Network Meta-Analysis Comparing the Short- and Long-Term Outcomes of Alternative Access for Transcatheter Aortic Valve Replacement.

BACKGROUND: Several studies have pair-wise compared access sites for transcatheter aortic valve replacement (TAVR) but pooled estimate of overall comparative efficacy and safety outcomes are not well known. We sought to compare short- and long-term outcomes following various alternative access routes for TAVR. METHODS: Thirty-four studies with a pooled sample size of 32,756 patients were selected by searching PubMed and Cochrane library databases from inception through 11th June 2021 for patients undergoing TAVR via 1 of 6 different access sites: Transfemoral (TF), Transaortic (TAO), Transapical (TA), Transcarotid (TC), Transaxillary/Subclavian (TSA), and Transcaval (TCV). Data were extracted to conduct a frequentist network meta-analysis with a random-effects model using TF access as a reference group. RESULTS: Compared with TF, both TAO [RR 1.91, 95% CI (1.46-2.50)] and TA access [RR 2.12, 95% CI (1.84-2.46)] were associated with an increased risk of 30-day mortality. No significant difference was observed for stroke, myocardial infarction, major bleeding, conversion to open surgery, and major adverse cardiovascular or cerebrovascular events at 30 days between different accesses. Major vascular complications were lower in TA [RR 0.43, (95% CI, 0.28-0.67)] and TC [RR 0.51, 95% CI (0.35-0.73)] access compared to TF. The 1-year mortality was higher in TAO [RR of 1.35, (95% CI, 1.01-1.81)] and TA [RR 1.44, (95% CI, 1.14-1.81)] groups. CONCLUSION: Non-thoracic alternative access site utilization for TAVR implantation (TC, TSA and TCV) is associated with outcomes similar to conventional TF access. Thoracic TAVR access (TAO and TA) translates into increased short and long-term mortality.

Clinical comparison of V122I genotypic variant of transthyretin amyloid cardiomyopathy with wild-type and other hereditary variants: a systematic review.

V122I genotype variant (pV142I) is the most common hereditary transthyretin amyloidosis (hATTR) in the USA, with 3-3.5% of African-Americans being the carriers of this mutation. We aimed to compare baseline clinical features, cardiac parameters, and mortality in V122I-ATTR with the wild-type ATTR and other hATTR subtypes. We systematically searched PubMed/Medline and Google Scholar databases to identify relevant studies from inception to 10th September, 2020 reporting phenotypic, echocardiographic, and/or laboratory parameters in patients with hereditary and wild types of cardiac amyloidoses. A total of 2843 patients from 7 individual studies with 67-100% males and an overall follow-up duration of 51.6 ± 30.4 months were identified. The mean age of diagnosis among wild-type ATTR patients was 77 years, followed by 71.2 and 65 years in V122I and T60A group patients, respectively. V122I patients were mostly black, had a poor quality of life, and highest mortality risk compared with other subtypes. Merely, the presence of V122I mutation was identified as an independent predictor of mortality. V30M subtype correlated with the least severe cardiac disease and a median survival duration comparable with T60A subtype. V122I ATTR is an aggressive disease, prevalent in African-Americans, and is associated with a greater morbidity and mortality, which is partly attributed to its misdiagnosis and/or late diagnosis. Current advances in non-invasive studies to diagnose hATTR coupled with concurrent drug therapies have improved quality of life and provide a survival benefit to these patients.

In-Hospital Characteristics and 30-Day Readmissions for Acute Myocardial Infarction and Major Bleeding in Patients With Active Cancer.

There are limited data on readmission with ischemic and major bleeding events in patients with acute myocardial infarction (AMI) with active cancer. The purpose of our study was to evaluate in-hospital characteristics and 30-day readmission rates for recurrent AMI and major bleeding by cancer type in patients with AMI and active cancer. From 2016 through 2018, patients in the Nationwide Readmission Database admitted with AMI and underlying active colon, lung, breast, prostate, and hematological cancers were included. Thirty-day readmission for recurrent AMI and major bleeding were reported. Of 1,524,677 index hospitalizations for AMI, 35,790 patients (2.2%) had cancer (0.9% hematological; 0.5% lung; 0.4% prostate; 0.2% breast; and 0.1% colon). Compared with patients without cancer, patients with cancer were about 6 to 10 years older and had a higher proportion of atrial fibrillation, valvular heart disease, previous stroke, and a greater co-morbidity burden. Of all cancer types, only active breast cancer (adjusted odds ratios 1.82, 95% CI 1.11 to 2.98) was found to be significantly associated with elevated odds of readmission for major bleeding; no such association was observed for recurrent AMI. In conclusion, AMI in patients with breast cancer is associated with significantly greater odds of readmission for major bleeding within 30 days after discharge. Management of patients with concomitant AMI and cancer is challenging but should be based on a multidisciplinary approach and estimation of an individual patient's risk of major coronary thrombotic and bleeding events.

Role of pulmonary arterial capacitance in predicting mortality in patients with pulmonary hypertension: A systematic review and meta-analysis.

BACKGROUND: Pulmonary arterial capacitance or compliance (PAC) has been reported as an independent predictor of mortality in patients with pulmonary arterial hypertension (PAH) and pulmonary hypertension secondary to left heart disease (PH-LHD). METHODS: We conducted a literature search of PubMed/Medline, Google Scholar, and Cochrane library databases from July 30th to September 4th, 2020, and identified all the relevant studies reporting mortality outcomes in patients with PAH and PH-LHD. Pooled data from these studies were used to perform a meta-analysis to identify the role of PAC in predicting all-cause mortality in this subset of patients. RESULTS: Pooled data on 4997 patients from 15 individual studies showed that the mortality risk in patients with PAH and PH-LHD varies significantly per unit change in PAC either from baseline or during follow-up. A reduction in PAC per 1 ml/mmHg was associated with a 4.25 times higher risk of all-cause mortality (95% CI 1.42-12.71; p = 0.021) in PAH patients. Among patients with PH-LHD, mortality risk increased by ~30% following a unit decrease in PAC (HR, 1.29; p = 0.019), whereas an increase in PAC by 1 ml/mmHg lowered the mortality risk by 30% (HR, 0.70). CONCLUSION: PAC is a strong and independent predictor of all-cause mortality in both patients with PAH and PH-LHD. A decrease in PAC by 1 ml/mmHg from baseline or during follow-up significantly increases the risk of all-cause mortality among both patients with PAH and PH-LHD. Treatment modalities targeted at PAC improvement can affect the overall survival and quality of life in such patients.

Percutaneous catheter drainage of uncomplicated amoebic liver abscess: prospective evaluation of a clinical protocol for catheter removal and the significance of residual collections.

INTRODUCTION: Patients with amoebic liver abscess (ALA) may require percutaneous catheter drainage (PCD). Once the PCD output is substantially reduced or has ceased along with clinical recovery, residual collections on radiological evaluation may concern the treating physicians. The prevalence and significance of such collections is unknown, and the subsequent approach how to tackle them is unclear. METHODS: Consecutive patients with one or more uncomplicated ALAs requiring drainage were prospectively enrolled from 3 hospitals and managed based on a standard approach. Catheter removal was attempted after the patients fulfilled all 4 of the following criteria: disappearance of abdominal pain, absence of fever for at least 48 h, an improving trend of TLC (documented on 2 consecutive reports), and catheter drain output of < 10 ml/day for at least 2 consecutive days. RESULTS: A total of 110 patients (mean age 46.6 ± 10.5 years, 93.6% males, 89.1% alcoholics) underwent PCD placement; 69 patients (69/110; 62.7%) met all 4 criteria within 5 days of PCD placement (optimal response) and had an uncomplicated course. Patients with suboptimal responses (41/110; 37.3%) were evaluated for local and systemic complications; the appearance of fresh collections (5/110; 4.5%), abscess rupture (2/110; 1.8%), bile leakage (3/110; 2.7%), cholangitis (2/110; 1.8%), thrombophlebitis (2/110; 1.8%) and hospital-acquired infections (2/110; 1.8%) were diagnosed and treated accordingly. Ultimately, PCD removal (based on the fulfilment of all 4 criteria) was universally successful after a median of 5 days (IQR, 4-9 days). None of the patients had symptom recurrence after PCD removal, although residual collections were still seen in 97.3% of patients at the time of PCD removal and in 92.1% and 84.9% of patients available for follow-up at 1 and 3 months, respectively. CONCLUSION: Based on our clinical protocol, PCD removal in ALA can be successfully expedited even in the presence of residual collections. An inability to fulfill all 4 criteria within 5 days of PCD placement warrants further evaluations for local and systemic complications that require additional therapeutic measures.

Aggressive versus conservative fluid resuscitation in septic hemodialysis patients.

PURPOSE: Sepsis and bacterial infections are common in patients with end-stage renal disease (ESRD). We aimed to compare patients with ESRD on hemodialysis presenting to hospital with severe sepsis or septic shock who received <20 ml/kg of intravenous fluid to those who received ≥20 ml/kg during initial resuscitation. MATERIALS AND METHODS: We conducted a retrospective chart review of adult patients with ICD codes for discharge diagnosis of sepsis, severe sepsis, septic shock, ESRD, and hemodialysis admitted to our institution between 2015 and 2018. RESULTS: We present outcomes for a total of 104 patients - 51 patients in conservative group and 53 in aggressive group. The mean age was 69.5 ± 11.2 years and 71 ± 11.5 years in the conservative group and aggressive group, respectively. There was no significant difference in the rate of ICU admission, and ICU or hospital length of stay between the two groups. Complications such as volume overload, rate of intubation, and urgent dialysis were not found to be significantly different. CONCLUSION: We found that aggressive fluid resuscitation with ≥20 ml/kg may not be detrimental in the initial resuscitation of ESRD patients with SeS or SS. However, a clinical decision of volume responsiveness should be made on a case-by-case basis rather than a universal approach for fluid resuscitation in ESRD patients.

Iatrogenic Delayed Pneumothorax After Transbronchial Biopsy.

Transbronchial biopsy (TBB) is one of the commonly performed procedures by pulmonologists in everyday practice. Although the procedure has a very low-risk profile, complications often develop in certain patients. Pneumothorax is one such complication pertaining to TBB. As only a small percent of procedures get complicated by pneumothorax, handful of cases have been reported with its delayed occurrence in the past 5 decades. The purpose of our report is to highlight another uncommon yet interesting case of delayed iatrogenic pneumothorax in an immunocompromised patient after TBB. Although the chain of events behind the pathophysiology of delayed pneumothorax largely remain a mystery, its development has been linked to altered immune mechanics as they are frequently recognized in immunocompromised patients.

Risk of early postoperative acute kidney injury with stroke volume variation-guided tetrastarch versus Ringer's lactate.

BACKGROUND: Whether intraoperative use of hydroxyethyl starch (HES) solutions is associated with postoperative acute kidney injury (AKI) continues to be researched. Urinary neutrophil gelatinase-associated lipocalin (NGAL) is validated for early detection of AKI. Previous studies are limited and use empirically predefined volumes of HES solutions with serum creatinine as marker for AKI. MATERIALS AND METHODS: Adults scheduled for orthopedic surgery under general anesthesia with >200-300 mL blood loss expected were included; 40 were randomized to receive 6% HES 130/0.4 (tetrastarch) (group HES) or Ringer's lactate (group RL) boluses when stroke volume variation (SVV) >10% in supine or lateral position, or >14% in prone position. Incidence of early postoperative AKI using urinary NGAL (>100 ng/mL) was the primary outcome, and using derangement of serum creatinine was the secondary measure. RESULTS: In 38 patients, intervention was completed, and incidence of AKI (postoperative urinary NGAL >100 ng/mL) among them was 0% in both groups. Patients with urinary NGAL >50 ng/mL were insignificantly higher for group RL versus group HES (6/19 vs. 4/19) (P = 0.461), as were those with incidence of AKI as per creatinine values (5/19 vs. 4/19) (P = 1.000). Group RL had significantly higher requirement of fluid (1211 ± 758 mL vs. 689 ± 394 mL) (P = 0.013) and lower cardiac index (P < 0.05) versus group HES. CONCLUSION: SVV-guided tetrastarch and Ringer's lactate do not result in postoperative AKI diagnosed by urinary NGAL >100 ng/mL; however, an insignificant trend for better renal functions as well as significantly more efficacious volume expansion and hemodynamic stability were seen with tetrastarch instead.