Transulnar versus transradial access for coronary angiography or percutaneous coronary intervention: A meta-analysis of randomized controlled trials.

BACKGROUND: Although transfemoral access (TFA) remains the standard of care for patients undergoing coronary angiography (CA) or percutaneous coronary intervention (PCI) in the USA, TRA is being increasingly used over TFA due to lower bleeding and mortality rates on the basis of meta-analyses and recently published MATRIX trial. In patients with unsuccessful ipsilateral radial access, TUA has been used as an alternative approach. The randomized controlled trials (RCTs) comparing TUA and TRA have reached mixed conclusions regarding the use of transulnar approach for coronary procedures. OBJECTIVES: To systematically review and perform a meta-analysis of published RCTs comparing the safety and efficacy of transulnar access (TUA) vs. transradial access (TRA) in patients undergoing CA or PCI. METHODS: PubMed, EMBASE, and CENTRAL databases were searched for RCTs since inception through December, 2014. Meta-analysis was performed using random-effects model. RESULTS: Five RCTs involving 2,744 total patients were included in the meta-analysis. TUA compared with TRA had similar risks of MACE [risk ratio (RR): 0.87; 95% confidence interval (CI): 0.56-1.36; P = 0.54] and access-related complications [RR: 0.92 (0.67-1.27); P = 0.62]. Higher rates of access cross-over [RR: 2.31 (1.07-4.98); P = 0.003] and number of punctures [1.57 vs. 1.4; mean difference (MD): 0.17; 95% CI: 0.08-0.26; P = 0.0002] were noted with TUA. There was no difference in arterial access time [12.8 vs. 10.9 min; MD: 1.86 (-1.35-5.7); P = 0.26], fluoroscopy time [7.6 vs. 7.2 min; MD: 0.37 (-0.39 - 1.13); P = 0.34] and contrast volume [151 vs. 153.7 ml; MD: -2.74 (-17.21 - 11.73); P = 0.71]. CONCLUSION: For patients requiring CA or PCI, TUA compared with TRA has similar efficacy and safety except for higher puncture rates and access cross-over.

Your Heart, My Hands: Cardiac surgeon Arun Singh's memoir an engrossing immigrant saga of struggles, successes - in life and in the OR.

[Full article available at http://rimed.org/rimedicaljournal-2019-02.asp].

Status of drug-eluting coronary stents.

Significant advances in interventional cardiology have occurred over the past 30 years, leading to substantial increases in the number and anatomic complexity of treated patients, the long-term success of these procedures, and a reduction in the need for coronary bypass surgery. While the risk ofrestenosis has been dramatically reduced by drug-eluting stents, delayed neo-intimal healing has led to a small, but significant occurrence of "late" stent thrombosis. This thrombotic risk is substantially reduced by continuation of dual-anti-platelet therapy for one or more years following DES placement. Current guidelines for patient selection for DES, for duration of DAT following DES, and for facing surgical and invasive procedures after DES were discussed, and the avoidance of early discontinuation of anti-platelet therapy following DES was emphasized.

Direct Oral Anticoagulants (DOACs): Current Status Among Distinct Patient Subgroups.

The landscape of anticoagulant therapy for atrial fibrillation and deep-vein thrombosis has evolved considerably in the last decade with the advent of Novel or Direct-Acting Oral Antiocoagulants (DOACs). The initial phase III randomized controlled trials established the individual DOACs as viable alternatives to warfarin for thromboprophylaxis but generalizations to the larger population were limited by the small number of protocol subjects with renal insufficiency, congestive heart failure, advanced age and other comorbidities. All the DOACs have some degree of renal excretion and while safe and effective in patients with mild to moderate renal insufficiency, dose adjustment is necessary based on creatinine clearance. Subsequent data registries and real-world experience with DOACs have continued to refine their role in these particular patient subgroups. Off-label use with both under- and overdosing is not uncommon in renal failure and carries increased risk. Their increasing use among the elderly, in patients with heart failure, hepatic and renal insufficiency and among the Asian population has been shown to be relatively safe and effective compared to warfarin. Gaps in our current understanding of this new class of anticoagulants will continue to narrow as additional data becomes available through ongoing registries and real-world experience. [Full article available at http://rimed.org/rimedicaljournal-2017-05.asp].

Spontaneous calcific coronary embolus from a degenerative calcific aortic valve-a rare cause of acute ST segment elevation myocardial infarction.

This case report describes pathology-proven spontaneous coronary embolization from a calcific aortic valve resulting in an acute ST segment elevation myocardial infarction. It serves as an important reminder that, especially for elderly patients with coexisting aortic valvular disease, initial treatment for abrupt coronary artery occlusion with aspiration thrombectomy catheterization is standard of care.