Outcomes of transcatheter aortic valve replacement in patients with history of chest wall irradiation: Propensity matched analysis of five years data from national inpatient sample (2016-2020).

INTRODUCTION: Chest radiotherapy has been utilized to treat intra-thoracic and mediastinal tumors. Chest wall irradiation (C-XRT) survivors frequently develop valvular disease, including aortic stenosis, which eventually requires valve replacement. Previous trials have shown worse outcomes with surgical aortic valve replacement. However, transcatheter aortic valve replacement (TAVR) outcomes-related data in patients with C-XRT is limited. METHODS: The national inpatient sample (NIS) database was queried from 2016 to 2020 to identify adult hospitalizations with TAVR, which were dichotomized based on a history of C-XRT using ICD-10-CM codes. Propensity score matching was performed to derive age, sex, hospital characteristics, and co-morbidities matched controls without a history of C-XRT. The outcomes studied were inpatient mortality and complications, mean length of stay (LOS), and total hospital charge (THC). Multivariate logistic and linear regression were used to analyze the outcomes. RESULTS: Of 296,670 patients who underwent TAVR between 2016 and 2020, 515 had a history of C-XRT. Upon propensity score matching in patients undergoing TAVR, Patients with a history of C-XRT showed significantly lower adjusted odds of in-hospital mortality (adjusted odd ratio [aOR] 0.04, 95 % CI [0.003-0.57], p = 0.017), lower mean LOS by 1.6 days (-1.88 to -1.26 days, p < 0.001) and reduced mean THC (-$74,720, [-$88,784 to -$60,655], p < 0.001). Additionally, patients with C-XRT had significantly lower adjusted odds of inpatient complications, mainly acute myocardial infarction, cerebrovascular events, acute respiratory failure, acute kidney injury, need for vasopressors and cardiopulmonary resuscitation, whereas similar odds of complications, including a requirement of intubation, mechanical ventilation, hemodialysis, and cardiogenic shock. CONCLUSION: Our analysis showed reduced adjusted odds of in-hospital mortality, length of stay, total hospital charges, and inpatient complications in patients undergoing TAVR with a history of C-XRT. TAVR appears to be a safe and viable alternative in this population subgroup.

Functional and Quality of Life Outcomes After TAVR in Patients With Low Gradient Aortic Stenosis.

Severe aortic stenosis is a common valvular heart disease associated with significant mortality and morbidity. Transcatheter aortic valve replacement (TAVR) is an effective treatment for this condition. Less data is available regarding functional and quality-of-life outcomes in patients with severe, low-gradient aortic stenosis following TAVR. This single-center, retrospective study compared changes in New York Heart Association (NYHA) class and Kansas City Cardiomyopathy Questionnaire (KCCQ) scores at 30 days and 1 year in patients with 3 variants of severe, low-gradient aortic stenosis following TAVR. Secondary outcomes included 1-year major adverse cardiovascular event. A total of 170 patients were included. All 3 low-gradient variants had significant improvement in NYHA class and KCCQ overall scores at 30 days and 1 year. There were no significant differences in KCCQ overall scores between the 3 groups and no significant differences in secondary outcomes. Patients with low-gradient aortic stenosis experienced significant improvements in functional and quality-of-life outcomes following TAVR.

Comparison of intravascular ultrasound, optical coherence tomography, and conventional angiography-guided percutaneous coronary interventions: A systematic review, network meta-analysis, and meta-regression.

BACKGROUND: Intracoronary imaging modalities, including intravascular ultrasound (IVUS) and optical coherence tomography (OCT), provide valuable supplemental data unavailable on coronary angiography (CA) and have shown to improve clinical outcomes. We sought to compare the clinical efficacy of IVUS, OCT, and conventional CA-guided percutaneous coronary interventions (PCI). METHODS: Frequentist and Bayesian network meta-analyses of randomized clinical trials were performed to compare clinical outcomes of PCI performed with IVUS, OCT, or CA alone. RESULTS: A total of 28 trials comprising 12,895 patients were included. IVUS when compared with CA alone was associated with a significantly reduced risk of major adverse cardiovascular events (MACE) (risk ratio: [RR] 0.74, 95% confidence interval: [CI] 0.63-0.88), cardiac death (RR: 0.64, 95% CI: 0.43-0.94), target lesion revascularization (RR: 0.68, 95% CI: 0.57-0.80), and target vessel revascularization (RR: 0.64, 95% CI: 0.50-0.81). No differences in comparative clinical efficacy were found between IVUS and OCT. Rank probability analysis bestowed the highest probability to IVUS in ranking as the best imaging modality for all studied outcomes except for all-cause mortality. CONCLUSION: Compared with CA, the use of IVUS in PCI guidance provides significant benefit in reducing MACE, cardiac death, and revascularization. OCT had similar outcomes to IVUS, but more dedicated studies are needed to confirm the superiority of OCT over CA.

Chronological comparison of TAVI and SAVR stratified to surgical risk: a systematic review, meta-analysis, and meta-regression.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) has been established as a reasonable alternative to surgical aortic valve replacement (SAVR) in patients with severe aortic stenosis. However, long-term outcomes including valve durability and the need for reintervention are unanswered, especially in younger patients who tend to be low surgical risk. We performed a meta-analysis comparing clinical outcomes after TAVI and SAVR over 5 years stratified to low, intermediate, and high surgical risks. METHODS: We identified propensity score-matched observational studies and randomised controlled trials comparing TAVI and SAVR. Primary outcomes, including all-cause mortality, moderate or severe aortic regurgitation, moderate or severe paravalvular regurgitation, pacemaker placement, and stroke, were extracted. Meta-analyses of outcomes after TAVI compared to SAVR were conducted for different periods of follow-up. Meta-regression was also performed to analyse the correlation of outcomes over time. RESULTS: A total of 36 studies consisting of 7 RCTs and 29 propensity score-matched studies were selected. TAVI was associated with higher all-cause mortality at 4-5 years in patients with low or intermediate surgical risk. Meta-regression time demonstrated an increasing trend in the risk of all-cause mortality after TAVI compared with SAVR. TAVI was generally associated with a higher risk of moderate or severe aortic regurgitation, moderate or severe paravalvular regurgitation, and pacemaker placement. CONCLUSIONS: TAVI demonstrated an increasing trend of all-cause mortality compared with SAVR when evaluated over a long-term follow-up. More long-term data from recent studies using newer-generation valves and state-of-the-art techniques are needed to accurately assign risks.

Transcatheter aortic valve implantation (TAVI) was associated with increased all-cause mortality at longer periods of follow-up irrespective of surgical risk. Aortic regurgitation, paravalvular regurgitation, major vascular complications, and pacemaker placement favoured surgical aortic valve replacement (SAVR) over TAVI. TAVI remained superior to SAVR in major bleeding and renal failure events. Long-term data on newer generation valves and up-to-date implantation techniques may provide better durability and improved outcomes after TAVI.

Network Meta-Analysis Comparing Angiotensin Receptor-Neprilysin Inhibitors, Angiotensin Receptor Blockers, and Angiotensin-Converting Enzyme Inhibitors in Heart Failure With Reduced Ejection Fraction.

The superiority of angiotensin receptor-neprilysin inhibitor (ARNI) over angiotensin-converting enzyme inhibitor (ACE-I) and angiotensin receptor blocker (ARB) has not been reassessed after the publication of recent trials that did not find clinical benefits. Therefore, we performed an updated network meta-analysis comparing the efficacy and safety of ARNI, ACE-I, ARB, and placebo in heart failure with reduced ejection fraction. We included randomized clinical trials that compared ARNI, ARB, ACE-I, and placebo in heart failure with reduced ejection fraction. We extracted prespecified efficacy end points and produced network estimates, p scores, and surface under the cumulative ranking curve scores using frequentist and Bayesian network meta-analysis approaches. A total of 28 randomized controlled trials including 47,407 patients were included. ARNI was associated with lower risk of all-cause mortality (relative risk [RR] 0.81, 95% confidence interval [CI] 0.68 to 0.96), cardiac death (RR 0.79, 95% CI 0.64 to 0.99), and major adverse cardiac events (MACEs; RR 0.83, 95% CI 0.72 to 0.97) but higher risk of hypotension (RR 1.46, 95% CI 1.02 to 2.10) than ARB. ARNI was associated with lower risk of MACE (RR 0.85, 95% CI 0.74 to 0.97), but higher risk of hypotension (RR 1.69, 95% CI 1.27 to 2.24) compared with ACE-I. P scores and surface under the cumulative ranking curve scores demonstrated superiority of ARNI over ARB and ACE-I in all-cause mortality, cardiac death, MACE, and hospitalization for heart failure. In conclusion, ARNI was associated with improved clinical outcomes, except for higher risk of hypotension, compared with ARB and ACE-I.

Abbreviated versus Standard Duration of DAPT after PCI: A Systematic Review and Network Meta-analysis.

BACKGROUND: Dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) with drug-eluting stent (DES) is typically continued for 6-12 months depending on clinical presentation. Recent studies have evaluated the safety of shorter durations of DAPT across stable and unstable coronary syndrome but are limited by smaller patient pools and varying indications. METHODS: The present study performed a systematic review and network meta-analysis comparing abbreviated (1-3 months) with standard (6-12 months) duration of DAPT. Both conventional and frequentist network meta-analyses with a random-effects model were conducted. RESULTS: Seventeen randomized controlled trials, nine of which included 1-3 months of DAPT, were selected. The risks of any bleeding (RR 0.68, 95% CI 0.54-0.85), major bleeding (RR 0.66, 95% CI 0.50-0.86), and net adverse clinical events (NACE) (RR 0.87, 95% CI 0.76-0.99) were lower with abbreviated (1-3 months) than standard-term (6-12 months) DAPT. No significant differences in the risk of myocardial infarction (RR 1.02, 95% CI 0.87-1.18), definite or probable stent thrombosis (RR 1.11, 95% CI 0.83-1.50), and major adverse cardiac events (MACE) (RR 0.96, 95% CI 0.86-1.06) were observed. Network meta-analysis demonstrated lower risk of any bleeding, major bleeding, and NACE with shorter durations of DAPT compared with 12 months. Risks of definite or probable stent thrombosis, myocardial infarction, and MACE were not significantly different. CONCLUSION: The results support the growing body of evidence that abbreviated duration (1-3 months) of DAPT may be considered to reduce the risk of bleeding without any differences in myocardial infarction, stent thrombosis, or MACE.

Systematic Review and Network Meta-Analysis Comparing Bifurcation Techniques for Percutaneous Coronary Intervention.

Background Bifurcation lesions account for 20% of all percutaneous coronary interventions and represent a complex subset which are associated with lower procedural success and higher rates of restenosis. The ideal bifurcation technique, however, remains elusive. Methods and Results Extensive search of the literature was performed to pull data from randomized clinical trials that met predetermined inclusion criteria. Conventional meta-analysis produced pooled relative risk (RR) and 95% CI of 2-stent technique versus provisional stent on prespecified outcomes. Both frequentist and Bayesian network meta-analyses were performed to compare bifurcation techniques. A total of 8318 patients were included from 29 randomized clinical trials. Conventional meta-analysis showed no significant differences in all-cause mortality, cardiac death, major adverse cardiac events, myocardial infarction, stent thrombosis, target lesion revascularization, and target vessel revascularization between 2-stent techniques and provisional stenting. Frequentist network meta-analysis revealed that double kissing crush was associated with lower cardiac death (RR, 0.57; 95% CI, 0.38-0.84), major adverse cardiac events (RR, 0.50; 95% CI, 0.39-0.64), myocardial infarction (RR, 0.60; 95% CI, 0.39-0.90), stent thrombosis (RR, 0.50; 95% CI, 0.28-0.88), target lesion revascularization, and target vessel revascularization when compared with provisional stenting. Double kissing crush was also superior to other 2-stent techniques, including T-stent or T and protrusion, dedicated bifurcation stent, and culotte. Conclusions Double kissing crush was associated with lower risk of cardiac death, major adverse cardiac events, myocardial infarction, stent thrombosis, target lesion revascularization, and target vessel revascularization compared with provisional stenting and was superior to other 2-stent techniques. Superiority of 2-stent strategy over provisional stenting was observed in subgroup meta-analysis stratified to side branch lesion length ≥10 mm.

Peripheral Vascular Disease Involving Transplant Renal Artery.

BACKGROUND: Transplant renal artery stenosis (TRAS) can afflict up-to one-fifth of patients with a transplanted kidney. It is associated with uncontrolled hypertension, loss of precious transplanted organs, and mortality. Pathophysiology, diagnosis, and treatment of TRAS is distinct from vascular diseases of the native kidney. The value of preservation of a transplanted kidney is unique, considering the emotional and surgical stakes involved. This field lacks large randomized trials, and ethically it may never be possible to randomize patients with a solitary transplanted kidney. Therefore, vascular interventionalists have to rely on treating factors that can cause graft malfunction like uncontrolled hypertension and renal ischemia, considering that sufficiently large, prospective, randomized data indicating that treating these factors make a difference may never emerge.

Invasive therapy versus conservative therapy for patients with stable coronary artery disease: An updated meta-analysis.

BACKGROUND: Heart disease remains the leading cause of death in the United States. Although there are clear indications for revascularization in patients with acute coronary syndromes, there is debate regarding the benefits of revascularization in stable ischemic heart disease. We sought to perform a comprehensive meta-analysis to assess the role of revascularization compared to conservative medical therapy alone in patients with stable ischemic heart disease. HYPOTHESIS: There is no significant difference in all-cause mortality or cardiovascular mortality between invasive and medical arms. METHODS: We performed a systematic literature search from January 2000 to June 2020. Our literature search yielded seven randomized controlled trials. We analyzed a total of 12 013 patients (6109 in revascularization arm and 5904 in conservative medical therapy arm). Primary outcome was all-cause mortality. Secondary outcomes included major adverse cardiac events (MACE) (death, myocardial infarction [MI], or stroke), cardiovascular mortality, MI, and stroke. Additional subgroup analysis for all-cause mortality was performed comparing percutaneous coronary intervention (PCI) with bare metal stent versus conservative therapy; and PCI with drug eluting stent versus conservative therapy. RESULTS: There was no statistically significant difference in primary outcome of all-cause mortality between either arm (odds ratio [OR] = 0.95; 95% CI [confidence interval], 0.83 to 1.08; p = .84). There were statistically significant lower rates of MACE (death, MI or stroke) in the revascularization arm when compared to conservative arm. CONCLUSIONS: Our analysis did not show any survival advantage of an initial invasive strategy over conservative medical therapy in patients with stable coronary artery disease (CAD).

Middle-Aged Man With Unstable Angina and an Inaccessible Right Coronary Artery.

Acute myocardial ischemia and infarction from retrograde dissection of the aortic root into the coronary ostia is a potentially fatal condition. Unrecognized type A aortic dissection at the time of angiography for acute coronary syndrome (ACS) carries a high burden of morbidity and mortality. Cardiac computed tomography angiography (CCTA) has emerged as one of the instrumental tools in the diagnosis of retrograde coronary involvement from type A aortic dissections. We present a case of ACS secondary to retrograde aortic dissection extending into the right coronary artery (RCA) suspected during coronary angiography and confirmed by CCTA. The patient was managed surgically with aortic root replacement and coronary artery bypass grafting.

Impact of chronic thrombocytopenia on in-hospital outcomes and healthcare resource utilization after transcatheter aortic valve replacement.

BACKGROUND: There is little data on the impact of chronic thrombocytopenia (CTP) on outcomes after transcatheter aortic valve repair (TAVR). Most studies are from single centers and mostly focused on postprocedure thrombocytopenia. OBJECTIVES: This study sought to report on the impact of CTP (>1 year) on in-hospital outcomes and healthcare resource utilization after TAVR. METHODS: From the National Inpatient Sample (NIS) between 2012 and 2015, we identified patients with CTP who underwent TAVR. A 1:1 propensity-matched cohort was created to examine in-hospital outcomes in patients with and without CTP. The primary outcome was in-hospital mortality. Secondary outcomes included postprocedure complications, length of stay, total cost, and discharge disposition. RESULTS: A matched pair of 4,300 patients with and without CTP were identified. Patients with CTP had higher in-hospital mortality as compared to no CTP patients (6.0 vs. 3.3%, p-value .007), increased postprocedure hemorrhage, platelet and blood transfusion, vascular complications, postop sepsis, and acute kidney injury. With regards to resource utilization, CTP patients had a longer length of stay, higher total cost and were more likely to be discharged to a facility (34.1 vs. 27.6%) other than home (All, p-value <.001). Subanalysis, however, revealed this difference in resource utilization was seen when patients developed postprocedure complications. CONCLUSION: This study demonstrated higher risk of in-hospital mortality, perioperative complications, and healthcare resource utilization in patients with baseline CTP undergoing TAVR. Further studies are required to investigate ways to improve the management of these patients.

Stress test to STEMI: Utility of coronary CTA in the diagnosis and management of anomalous right coronary artery from the left coronary cusp.

A 42-year-old woman presented to the emergency department with chest pain. Acute coronary syndrome was ruled out. During dobutamine stress echocardiography (DSE), she developed chest pain and inferior ST elevation. Emergent coronary angiography revealed no culprit lesions but did show an anomalous right coronary artery (RCA). Coronary CT angiography (CCTA) confirmed an anomalous RCA arising from the left coronary cusp with a slit-like ostium and interarterial course (ARCA-LCC-IA). Herein, we review the extant literature on ARCA-LCC-IA, its clinical presentation, the vital role of CTA and MRI in its diagnosis, as well as challenges and controversies surrounding management.

Comparative Analysis of Radial Versus Femoral Diagnostic Cardiac Catheterization Procedures in a Cardiology Training Program.

OBJECTIVES: This study was conducted to evaluate the differences in the procedural variables between transradial and transfemoral access for coronary angiography, with cardiology fellows as the primary operators. METHODS: This was a retrospective study of 163 radial and 180 femoral access diagnostic cardiac catheterization procedures, and involved cardiology fellowship trainees as primary operators. RESULTS: The radial approach was associated with significantly higher fluoroscopy time (8.0 ± 6.97 min vs 4.25 ± 3.01 min; P<.001), dose area product (10775 ± 6724 µGy/m² vs 7952 ± 4236 µGy/m²; P<.001), procedure time (38.31 ± 12.25 min vs 27 ± 17.56 min; P<.001), procedure start to vascular access time (8.24 ± 6.31 min vs 5.31 ± 4.59 min; P<.001), and vascular access to procedure end time (30 ± 15.34 min vs 21.2 ± 9.57 min; P<.001). These differences persisted after adjusting for patients with bypass grafts and additional imaging (P<.001). The contrast amount was not significantly different between the two groups (P=.12). Procedure start to vascular access time improved significantly with fellowship training year in both the radial (9.57 ± 6.96 min vs 8.23 ± 6.08 min vs 5.57 ± 4.82 min) and femoral groups (6.17 ± 5.07 min vs 5.47 ± 4.75 min vs 4.01 ± 3.31 min). Fluoroscopy time showed significant difference in only the femoral access group (P=.01). Dose area product did not improve with training in either access group. CONCLUSION: Radial procedures were associated with higher radiation dose and longer procedure time. Despite decrease in total procedural time for radial cases with the level of training, total radiation dose did not decrease.

Factors Associated with the Use of Drug-Eluting Stents in Patients Presenting with Acute ST-Segment Elevation Myocardial Infarction.

Background. Drug-eluting stents (DES) have proven clinical superiority to bare-metal stents (BMS) for the treatment of patients with ST-segment elevation myocardial infarction (STEMI). Decision to implant BMS or DES is dependent on the patient's ability to take dual antiplatelet therapy. This study investigated factors associated with DES placement in STEMI patients. Methods. Retrospective analysis was performed on 193 patients who presented with STEMI and were treated with percutaneous coronary intervention at an urban, tertiary care hospital. Independent factors associated with choice of stent type were determined using stepwise multivariate logistic regression. Odds ratio (OR) was used to evaluate factors significantly associated with DES and BMS. Results. 128 received at least one DES, while 65 received BMS. BMS use was more likely in the setting of illicit drug or alcohol abuse ([OR] 0.15, 95% CI 0.05-0.48, p ≤ 0.01), cardiogenic shock (OR 0.26, 95% CI 0.10-0.73, p = 0.01), and larger stent diameter (OR 0.28, 95% CI 0.11-0.68, p ≤ 0.01). Conclusions. In this analysis, BMS implantation was associated with illicit drug or alcohol abuse and presence of cardiogenic shock. This study did not confirm previous observations that non-White race, insurance, or income predicts BMS use.

Interchangeability of activated clotting time values across different point-of-care systems.

Significant variability in activated clotting time (ACT) measurement exists based on the type of point-of-care system used. We sought to determine the degree of agreement in ACT measurements by the Hemochron Response and the Hemochron Signature Elite Whole Blood coagulation systems and whether these 2 systems can be used interchangeably. We prospectively compared 126-paired samples in 77 patients undergoing percutaneous coronary intervention. ACT was measured for each sample using the Hemochron Response system with glass test tubes and the Hemochron Signature Elite system with low-range ACT cuvettes simultaneously. We used correlation and Bland-Altman analyses. Mean age of the study cohort was 67 ± 11 years, 49% were women, and 65% of measurements were made after systemic anticoagulation. There was a significant correlation between the Hemochron Response and Hemochron Signature Elite systems (r = 0.84, p <0.01). However, the mean bias for the ACT measurement was 9 seconds (95% confidence interval -69 to 86). In the therapeutic range of ACT measurements, the mean bias was 15 seconds (95% confidence interval -60 to 91). Thirty-three percent of total samples had >10% disagreement and 8% of samples had >20% disagreement in the ACTs measured with the Hemochron Response compared to the Hemochron Signature Elite. In conclusion, the Hemochron Response and Hemochron Signature Elite ACT values cannot be used interchangeably. Institutions using these 2 devices should be cognizant of this difference for ensuring patient safety.

Practical considerations of percutaneous ventricular assist devices.

Percutaneous ventricular assist devices are increasingly used today, allowing the scope of left ventricular support to move out of the operating room and into the interventional suite and cardiovascular care unit. This has given patients requiring short-term therapy an opportunity to undergo high-risk procedures and provide a failing left ventricular support until native recovery can occur. A growing body of evidence exists that demonstrates device efficacy and safety, as well as its potential clinical importance, a topic that will be reviewed here. Additionally, many providers seek a resource for technical considerations and troubleshooting. We also aim to provide insight into such considerations.

Multivessel intervention and placement of a percutaneous right ventricular assist device in a patient with acute myocardial infarction complicated by cardiac arrest.

We present a case of a 66-year-old male who presented with ST elevation myocardial infarction and complicated by cardiac arrest. The patient underwent emergent multivessel revascularization. However, the patient developed right ventricular failure with persistent and recalcitrant hemodynamic instability. Placement of a TandemHeart™ right ventricular assist device™ (Cardiac Assist, Pittsburgh, Pennsylvania) was undertaken to allow for right ventricular recovery. The device was removed after several days and the patient has had no further events one year after arrest.

Aortic root and valve thrombosis after implantation of a left ventricular assist device.

We describe the case of a 60-year-old female who presented with a non-ST elevation myocardial infarction 3 months following placement of a non-pulsatile left ventricular assist device (LVAD). Aortic root angiography not only revealed extensive aortic root thrombosis and left main thrombotic obstruction, but also vividly demonstrated the causative mechanism. To our knowledge, this rarely described mechanism of LVAD thrombosis has not been reported as clearly as this case illustrates.