Effect of Genotype-Guided Oral P2Y12 Inhibitor Selection After Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis of Randomized Clinical Trials.

BACKGROUND: Clopidogrel is the most frequently used P2Y12 inhibitor as a component of the dual antiplatelet regimen in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). Prior studies have shown the variable efficacy of clopidogrel due to genotypic differences in the CYP2C19 enzyme function, which converts clopidogrel to its active metabolite. The aim of this meta-analysis is to evaluate the effectiveness of genotype testing-guided P2Y12 inhibitor prescription therapy to patients after PCI for ACS compared to non-genotype guided conventional treatment. METHODS: A comprehensive literature search was performed in PubMed, Embase, and Cochrane to identify relevant trials. 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: Seven studies with 9617 patients were included. Genotype-guided strategy arm included prasugrel or ticagrelor prescription to patients with loss of function (LOF) of CYP219 alleles (most commonly alleles being *2 and *3) and clopidogrel prescription to those without the LOF allele. The conventional arm included patients treated with clopidogrel without genotype testing. Comparison of genotype arm with conventional arm showed decreased major adverse cardiovascular events (MACE), improved cardiovascular (CV) mortality, and reduced incidence of myocardial infarction (MI) in the genotype arm, and a similar stroke incidence in the two arms. Regarding adverse events, the incidence of stent thrombosis was lower in the genotype arm than the conventional arm. CONCLUSION: Our analysis illustrates the possible advantages of genotype-guided P2Y12 inhibitor prescription strategy compared to non-genotype-guided strategy with reductions in MACE, CV mortality, MI, and stent thrombosis. This analysis can be used as a stepping stone to conducting further trials determining the efficacy of this treatment strategy in various ACS subtypes.

Next-Day Discharge vs Early Discharge After Transcatheter Aortic Valve Replacement: Systematic Review and Meta-Analysis.

With the growing utilization of transcatheter aortic valve replacement (TAVR) as an alternative option to surgical valve replacement (SAVR) in patients considered to be suboptimal for surgery, there is a need to explore the possibility of next day discharge (NDD) and its potential outcomes. The aim of our study is to compare outcomes and complications following NDD vs the standard early discharge (ED) (less than 3 days). A comprehensive literature search was performed in PubMed, Embase, and Cochrane to identify relevant trials. Summary effects were calculated using a DerSimonian and Laird random effects model as odds ratio with 95% confidence intervals for all the clinical endpoints. Studies comparing same-day or next-day discharge vs discharge within the next three days were included in our analysis. 6 studies with 2,672 patients were identified. The risk of bleeding and vascular complications was significantly lower in patients with NDD compared to ED (OR 0.10, P < 0.00001 and OR 0.22, P = 0.002 respectively). The incidence of permanent pacemaker (PPM) implants was significantly lower in patients who had NDD compared to ED (OR 0.21, P = 0.0005). The incidence of 30 day mortality, stroke, AKI and readmission rates was not different between the two groups. NDD after TAVR allows for reduction in hospital stay and can mitigate hospital costs without an increased risk of complications. Our analysis shows that complication rate is comparable to ED, NDD is a reasonable option for certain patients with severe aortic stenosis who undergo TAVR. Further studies are needed to elucidate whether higher risk patients who would benefit from an extended inpatient monitoring post TAVR.

Multimodality Imaging and Percutaneous Closure of Right Sinus of Valsalva to Right Ventricular Outflow Tract Fistula After Transcatheter Aortic Valve Replacement.

We present the diagnosis and treatment of a 90-year-old male with critical aortic stenosis and multiple medical comorbidities who underwent TAVR that was complicated by annular rupture.

Atherosclerosis of the Internal Mammary Artery: Intravascular Ultrasound and Virtual Histology Imaging.

Atherosclerotic disease of the shaft of the internal mammary artery (IMA) is rare. This imaging series demonstrates that angiography or arterial duplex ultrasound before bypass surgery of the IMA should be performed even when considering the patient for an emergent bypass surgery.

Multimodality Imaging and Percutaneous Closure of a Large Left Main Coronary Artery to Superior Vena Cava Fistula.

Images illustrate 3D reconstruction CT showing fistula arising from the left main coronary artery draining into the superior vena cava. Additional angiographic images show the fistula before and after percutaneous closure with Amplatzer Vascular plugs.