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BACKGROUND: Scarce data exist on the evolution of device-related thrombus (DRT) after left atrial appendage closure (LAAC). OBJECTIVES: This study sought to assess the incidence, predictors, and clinical impact of persistent and recurrent DRT in LAAC recipients. METHODS: Data were obtained from an international multicenter registry including 237 patients diagnosed with DRT after LAAC. Of these, 214 patients with a subsequent imaging examination after the initial diagnosis of DRT were included. Unfavorable evolution of DRT was defined as either persisting or recurrent DRT. RESULTS: DRT resolved in 153 (71.5%) cases and persisted in 61 (28.5%) cases. Larger DRT size (OR per 1-mm increase: 1.08; 95% CI: 1.02-1.15; P = 0.009) and female (OR: 2.44; 95% CI: 1.12-5.26; P = 0.02) were independently associated with persistent DRT. After DRT resolution, 82 (53.6%) of 153 patients had repeated device imaging, with 14 (17.1%) cases diagnosed with recurrent DRT. Overall, 75 (35.0%) patients had unfavorable evolution of DRT, and the sole predictor was average thrombus size at initial diagnosis (OR per 1-mm increase: 1.09; 95% CI: 1.03-1.16; P = 0.003), with an optimal cutoff size of 7 mm (OR: 2.51; 95% CI: 1.39-4.52; P = 0.002). Unfavorable evolution of DRT was associated with a higher rate of thromboembolic events compared with resolved DRT (26.7% vs 15.1%; HR: 2.13; 95% CI: 1.15-3.94; P = 0.02). CONCLUSIONS: About one-third of DRT events had an unfavorable evolution (either persisting or recurring), with a larger initial thrombus size (particularly >7 mm) portending an increased risk. Unfavorable evolution of DRT was associated with a 2-fold higher risk of thromboembolic events compared with resolved DRT.
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Apéndice Atrial , Fibrilación Atrial , Accidente Cerebrovascular , Tromboembolia , Trombosis , Humanos , Femenino , Incidencia , Apéndice Atrial/diagnóstico por imagen , Resultado del Tratamiento , Fibrilación Atrial/epidemiología , Fibrilación Atrial/terapia , Fibrilación Atrial/complicaciones , Tromboembolia/diagnóstico por imagen , Tromboembolia/epidemiología , Tromboembolia/etiología , Trombosis/diagnóstico por imagen , Trombosis/epidemiología , Trombosis/etiología , Accidente Cerebrovascular/etiologíaRESUMEN
BACKGROUND: Device-related thrombus (DRT) has been considered an Achilles' heel of left atrial appendage occlusion (LAAO). However, data on DRT prediction remain limited. OBJECTIVES: This study constructed a DRT registry via a multicenter collaboration aimed to assess outcomes and predictors of DRT. METHODS: Thirty-seven international centers contributed LAAO cases with and without DRT (device-matched and temporally related to the DRT cases). This study described the management patterns and mid-term outcomes of DRT and assessed patient and procedural predictors of DRT. RESULTS: A total of 711 patients (237 with and 474 without DRT) were included. Follow-up duration was similar in the DRT and no-DRT groups, median 1.8 years (interquartile range: 0.9-3.0 years) versus 1.6 years (interquartile range: 1.0-2.9 years), respectively (P = 0.76). DRTs were detected between days 0 to 45, 45 to 180, 180 to 365, and >365 in 24.9%, 38.8%, 16.0%, and 20.3% of patients. DRT presence was associated with a higher risk of the composite endpoint of death, ischemic stroke, or systemic embolization (HR: 2.37; 95% CI, 1.58-3.56; P < 0.001) driven by ischemic stroke (HR: 3.49; 95% CI: 1.35-9.00; P = 0.01). At last known follow-up, 25.3% of patients had DRT. Discharge medications after LAAO did not have an impact on DRT. Multivariable analysis identified 5 DRT risk factors: hypercoagulability disorder (odds ratio [OR]: 17.50; 95% CI: 3.39-90.45), pericardial effusion (OR: 13.45; 95% CI: 1.46-123.52), renal insufficiency (OR: 4.02; 95% CI: 1.22-13.25), implantation depth >10 mm from the pulmonary vein limbus (OR: 2.41; 95% CI: 1.57-3.69), and non-paroxysmal atrial fibrillation (OR: 1.90; 95% CI: 1.22-2.97). Following conversion to risk factor points, patients with ≥2 risk points for DRT had a 2.1-fold increased risk of DRT compared with those without any risk factors. CONCLUSIONS: DRT after LAAO is associated with ischemic events. Patient- and procedure-specific factors are associated with the risk of DRT and may aid in risk stratification of patients referred for LAAO.
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Apéndice Atrial/cirugía , Fibrilación Atrial/cirugía , Cateterismo Cardíaco/efectos adversos , Complicaciones Posoperatorias/etiología , Sistema de Registros , Dispositivo Oclusor Septal/efectos adversos , Trombosis/etiología , Anciano , Apéndice Atrial/diagnóstico por imagen , Ecocardiografía Transesofágica , Europa (Continente)/epidemiología , Femenino , Estudios de Seguimiento , Cardiopatías/diagnóstico , Cardiopatías/epidemiología , Cardiopatías/etiología , Humanos , Incidencia , Masculino , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/epidemiología , Factores de Riesgo , Tasa de Supervivencia/tendencias , Trombosis/diagnóstico , Trombosis/epidemiología , Factores de Tiempo , Resultado del TratamientoRESUMEN
Transradial intervention (TRI) was first introduced by Lucien Campeau in 1989 and since then has created a lasting impact in the field of interventional cardiology. Several studies have demonstrated that TRI is associated with fewer vascular site complications, offer earlier ambulation and greater post-procedural comfort. Patients presenting with ST Segment Elevation Myocardial Infarction (STEMI) have experienced survival benefit and higher quality-of-life metrics as well with TRI. While both the updated scientific statement by the American Heart Association and the 2017 European Society of Cardiology guidelines recommend a "radial first" approach there appears to be a lag in physicians adapting TRI as the preferred vascular access. We present a review focusing on identification and management of TRA related challenges and complications using a systematic algorithmic approach.
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Intervención Coronaria Percutánea , Infarto del Miocardio con Elevación del ST , Algoritmos , Arteria Femoral , Humanos , Arteria Radial , Resultado del TratamientoRESUMEN
Potassium is the predominant intracellular cation, with its extracellular concentrations maintained between 3. 5 and 5 mM. Among the different potassium disorders, hypokalaemia is a common clinical condition that increases the risk of life-threatening ventricular arrhythmias. This review aims to consolidate pre-clinical findings on the electrophysiological mechanisms underlying hypokalaemia-induced arrhythmogenicity. Both triggers and substrates are required for the induction and maintenance of ventricular arrhythmias. Triggered activity can arise from either early afterdepolarizations (EADs) or delayed afterdepolarizations (DADs). Action potential duration (APD) prolongation can predispose to EADs, whereas intracellular Ca2+ overload can cause both EADs and DADs. Substrates on the other hand can either be static or dynamic. Static substrates include action potential triangulation, non-uniform APD prolongation, abnormal transmural repolarization gradients, reduced conduction velocity (CV), shortened effective refractory period (ERP), reduced excitation wavelength (CV × ERP) and increased critical intervals for re-excitation (APD-ERP). In contrast, dynamic substrates comprise increased amplitude of APD alternans, steeper APD restitution gradients, transient reversal of transmural repolarization gradients and impaired depolarization-repolarization coupling. The following review article will summarize the molecular mechanisms that generate these electrophysiological abnormalities and subsequent arrhythmogenesis.
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BACKGROUND: There is a paucity of data regarding the optimum timing of PCI in relation to TAVR. OBJECTIVE: We compared the major adverse cardiovascular and cerebrovascular events (MACCE) rates among patients who underwent percutaneous coronary intervention (PCI) before transcatheter aortic valve replacement (TAVR) with those who received PCI with/after TAVR. METHODS: In this multicenter study, we pooled all consecutive patients who underwent TAVR at three high volume centers. RESULTS: Among 3,982 patients who underwent TAVR, 327 (8%) patients underwent PCI within 1 year before TAVR, 38 (1%) had PCI the same day as TAVR and 15 (0.5%) had PCI within 2 months after TAVR. Overall, among patients who received both PCI and TAVR (n = 380), history of previous CABG (HR:0.501; p = .001), higher BMI at TAVR (HR:0.970; p = .038), and statin therapy after TAVR (HR:0.660, p = .037) were independently associated with lower MACCE while warfarin therapy after TAVR was associated with a higher risk of MACCE (HR:1.779, p = .017). Patients who received PCI within 1 year before TAVR had similar baseline demographics, STS scores, clinical risk factors when compared to patients receiving PCI with/after TAVR. Both groups were similar in PCI (Syntax Score, ACC/AHA lesion class) and TAVR (valve types, access) related variables. There were no significant differences in terms of MACCE (log rank p = .550), all-cause mortality (log rank p = .433), strokes (log rank p = .153), and repeat PCI (log rank p = .054) in patients who underwent PCI with/after TAVR when compared to patients who received PCI before TAVR. CONCLUSION: Among patients who underwent both PCI and TAVR, history of CABG, higher BMI, and statin therapy had lower, while those discharged on warfarin, had higher adverse event rates. Adverse events rates were similar regardless of timing of PCI.
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Estenosis de la Válvula Aórtica , Enfermedad de la Arteria Coronaria , Intervención Coronaria Percutánea , Reemplazo de la Válvula Aórtica Transcatéter , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/cirugía , Enfermedad de la Arteria Coronaria/cirugía , Enfermedad de la Arteria Coronaria/terapia , Humanos , Intervención Coronaria Percutánea/efectos adversos , Sistema de Registros , Factores de Riesgo , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Resultado del TratamientoRESUMEN
BACKGROUND: Outcome data following transcatheter mitral valve repair (TMVR) with the MITRACLIP® device are scarce outside the pivotal randomized controlled trials. METHODS: The Nationwide Readmission Data base (NRD) was utilized for years 2013-2017 to identify the study population. Thirty-day readmission pattern, in-hospital complications, causes of readmissions, and multivariate predictors for readmission, complications and mortality were explored. RESULTS: We noted a total of 14,647 index admissions related to MITRACLIP of which 48% of procedures were performed at high volume centers (Annual hospital volume ≥ 25). A total of 15% of patients were readmitted within 30 days of discharge most frequently due to cardiac causes. Approximately 33% of patients were discharged within 24 h of the procedure. The in-hospital mortality rate was 2.8% and in-hospital complication rate was 14.6%. The most common complications were cardiac complications (8.2%), bleeding related complications (5.9%) and vascular complications (0.65%). On multivariate modeling, female sex, CHF, Atrial fibrillation, prior PCI, COPD, CKD, transfer to skilled nursing facility, length of stay ≥2 days were associated with a high risk of readmission. Additionally, coagulopathy, chronic kidney disease and lengthier hospital stays were associated with high risk of complication or death. CONCLUSION: The 30-day readmission rate following commercial treatment with the MITRACLIP device is 15%. Half of these admission were from a cardiac etiology. Heart failure, atrial arrhythmias and clip related complications round out the top 3 cardiac reasons for readmission. There was no impact of hospital size, teaching status or case volume on mortality and in hospital complication rates.
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Implantación de Prótesis de Válvulas Cardíacas , Intervención Coronaria Percutánea , Cateterismo Cardíaco , Femenino , Humanos , Válvula Mitral/diagnóstico por imagen , Válvula Mitral/cirugía , Readmisión del Paciente , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
Influenza is associated with significant morbidity in the United States but its influence on in-hospital outcomes in patients with AMI has not been well studied. The Nationwide Readmission Database (NRD) from 2010 to 2014 was queried using the International Classification of Diseases-Ninth edition, Clinical Modification (ICD-9-CM) codes to identify all patients ≥18 years who were admitted for AMI with and without concurrent influenza. Propensity score matching was used to adjust patients' baseline characteristics and co-morbidities. In-hospital mortality, 30-day readmission rates, in-hospital complications, and resource utilization were analyzed. We identified a total of 2,428,361 patients admitted with AMI, of whom 3,006 (0.12%) had coexisting influenza. We noted significantly higher in-hospital mortality (7.7% vs 5.6%, p <0.01) and 30-day readmission rates (15.8% vs 14.1%, p <0.01) in patients with influenza compared with those without it. After propensity matching, the differences in in-hospital mortality and 30-day readmission were no longer statistically significant between the groups. Patients with influenza had a higher incidence of acute kidney injury (30.9% vs 24.6%, p <0.01), acute respiratory failure (50.2% vs 32.2%, p <0.01), need for mechanical ventilation (13.9% vs 9.2%, p <0.01), and sepsis (10% vs 3.8%, p <0.01) in the matched cohort. Patients with influenza had longer hospital stays (8.4 days vs 6.4 days, p <0.01) and mean costs of care (26,200USD vs 23,400USD, p <0.01). In conclusion, AMI patients with concomitant influenza infection had higher in-hospital mortality, 30-day readmission, in-hospital complications, and higher resource utilization compared with those without influenza.
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Mortalidad Hospitalaria , Gripe Humana/complicaciones , Infarto del Miocardio/complicaciones , Readmisión del Paciente/estadística & datos numéricos , Adolescente , Adulto , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/mortalidad , Adulto JovenRESUMEN
Transcatheter aortic valve implantation (TAVI) has become the mainstream treatment for severe aortic stenosis. Despite improvement in device iteration and operator experience rigorous outcome data outside the scope of clinical trials is lacking. Nationwide readmission database 2016 and 2017 was utilized to identify the study population. International Classification of Disease,10th edition codes were used to identify TAVI admissions. Outcomes of interest were the 90-day readmission pattern and in hospital complications of the TAVI procedure. A total of 73,784 TAVI related index admissions were identified in the Nationwide Readmission Database in 2016 to 2017. Forty four percent of patients undergoing TAVI in that timeframe were discharged within 48 hours of their procedure. 16,343 patients (22.2%) were readmitted within 90 days after discharge. Major cardiac co-morbidities like heart failure were prevalent more often in the group of patients that were readmitted within 90 days. Noncardiac causes however accounted for two thirds of these readmissions. The median time to 90-day readmission was 31 days. Multivariate analysis showed that nonagenarians, patients undergoing transapical TAVI, and patients with a higher comorbidity burden were more likely to be readmitted within 90 days. In conclusion, almost half of TAVI patients in the US are discharged within 48 hours after their procedure and 20% of all TAVI patients are readmitted within 90 days. Most readmissions are due to noncardiac causes.
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Estenosis de la Válvula Aórtica/cirugía , Readmisión del Paciente/estadística & datos numéricos , Reemplazo de la Válvula Aórtica Transcatéter , Anciano , Anciano de 80 o más Años , Bases de Datos Factuales , Femenino , Humanos , Masculino , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversosRESUMEN
BACKGROUND: Intravascular brachytherapy (VBT) is an established treatment for the management of in-stent restenosis (ISR). However, whether VBT is associated with improved patient reported outcomes unknown. METHODS: We evaluated 51 consecutive patients undergoing VBT in one or more coronary arteries from January 2018 to September 2019. Data on baseline characteristics, procedural outcomes and adverse events were obtained. All patients completed the Seattle Angina Questionnaire - 7 (SAQ-7) form before and after VBT at 1 month and 6 months. RESULTS: The mean age was 69 ± 9 years and 29 (57%) of patients were males. Procedural success was 94.1%. The mean summary SAQ-7 score improved significantly (53.2 ± 21 vs. 83 ± 19, p < .001) at 30-days. The median Quality of Life (QoL) component of SAQ-7 score was 31.3 (Interquartile Range [IQR]: 18.8, 62.5) and improved to 82.5 (IQR: 62.5, 100), p < .001 at 30 days and 87.5 [IQR: 75, 100), p < .001 at last follow up. Likewise, the median angina frequency component of the SQL-7 score pre-VBT was 55 (IQR: 45, 80) and improved significantly to 90 (IQR: 60, 100) at 30-days, p < .001 and 100 [IQR: 68.8, 100], p = .02 at last follow up. Lastly, the median activity component of the SAQ-7 score improved from 83.3 (IQR: 60-100) to 100 (IQR: 83, 100), p = .01 at 30-days. Thus, results were evident as early as 1 month and sustained at median follow up of 17 months. CONCLUSION: VBT is associated with improvement in patient reported outcome measures at short term and long term follow up.
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Braquiterapia , Enfermedad de la Arteria Coronaria , Reestenosis Coronaria , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Medición de Resultados Informados por el Paciente , Calidad de Vida , StentsRESUMEN
BACKGROUND: There is limited data identifying patients at risk for significant mitral regurgitation (MR) after transcatheter mitral valve replacement (TMVR). We hypothesized that software modeling based on computed tomography angiography (CTA) can predict the risk of moderate or severe MR after TMVR. METHODS: 58 consecutive patients underwent TMVR at two institutions, including 31 valve-in-valve, 16 valve-in-ring, and 11 valve-in-mitral annular calcification. 12 (20%) patients developed moderate or severe MR due to paravalvular leak (PVL). RESULTS: The software model correctly predicted 8 (67%) patients with significant PVL, resulting in sensitivity of 67%, specificity 96%, positive predictive value 89%, and negative predictive value 86%. There was excellent agreement between CTA readers using software modeling to predict PVL (kappa 0.92; p < 0.01). On univariate analysis, CTA predictors of moderate or severe PVL included presence of a gap between the virtual valve and mitral annulus on the software model (OR 48; p < 0.01), mitral annular area (OR 1.02; p 0.01), and % valve oversizing (OR 0.9; p 0.01). On multivariate analysis, only presence of a gap on the software model remained significant (OR 36.8; p < 0.01). CONCLUSIONS: Software modeling using pre-procedural CTA is a straightforward method for predicting the risk of moderate and severe MR due to PVL after TMVR.
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Cateterismo Cardíaco/efectos adversos , Angiografía por Tomografía Computarizada , Angiografía Coronaria , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Insuficiencia de la Válvula Mitral/etiología , Válvula Mitral/cirugía , Modelación Específica para el Paciente , Programas Informáticos , Anciano , Anciano de 80 o más Años , Arizona , Femenino , Humanos , Masculino , Persona de Mediana Edad , Válvula Mitral/diagnóstico por imagen , Válvula Mitral/fisiopatología , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/fisiopatología , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Índice de Severidad de la Enfermedad , Resultado del TratamientoRESUMEN
BACKGROUND: Percutaneous coronary intervention (PCI) outcomes for patients with significant calcification have been consistently inferior compared to patients without significant calcification. Procedural success and long-term outcomes after PCI have been worse in patients with severe coronary calcium. OBJECTIVE: A Bayesian meta-analysis of outcomes comparing rotational atherectomy (RA) with orbital atherectomy (OA) was performed. METHODS: PubMed, Embase, and Cochrane Library databases were searched through 30th November 2018 and identified 4 observational studies. RESULTS: The primary end-point, Major Adverse Cardiac Event (MACE) composing of death, MI and stroke at 1â¯year was more likely with RA (ORâ¯=â¯1.61; 95% CI: 1.11-2.33; pâ¯=â¯0.01) as compared to OA. The driver of the difference in MACE between the two groups was a statistically significant difference in mortality favoring OA (ORâ¯=â¯4.65; 95% CI: 1.36-15.87; pâ¯=â¯0.01). Peri-procedural MI, the other component of the primary end-point was 1.3 times more likely in the RA arm (ORâ¯=â¯1.35; 95% CI 0.95-1.92; p-0.09) and was not statistically different between the groups. The odds of a vascular complication were not different in the two groups (ORâ¯=â¯1.26; 95% CI: 0.73-2.17; pâ¯=â¯0.41). In an adjusted Bayesian analysis, mortality (ORâ¯=â¯3.69; 95% CI: 0.30-38.51), MACE (ORâ¯=â¯1.68; 95% CI: 0.55-5.49), MI (ORâ¯=â¯1.42; 95% CI: 0.50-4.29) and dissections/perforations (ORâ¯=â¯0.38; 95% CI: 0.10-1.38) were not different in RA and OA groups. CONCLUSION: Our study is the first published Bayesian meta-analysis comparing MACE and peri-procedural outcomes in RA compared to OA. These findings lay the foundation for a randomized comparison between the two competing technologies.
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Aterectomía Coronaria , Enfermedad de la Arteria Coronaria/terapia , Intervención Coronaria Percutánea , Calcificación Vascular/terapia , Aterectomía Coronaria/efectos adversos , Aterectomía Coronaria/mortalidad , Teorema de Bayes , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/fisiopatología , Humanos , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/mortalidad , Factores de Riesgo , Índice de Severidad de la Enfermedad , Resultado del Tratamiento , Calcificación Vascular/diagnóstico por imagen , Calcificación Vascular/mortalidad , Calcificación Vascular/fisiopatologíaRESUMEN
BACKGROUND: Transcatheter left atrial appendage occlusion (LAAO) has become a suitable alternative to anticoagulation in patients with atrial fibrillation (AF). However, volume-outcome relationships at the individual operator level have not been studied. METHODS: Study population included 425 consecutive patients with AF undergoing LAAO from August 2015 to November 2018 by seven operators at BUMC-Phoenix. Operator volume was divided in tertiles by those with <40 cases/year (2 operators), 41-80 cases/year (3 operators) and >80 cases/year (2 operators). Patient data including comorbidities, labs, medications, procedural characteristics and outcomes were collected. The primary composite outcome was major adverse cardiac events (MACE) including mortality, stroke, bleeding and vascular complications. RESULTS: Mean age was 75⯱â¯8â¯years and 251 (59%) were males. Mean CHA2DS2-VASc score was 4.5⯱â¯1.3 points and mean HASBLED score was 3.9⯱â¯1.0 points. MACE outcome was similar in the three operator groups in both unadjusted (pâ¯=â¯0.83) and adjusted (ORâ¯=â¯0.59: 95% Confidence Interval [CI]: 0.15-2.29, pâ¯=â¯0.45) analysis. The occurrence MACE was also similar between Interventional Cardiologist (IC) and Electrophysiologist (EP) operators in an unadjusted (pâ¯=â¯0.24) and adjusted (ORâ¯=â¯0.60: 95% CI: 0.21-1.68, pâ¯=â¯0.33) analysis. The secondary outcome of technical success did not differ among the three tertiles (pâ¯=â¯0.37) and among IC & EP operators respectively (pâ¯=â¯0.24) as well. CONCLUSION: Operator experience does not affect MACE and technical success even after adjusting for comorbidities. These results suggest a lower learning curve for LAAO with high technical success achievable even by low volume operators.
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Apéndice Atrial/fisiopatología , Fibrilación Atrial/terapia , Función del Atrio Izquierdo , Cateterismo Cardíaco/instrumentación , Frecuencia Cardíaca , Accidente Cerebrovascular/prevención & control , Anciano , Anciano de 80 o más Años , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/mortalidad , Fibrilación Atrial/fisiopatología , Cateterismo Cardíaco/efectos adversos , Cateterismo Cardíaco/mortalidad , Competencia Clínica , Femenino , Humanos , Curva de Aprendizaje , Masculino , Diseño de Prótesis , Sistema de Registros , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/mortalidad , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Studies evaluating safety of warfarin and direct oral anticoagulants (DOACs) for prevention of stroke in patients with atrial fibrillation (AF) are lacking. METHODS & RESULTS: All patients (n = 196,521) receiving care at veteran's affairs with active cancer and AF from 2010-2015 were included. One-year mortality was significantly higher in unadjusted analysis with warfarin (44.9%) compared to dabigatran (25%, P < 0.001), rivaroxaban (24.4%, P < 0.001) and apixaban (30%, P < 0.001) and after adjusting for age, sex and type of cancer mortality (OR = 2.66, 95% CI: 2.52-2.82, P < 0.001). Risk of ischemic stroke (13.5% vs. 11.1%, 12.0%, 14.0%) was similar, however risk of hemorrhagic stroke was significantly higher among patients receiving warfarin (1.2%) compared to patients receiving dabigatran (0.5%), rivaroxaban (0.7%) and apixaban (0.8%) respectively, P = 0.04. CONCLUSIONS: We demonstrated the superior safety profile of DOACs compared to warfarin among patients with underlying cancer and AF. Warfarin was associated with higher mortality, similar ischemic stroke risk but higher risk of hemorrhagic stroke.
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PURPOSE OF REVIEW: Chronic total occlusion (CTO) of the coronary arteries is a significant clinical problem and has traditionally been treated by medical therapy or coronary artery bypass grafting. Recent studies have examined percutaneous coronary intervention (PCI) as an alternative option. RECENT FINDINGS: This systematic review and meta-analysis compared medical therapy to PCI for treating CTOs. PubMed and Embase were searched from their inception to March 2019 for studies that compared medical therapy and PCI for clinical outcomes in patients with CTOs. Quality of the included studies was assessed by Newcastle-Ottawa scale. The results were pooled by DerSimonian and Laird random- or fixed-effect models as appropriate. Heterogeneity between studies and publication bias was evaluated by I2 index and Egger's regression, respectively. Of the 703 entries screened, 17 studies were included in the final analysis. This comprised 11,493 participants. Compared to PCI, medical therapy including randomized and observational studies was significantly associated with higher risk of all-cause mortality (risk ratio (RR) 1.99, 95% CI 1.38-2.86), cardiac mortality (RR 2.36 (1.97-2.84)), and major adverse cardiac event (RR 1.25 (1.03-1.51)). However, no difference in the rate of myocardial infarction and repeat revascularization procedures was observed between the two groups. Univariate meta-regression demonstrated multiple covariates as independent moderating factors for myocardial infarction and repeat revascularization but not cardiac death and all-cause mortality. However, when only randomized studies were included, there was no difference in overall mortality or cardiac death. In CTO, when considering randomized and observational studies, medical therapy might be associated with a higher risk of mortality and myocardial infarction compared to PCI treatment.
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Oclusión Coronaria/terapia , Vasos Coronarios/cirugía , Fibrinolíticos/uso terapéutico , Intervención Coronaria Percutánea/métodos , Terapia Trombolítica/métodos , Enfermedad Crónica , Angiografía Coronaria , Oclusión Coronaria/diagnóstico , Vasos Coronarios/diagnóstico por imagen , HumanosAsunto(s)
Oclusión Coronaria/terapia , Alta del Paciente , Intervención Coronaria Percutánea , Anciano , Arizona , Enfermedad Crónica , Oclusión Coronaria/diagnóstico por imagen , Oclusión Coronaria/mortalidad , Estudios de Factibilidad , Femenino , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/mortalidad , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVES: We investigated the hemodynamic durability of the transcatheter aortic valves (TAVs) using the updated Valve Academic Research Consortium-2 (VARC-2) criteria. BACKGROUND: The updated VARC-2 consensus criteria combine flow-dependent and flow-independent echocardiographic parameters for hemodynamic assessment of TAVR. Data on the hemodynamic durability of TAV and clinical risk factors associated with valve hemodynamic deterioration (VHD) are lacking. METHODS: All patients (n = 276) who received TAV between 2006 and 2012 and had ≥2 follow-up echocardiograms were studied. RESULTS: During a median follow up period of 3.3 (1.8-4.4) years, 8 patients (3%) developed moderate to severe valve stenosis per the VARC-2 criteria, while 20 had mild stenosis. In a Cox proportional hazards model analysis, moderate to severe stenosis by VARC-2 criteria was associated with younger age (P = 0.03, HR 0.94), absence of dual antiplatelet therapy (DAPT) (P = 0.026, HR 0.18), and lower baseline left ventricular ejection fraction (LVEF) (P = 0.006, HR 0.94). Longitudinal analysis using a mixed effect model showed that presence of stenosis by VARC-2 criteria was associated with an increase in aortic valve mean gradient (P < 0.001, +2.34 mmHg per year). In a subset of 93 patients with analyzable fluoroscopic images, deeper valve implantation was associated with increase in mean gradient (P = 0.004, +0.2 mmHg per year per 1 mm increase in implantation depth). CONCLUSION: Despite good hemodynamic durability of TAV, patients with younger age, lower LVEF and those not on DAPT after undergoing a TAV replacement, are at a higher risk for development of VHD.
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Estenosis de la Válvula Aórtica/cirugía , Válvula Aórtica/cirugía , Bioprótesis , Prótesis Valvulares Cardíacas , Hemodinámica , Reemplazo de la Válvula Aórtica Transcatéter/instrumentación , Factores de Edad , Anciano , Anciano de 80 o más Años , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/fisiopatología , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/fisiopatología , Femenino , Humanos , Masculino , Inhibidores de Agregación Plaquetaria/uso terapéutico , Diseño de Prótesis , Falla de Prótesis , Recurrencia , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Índice de Severidad de la Enfermedad , Estrés Mecánico , Factores de Tiempo , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Resultado del Tratamiento , Función Ventricular IzquierdaRESUMEN
BACKGROUND: The electrocardiographic criteria currently available for the diagnosis of left ventricular hypertrophy (LVH) are low in sensitivity. Thus, we compared the diagnostic performance of newly proposed electrocardiographic criteria to the existing criteria in a Chinese population. METHODS: A total of 235 consecutive hypertensive patients, hospitalized in our department between May 2017 and April 2018, were included. They were divided into two groups based on the gold standard echocardiogram: those with (n = 116) and without LVH (n = 119). The newly proposed ECG criteria were calculated by summating the amplitude of the deepest S wave (SD ) in any single lead and the S-wave amplitude of lead V4 (SV4 ). The area under the curve was calculated and compared against the sex-specific Cornell limb lead and Sokolow-Lyon criteria. RESULTS: ECG analysis of the cohort showed that the newly proposed criteria had the highest sensitivity in diagnosing LVH (male: 65.5%; female: 81%), followed by the Cornell limb lead criteria (male: 55.2%; female: 56.9%). The specificities of both sets of criteria were higher than 70%, with no significant differences between them. Receiver operator curve analysis showed an optimal cutoff of ≥2.1 mV for females (AUC: 0.832; 95% CI: 0.757-0.906) and ≥2.6 mV for males (AUC: 0.772; 95% CI: 0.687-0.856). CONCLUSION: The newly proposed SD + SV4 criteria provide an improved sensitivity for the ECG diagnosis of LVH compared to existing criteria, but its routine use will require further validation in larger populations.
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Ecocardiografía Doppler/métodos , Electrocardiografía/métodos , Hipertensión/epidemiología , Hipertrofia Ventricular Izquierda/diagnóstico por imagen , Hipertrofia Ventricular Izquierda/epidemiología , Anciano , Determinación de la Presión Sanguínea/métodos , Estudios de Casos y Controles , China/epidemiología , Femenino , Hospitalización , Humanos , Hipertensión/diagnóstico , Hipertrofia Ventricular Izquierda/diagnóstico , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Curva ROC , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Análisis de SupervivenciaRESUMEN
BACKGROUND: Increased afterload and reduced left ventricular (LV) performance are sequela of mitral valve repair. However, hemodynamic left atrial and ventricular parameters that can predict outcome following mitral valve repair remain elusive. METHODS: One hundred and two consecutive patients undergoing MitraClip procedure from 2014 to 2017 at Banner University Medical Center were enrolled in this study. All patients underwent pre-procedure echocardiograms and intra-procedure invasive left atrial (LA) pressure monitoring. Clinical, laboratory, and procedural parameters were collected. The primary end-point was the composite outcome of all-cause mortality and repeat hospitalization within 90 days. RESULTS: The mean age was 77 ±10 years, the majority were Caucasians (93, 91.2%) and 47 (46.1%) were males. Thirty-two patients (31.4%) had diabetes, 39 (38.2%) had renal insufficiency, and 38 (37.3%) had a history of congestive heart failure. The median society of thoracic surgeons score was 6.7% (Interquartile range [IQR]: 3.9, 10.2). Immediately post-procedure there was a significant reduction in the LA pressure (Mean 12.0 vs. 18.6 mmHg, P < 0.001) and pulmonary artery systolic pressure (43.5 vs. 53.2 mmHg, P = 0.001) compared to baseline. LA pressure was an independent predictor of the composite outcome in an unadjusted (OR = 1.07, 95% CI: 1.00-1.13, P = 0.03) and adjusted (OR = 1.07, 95% CI: 1.00-1.14, P = 0.03) analysis respectively. CONCLUSION: LA pressure drop is an independent predictor of outcome after the MitraClip procedure. This finding has implications for early identification of patients at risk of poor outcomes and instituting aggressive medical therapy and close follow-up for avoiding hospitalizations for heart failure decompensation.
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Función del Atrio Izquierdo , Presión Atrial , Cateterismo Cardíaco/instrumentación , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Prótesis Valvulares Cardíacas , Insuficiencia de la Válvula Mitral/cirugía , Válvula Mitral/cirugía , Disfunción Ventricular Izquierda/fisiopatología , Función Ventricular Izquierda , Remodelación Ventricular , Anciano , Anciano de 80 o más Años , Cateterismo Cardíaco/efectos adversos , Femenino , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/métodos , Humanos , Masculino , Válvula Mitral/diagnóstico por imagen , Válvula Mitral/fisiopatología , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/fisiopatología , Diseño de Prótesis , Recuperación de la Función , Sistema de Registros , Estudios Retrospectivos , Factores de Riesgo , Índice de Severidad de la Enfermedad , Factores de Tiempo , Resultado del Tratamiento , Disfunción Ventricular Izquierda/diagnóstico por imagenRESUMEN
BACKGROUND: Frontal QRS-T angle (FQRST) has previously been correlated with mortality in patients with stable coronary artery disease, but its role as survival predictor after ST-elevation myocardial infarction (STEMI) remains unknown. METHODS: We evaluated 267 consecutive patients with STEMI undergoing reperfusion or coronary artery bypass grafting. Data assessed included demographics, clinical presentation, electrocardiograms, medical therapy, and one-year mortality. RESULTS: Of 267 patients, 187 (70%) were males and most (49.4%) patients were Caucasian. All-cause mortality was significantly higher among patients with the highest (101-180°) FQRST [28% vs. 15%, p = 0.02]. Patients with FQRST 1-50° had higher survival (85.6%) compared with FQRST = 51-100° (72.3%) and FQRST = 101-180° (67.9%), [log rank, p = 0.01]. Adjusting for significant variables identified during univariate analysis, FQRST (OR = 2.04 [95% CI: 1.31-13.50]) remained an independent predictor of one-year mortality. FQRST-based risk score (1-50° = 0 points, 51-100° = 2 points, 101-180° = 5 points) had excellent discriminatory ability for one-year mortality when combined with Mayo Clinic Risk Score (C statistic = 0.875 [95%CI: 0.813-0.937]. A high (>4 points) FQRST risk score was associated with greater mortality (32% vs. 19%, p = 0.02) and longer length of stay (6 vs. 2 days, p < 0.001). CONCLUSION: FQRST represents a novel independent predictor of one-year mortality in patients with STEMI undergoing reperfusion. A high FQRST-based risk score was associated with greater mortality and longer length of stay and, after combining with Mayo Clinic Risk Score, improved discriminatory ability for one-year mortality.