revascularization, and major bleeding. Random effects model using the frequentist approach was used to perform a network meta-analysis using R software. RESULTS: Five trials with a total of 5194 patients were included in our analysis. For ischemic outcomes, including MI, stroke, and revascularization, prasugrel had the most favorable trend. However, clopidogrel had the highest probability of being most effective for major bleeding and all-cause mortality. None of these trends was statistically significant due to lack of power for each outcome. CONCLUSION: Although prasugrel and ticagrelor are known as more potent antiplatelet agents, their effects in preventing MI and stroke are marginal and do not translate into improved overall mortality and bleeding compared with clopidogrel.

In CV disease, clopidogrel reduces nonfatal MI and MACE vs. aspirin but not stroke or mortality.

SOURCE CITATION: Tasoudis PT, Kyriakoulis IG, Sagris D, et al. Clopidogrel monotherapy versus aspirin monotherapy in patients with established cardiovascular disease: systematic review and meta-analysis. Thromb Haemost. 2022;122:1879-87. 35577054.

Impact of right ventricular impairment on morbidity and mortality in takotsubo syndrome-a meta-analysis of observational trials.

The impact of right ventricular impairment (RVI) on the morbidity and mortality of patients with Takotsubo syndrome (TTS) is well-debated. We conducted a meta-analysis to evaluate the mortality and morbidity risk associated with RVI compared with those without RVI in patients with TTS. A comprehensive search was performed in PubMed and Embase from inception to April 19, 2019. Our primary outcome of interest was in-hospital and long-term mortality. Other outcomes of interest were acute heart failure, left ventricular systolic function, tricuspid and mitral regurgitation, and length of hospital stay (LOS). We are reporting our outcomes as a cumulative odds ratio (OR). After an initial search, 10 studies with 1210 subjects were included in the quantitative analysis. Mean follow-up was 31 months. The odds of in-hospital and long-term mortality in TTS patients with and without RVI were not significantly different (p = 0.13 and 0.40). In TTS patients without RVI, the odds of acute heart failure, and mitral and tricuspid regurgitation were significantly lower at an OR of 0.26 (p < 0.0001), 0.40 (p = 0.0001), and 0.52 (p = 0.02) respectively. TTS patients with RVI had significantly lower mean LVEF (34% vs 41%, p = 0.03) and numerically higher mean LOS (9.5 days vs 7.6 days, p = 0.52) compared with those without RVI. The presence of RVI represents a severe form of TTS disease spectrum, characterized by severely reduced LVEF, higher incidence of MR and presence of TR. Although there was a trend toward increased in-hospital and long-term mortality, RVI in TTS does not portend worse survival.

The 30-day readmission rate of same-day discharge protocol following catheter ablation for atrial fibrillation: a propensity score-matched analysis from National Readmission Database.

AIMS: The effectiveness and safety of same-day discharge (SDD) for catheter ablation (CA) for atrial fibrillation (AF) has not been fully elucidated using a large nationwide database. This study aimed to evaluate the all-cause readmission rates within 30-days among patients receiving CA for AF with an SDD protocol compared with a conventional overnight stay (ONS). METHODS AND RESULTS: We performed a retrospective cohort study using the US Nationwide Readmission Database. The primary outcome was all-cause 30-day readmission following discharge in patients receiving CA and a secondary outcome was requiring total healthcare cost. A 1 : 3 propensity score matching was conducted to compare the safety and efficacy within both SDD and ONS group. Among 30 776 patients [mean 67.2 ± 11.4 years, 12 590 female (41.5%)] who received CA from 2016 through 2018, 440 (1.42%) patients were discharged on the same-day following CA (SDD group), and the remaining 30 336 patients stayed at least one night in the hospital (ONS group). A propensity score analysis generated 1751 matched pairs (440 in the SDD group; 1311 in the ONS group). The 30-day readmission following discharge was not significantly higher in the SDD group than the ONS group (SDD vs. ONS: 12.7% vs. 9.7%; hazard ratio: 1.17, 95% confidence interval: 0.76-1.81, P = 0.47). Healthcare cost was significantly higher in the ONS group ($25 237 ± 14 036 vs. $30 749 ± 16 383; P < 0.01). CONCLUSION: In this nationwide database study, there was no significant difference in the all-cause 30-day readmission following SDD for CA compared with ONS.

Efficacy of Sacubitril/Valsartan in Hypertension.

BACKGROUND: Sacubitril/valsartan (LCZ696) has progressed to be one of the most promising medication since its approval for chronic heart failure with reduced ejection fraction. Recent data have suggested a superior blood pressure control with LCZ696. STUDY QUESTION: What is the antihypertensive efficacy and safety profile of sacubitril/valsartan? DATA SOURCES: Randomized controlled trials (RCTs) comparing the efficacy and safety of LCZ696 against a placebo or angiotensin receptor blocker (ARB). RCTs were identified from a comprehensive search in PubMed, Embase, Cochrane library, and clinicaltrials.gov. STUDY DESIGN: We used a change in systolic and diastolic blood pressures, both sitting as well as ambulatory, to calculate relevant effect sizes with their standard errors from the available change in mean and SD data. In addition, we also collected categorical data for the reported adverse effects from these trials. We performed a series of pairwise meta-analyses between LCZ696 versus an active comparator or a placebo. RESULTS: Eleven RCTs with a total of 6028 participants had the relevant data available. Our meta-analysis showed that LCZ696 is an effective and a safe treatment for hypertension. It outperformed ARBs in every category, and the results are consistent across the different dosages of LCZ696. Compared with ARBs, 200 mg of LCZ696 reduced systolic blood pressure and diastolic blood pressure (DBP) by 4.62 mm Hg (95% confidence interval, 3.33-5.90, P < 0.001) and 2.13 mm Hg (95% confidence interval, 1.69-2.57, P < 0.001), respectively. Similarly, 400 mg of LCZ696 reduced systolic blood pressure and diastolic blood pressure by 5.50 mm Hg (2.94-8.07, P < 0.001) and 2.51 mm Hg (1.80-3.21, P < 0.001), respectively, in comparison with ARBs. The adverse effects with LCZ696 were not significantly higher compared with ARBs or placebo. CONCLUSIONS: Sacubitril/valsartan is more effective for the management of hypertensive patients, compared with an ARB. Long-term prospective studies are required to identify whether this result translates into morbidity and mortality benefits.

Predictors of permanent pacemaker insertion after TAVR: A systematic review and updated meta-analysis.

OBJECTIVES: The aim of this analysis was to evaluate the predictors associated with increased risk of permanent pacemaker implantation (PPMI) following transcatheter aortic valve replacement (TAVR). BACKGROUND: While TAVR has evolved as the standard of care for patients with severe aortic stenosis, conduction abnormalities leading to the need for PPMI is one of the most common postprocedural complications. METHODS: A systematic literature search was performed to identify relevant trials from inception to May 2020. Summary effects were calculated using a DerSimonian and Laird random-effects model as odds ratio with 95% confidence intervals for all the clinical endpoints. RESULTS: Thirty-seven observational studies with 71 455 patients were identified. The incidence of PPMI following TAVR was 22%. Risk was greater in men and increased with age. Patients with diabetes mellitus, presence of right bundle branch block, baseline atrioventricular conduction block, and left anterior fascicular block were noted to be at higher risk. Other significant predictors include the presence of high calcium volume in the area below the left coronary cusp and noncoronary cusp, use of self-expandable valve over balloon-expandable valve, depth of implant, valve size/annulus size, predilatation balloon valvuloplasty, and postimplant balloon dilation. CONCLUSION: Fourteen factors were found to be associated with increased risk of PPMI after TAVR, suggesting early identification of high-risk populations and targeting modifiable risk factors may aid in reducing the need for this post TAVR PPMI.

Impact of weight on the efficacy and safety of direct-acting oral anticoagulants in patients with non-valvular atrial fibrillation: a meta-analysis.

AIMS: This study sought to determine the impact of weight and body mass index (BMI) on the safety and efficacy of direct-acting oral anticoagulants (DOACs) compared with warfarin in patients with non-valvular atrial fibrillation. METHODS AND RESULTS: A systematic literature search was employed in PubMed, Embase, and Cochrane clinical trials with no language or date restrictions. Randomized trials or their substudies were assessed for relevant outcome data for efficacy that included stroke or systemic embolization (SSE), and safety including major bleeding and all-cause mortality. Binary outcome data and odds ratios from the relevant articles were used to calculate the pooled relative risk. For SSE, the data from the four Phase III trials showed that DOACs are better or similarly effective with low BMI 0.73 (0.56-0.97), normal BMI 0.72 (0.58-0.91), overweight 0.87 (0.76-0.99), and obese 0.87 (0.76-1.00). The risk of major bleeding was also better or similar with DOACs in all BMI subgroups with low BMI 0.62 (0.37-1.05), normal BMI 0.72 (0.58-0.90), overweight 0.83 (0.71-0.96), and obese 0.91 (0.81-1.03). There was no impact on mortality in all the subgroups. In a meta-regression analysis, the effect size advantage of DOACs compared with warfarin in terms of safety and efficacy gradually attenuated with increasing weight. CONCLUSION: Our findings suggest that a weight-based dosage adjustment may be necessary to achieve optimal benefits of DOACs for thromboembolic prevention in these patients with non-valvular atrial fibrillation. Further dedicated trials are needed to confirm these findings. PROSPERO 2019 CRD42019140693. Available from: https://www.crd.york.ac.uk/prospero/display_record.php? ID=CRD42019140693.

Comparative Therapeutic Assessment of Atrial Fibrillation in Heart Failure With Reduced Ejection Fraction-A Network Meta-Analysis.

BACKGROUND: Catheter ablation (CA) continues to prove to be an intriguing therapeutic option for the management of atrial fibrillation (AF) especially in patients with heart failure with reduced ejection fraction (HFrEF). Recent data have suggested that CA may be a viable first-line strategy for these patients. STUDY QUESTION: Is CA more effective in managing patients with AF with HFrEF compared to optimal medical treatment and anti-arrhythmic drugs? DATA SOURCES: Randomized controlled trials (RCTs) comparing CA, medical treatment, or antiarrhythmic drugs to each other or a placebo group for the treatment of AF in HFrEF. We performed a comprehensive search in PubMed, Embase, and Cochrane library to identify relevant RCTs. STUDY DESIGN: Our primary outcomes of interest were all-cause mortality, hospitalization for heart failure, and the percentage change in left ventricular ejection fraction. Also, we looked at functional outcomes such as Minnesota Living with Heart Failure Questionnaire and 6-minute walking distance. We used event rates for categorical variables and mean differences between the groups for the continuous variables. We used a frequentist approach employing a graph theory methodology to construct a network meta-analysis model. RESULTS: We ended up with 17 RCTs with 5460 participants and 5 different treatments in our network meta-analysis. Compared to optimal medical therapy, CA was effective in reducing all-cause mortality odds ratio (OR) 0.44 (95% confidence interval, 0.27-0.74; P-value: <0.001) and hospitalization for heart failure OR 0.41 (0.28-0.59; P-value: <0.001). CA also resulted in improvement in left ventricular ejection fraction OR 9.34 (7.13-11.55; P-value: <0.001), Minnesota Living with Heart Failure Questionnaire OR -7.75 (-13.98 to -1.52; P-value: <0.01), and 6MWT OR 27.30 (5.27-49.33; P-value: <0.02). CONCLUSIONS: CA is the most effective and safe treatment for AF patients with HFrEF. We should consider this as a first-line therapy for the management of these patients.

Trends of utilization and outcomes after transcatheter and surgical aortic valve replacement on chronic dialysis.

BACKGROUND AND AIM: Trends of utilization and outcomes of transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) for patients on chronic dialysis (CD) are not well described. We aimed to assess the trends in utilization and outcomes of TAVR and SAVR on CD. METHODS: Nationwide Readmission Databases from 2013 to 2017 was analyzed. International Classification of Diseases Clinical Modification 9 and 10 codes were used to identify diagnoses and procedures. A multivariable regression model was used to compare the outcomes expressed as adjusted odds ratio (aOR) and 95% confidence interval (CI). RESULTS: A total of 5731 TAVR and 6491 SAVR were performed in patients with CD, respectively. The volume of TAVR increased by approximately four-folds and SAVR increased by approximately 33%. However, amongst patients with CD, the percentage of TAVR increased, whereas that of SAVR decreased (p < .001 for all). In 2016 and 2017, TAVR volume surpassed that of SAVR on CD. In-hospital mortality remained similar in TAVR (aOR: 0.92; 95% CI: 0.79-1.07; p-trend = .23) whereas it increased significantly in SAVR (aOR: 1.14: 95% CI: 1.05-1.25, p-trend = .002). In 2017, in-hospital mortality and 30-day readmission were significantly higher in TAVR among CD than non-CD patients. CONCLUSION: Despite increased use of TAVR among CD, there still is an opportunity for improvement in outcome of aortic valve replacement for those on CD.

Prevention of Recurrent Ventricular Tachycardia in Patients With Implantable Cardioverter Defibrillators-A Network Meta-analysis.

BACKGROUND: The optimal management for the prevention of recurrent ventricular tachycardia in patients with implantable cardioverter-defibrillators (ICDs) offers a challenge with no set guidelines regarding which therapy offers a best safety and efficacy profile. STUDY QUESTION: Which therapeutic strategy, among antiarrhythmic drugs and catheter ablation (CA), offers the most effective and safe approach in patients with ICDs? DATA SOURCES: Randomized controlled trials (RCTs) comparing the efficacy and safety of antiarrhythmic drugs or CA against a placebo group. RCTs were identified from a comprehensive search in PubMed, Embase, and Cochrane library. STUDY DESIGN: Our outcomes of interest were reductions in appropriate ICD shocks, inappropriate ICD shocks, and overall mortality. We used the event rates in both groups, and then using a frequentist approach employing a graph theory methodology, we constructed a network meta-analysis model. RESULTS: Fourteen RCTs with 3815 participants and 6 different interventions treatments were included in our network meta-analysis. The most effective treatment for the prevention of recurrent ventricular tachycardia after ICD is amiodarone followed by CA. Amiodarone is most effective in the reduction of appropriate and inappropriate ICD shocks with an odds ratio (OR) of 0.29 [95% confidence interval (CI), 0.11-0.74] and 0.15 (95% CI, 0.04-0.60), respectively. CA was effective in the reduction of appropriate ICD shocks (OR, 0.41; 95% CI, 0.20-0.87), whereas sotalol was effective in the reduction of inappropriate ICD shocks (OR, 0.46; 95% CI, 0.22-0.95). There was no significant reduction in the overall mortality from any therapy. There was a trend of increased mortality associated with amiodarone therapy (OR, 2.40; 95% CI, 0.92-6.26). CONCLUSIONS: Amiodarone remains the most efficacious therapy for the reduction of appropriate and inappropriate shocks in patients with ICD. No therapy resulted in mortality reduction, but amiodarone showed a trend toward increased mortality.

Frequency and Impact of Infectious Disease Conditions Diagnosed During Decompensated Heart Failure Hospitalizations in the United States.

There are limited data on the frequency of diagnosis of infectious disease and its impact on patients hospitalized with decompensated heart failure. We sought to evaluate the prevalence, types, trends, and outcomes of infectious disease diagnosis in patients admitted with decompensated heart failure. We performed a retrospective cohort study in patients admitted with a primary diagnosis of heart failure using the National Inpatient Sample database from 2009 to 2019. Patients with a length of stay ≥3 days were included. Patients with chronic dialysis, left ventricular assist devices, cardiogenic shock, or solid organ transplantation or who required mechanical ventilation or mechanical circulatory support were excluded. Patients were stratified according to the presence or absence of infectious disease diagnosis. Outcomes of interest were in-hospital mortality, length of stay, and resource utilization. Among the 7,228,521 admissions with a primary diagnosis of heart failure that met the inclusion and exclusion criteria, an infectious disease diagnosis was reported in 1,806,514 (24.9%). Infectious disease diagnosis was more frequent in patients who were female, older, and White, and who had higher baseline co-morbidity. Since 2014, there has been a steady decrease in infectious conditions in patients admitted with a primary diagnosis of heart failure (p for trend <0.01). After propensity match analysis was performed, patients with infectious disease diagnosis had a longer length of stay (6.9 vs 5.7 days, p <0.001) and higher cost ($14,305 vs $11,760, p <0.001), were less likely to be discharged home (35.3% vs 44.7%, p <0.001), and had higher in-hospital mortality (2.6% vs 1.6%, p <0.001). In conclusion, approximately 1 in 4 patients admitted with primary heart failure will be diagnosed with an infectious condition. The presence of an infectious disease diagnosis is associated with increased morbidity and mortality.

Nationwide Analysis of the Outcomes and Mortality of Hospitalized COVID-19 Patients.

INTRODUCTION: The Coronavirus disease 2019 (COVID-19) pandemic has affected people worldwide with the United States (US) with the largest number of reported cases currently. Previous studies in hospitalized COVID-19 patients have been limited by sample size. METHODS: The National Inpatient Sample database which is the largest inpatient database in the US was queried in the year 2020 for the diagnosis of COVID-19 based on ICD-10-CM U07.1 and associated outcomes. Multivariate logistic regression analysis was used to identify predictors of mortality. STATA 16.0 was used for statistical analysis. RESULTS: A weighted total of 1,678,995 hospitalizations for COVID-19 were identified. Median age of admitted patients with COVID-19 was 65 year (51-77) with 47.9% female and 49.2% White. Majority of the patients admitted were >65 years of age (49.3%). Hypertension and diabetes were the most common comorbidities (64.2% and 39.5%, respectively). Overall inpatient mortality was 13.2% and increasing to 55.9% in patients requiring mechanical ventilation. Trend of inpatient mortality was significantly decreasing over the year. Predictors of inpatient mortality included age, male sex, diabetes, chronic kidney disease, heart failure, arrythmia, obesity, and coagulopathy. Despite a lower proportion of patients admitted to hospital with COVID-19, Black, Hispanic, and Native Americans were at an increased adjusted odds of inpatient mortality. Disparity was also noted in income, with low median household income associated with higher risk of mortality. CONCLUSION: In the largest US cohort with >1.6 million hospitalized COVID-19 patients in 2020, overall inpatient mortality was 13.6% with significantly higher mortality in ventilated patients. Significant socioeconomic and racial disparities were present with minorities at higher odds of mortality.

Rilonacept and Other Interleukin-1 Inhibitors in the Treatment of Recurrent Pericarditis.

Pericarditis is the commonest form of pericardial disease. Unfortunately, despite optimal treatment, approximately 15-30% of patients with acute pericarditis have recurrence. Many of these patients are refractory to colchicine, and become corticosteroid-dependent. Recurrent pericarditis severely impairs quality of life, and is associated with significant morbidity. Inflammasome formation and overproduction of interleukin (IL)-1 have been found to drive the systemic inflammatory response in recurrent autoinflammatory pericarditis. Several IL-1 inhibitors have been evaluated for their usefulness as therapeutic options. Rilonacept is a dimeric fusion protein that functions as a soluble decoy receptor that binds to both IL-1α and IL-1ß, thereby inhibiting the IL-1 pathway. It is safe and efficacious in the treatment of recurrent pericarditis in the RHAPSODY II and III trials. Anakinra is a recombinant IL-1 receptor antagonist that blocks the action of circulating IL-1α and IL-1ß. It has also been shown to be safe and efficacious in the AIRTRIP and IRAP studies. Canakinumab is a selective human monoclonal antibody against IL-1ß, and data on its use in recurrent pericarditis is scarce. Several questions regarding IL-1 inhibitor therapy, such as the duration of treatment and the recommended tapering protocols, as well as their use in special populations like pregnant or lactating women, remain unanswered and need to be addressed in future studies.

Transcatheter Aortic Valve Replacement in Patients With or Without Active Cancer.

Background Data on clinical outcomes after transcatheter aortic valve replacement (TAVR) in specific cancer types or the presence of metastatic disease remain sparse. This study aimed to investigate the impact of active cancer on short-term mortality, complications, and readmission rates after TAVR across different cancer types. Methods and Results The authors assessed the Nationwide Readmissions Database for TAVR cases from 2012 to 2019. Patients were stratified by specific cancer types. Primary outcome was in-hospital mortality. Secondary outcomes included bleeding requiring blood transfusion and readmissions at 30, 90, and 180 days after TAVR. Overall, 122 573 patients undergoing TAVR were included in the analysis, of whom 8013 (6.5%) had active cancer. After adjusting for potential confounders, the presence of active cancer was not associated with increased in-hospital mortality (adjusted odds ratio [aOR], 1.06 [95% CI, 0.89-1.27]; P=0.523). However, active cancer was associated with an increased risk of readmission at 30, 90, and 180 days after TAVR and increased risk of bleeding requiring transfusion at 30 days. Active colon and any type of metastatic cancer were individually associated with readmissions at 30, 90, and 180 days after TAVR. At 30 days after TAVR, colon (aOR, 2.51 [95% CI, 1.68-3.76]; P<0.001), prostate (aOR, 1.40 [95% CI, 1.05-1.86]; P=0.021), and any type of metastatic cancer (aOR, 1.65 [95% CI, 1.23-2.22]; P=0.001) were individually associated with an increased risk of bleeding requiring transfusion. Conclusions Patients with active cancer had similar in-hospital mortality after TAVR but higher risk of readmission and bleeding requiring transfusion, the latter depending on certain types of cancer.

Meta-analysis Comparing the Efficacy of Dobutamine Versus Milrinone in Acute Decompensated Heart Failure and Cardiogenic Shock.

This study aims to evaluate the difference between dobutamine and milrinone in patients presenting with acute decompensated heart failure (AHF). Inotropes are indicated for treating AHF, especially in patients with concomitant hypoperfusion indicative of cardiogenic shock. However, previous studies have not identified the optimal inotrope. We sought to compare outcomes associated with milrinone versus dobutamine in patients with AHF. A systematic literature search was performed to identify relevant trials from inception to August 2021. Our primary outcome of interest was mortality. Analysis was sub-categorized according to subpopulation, including AHF, AHF with cardiogenic shock (AHF-shock), AHF with a bridge to transplantation, and AHF with destination therapy. Summary effects were calculated using a fixed-effects model as risk ratio or mean difference with 95% confidence intervals for all the clinical endpoints. Ten studies, including one randomized controlled trial with 21,106 patients, were included in the analysis (4918 patients were in the Milrinone group, while 15188 were in the Dobutamine group). Milrinone was associated with a lower risk of mortality in patients with AHF (relative risk 0.87; confidence interval :0.79-0.97; P < 0.05, heterogeneity I²â€¯= 0%) with event rates of 9.4% vs 9.8% (number needed to treat of 250). Milrinone was also associated with improved mortality with relative risk 0.76 (0.79-0.95; P < 0.05) in patients with AHF with destination therapy. There was a non-significant trend towards improved mortality in AHF-shock patients. However, AHF with a bridge to transplantation patients had a non-significant trend towards improved mortality with dobutamine. There was no difference between the 2 strategies for the outcomes of acute kidney injury, initiation of renal replacement therapy, mechanical ventilation, arrhythmias, symptomatic hypotension, and length of hospital stay in the overall population. Intensive care unit length of hospital stay was lower in AHF-shock patients in the milrinone group, whereas dobutamine was associated with a lower length of intensive care unit stay in AHF patients. The cumulative data comparing milrinone with dobutamine indicate an overall marginal benefit of milrinone compared to dobutamine in the totality of patients with AFH with or without cardiogenic shock, and whether or not they are bridged to transplantation or destination assist device. More appropriately powered prospective studies are needed to identify a conclusive benefit of one inotrope over another.

Temporary Mechanical Circulatory Support in Cardiogenic Shock due to ST-Elevation Myocardial Infarction: Analysis of the National Readmissions Database.

Despite advances in temporary mechanical circulatory support (TMCS), in-hospital mortality and morbidity related to cardiogenic shock due to ST elevation myocardial infarction (CS-STEMI) are highly prevalent. We identified admissions with CS-STEMI between 2016 and 2019 from the National Readmission Database (NRD). Among 80 997 patients with CS-STEMI, we identified 42,139 without TMCS, while the remaining received various types of TMCS (Extra corporeal membrane oxygenation [ECMO] alone: n = 753; Intra-aortic balloon pump [IABP] alone: n = 27 556; Impella alone: n = 9055; ECMO with IABP or Impella: n = 1494). 30-day readmission rates did not differ among groups, whereas 90-day readmissions were higher among those with combined ECMO and IABP or Impella support (P = .027). In-hospital mortality and complications including hemodialysis, transfusion, and stroke were the highest in the Impella and combined ECMO and IABP/Impella groups. Heart failure was the most common cause of readmission. Multivariable logistic regression revealed female gender, diabetes, prior myocardial infarction, heart failure, chronic kidney, and peripheral artery disease as risk factors for 90-day readmissions. Our study unveiled several important factors associated with readmission and mortality related to TMCS in CS-STEMI. Approaches to identify and prevent readmissions by addressing these factors may lead to lower morbidity, healthcare cost related to readmission, and improved quality of life.