Transcatheter Mitral Annuloplasty: Carillon Device.

Functional mitral regurgitation (FMR) is a common valvular heart disease in the geriatric population across the United States. This patient cohort is multimorbid and often has a prohibitive risk for conventional open-heart surgery. The diverse anatomic pathology of FMR is a complex problem and unfortunately does not have a universal solution. Carillon Mitral Contour System (Cardiac Dimensions, Kirkland, WA, USA) is a new device that provides transcatheter annular remodeling. In this review article, the authors summarize the evidence for the Carillon Mitral Contour System for FMR.

Concomitant Redo Transcatheter Aortic Valve Replacement and Valve-in-Mitral Annular Calcification.

Contemporary challenges in structural heart intervention include redo transcatheter aortic valve replacement and transcatheter mitral valve replacement in severe mitral annular calcification. We report a case of concomitant redo transcatheter aortic valve replacement and transcatheter mitral valve replacement in mitral annular calcification in a patient with radiation heart disease. (Level of Difficulty: Advanced.).

A systematic review and meta-analysis of the clinical outcomes of TAVI versus SAVR in the octogenarian population.

BACKGROUND: Surgical aortic valve replacement (SAVR) has shown safe, robust results in elderly populations, and up until recently, was the gold standard for management of severe aortic stenosis. The approach to severe aortic stenosis in high-risk populations, such as octogenarians, has been challenged with the development of transcatheter-based strategies. We sought to systematically analyse outcomes between surgical and transcatheter aortic valve replacement (TAVI) in octogenarians. METHOD: Electronic databases were searched from their inception until November 2018 for studies comparing SAVR to TAVI in octogenarians, according to a predefined search criterion. The primary end point was mortality, and secondary end points included post-procedural complications. RESULTS: The review yielded four observational studies. The total number of patients included was 1221 including 395 who underwent TAVI and 826 SAVR. On average, patients from both subgroups carried a high number of cardiac risk factors, and STS-PROM scoring yielded mean values equating to high-risk population groups, with significantly higher values for TAVI patients across the board. The presence of post-procedural moderate aortic regurgitation was noted only in the TAVI population (OR = 8.88; 95% CI (1.47-53.64), χ2 = 1.22; p = 0.02; I 2 = 0%). Otherwise, there were no significant differences when accounting for mortality (OR = 0.68; 95% CI (0.44-1.05), χ2 = 1.88; p = 0.60; I 2 = 0%), permanent pacemaker implantation groups (OR = 0.45; 95% CI (0.44-1.49), χ2 = 0.11; p = 0.19; I 2 = 0%), and neurological events (OR = 0.72; 95% CI (0.42-1.23), χ2 = 2.57; p = 0.23; I 2 = 22%). DISCUSSION: The analysed data on TAVI versus SAVR in the octogenarian population show that TAVI shows similar outcomes with relation to mortality and inpatient admission times, in a population with significantly higher risk profiles than their SAVR counterparts. TAVI has higher occurrences of post-procedural AR. TAVI still does not have robust long-term data to ensure its efficacy and rate of complications, but is showing promising results nonetheless.

Implications of Renal Disease in Patients Undergoing Structural Interventions.

Chronic kidney disease patients have a high prevalence of severe valvular heart disease, which reduces life expectancy. Transcatheter valve interventions has revamped the way we manage severe valvular heart disease and are an attractive alternative to invasive surgery in patients with chronic kidney disease and severe valvular heart disease. This review summarizes the impact of transcatheter valve interventions in patients with severe valvular heart disease and chronic kidney disease.

Functional tricuspid regurgitation: Feasibility of transcatheter interventions.

Functional tricuspid regurgitation (TR) develops secondary to annular dilation and leaflet tethering as a result of right ventricular remodeling. Invasive surgery for isolated TR is rarely performed due to high inpatient mortality. Transcatheter tricuspid valve intervention is an appealing solution but is challenging as crucial structures are closely related to the tricuspid valve, and intracardiac devices pose further challenges to device delivery and implantation.

Contemporary review of percutaneous therapy for tricuspid valve regurgitation.

Introduction: Moderate to severe tricuspid regurgitation (TR) is a poor prognostic factor regardless of right ventricular function. However, a majority of patients are managed medically rather than undergoing isolated tricuspid valve surgery due to high in-hospital mortality. Percutaneous therapy in the form of transcatheter tricuspid valve repair or replacement is an attractive option for this high risk multimorbid cohort.Areas covered: A literature search was performed for tricuspid valve repair or replacement using MEDLINE, Current Contents Connect, Google Scholar, EMBASE, Cochrane library, PubMed, ScienceDirect, and Web of Science (Till 10/19). This review outlines the anatomical challenges specific to the tricuspid valve, provides an insight into patient selection for percutaneous treatment, and summarizes the current evidence for the available devices.Expert opinion: With the recent understanding that percutaneous repair of TR is feasible and provides better patient outcomes, we must more closely evaluate our patients with tricuspid regurgitation and consider treatment. MitraClip in the tricuspid position (TriClip) is the most widely used TV repair device, and several prospective trials are currently investigating various devices in this arena that hopefully will hopefully provide greater insight into patient selection and anatomically specific device choice.

Unplanned hospital readmissions after acute myocardial infarction: a nationwide analysis of rates, trends, predictors and causes in the United States between 2010 and 2014.

BACKGROUND: Unplanned hospital readmissions are an important quality metric for benchmarking, but there are limited data following an acute myocardial infarction (AMI). This study aims to examine the 30-day unplanned readmission rate, predictors, causes and outcomes after hospitalization for AMI. METHODS: The USA Nationwide Readmission Database was utilized to analyze patients with a primary diagnosis of AMI between 2010 and 2014. Rates of readmissions, causes and costs were determined and multiple logistic regressions were used to identify predictors of readmissions. RESULTS: Of 2 204 104 patients with AMI, the 30-day unplanned readmission rate was 12.3% (n = 270 510), which changed from 13.0 to 11.5% between 2010 and 2014. The estimated impact of readmissions in AMI was ~718 million USD and ~281000 additional bed days per year. Comorbidities such as diabetes [odds ratio (OR) 1.27, 95% confidence interval (CI) 1.25-1.29], chronic lung disease (OR 1.29, 95% CI 1.26-1.31), renal failure (OR 1.38, 95% CI 1.35-1.40) and cancer (OR 1.35, 95% CI 1.30-1.41) were independently associated with unplanned readmission. Discharge against medical advice was the variable most strongly associated with unplanned readmission (OR 2.40, 95% CI 2.27-2.54). Noncardiac causes for readmissions accounted for 52.9% of all readmissions. The most common cause of cardiac readmission was heart failure (14.3%) and for noncardiac readmissions was infections (8.8%). CONCLUSION: Readmissions during the first month after AMI occur in more than one in 10 patients resulting in a healthcare cost of ~718 million USD per year and ~281000 additional bed days per year. These findings have important public health implications. Strategies to identify and reduce readmissions in AMI will dramatically reduce healthcare costs for society.

Hybrid Robotic Impella-Assisted Single Arterial Access ComplexHigh-Risk Percutaneous Coronary Intervention.

Robotic-assisted percutaneous coronary intervention (PCI) has become popular among operators due to substantial reduction in radiation dose. Complex coronary intervention often requires mechanical support and have long fluoroscopy time. Robotic PCI offers an elegant solution by reducing operator fatigue and offering better analysis in the robotic console. We report a hybrid robotic impella assisted single arterial access complex high-risk PCI to the left anterior descending artery via the left internal mammary artery.

Same-Day Discharge After Transcatheter Native Aortic and Mitral Valve-in-Valve Replacement.

Transcatheter aortic valve replacement has become the gold standard of care in the management of patients with severe aortic stenosis and transcatheter mitral valve-in-valve replacement seems to be an attractive alternative to redo surgery. We report the first case of concomitant transcatheter aortic valve replacement/transcatheter mitral valve-in-valve replacement that was performed under conscious sedation who was subsequently discharged the same day. (Level of Difficulty: Advanced.).

Outcomes of patients who undergo percutaneous coronary intervention with covered stents for coronary perforation: A systematic review and pooled analysis of data.

OBJECTIVES: This review aims to evaluate the adverse outcomes for patients after treatment with covered stents. BACKGROUND: Coronary perforation is a potentially fatal complication of percutaneous coronary revascularization which may be treated using covered stents. Studies have evaluated long-term outcomes among patients who received these devices, but hitherto no literature review has taken place. METHODS: We conducted a systematic review of adverse outcomes for patients after treatment with covered stents. Data from studies were pooled and outcomes were compared according to stent type. RESULTS: A total of 29 studies were analyzed with data from 725 patients who received covered stents. The proportion of patients with chronic total occlusions, vein graft percutaneous coronary intervention (PCI), intracoronary imaging and rotational atherectomy were 16.9, 11.5, 9.2, and 6.6%, respectively. The stents used were primarily polytetrafluoroethylene (PTFE) (70%) and Papyrus (20.6%). Mortality, major adverse cardiovascular events, pericardiocentesis/tamponade and emergency surgery were 17.2, 35.3, 27.1, and 5.3%, respectively. Stratified analysis by use of PTFE, Papyrus and pericardial stents, suggested no difference in mortality (p = .323), or target lesion revascularization (p = .484). Stent thrombosis, pericardiocentesis/tamponade and emergency coronary artery bypass surgery (CABG) occurred more frequently in patients with PTFE stent use (p = .011, p = .005, p = .012, respectively). In-stent restenosis was more common with pericardial stent use (<.001, pooled analysis for first- and second-generation pericardial stents). CONCLUSIONS: Cases of coronary perforation which require implantation of a covered stent are associated with a high rate of adverse outcomes. The use of PTFE covered stents appears to be associated with more stent thrombosis, pericardiocentesis/tamponade, and emergency CABG when compared to Papyrus or pericardial stents.

Impact of Incomplete Percutaneous Revascularization in Patients With Multivessel Coronary Artery Disease: A Systematic Review and Meta-Analysis.

BACKGROUND: Up to half of patients undergoing percutaneous coronary intervention have multivessel coronary artery disease (MVD) with conflicting data regarding optimal revascularization strategy in such patients. This paper assesses the evidence for complete revascularization (CR) versus incomplete revascularization in patients undergoing percutaneous coronary intervention, and its prognostic impact using meta-analysis. METHODS AND RESULTS: A search of PubMed, EMBASE, MEDLINE, Current Contents Connect, Google Scholar, Cochrane library, Science Direct, and Web of Science was conducted to identify the association of CR in patients with multivessel coronary artery disease undergoing percutaneous coronary intervention with major adverse cardiac events and mortality. Random-effects meta-analysis was used to estimate the odds of adverse outcomes. Meta-regression analysis was conducted to assess the relationship with continuous variables and outcomes. Thirty-eight publications that included 156 240 patients were identified. Odds of death (OR 0.69, 95% CI 0.61-0.78), repeat revascularization (OR 0.60, 95% CI 0.45-0.80), myocardial infarction (OR 0.64, 95% CI 0.50-0.81), and major adverse cardiac events (OR 0.63, 95% CI 0.50-0.79) were significantly lower in the patients who underwent CR. These outcomes were unchanged on subgroup analysis regardless of the definition of CR. Similar findings were recorded when CR was studied in the chronic total occlusion (CTO) subgroup (OR 0.65, 95% CI 0.53-0.80). A meta-regression analysis revealed a negative relationship between the OR for mortality and the percentage of CR. CONCLUSION: CR is associated with reduced risk of mortality and major adverse cardiac events, irrespective of whether an anatomical or a score-based definition of incomplete revascularization is used, and this magnitude of risk relates to degree of CR. These results have important implications for the interventional management of patients with multivessel coronary artery disease.

Is Sentinel Lymph Node Biopsy Necessary in Patients Undergoing Prophylactic Mastectomy? A Systematic Review and Meta-Analysis.

The gain by performing sentinel lymph node biopsy (SLNB) during prophylactic mastectomy (PM) is debatable, and we performed a meta-analysis of existing literature to evaluate that the role of SLNB in subjects undergoing PM. A systematic search was conducted using MEDLINE, PubMed, EMBASE, Current Contents Connect, Cochrane library, Google Scholar, Science Direct, and Web of Science. The search identified 11 relevant articles reporting on patients who underwent SLNB at the time of PM. Data were abstracted from each study and used to calculate a pooled odds ratio (OR) and 95% confidence interval (95% CI). We included 14 studies comprising of 2,708 prophylactic mastectomies. Among 2,708 prophylactic mastectomies, the frequency of occult invasive cancer (51 cases) was 1.8% and the rate of positive SLNs (33 cases) was 1.2%. In 25 invasive cancers at the time of PM were found to have negative SLNs which avoided axillary lymph node dissection (ALND). In seven cases with positive SLNBs were found not to have invasive cancer at the time of PM and needed a subsequent ALND. Most of the patients with positive SLNs had locally advanced disease in the contralateral breast. SLNB may be suitable for patients with ipsilateral, locally advanced breast cancer and is not recommend for all patients undergoing PM.

HER2 expression in gastric and oesophageal cancer: a meta-analytic review.

BACKGROUND: Since the advent and the success of adjuvant medical therapy for human epidermal growth factor receptor 2 (HER2)-positive breast cancer in the form of trastuzumab there has been increasing interest in the development of similar therapies in other solid organ malignancies including gastric cancer and oesophageal cancer. Over the years, multiple observational studies have been inconsistent. Several meta-analyses have been published looking at the association between HER2 and gastric cancer and oesophageal cancer. This review aims to summarize the meta-analytic evidence for the association between HER2 in gastric and oesophageal cancer. METHODS: A systematic search was conducted using MEDLINE, PubMed, EMBASE, Current Contents Connect, Cochrane Library, Google Scholar, Science Direct, and Web of Science. RESULTS: Of the articles selected, only nine studies met full criteria. Six of them reviewed the role of HER2 in gastric cancer and the remaining three reviewed its role in oesophageal cancer. CONCLUSIONS: The current evidence regarding the role of HER2 is unclear. However, it clearly plays a key role in the pathogenesis of gastric and oesophageal carcinomas. Targeted therapy towards this subgroup (despite variable frequency and association with survival) would offer a mortality benefit and improve survival.

Recurrence and functional outcomes of partial adrenalectomy: a systematic review and meta-analysis.

BACKGROUND: Partial adrenalectomy is typically performed for the treatment of hereditary and sporadic bilateral tumours, to reduce the risk of adrenal failure, particularly in younger patients. Partial adrenalectomy proposes a postoperative steroid-free course nevertheless, is associated with the risk of local recurrence. In this study we evaluate the recurrence and functional outcomes of partial adrenalectomy. METHODS: A systematic search was conducted using MEDLINE, PubMed, EMBASE, Current Contents Connect, Cochrane library, Google Scholar, Science Direct, and Web of Science. The search identified 60 relevant articles reporting on patients who underwent partial adrenalectomy. Data was extracted from each study and used to calculate a pooled event rate and 95% confidence interval (95% CI). RESULTS: The overall recurrence rate was 8% (95% CI: 0.05-0.12) and the 85% (95% CI: 0.78-0.9) of the patients were steroid free. The recurrence rates were the least in the retroperitoneoscopic group 1% (95% CI: 0-0.04) and Conn's syndrome group 2% (95% CI: 0.01-0.05) and highest in open group 15% (95% CI: 0.07-0.28) and Pheochromocytoma group 10% (95% CI: 0.07-0.16). Steroid independence rates were best in the Conn's syndrome group 97% (95% CI: 0.85-0.99) and laparoscopic group 88% (95% CI: 0.75-0.95). CONCLUSIONS: Partial adrenalectomy can obviate the need for steroid replacement in the majority of patients and local recurrence rates appear to be infrequent. For patients with hereditary and bilateral adrenal tumours, partial adrenalectomy should be recommended as a primary surgical approach whenever possible.

Systematic review and meta-analysis of minimally invasive techniques for the management of cholecysto-choledocholithiasis.

BACKGROUND: The optimal management of patients with symptomatic gallstones and possible or proven common bile duct (CBD) stones and gallstones is still evolving. Today a number of options exist: preoperative endoscopic retrograde cholangiopancreatography (pre-op ERCP), laparoscopic cholecystectomy (LC) combined with intraoperative endoscopic sphincterotomy (IOES), laparoscopic common bile duct exploration (LCBDE) and postoperative ERCP (post-op ERCP). This meta-analysis was done to compare these management options and determine if any single option was clearly superior. METHODS: A systematic search was conducted using several electronic databases. The search revealed 15 randomized controlled trials (RCTs). Six comparing pre-op ERCP with LCBDE, five comparing pre-op ERCP with IOES, two comparing IOES with LCBDE and two comparing post-op ERCP with LCBDE, comprising a total of 1992 patients. RESULTS: The pre-op ERCP group had a significantly higher incidence of ERCP related complications (odds ratio: 2.40, 95% confidence interval: 1.21-4.75). CONCLUSIONS: The evidence provided by this meta-analysis suggests that both of these approaches would appear comparable. To fully address which would be the better approach would require an RCT as discussed above.

Ill-fitting dentures and oral cancer: a meta-analysis.

OBJECTIVES: Several studies have investigated the relationship between the use of dentures and the duration of denture use and cancer development. Of particular interest is whether ill-fitting dentures increase the likelihood of the development of oral cancer. We conducted a meta-analysis to determine the relationship between dentures and the development of cancer. MATERIALS AND METHODS: We searched several databases (PubMed, Medline, EMBASE, Web of Science, and the Cochrane Database of Systematic Reviews) to find published papers on the topic. In particular, the duration of denture use and the comfort and fit of the dentures were investigated. RESULTS: The use of dentures by itself is associated with an increased risk of developing cancer (OR: 1.42, 95% CI: 1.01-1.99). In addition, ill-fitting dentures appears to substantially increase the risk of developing cancer (OR: 3.90, 95% CI: 2.48-6.13). In addition, there was no link between the duration of denture use and cancer development. This might be due to the arbitrary nature of what we defined as short and long term denture use and may have been affected by the inconsistency in time categorization between different studies. CONCLUSION: Ill-fitting dentures are a risk factor for the development of oral cancer, greater patient education and regular checking of dentures by dentists should be undertaken as a prevention measure.

Transcatheter valve-in-valve implantation: a systematic review of literature.

INTRODUCTION: Transcatheter aortic valve implantation (TAVI) has become an alternative to open surgery in those deemed high risk. The purpose of this study was to evaluate the effectiveness and outcomes of this emerging procedure. We have examined available literature to provide an overview of valve-in-valve implantation using transcatheter heart valves (THVs) in aortic, mitral, pulmonary, tricuspid positions. METHODS: A systematic search was conducted using MEDLINE, PubMed, EMBASE, Current Contents Connect, Cochrane library, Google Scholar, Science Direct, and Web of Science. RESULTS: Only 61 studies met full criteria and were included the review. This included 31 studies reporting transcatheter aortic valve-in-valve implantation, mitral valve-in-valve implantation (13 studies), tricuspid valve-in-valve implantation (12 studies), and pure native aortic valve regurgitation (nine studies). One of the limitations of this review is that most of the studies included were case reports, together with some case series. CONCLUSION: Valve-in-valve implantation can be considered as an acceptable alternative to conventional open heart surgery for elderly high-risk surgical patients with bioprosthetic degeneration. Long-term follow-up of treated patients will be necessary to establish the true role of valve-in-valve implantation for bioprosthetic degeneration. Patients should be evaluated on an individual basis until outcomes are proven in large cohort studies or randomised trials.

Endoscopic stenting versus operative gastrojejunostomy for malignant gastric outlet obstruction-a systematic review and meta-analysis of randomized and non-randomized trials.

BACKGROUND: Open surgical gastrojejunostomy (GJ) has been the treatment of choice, but it has high morbidity and mortality rates. During the last decade, endoscopic self-expandable metal stents (SEMS) have been used. This meta-analysis aimed to compare surgical GJ and endoscopic stenting in palliation of malignant gastric outlet obstruction (GOO). METHODS: A systematic search was conducted using MEDLINE, PubMed, EMBASE, Current Contents Connect, Cochrane library, Google Scholar, Science Direct, and Web of Science. The search identified 3 randomized controlled trials (RCTs) and 14 non-RCTs reporting on patients who underwent surgical GJ or endoscopic stenting for malignant gastroduodenal outflow obstruction. RESULTS: THE RESULTS OF THE THREE RCTS DEMONSTRATED THAT SEMS RESULTED IN COMPARABLE MAJOR [ODDS RATIO (OR): 0.62, 95% confidence intervals (CI): 0.021-18.371] and minor (OR: 0.32, 95% CI: 0.049-2.089) complications in a shorter time to tolerating an oral intake (SEMS: 3.55 days and GJ: 7.15 days) and shorter hospital stay (SEMS: 5.1 days and GJ: 12.13 days, however, statistical insignificant P value =0.11). Among the non RCTs: SEMS resulted in a shorter time to tolerating an oral intake (SEMS: 1.48 days and GJ: 8.07 days, P value <0.01), similar rate of complications (OR: 0.33, 95% CI: 0.1-1.08), lower mortality (OR: 0.5, 95% CI: 0.21-1.20, P value <0.01) and a shorter hospital stay (SEMS: 7.61 days and GJ: 19.04 days, P value <0.0001). There was no significant difference between median survival times among RCTs and non RCTs. CONCLUSIONS: These findings suggest that stent placement is associated with better short-term outcomes and hence, duodenal stenting is a safe means of palliating malignant gastric outflow obstruction. However, a large RCT is needed to systematically compare stent placement with GJ with regard to medical effects, quality of life and costs.

Safety and efficacy of esophageal stents preceding or during neoadjuvant chemotherapy for esophageal cancer: a systematic review and meta-analysis.

BACKGROUND: Patients with locally advanced esophageal cancer who require neoadjuvant therapy have significant dysphagia and may severely impair nutritional status. We conducted a meta-analysis to assess the efficacy of self-expandable metal stents prior to neoadjuvant therapy. METHODS: A systematic search was conducted using MEDLINE, PubMed, EMBASE, Current Contents Connect, Cochrane library, Google Scholar, Science Direct, and Web of Science. Original data was abstracted from each study and used to calculate a pooled odd ratio (OR) and 95% confidence interval (95% CI). RESULTS: Only nine studies comprising of 180 patients were included for analysis. The overall procedural success rate was 95% (95% CI, 0.895-0.977). There was a substantial decrease in the dysphagia scores standard difference in means (SDM) -0.81 [standard error (SE) 0.15, 95% CI, -1.1 to -0.51], similar increase in weight SDM 0.591 (SE 0.434, 95% CI, -0.261 to 1.442) and serum albumin SDM 0.35 (SE 0.271, 95% CI, -0.181 to 0.881). The incidence of major adverse events included stent migration 32% (95% CI, 0.258-0.395) and chest discomfort 51.4% (95% CI, 0.206-0.812). CONCLUSIONS: Placement of stents in patients with locally advanced esophageal cancer significantly improves dysphagia and allows for oral nutrition during neoadjuvant therapy. Stents appear to be effective for palliating dysphagia. Stent migration was a common occurrence; however, migration may be a sign of tumor response to neoadjuvant therapy.