Carotid access for transcatheter aortic valve replacement: A meta-analysis.

OBJECTIVE: We sought to evaluate the feasibility and safety of carotid access transcatheter aortic valve replacement (TAVR) by performing a meta-analysis of published cases. BACKGROUND: Several case series and regional data have provided initial basis for carotid access TAVR in patients with prohibitive femoral approach. We performed this meta-analysis to provide further evidence of feasibility and safety of carotid TAVR. METHODS: We searched PubMed, EMBASE, CINAHL, and Cochrane CENTRAL for any study on carotid access TAVR involving ⩾5 patients since inception till March 1, 2020. Random-effects model was used to compute overall effects. The outcomes analyzed were all-cause mortality, Transient ischemic attack (TIA)/stroke, need for permanent pacemaker (PPM) implantation, pericardial tamponade, access site complications, major bleeding, and length of stay. RESULTS: There was a total of 17 retrospective studies (n = 2082) with a median follow-up of 1 month. Mean age of the patient was 80 years. Mean Euroscore and STS scores were 15 ± 6.2 and 7.9 ± 3.3, respectively. The procedural success rate was 99%. The rate of all-cause mortality was 6.7% (range 4.6-9.7%, p < .001, I2 = 67%). Incidence of TIA/stroke was 3.9% (range 3.1-4.8%, p < .001, I2 = 0%) and PPM implantation was 16.7% (range 12.5-21.9%, p < .001, I2 = 56%). Rate of pericardial tamponade, vascular complication, and major bleeding were 1.7, 2.5, and 7%, respectively. Average length of hospital stay was 7.7 days. CONCLUSION: Our results show that transcarotid approach is a feasible option in patients with prohibitive femoral access for TAVR.

Recognizing Debilitating and Fatal Dysautonomia in Patients With Parkinson's Disease in the Emergency Room: A Case Report and Narrative Review.

Dysautonomia impacts multiple systems leading to a spectrum of severe disorders independent of the motor symptoms in Parkinson's disease (PD). Although the motor symptoms of dyskinesia and immobility in patients with PD were traditionally considered the major reasons leading to emergency visits, the significance of non-motor symptoms, particularly dysautonomia-related disorders, have been increasingly appreciated during their emergent encounters. We present the case of an elderly patient with advanced PD who was hit by a full spectrum of dysautonomia-related disorders, had frequent emergency visits and hospital admissions over one year, and eventually died on his fifth emergency visit. His dysautonomia-related disorders included dysphagia, gastroesophageal reflux disease, neurogenic bladder, chronic constipation, and cardiac dysautonomia with orthostatic intolerance. We further review emergent presentations, assessments, and immediate management of these dysautonomia-associated disorders in patients with PD. In summary, these dysautonomia-linked comorbidities can be debilitating and sometimes fatal. As for our case, the patient was on a clinical decline majorly due to dysautonomia and nearing the end of life over the past year. A holistic approach of possible de-escalating care and palliative care might lead to a better quality of life for the patients and their families. Nevertheless, generally speaking, emergent presentations of dysautonomia symptoms in patients with PD should be recognized and treated timely and appropriately in the emergency room. Emergency clinicians need to increase awareness and make efforts to manage these acute worsening episodes of dysautonomia disorders in patients with PD to prevent debilitating and fatal complications.

Post-Myocardial Infarction (MI) Left Ventricular Free Wall Rupture Managed Conservatively.

Left ventricular free wall rupture (LVFWR) is an uncommon but often fatal complication of acute myocardial infarction. LVFWR is managed with hemodynamic stabilization and is typically followed by surgical intervention with varying approaches depending on the type of LVFWR. A 78-year-old male with a history of coronary artery bypass graft (CABG) was admitted with ST-segment elevation myocardial infarction. Left heart catheterization showed complete occlusion of the saphenous vein graft to the 1st obtuse marginal artery. The patient was not a candidate for percutaneous coronary intervention or CABG. The patient later developed atrial fibrillation with a rapid ventricular response which was managed with beta blockers. Computed tomography pulmonary angiogram was done to rule out pulmonary embolus; however, it demonstrated findings of a lateral LVFWR. The patient was deemed a poor surgical candidate for cardiothoracic surgery, and the LVFWR was managed conservatively with metoprolol succinate and bed rest. He later required amiodarone and direct current cardioversion due to the recurrence of atrial fibrillation. Two months following the LVFWR, the patient remained stable with no apparent complications. In a certain subset of LVFWR patients, surgical management may not be possible given patient anatomy and other high-risk factors. In these cases, conservative management with bed rest and beta blockers and treatment of ventricular and atrial arrhythmias may be a viable therapeutic option.

Clozapine-Related Functional Bowel Obstruction: A Rare Adverse Effect Unmasking Quetiapine and Benztropine Interaction Raising Need for Bowel Surveillance.

Randomized controlled trials demonstrate a significant decline in hospital admissions and length of stay following the initiation of clozapine in individuals with bipolar disorder and schizophrenia, along with an increase in quality-adjusted life years. The morbidity and mortality associated with clozapine-induced gastrointestinal hypomotility (CIGH) is greater than agranulocytosis. Despite this, we only have clozapine risk evaluation and mitigation strategies by the US Food and Drug Administration for white cell count monitoring, but none exists for CIGH. Our case highlights CIGH due to multiple factors and recommendations to prevent it and enhance clozapine compliance by conducting a thorough literature review.

Oculogyric Crisis Following Dosage Increase of Aripiprazole: A Case Report.

Oculogyric crisis (OGC) is a form of acute dystonia with involuntary conjugated ocular gaze in a fixed position. Common causes include metabolic disorders and medications, primarily typical antipsychotics. A 24-year-old male with a history of persistent depressive disorder and possible bipolar disorder was admitted to the psychiatric unit due to suicidal ideation. He was started on aripiprazole 5 mg and subsequently increased to 10 mg due to uncontrolled mood disorder. The patient subsequently developed OGC, which resolved with benztropine and diphenhydramine. This case report highlights aripiprazole-induced OGC and prompt management with benztropine and first-generation antihistamines.

Chronic total occlusion rotational atherectomy (CTO RA) versus non-CTO RA in coronary artery disease: A meta-analysis of clinical outcomes and complications.

Background: Chronic total occlusion rotational atherectomy (CTO RA) is an emerging intervention in coronary artery disease (CAD), although data comparing its outcomes and complications with non-CTO RA are scarce. We sought to evaluate the outcomes of RA in CTO lesions compared to those in non-CTO lesions by performing a meta-analysis. Methods: We conducted a systematic review and meta-analysis of studies comparing the clinical outcomes and complications between CTO RA and non-CTO RA in patients with CAD. We searched PUBMED, CINAHL, EMBASE and Cochrane Central Register of Clinical Trials for any studies that compared the outcomes of RA in CTO and non-CTO lesions. The outcomes analyzed included in-hospital major adverse cardiovascular events (MACE), target vessel revascularization (TVR), angiographic success, procedural success, periprocedural complications, coronary perforation, and all-cause mortality. Results: Four studies with a total of 1868 patients were included, spanning from 2018 to 2022, from Germany, Taiwan, and Korea. The median age of included patients was 71. The rate of the pooled results indicated a moderate, non-significant increase in in-hospital MACE and TVR for CTO RA compared to non-CTO RA. There was a small, non-significant decrease in angiographic and procedural success in CTO RA compared to non-CTO RA. CTO RA was associated with a non-significant increase in periprocedural complications and a significant increase in coronary perforation compared to non-CTO RA. All-cause mortality showed a non-significant increase in the CTO RA group. Conclusion: This meta-analysis provides evidence that while CTO RA may be associated with a higher risk of coronary perforation, the risk of other outcomes including MACE, TVR, and all-cause mortality is not significantly different compared to non-CTO RA. More research is needed to further understand these relationships and to optimize treatment strategies in patients with CAD undergoing CTO RA.