Optimal antiplatelet and antithrombotic regimen post-transcatheter aortic valve replacement.

BACKGROUND: There are limited data regarding optimal antiplatelet/antithrombotic therapy following transcatheter aortic valve replacement (TAVR). METHODS: In this single-centre retrospective study including TAVR patients from 2012 to 2020, ischemic and bleeding outcomes were compared between antiplatelet (dual antiplatelet [DAPT] vs. single antiplatelet [SAPT]) and oral anticoagulation (OAC) groups using incidence rate, Kaplan-Meier and Cox proportional hazards analysis. RESULTS: Total 492 patients (mean age 79.7 ± 7.7 years, 53.7% males, 83.5% Caucasian) were included. There was higher incidence of 1-year death or ischemia with DAPT vs. SAPT (23.6 vs. 14.8 per 100 patient-years [PY], incidence rate ratio [IRR] 1.60, 95% confidence interval [CI] 0.97-2.68, p = .05), especially in those without coronary artery disease (23.9 vs. 10.7 per 100 PY, IRR 2.24, 95% CI 1.10-4.47, p = .017). There was significantly higher major bleeding in those on OAC vs. no OAC (15 vs. 8 per 100 PY, IRR 1.87, 95% CI 1.10-3.11, p = .016), especially late (>1-year) bleeding (10.2 vs. 3.6 per 100 PY, IRR 2.81, 95% CI 1.33-5.92, p = .004). In multivariate analysis, DAPT was an independent predictor of death or ischemia (adjusted hazard ratio [aHR] 1.41, 95% CI 1.01-1.96, p = .041). OAC was an independent predictor of major bleeding (aHR 2.32, 95% CI 1.31-4.13, p = .004). CONCLUSIONS: There is signal to harm with routine use of DAPT post-TAVR. There is higher incidence of late bleeding post-TAVR with OAC, suggesting potential role for alternate antithrombotic strategies.

Reassessing hepatocellular carcinoma staging in a changing patient population.

OBJECTIVE: Hepatocellular carcinoma (HCC) staging systems were developed using data predominantly from patients who had hepatitis and cirrhosis. Given the recent change in prevalence of viral hepatitis and cirrhosis at oncology centers, which has altered the natural history of HCC, we aimed at comparing the accuracy of HCC staging systems in patients with or without hepatitis and cirrhosis. METHODS: A total of 438 patients were enrolled. Baseline clinicopathologic parameters, Barcelona Clinic Liver Cancer stage, Cancer of the Liver Italian Program score, TNM (6th edition) stage, Okuda stage, and Chinese University Prognostic Index score were prospectively obtained for all patients, and retrospectively analyzed. Kaplan-Meier analysis was used to determine overall survival (OS), Cox regression analyses were performed, and Harrell's Correspondence Index compared the staging systems' ability to predict OS duration. Subgroup analyses of patients with or without hepatitis or cirrhosis were performed. RESULTS: Median patient OS was 13.9 months; 165 patients (37.7%) had no cirrhosis and 256 patients (58.4%) had no hepatitis. Overall, all staging systems were significantly less predictive of OS in patients who did not have cirrhosis or hepatitis. CONCLUSION: Our results advocate the need to further stratify HCC based on cirrhosis and hepatitis status, which may change patient risk-stratification and, ultimately, treatment decisions.

Rare Manifestation of COVID-19 Resulting in Coronary Artery Vasculitis.

We present the case of a 59-year-old African American female with end-stage renal disease (ESRD) who presented to the emergency department with chest discomfort. She had a coronary angiogram six months ago that showed no occlusive epicardial coronary artery disease. She had elevated troponin I levels and new regional wall motion abnormalities on echocardiogram. Her SARS-CoV-2 returned positive. After a multidisciplinary team approach, she underwent another coronary angiogram that showed new severe multivessel ostial lesions and a left main coronary artery aneurysm. COVID-19-related coronary artery vasculitis was suspected based on her clinical presentation, angiogram findings, and negative autoimmune workup. The patient underwent successful coronary artery bypass grafting and recovered without complications.

Iatrogenic Left Ventricle Outflow Tract Ventricular Tachycardia Following Transcatheter Aortic Valve Replacement: A Case Series.

Focal left ventricular outflow tract ventricular tachycardia (LVOT-VT) is rarely reported following transcatheter aortic valve replacement (TAVR). Similarly, unexplained sudden cardiac death after TAVR also is rarely described and may be attributed to VT. We present two cases of patients who underwent TAVR and later presented with VT of suggested LVOT origin. Both patients were treated with amiodarone for suppression of VT.