RESUMO
BACKGROUND: Clinical outcomes of patients presenting with STEMI are significantly improved by reducing time from vessel occlusion to coronary blood flow restoration. In an effort to improve outcomes, we developed a secure mobile application, STEMIcathAID, and designed a pilot project implementing the app into the workflow for STEMI patients transfer. The aim of the study is to assess the impact of the app on key metrics for STEMI transfer before (historic) and after app launch. METHODS: The pilot project included physicians, nurses and technicians from the Emergency Medicine and Nursing Departments at the referring center, the catheterization laboratory and transfer center. From July 2021 to February 2023, the referring center activated STEMIcathAID alarms in parallel with the previously established STEMI activation with traditional phone call to transfer center. RESULTS: One hundred eleven suspected STEMI calls were activated through the app with 66 accepted and 45 rejected cases; thirty-one STEMI cases with available device time were compared with 42 STEMIs activated through the traditional pathway before the app implementation. Median door-to-device time for STEMIcathAID-assisted transfer decreased from 106 to 86 min (p < 0.001). The significant improvement, 20 min (19%), of the key metric for interhospital transfer resulted in all STEMI cases meeting the AHA goal of door-to-device time ≤ 120 min. In addition, median door-in-door-out time at the referral hospital decreased from 56 to 50 min (p = 0.01). CONCLUSIONS: Implementation of a mobile app into STEMI workflow of a large urban healthcare system significantly improved the quality of care for transfer of STEMI patients. TRIAL REGISTRATION: AHA Get With The Guidelines-Coronary Artery Disease® (GWTG-CAD) registry is a national quality improvement program and is not subject to the institutional review board approval.
RESUMO
INTRODUCTION: Despite the growing use of temporary mechanical circulatory support (tMCS), little data exists to inform management and weaning of these devices. METHODS: We performed an online survey among cardiac intensive care unit directors in North America to examine current practices in the management of patients treated with intraaortic balloon pump and Impella. RESULTS: We received responses from 84% of surveyed centers (n=37). Our survey focused on three key aspects of daily management: 1. Hemodynamic monitoring; 2. Hemocompatibility; and 3. Weaning and removal. We found substantial variability surrounding all three areas of care. CONCLUSION: Our findings highlight the need for consensus around practices associated with improved outcomes in patients treated with tMCS.
Assuntos
Coração Auxiliar , Balão Intra-Aórtico , Humanos , América do Norte , Inquéritos e Questionários , Balão Intra-Aórtico/métodos , Balão Intra-Aórtico/estatística & dados numéricos , Remoção de Dispositivo/métodos , Remoção de Dispositivo/estatística & dados numéricos , Monitorização Hemodinâmica/métodos , Insuficiência Cardíaca/terapiaRESUMO
An 83-year-old woman with symptomatic severe aortic stenosis was referred for transcatheter aortic valve replacement. Diagnostic left heart catheterization documented diffuse 3-vessel coronary artery disease.
RESUMO
Intracoronary imaging has become an important tool in the treatment of complex lesions with percutaneous coronary intervention (PCI). This retrospective cohort study identified 1,118,475 patients with PCI from the Nationwide Readmissions Database from 2017 to 2019. Intravascular ultrasound (IVUS) and optical coherence tomography (OCT) were identified with appropriate International Classification of Diseases, Tenth Revision codes. The primary outcome was major adverse cardiac events. The secondary outcomes include net adverse clinical events (NACEs), all-cause mortality, myocardial infarction (MI) readmission, admission for stroke, and emergency revascularization. The multivariate Cox proportional hazard regression was used to adjust for demographic and co-morbid confounders. Of 1,118,475 PCIs, 86,140 (7.7%) used IVUS guidance and 5,617 (0.5%) used OCT guidance. The median follow-up time was 184 days. The primary outcome of major adverse cardiac events was significantly lower for the IVUS (6.5% vs 7.6%; hazard ratio [HR] 0.89, 95% confidence interval [CI] 0.86 to 0.91, p <0.001) and OCT (4.4% vs 7.6%; HR 0.69, 95% CI 0.61 to 0.79, p <0.001) groups. IVUS was associated with significantly lower rates of NACEs (8.4% vs 9.4%; HR 0.92, 95% CI 0.89 to 0.94, p <0.001), all-cause mortality (3.5% vs 4.3%; HR 0.85, 95% CI 0.82 to 0.88, p <0.001), readmission for MI (2.7% vs 3.0%; HR 0.95, 95% CI 0.91 to 0.99, p = 0.012), and admission for stroke (0.5% vs 0.6%; HR 0.86, 95% CI 0.78 to 0.95, p = 0.002). OCT was associated with significantly lower rates of NACEs (6.6% vs 9.4%; HR 0.81, 95% CI 0.73 to 0.89, p <0.001) and all-cause mortality (1.8% vs 4.3%; HR 0.51, 95% CI 0.42 to 0.63, p <0.001). Emergency revascularization was not significantly different with IVUS guidance. Readmission for MI, stroke, and emergency revascularization were not significantly different with OCT guidance. A subgroup analysis of patients with ST-elevation MI and non-ST-elevation MI showed similar results. In conclusion, the use of IVUS and OCT guidance with PCI were associated with significantly lower rates of morbidity and mortality in real-world practice.
Assuntos
Doença da Artéria Coronariana , Infarto do Miocárdio , Intervenção Coronária Percutânea , Acidente Vascular Cerebral , Humanos , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/cirurgia , Tomografia de Coerência Óptica , Angiografia Coronária/métodos , Intervenção Coronária Percutânea/métodos , Estudos Retrospectivos , Resultado do Tratamento , Ultrassonografia de Intervenção/métodos , Acidente Vascular Cerebral/etiologiaRESUMO
AIMS: Invasive haemodynamic assessment with a pulmonary artery catheter is often used to guide the management of patients with cardiogenic shock (CS) and may provide important prognostic information. We aimed to assess prognostic associations and relationships to end-organ dysfunction of presenting haemodynamic parameters in CS. METHODS AND RESULTS: The Critical Care Cardiology Trials Network is an investigator-initiated multicenter registry of cardiac intensive care units (CICUs) in North America coordinated by the TIMI Study Group. Patients with CS (2018-2022) who underwent invasive haemodynamic assessment within 24 h of CICU admission were included. Associations of haemodynamic parameters with in-hospital mortality were assessed using logistic regression, and associations with presenting serum lactate were assessed using least squares means regression. Sensitivity analyses were performed excluding patients on temporary mechanical circulatory support and adjusted for vasoactive-inotropic score. Among the 3603 admissions with CS, 1473 had haemodynamic data collected within 24 h of CICU admission. The median cardiac index was 1.9 (25th-75th percentile, 1.6-2.4) L/min/m2 and mean arterial pressure (MAP) was 74 (66-86) mmHg. Parameters associated with mortality included low MAP, low systolic blood pressure, low systemic vascular resistance, elevated right atrial pressure (RAP), elevated RAP/pulmonary capillary wedge pressure ratio, and low pulmonary artery pulsatility index. These associations were generally consistent when controlling for the intensity of background pharmacologic and mechanical haemodynamic support. These parameters were also associated with higher presenting serum lactate. CONCLUSION: In a contemporary CS population, presenting haemodynamic parameters reflecting decreased systemic arterial tone and right ventricular dysfunction are associated with adverse outcomes and systemic hypoperfusion.
Assuntos
Hemodinâmica , Choque Cardiogênico , Humanos , Prognóstico , Resistência Vascular , LactatosRESUMO
BACKGROUND: The appropriate use of pulmonary artery catheters (PACs) in critically ill cardiac patients remains debated. OBJECTIVES: The authors aimed to characterize the current use of PACs in cardiac intensive care units (CICUs) with attention to patient-level and institutional factors influencing their application and explore the association with in-hospital mortality. METHODS: The Critical Care Cardiology Trials Network is a multicenter network of CICUs in North America. Between 2017 and 2021, participating centers contributed annual 2-month snapshots of consecutive CICU admissions. Admission diagnoses, clinical and demographic data, use of PACs, and in-hospital mortality were captured. RESULTS: Among 13,618 admissions at 34 sites, 3,827 were diagnosed with shock, with 2,583 of cardiogenic etiology. The use of mechanical circulatory support and heart failure were the patient-level factors most strongly associated with a greater likelihood of the use of a PAC (OR: 5.99 [95% CI: 5.15-6.98]; P < 0.001 and OR: 3.33 [95% CI: 2.91-3.81]; P < 0.001, respectively). The proportion of shock admissions with a PAC varied significantly by study center ranging from 8% to 73%. In analyses adjusted for factors associated with their placement, PAC use was associated with lower mortality in all shock patients admitted to a CICU (OR: 0.79 [95% CI: 0.66-0.96]; P = 0.017). CONCLUSIONS: There is wide variation in the use of PACs that is not fully explained by patient level-factors and appears driven in part by institutional tendency. PAC use was associated with higher survival in cardiac patients with shock presenting to CICUs. Randomized trials are needed to guide the appropriate use of PACs in cardiac critical care.
Assuntos
Insuficiência Cardíaca , Artéria Pulmonar , Humanos , Insuficiência Cardíaca/terapia , Unidades de Terapia Intensiva , Hospitalização , Mortalidade Hospitalar , CatéteresRESUMO
BACKGROUND: ST-segment elevation myocardial infarction (STEMI) is a high-risk patient medical emergency. We developed a secure mobile application, STEMIcathAID, to optimize care for STEMI patients by providing a digital platform for communication between the STEMI care team members, EKG transmission, cardiac catherization laboratory (cath lab) activation and ambulance tracking. The aim of this report is to describe the implementation of the app into the current STEMI workflow in preparation for a pilot project employing the app for inter-hospital STEMI transfer. APPROACH: App deployment involved key leadership stakeholders from all multidisciplinary teams taking care of STEMI patients. The team developed a transition plan addressing all aspects of the health system improvement process including the workflow analysis and redesign, app installation, personnel training including user account access to the app, and development of a quality assurance program for progress evaluation. The pilot will go live in the Emergency Department (ED) of one of the hospitals within the Mount Sinai Hospital System (MSHS) during the daytime weekday hours at the beginning and extending to 24/7 schedule over 4-6 weeks. For the duration of the pilot, ED personnel will combine the STEMIcathAID app activation with previous established STEMI activation processes through the MSHS Clinical Command Center (CCC) to ensure efficient and reliable response to a STEMI alert. More than 250 people were provisioned app accounts including ED Physicians and frontline nurses, and trained on their user-specific roles and responsibilities and scheduled in the app. The team will be provided with a feedback form that is discipline specific to complete after every STEMI case in order to collect information on user experience with the STEMIcathAID app functionality. The form will also provide quantitative metrics for the key time sensitive steps in STEMI care. CONCLUSIONS: We developed a uniform approach for deployment of a mobile application for STEMI activation and transfer in a large urban healthcare system to optimize the clinical workflow in STEMI care. The results of the pilot will demonstrate whether the app has a significant impact on the quality of care for transfer of STEMI patients.
Assuntos
Aplicativos Móveis , Infarto do Miocárdio , Infarto do Miocárdio com Supradesnível do Segmento ST , Atenção à Saúde , Humanos , Projetos Piloto , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Fluxo de TrabalhoRESUMO
BACKGROUND: Coronaviruses are important emerging human and animal pathogens. SARS-CoV-2, the virus that causes COVID-19, is responsible for the current global pandemic. Early in the course of the pandemic, New York City became one of the world's "hot spots" with more than 250,000 cases and more than 15,000 deaths. Although medical providers in New York were fortunate to have the knowledge gained in China and Italy before it came under siege, the magnitude and severity of the disease were unprecedented and arguably under appreciated. The surge of patients with significant COVID-19 threatened to overwhelm health care systems, as New York City health systems realized that the number of specialized critical care providers would be inadequate. A large academic medical system recognized that rapid redeployment of noncritical providers into such roles would be needed. An educational gap was therefore identified: numerous providers with minimal critical care knowledge or experience would now be required to provide critical-level patient care under supervision of intensivists. Safe provision of such high level of patient care mandated the development of "educational crash courses." METHODS: The purpose of this special article is to summarize the approach adopted by the Institute for Critical Care Medicine and Department of Anesthesiology, Perioperative and Pain Medicine's Human Emulation, Education, and Evaluation Lab for Patient Safety and Professional Study Simulation Center in developing a training program for noncritical care providers in this novel disease. RESULTS: Using this joint approach, we were able to swiftly educate a wide range of nonintensive care unit providers (such as surgical, internal medicine, nursing, and advanced practice providers) by focusing on refreshing critical care knowledge and developing essential skillsets to assist in the care of these patients. CONCLUSIONS: We believe that the practical methods reviewed here could be adopted by any health care system that is preparing for an unprecedented surge of critically ill patients.
Assuntos
COVID-19 , COVID-19/epidemiologia , Cuidados Críticos , Humanos , Cidade de Nova Iorque/epidemiologia , Pandemias/prevenção & controle , SARS-CoV-2RESUMO
BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic resulted in a surge of critically ill patients. This was especially true in New York City. We present a roadmap for hospitals and healthcare systems to prepare for a Pandemic. METHODS: This was a retrospective review of how Mount Sinai Hospital (MSH) was able to rapidly prepare to handle the pandemic. MSH, the largest academic hospital within the Mount Sinai Health System, rapidly expanded the intensive care unit (ICU) bed capacity, including creating new ICU beds, expanded the workforce, and created guidelines. RESULTS: MSH a 1,139-bed quaternary care academic referral hospital with 104 ICU beds expanded to 1,453 beds (27.5% increase) with 235 ICU beds (126% increase) during the pandemic peak in the first week of April 2020. From March to June 2020, with follow-up through October 2020, MSH admitted 2,591 COVID-19-positive patients, 614 to ICUs. Most admitted patients received noninvasive support including a non-rebreather mask, high flow nasal cannula, and noninvasive positive pressure ventilation. Among ICU patients, 68.4% (n=420) received mechanical ventilation; among the admitted ICU patients, 42.8% (n=263) died, and 47.8% (n=294) were discharged alive. CONCLUSIONS: Flexible bed management initiatives; teamwork across multiple disciplines; and development and implementation of guidelines were critical accommodating the surge of critically ill patients. Non-ICU services and staff were deployed to augment the critical care work force and open new critical care units. This approach to rapidly expand bed availability and staffing across the system helped provide the best care for the patients and saved lives.
RESUMO
Aims: Technological advancements have transformed healthcare. System delays in transferring patients with ST-segment elevation myocardial infarction (STEMI) to a primary percutaneous coronary intervention (PCI) centre are associated with worse clinical outcomes. Our aim was to design and develop a secure mobile application, STEMIcathAID, streamlining communication, and coordination between the STEMI care teams to reduce ischaemia time and improve patient outcomes. Methods and results: The app was designed for transfer of patients with STEMI to a cardiac catheterization laboratory (CCL) from an emergency department (ED) of either a PCI capable or a non-PCI capable hospital. When a suspected STEMI arrives to a non-PCI hospital ED, the ED physician uploads the electrocardiogram and relevant patient information. An instant notification is simultaneously sent to the on-call CCL attending and transfer centre. The attending reviews the information, makes a video call and decides to either accept or reject the transfer. If accepted, on-call CCL team members receive an immediate push notification and begin communicating with the ED team via a HIPAA compliant chat. The app provides live GPS tracking of the ambulance and frequent clinical status updates of the patient. In addition, it allows for screening of STEMI patients in cardiogenic shock. Prior to discharge, important data elements have to be entered to close the case. Conclusion: We developed a novel mobile app to optimize care for STEMI patients and facilitate electronic extraction of relevant performance metrics to improve allocation of resources and reduction of costs.
RESUMO
INTRODUCTION: Numerous case series have reported on the baseline characteristics and in-hospital mortality of patients with COVID-19, however, these studies included patients localized in a specific geographic region. The purpose of our study was to identify differences in the clinical characteristics and the in-hospital mortality of patients with a laboratory-confirmed diagnosis of COVID-19 internationally. METHODS: A comprehensive search of all published literature on adult patients with laboratory-confirmed diagnosis of COVID-19 that reported on the clinical characteristics and in-hospital mortality was performed. Groups were compared using a Chi-square test with Yates correction of continuity. A two-tailed p value of less than 0.05 was considered as statistically significant. RESULTS: After screening 516 studies across the globe, 43 studies from 12 countries were included in our final analysis. Patients with COVID-19 in America and Europe were older compared to their Asian counterparts. Europe had the highest percentage of male patients. American and European patients had a higher incidence of co-morbid conditions (p < 0.05 for all variables). In-hospital mortality was significantly higher in America (22.23%) and Europe (22.9%) compared to Asia (12.65%) (p < 0.0001), but no difference was seen when compared with each other (p = 0.49). CONCLUSIONS: There is a significant variation in the clinical characteristics in patients diagnosed with COVID-19 across the globe. In-hospital mortality is similar between America and Europe, but considerably higher than Asia.
RESUMO
OBJECTIVES: To determine if non-invasive cerebral perfusion estimation provided by a new acousto-optic technology can be used as a reliable predictor of neurological outcome. PATIENTS AND METHODS: We performed a prospective, observational cohort study of consecutive comatose patients successfully resuscitated from out-of-hospital cardiac arrest. Patients were monitored using c-FLOW (Ornim Medical) from critical care unit admission up to 72â¯h, full awakening, or death. Primary outcome was favourable neurological outcome at hospital discharge, defined as a Cerebral Performance Category score of 1 or 2. RESULTS: A total of 21 patients were enrolled, without any loss to follow-up. Mean perfusion index over the monitoring period was not associated with functional outcome at hospital discharge (OR 1.03 [0.93, 1.17]). Adjustment for initial rhythm, time to return of spontaneous circulation and Glasgow coma scale motor score did not significantly alter the results (OR 1.06 [0.99, 1.12]). Mean perfusion index showed a poor discriminative value with an area under the curve of 0.60 for functional outcome (0.64 for survival). Correlation between the probes was weak (Pearson coefficient 0.35). CONCLUSION: Cerebral perfusion monitoring using a c-FLOW device in survivors of cardiac arrest is feasible, but reliability of the information provided has yet to be demonstrated. In our cohort, we were unable to identify any association between the perfusion index and clinical outcomes at discharge. As such, clinical management of cardiac arrest patients based on non-invasive perfusion index is not supported and should be limited to research protocols. The trial was registered with ClinicalTrials.gov, number NCT02575196.
Assuntos
Circulação Cerebrovascular , Parada Cardíaca/complicações , Monitorização Hemodinâmica/métodos , Hipóxia-Isquemia Encefálica/diagnóstico por imagem , Imagem de Perfusão/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Área Sob a Curva , Velocidade do Fluxo Sanguíneo , Dano Encefálico Crônico/etiologia , Capilares/fisiopatologia , Reanimação Cardiopulmonar , Coma/etiologia , Coma/fisiopatologia , Sistemas Computacionais , Feminino , Seguimentos , Parada Cardíaca/mortalidade , Parada Cardíaca/fisiopatologia , Parada Cardíaca/terapia , Monitorização Hemodinâmica/instrumentação , Humanos , Hipóxia-Isquemia Encefálica/etiologia , Hipóxia-Isquemia Encefálica/fisiopatologia , Masculino , Pessoa de Meia-Idade , Imagem de Perfusão/instrumentação , Projetos Piloto , Estudos Prospectivos , Espectroscopia de Luz Próxima ao Infravermelho/instrumentação , Espectroscopia de Luz Próxima ao Infravermelho/métodos , Resultado do Tratamento , Ultrassonografia/instrumentação , Ultrassonografia/métodosAssuntos
Betacoronavirus , Infecções por Coronavirus/sangue , Metemoglobinemia/virologia , Pandemias , Pneumonia Viral/sangue , Azitromicina/uso terapêutico , COVID-19 , Infecções por Coronavirus/tratamento farmacológico , Diabetes Mellitus , Deficiência de Glucosefosfato Desidrogenase/sangue , Hemólise , Humanos , Hidroxicloroquina/uso terapêutico , Masculino , Pessoa de Meia-Idade , Obesidade Mórbida , SARS-CoV-2 , Tratamento Farmacológico da COVID-19RESUMO
As health systems worldwide grapple with the coronavirus disease-2019 (COVID-19) pandemic, patients with durable LVAD support represent a unique population at risk for the disease. This paper outlines the case of such a patient who developed COVID-19 complicated by a "cytokine storm" with severe acute respiratory distress syndrome and myocardial injury and describes the challenges that arose during management.
RESUMO
BACKGROUND: Coronary artery calcification is associated with poor outcomes in patients undergoing percutaneous coronary intervention (PCI). Atheroablative techniques such as orbital atherectomy (OA) and rotational atherectomy (RA) are routinely utilized to treat these calcified lesions in order to optimize lesion preparation and facilitate stent delivery. OBJECTIVES: The purpose of this systematic review and meta-analysis is to compare the performance of OA versus RA in patients with calcified coronary artery disease (CAD) undergoing PCI. METHODS: We conducted an electronic database search of all published data for studies that compared OA versus RA in patients with calcified coronary artery disease undergoing PCI and reported on outcomes of interest. Event rates were compared using a forest plot of odds ratios using a random-effects model assuming interstudy heterogeneity. RESULTS: A total of five observational studies (total number of patients = 1872; OA = 535, RA = 1337) were included in the final analysis. On pooled analysis, OA compared to RA was associated with a significant reduction in fluoroscopy times (OR = -6.33; 95% CI = -9.90 to -2.76; p < .0005; I2 = 82). There was no difference between the two techniques in terms of contrast volume, coronary artery dissection, device induced arterial perforation, cardiac tamponade, slow flow/no reflow, periprocedural myocardial infarction (MI), in-hospital mortality, 30-day mortality, 30-day MI, 30-day target vessel revascularization (TVR), and 30-day major adverse cardiovascular events (MACE). CONCLUSION: Except for lower fluoroscopy time with OA, there are no significant differences between OA and RA in relation to procedural, periprocedural, and thirty day outcomes among patients with calcified CAD undergoing PCI.
Assuntos
Aterectomia Coronária/métodos , Doença da Artéria Coronariana/cirurgia , Vasos Coronários/cirurgia , Calcificação Vascular/cirurgia , Doença da Artéria Coronariana/etiologia , Humanos , Fatores de Risco , Calcificação Vascular/complicaçõesAssuntos
Síndrome Coronariana Aguda/terapia , Anticoagulantes/administração & dosagem , Fibrilação Atrial/tratamento farmacológico , Fibrinolíticos/administração & dosagem , Intervenção Coronária Percutânea , Inibidores da Agregação Plaquetária/administração & dosagem , Acidente Vascular Cerebral/prevenção & controle , Síndrome Coronariana Aguda/diagnóstico , Síndrome Coronariana Aguda/epidemiologia , Administração Oral , Anticoagulantes/efeitos adversos , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/epidemiologia , Trombose Coronária/epidemiologia , Trombose Coronária/prevenção & controle , Terapia Antiplaquetária Dupla , Fibrinolíticos/efeitos adversos , Hemorragia/induzido quimicamente , Humanos , Intervenção Coronária Percutânea/efeitos adversos , Inibidores da Agregação Plaquetária/efeitos adversos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Resultado do TratamentoRESUMO
INTRODUCTION: The purpose of this meta-analysis is to compare the efficacy of MitraClip plus medical therapy versus medical therapy alone in patients with functional mitral regurgitation (FMR). FMR caused by left ventricular dysfunction is associated with poor prognosis. Whether MitraClip improves clinical outcomes in this patient population remains controversial. METHODS: We conducted an electronic database search of PubMed, CINAHL, Cochrane Central, Scopus, Google Scholar, and Web of Science databases for randomized control trials (RCTs) and observational studies with propensity score matching (PSM) that compared MitraClip plus medical therapy with medical therapy alone for patients with FMR and reported on subsequent mortality, heart failure re-hospitalization, and other outcomes of interest. Event rates were compared using a random-effects model with odds ratio as the effect size. RESULTS: Five studies (n = 1513; MitraClip = 796, medical therapy = 717) were included in the final analysis. MitraClip plus medical therapy compared to medical therapy alone was associated with a significant reduction in overall mortality (OR = 0.66, 95% CI = 0.44-0.99, P = 0.04) and heart failure (HF) re-hospitalization rates (OR = 0.57, 95% CI = 0.36-0.91, P = 0.02). There was reduced need for heart transplantation or mechanical support requirement (OR = 0.48, 95% CI = 0.25-0.91, P = 0.02) and unplanned mitral valve surgery (OR = 0.21, 95% CI = 0.07-0.61, P = 0.004) in the MitraClip group. No effect was observed on cardiac mortality (P = 0.42) between the two groups. CONCLUSIONS: MitraClip plus medical therapy improves overall mortality and reduces HF re-hospitalization rates compared to medical therapy alone in patients with FMR.
RESUMO
OBJECTIVE: The purpose of this meta-analysis is to compare the safety and efficacy of transcatheter aortic-valve replacement (TAVR) to surgical aortic valve replacement (SAVR) in low-surgical-risk patients. BACKGROUND: TAVR is proven to be safe and effective in patients with high- and intermediate-risk aortic stenosis. However, there is limited data on the safety and efficacy of TAVR in patients with low surgical risk. METHODS: We conducted an electronic database search of all published data for studies that compared TAVR to SAVR in low-surgical-risk patients (mean society for thoracic surgery [STS] score <4% and/or logistic EuroScore <10%) and reported on subsequent all-cause mortality, cardiac mortality, stroke rates, and other outcomes of interest. Event rates were compared with a forest plot of odds ratio using a random-effects model assuming interstudy heterogeneity. RESULTS: A total of seven studies (n = 6,293 patients; TAVR = 2,912; and SAVR = 3,381) were included in the final analysis. There was no significant difference between TAVR and SAVR in terms of all-cause mortality (OR 0.82; 95% CI 0.50-1.36, I2 = 51%), cardiac mortality (OR 0.57; 95% CI 0.32-1.02, I2 = 0%), new pacemaker implantation (OR = 3.11; 95% CI 0.58-16.60, I2 = 89%), moderate/severe paravalvular leak (PVL; OR 3.50; 95% CI 0.64-19.10, I2 = 54%) and rate of stroke (OR 0.63; 95% CI 0.34-1.15, I2 = 39%) at 1-year follow-up. TAVR was found to have a significantly lower incidence of atrial fibrillation (AF; OR 0.15, 95% CI 0.10-0.24, I2 = 38%) as compared to SAVR. CONCLUSION: The results of our meta-analysis demonstrate similar rates of all-cause mortality, cardiac mortality, and stroke at 1-year follow-up in patients undergoing TAVR and SAVR. TAVR is associated with a lower incidence of AF relative to SAVR. However, there was a significantly higher incidence of PVL with TAVR compared to SAVR.