Comparison of coronary artery bypass graft versus drug-eluting stents in dialysis patients: an updated systemic review and meta-analysis.

INTRODUCTION: As percutaneous coronary intervention (PCI) technologies have been far improved, we hence conducted an updated systemic review and meta-analysis to determine the comparability between coronary artery bypass graft (CABG) and PCI with drug-eluting stent (DES) in ESRD patients. METHODS: We comprehensively searched the databases of MEDLINE, EMBASE, PUBMED and the Cochrane from inception to January 2020. Included studies were published observational studies that compared the risk of cardiovascular outcomes among dialysis patients with CABG and DES. Data from each study were combined using the random-effects, generic inverse variance method of DerSimonian and Laird to calculate risk ratios and 95% confidence intervals. Subgroup analyses and meta-regression were performed to explore heterogeneity. RESULTS: Thirteen studies were included in this analysis, involving total 56 422 (CABG 21 740 and PCI 34 682). Compared with DES, our study demonstrated CABG had higher 30-day mortality [odds ratio (OR) 3.85, P = 0.009] but lower cardiac mortality (OR 0.78, P < 0.001), myocardial infarction (OR 0.5, P < 0.001) and repeat revascularization (OR 0.35, P < 0.001). No statistical differences were found between CABG and DES for long-term mortality (OR 0.92, P = 0.055), composite outcomes (OR 0.88, P = 0.112) and stroke (OR 1.49, P = 0.457). Meta-regression suggested diabetes and the presence of left main coronary artery disease as an effect modifier of long-term mortality. CONCLUSION: PCI with DES shared similar long-term mortality, composite outcomes and stroke outcomes to CABG among dialysis patients but still was associated with an improved 30-day survival. However, CABG had better rates of myocardial infarction, repeat revascularization and cardiac mortality.

Diagnostic challenge in primary cardiac lymphoma: a case report.

BACKGROUND: Primary cardiac lymphoma is an extra-nodal non-Hodgkin's lymphoma, which usually responds well to chemotherapy. The disease has high mortality rate unless it is recognized and treated in time. Tissue pathology is crucially the diagnosis gold standard for treatment plan. This is a case report of an elderly female who presented with a huge right-sided cardiac tumour obstructing tricuspid flow. CASE SUMMARY: An 81-year-old Asian female presented with clinical right-sided heart failure. Echocardiogram showed a large mass compressing and obliterating the right atrium. Trans-jugular tissue biopsy was performed. Initial pathology report was consistent with an angiosarcoma, based on an expression of Fli-1 (Friend leukaemia virus integration 1) from immunohistochemical staining. She died shortly after refusal to surgery. Autopsy was performed with diagnosis change to a diffuse large B-cell lymphoma (DLBCL) after tissue pathology. DISCUSSION: Primary cardiac lymphoma is extremely rare. Adequate tissue and proper immunohistochemical staining are mandatory for treatment plan. Besides an angiosarcoma, DLBCL should be considered in the differential diagnosis of Fli-1 positive tissue cardiac mass.

Incidence and impact of acute kidney injury on patients with implantable left ventricular assist devices: a Meta-analysis.

Background: We aimed to evaluate the acute kidney injury (AKI) incidence and its associated risk of mortality in patients with implantable left ventricular assist devices (LVAD).Methods: A systematic literature search in Ovid MEDLINE, EMBASE, and Cochrane Databases was conducted through January 2020 to identify studies that provided data on the AKI incidence and AKI-associated mortality risk in adult patients with implantable LVADs. Pooled effect estimates were examined using random-effects, generic inverse variance method of DerSimonian-Laird.Results: Fifty-six cohort studies with 63,663 LVAD patients were enrolled in this meta-analysis. The pooled incidence of reported AKI was 24.9% (95%CI: 20.1%-30.4%) but rose to 36.9% (95%CI: 31.1%-43.1%) when applying the standard definition of AKI per RIFLE, AKIN, and KDIGO criteria. The pooled incidence of severe AKI requiring renal replacement therapy (RRT) was 12.6% (95%CI: 10.5%-15.0%). AKI incidence did not differ significantly between types of LVAD (p = .35) or indication for LVAD use (p = .62). While meta-regression analysis did not demonstrate a significant association between study year and overall AKI incidence (p = .55), the study year was negatively correlated with the incidence of severe AKI requiring RRT (slope = -0.068, p < .001). The pooled odds ratios (ORs) of mortality at 30 days and one year in AKI patients were 3.66 (95% CI, 2.00-6.70) and 2.22 (95% CI, 1.62-3.04), respectively. The pooled ORs of mortality at 30 days and one year in severe AKI patients requiring RRT were 7.52 (95% CI, 4.58-12.33) and 5.41 (95% CI, 3.63-8.06), respectively.Conclusion: We found that more than one-third of LVAD patients develop AKI based on standard definitions, and 13% develop severe AKI requiring RRT. There has been a potential improvement in the incidence of severe AKI requiring RRT for LVAD patients. AKI in LVAD patients was associated with increased 30-day and 1 year mortality.

Cardiac Shock Care Centers: JACC Review Topic of the Week.

Despite advances over the past decade, the incidence of cardiogenic shock secondary to acute myocardial infarction has increased, with an unchanged mortality near 50%. Recent trials have not clarified the best strategies in treatment. While dedicated cardiac shock centers are being established, there are no standardized agreements on the utilization of mechanical circulatory support and the timeliness of percutaneous coronary intervention strategies. In some centers and prospective registries, outcomes after placement of advanced mechanical circulatory support prior to reperfusion therapy with percutaneous coronary intervention have been encouraging with improved survival. Here, we suggest systems of care with a treatment pathway for patients with acute myocardial infarction complicated by cardiogenic shock.

Outcomes of rotational atherectomy in patients with severe left ventricular dysfunction without hemodynamic support.

INTRODUCTION: Elective insertion of a percutaneous circulatory assist device (PCAD) in high-risk patients is considered a reasonable adjunct to percutaneous coronary intervention (PCI). There is limited data examining the safety and efficacy of rotational atherectomy (RA) without hemodynamic support in patients with reduced left ventricular ejection fraction (LVEF). METHODS: We retrospectively identified 131 consecutive patients undergoing RA without elective PCAD over a three-year period. Patients were categorized into three groups: LVEF ≤30%, LVEF 31-50%, and LVEF >50%. The incidence of procedural hypotension, major adverse cardiac events (MACE), and mortality were recorded. RESULTS: Statistical analysis included 18, 42, and 71 patients with LVEF ≤30%, 31-50%, and >50%, respectively. Bailout hemodynamic support was required in four cases. Analysis revealed a significant trend as bailout hemodynamic support was required in 11.1% vs 2.4% (P = 0.1551) in the ≤30% vs 31-50% and 11.1% vs 1.4% (P = 0.0416) in the ≤30% vs >50% subgroups. Combined subgroup analysis also demonstrated statistical significance 11.1% vs 1.8% (P = 0.0324) in the ≤30% vs >30% subgroups. No-reflow phenomenon was more prevalent in patients with reduced LVEF (LVEF ≤30%: 11.1%, LVEF 31-50%: 2.4%, LVEF >50%: 0%; P = 0.0190). Otherwise, no significant differences in in-hospital MACE, or mortality were observed. CONCLUSION: RA can be effectively utilized in patients with severely reduced LVEF; however, these patients are at increased risk of prolonged procedural hypotension requiring bailout hemodynamic support. If indicated, prompt implementation of hemodynamic support mitigated any impact of procedural hypotension on in-hospital MACE and mortality.

Efficacy of a heparin based rota-flush solution in patients undergoing rotational atherectomy.

INTRODUCTION: The efficacy of heparin based flush solutions in rotational atherectomy (RA) has not been validated. Recently, a single center study demonstrated the feasibility of an alternative flush solution with 10,000U of unfractionated heparin (UFH) in 1L of normal saline. We aimed to evaluate the safety and efficacy of an alternative flush solution intermittently utilized at our institution. METHODS: We retrospectively identified 150 patients undergoing RA over a three year period. One hundred cases utilized an alternative flush solution containing 10,000U UFH, 400mcg nitroglycerin, and 10mg verapamil in 1L normal saline and fifty cases utilized RotaGlide Lubricant (Boston Scientific) in addition to heparin and vasodilators in the same dose. The primary end point was to compare rates of procedural success. Secondary endpoints were to report procedural characteristics including the incidence of major adverse cardiac events (MACE) and minor periprocedural complications. RESULTS: Procedural success was achieved in 98% (98/100) of cases utilizing the alternative Rota-Flush solution compared to 100% (50/50) in the Rota-Glide group (P=0.553). A total of 292 lesions (200 Rota-Flush vs 92 Rota-Glide) were targeted for intervention. MACE occurred in 13 (13%) and 4 (8%) cases in the Rota-Flush and Rota-Glide groups, respectively (P=0.425). CONCLUSION: Rotational atherectomy performed with the previously defined Rota-Flush or Rota-Glide solutions resulted in similar rates of procedural success. There were no significant disparities in incidence of MACE and minor periprocedural complications between the two groups. Heparin based rota-flush solutions can be effective alternatives to traditional solutions containing RotaGlide Lubricant.

Comparison of renal outcomes in off-pump versus on-pump coronary artery bypass grafting: A systematic review and meta-analysis of randomized controlled trials.

AIM: The objective of this meta-analysis was to compare the effects of off-pump and on-pump coronary artery bypass grafting (CABG) on acute kidney injury (AKI) and the need of dialysis after surgery. METHODS: Comprehensive literature searches for randomized controlled trials (RCTs) of CABG with on-pump and off-pump was performed using MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials Systematic Reviews and clinicaltrials.gov from inception through September 2014. Primary outcomes were the incidence of AKI and the need of dialysis. Mortality was assessed among the studies that reported renal outcomes. Pooled risk ratios (RRs) and 95% confidence interval (CI) were calculated using a random-effect, generic inverse variance method. RESULTS: Thirty-three RCTs with 17 322 patients were enrolled in our study. Patients in the off-pump CABG group had overall lower incidence of AKI (19.1%) compared with the on-pump CABG group (22.2%). There was a protective effect of off-pump CABG on the incidence of AKI compared with the on-pump CABG group (RR: 0.87; 95% CI: 0.77-0.98). However, there was no significant difference in the need for dialysis in the off-pump group compared with the on-pump group (RR: 0.84; 95% CI 0.63-1.13). Within the selected trials, post hoc analysis assessing the mortality outcome demonstrated a pooled RR of 0.97 (95% CI, 0.77-1.23) in off-pump versus on-pump CABGs. CONCLUSIONS: Our study demonstrates a beneficial effect of off-pump CABG on the incidence of AKI. However, our meta-analysis does not show benefits of the need of dialysis or survival among patients undergoing off-pump CABG.