Development of In-Hospital Outcomes in Patients undergoing Transcatheter Aortic Valve Implantation (TAVI) at an Interdisciplinary Heart Center: A Single-Center Experience of 489 Consecutive Cases.

Background: Transcatheter Aortic Valve Implantation (TAVI) has emerged over time, reflected in appropriate adjustments in the European Society of Cardiology (ESC) guidelines in 2007, 2012 and 2017. Objective: The aim of this study was to analyze in-hospital outcomes after TAVI in the development within a single heart center over a period of 10 years depending on adjustments in the guidelines, infrastructural and procedural determinants. Methods: 489 consecutive patients who underwent TAVI from 2010 and 2019 at our center were analyzed retrospectively. Patients were divided into 3 groups of different treatment circumstances depending on guidelines adjustments and local infrastructural progress (group 1: 2010-2015 (n = 132), group 2: 2016-2017 (n = 155), group 3: 2018-2019 (n = 202). The primary endpoint was defined as all-cause in-hospital mortality. Secondary endpoints were selected according to the Valve Academic Research Consortium (VARC)-2 definitions. Multivariate logistic regression analysis was performed to determine predictors of in-hospital mortality. Statistical significance was assumed for p < 0.05. Results: 489 patients (346 (70.8 %) transfemoral and 143 (29.2 %) transapical) underwent TAVI. Comparing periods (group 1 vs. 2 vs. 3) age (82.1 ± 6.2 vs. 82.5 ± 4.8 vs. 81.1 ± 5.1 years, p = 0.012) and EuroSCORE II (8.4 ± 6.0 vs. 5.8 ± 4.9 vs. 5.5 ± 5.0 %, p < 0.001) declined over time. Rates of in-hospital mortality decreased significantly (9.1 % vs. 5.8 % vs. 2.5 %, p = 0.029), especially with observed-to-expected mortality ratios indicating a disproportionate decline of in-hospital mortality (1.08 vs. 1.00 vs. 0.45). Furthermore, post-procedural complications, such as acute kidney injury stage 3 (10.6 % vs. 3.2 % vs. 4.5 %, p = 0.016) and bleeding complications (14.4 % vs. 11.6 % vs 7.9 %, p = 0.165) decreased from group 1 to 3. However, rates of permanent pacemaker implantations (7.6 % vs. 11.0 % vs. 22.8 %, p < 0.001) increased, associated with a switch towards self-expanding valves (0.0 % vs. 61.3 % vs. 76.7 %, p < 0.001). Length of hospitalization as well as stay at intensive care and intermediate care unit could be reduced significantly during the observation period. In multivariate analysis age (OR: 1.103; 95 % CI: 1.013 - 1.202; p = 0.025), creatinine level before TAVI (OR: 1.497; 95 % CI: 1.013 - 2.212; p = 0.043), atrial fibrillation (OR: 2.956; 95 % CI: 1.127 - 7.749; p = 0.028) and procedure duration (OR: 1.017; 95 % CI: 1.009 - 1.025; p < 0.001) could be identified as independent predictors of in-hospital mortality. Conclusion: This study identified age, creatinine level before TAVI, the presence of atrial fibrillation and procedure duration as independent predictors for in-hospital mortality. Although these predictors decreased during the observation period, the decline in hospital-mortality was disproportionate, which was indicated by an observed-to-expected mortality ratio of 0.45 for the last observation period. However, it can be assumed that apart from patient-related factors, there were further institutional, technical and procedural developments, which ran in parallel and affected in-hospital mortality rates after TAVI.

Novel concept of routine total arterial coronary bypass grafting through a left anterior approach avoiding sternotomy.

Coronary artery bypass grafting (CABG) via full sternotomy remains a very invasive procedure, often requiring prolonged recovery of the patient. We describe a novel, less invasive approach for totally arterial CABG via a small left anterior thoracotomy in a pilot series of 20 unselected patients. From January to March 2020, 20 consecutive patients (mean age 65.9 ± 9.2 years, 100% male, STS-score: 1.6 ± 2) underwent CABG using only arterial conduits via a small left anterior thoracotomy. Patients were operated on cardiopulmonary bypass with peripheral cannulation and transthoracic aortic cross-clamping. Pulling tapes encircling the great vessels, the arrested empty heart was rotated and moved within the pericardium to enable conventional anastomotic techniques especially on lateral and inferior wall coronary targets. In all patients, left internal mammary artery and radial artery were utilized for bypass with 3.3 ± 0.7 distal coronary anastomoses per patient. Anterior, lateral, and inferior wall territories were revascularized in 100%, 85%, and 70% of patients, respectively. Complete anatomical revascularization was achieved in 95% of patients. ICU stay was 1 day in 17 patients, and 14 of patients left the hospital within 8 days. There was no hospital death, no stroke, no myocardial infarction, and no repeat revascularization. In this pilot series of 20 patients, minimally invasive, totally arterial CABG with avoidance of sternotomy was technically feasible with favorable patient outcomes.

Clinical and cardiac magnetic resonance findings in post-COVID patients referred for suspected myocarditis.

OBJECTIVES: We assessed possible myocardial involvement in previously cardiac healthy post-COVID patients referred for persisting symptoms with suspected myocarditis. BACKGROUND: Prior studies suggested myocardial inflammation in patients with coronavirus-induced disease 2019 (COVID-19). However, the prevalence of cardiac involvement among COVID patients varied between 1.4 and 78%. METHODS: A total of 56 post-COVID patients without previous heart diseases were included consecutively into this study. All patients had positive antibody titers against SARS-CoV-2. Patients were referred for persistent symptoms such as chest pain/discomfort, shortness of breath, or intolerance to activity. All patients underwent standardized cardiac assessment including electrocardiogram (ECG), cardiac biomarkers, echocardiography, and cardiac magnetic resonance (CMR). RESULTS: 56 Patients (46 ± 12 years, 54% females) presented 71 ± 66 days after their COVID-19 disease. In most patients, the course of COVID-19 was mild, with hospital treatment being necessary in five (9%). At presentation, patients most often reported persistent fatigue (75%), chest pain (71%), and shortness of breath (66%). Acute myocarditis was confirmed by T1/T2-weighed CMR and elevated NTpro-BNP levels in a single patient (2%). Left ventricular ejection fraction was 56% in this patient. Additional eight patients (14%) showed suspicious CMR findings, including myocardial edema without fibrosis (n = 3), or non-ischemic myocardial injury suggesting previous inflammation (n = 5). However, myocarditis could ultimately not be confirmed according to 2018 Lake Louise criteria; ECG, echo and lab findings were inconspicuous in all eight patients. CONCLUSIONS: Among 56 post-COVID patients with persistent thoracic complaints final diagnosis of myocarditis could be confirmed in a single patient using CMR.

Current options and recommendations for the use of thoracic endovascular aortic repair in acute and chronic thoracic aortic disease: an expert consensus document of the European Society for Cardiology (ESC) Working Group of Cardiovascular Surgery, the ESC Working Group on Aorta and Peripheral Vascular Diseases, the European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the ESC and the European Association for Cardio-Thoracic Surgery (EACTS).

Since its clinical implementation in the late nineties, thoracic endovascular aortic repair (TEVAR) has become the standard treatment of several acute and chronic diseases of the thoracic aorta. While TEVAR has been embraced by many, this disruptive technology has also stimulated the continuing evolution of open surgery, which became even more important as late TEVAR failures do need open surgical correction justifying the need to unite both treatment options under one umbrella. This fact shows the importance of-in analogy to the heart team-aortic centre formation and centralization of care, which stimulates continuing development and improves outcome . The next frontier to be explored is the most proximal component of the aorta-the aortic root, in particular in acute type A aortic dissection-which remains the main challenge for the years to come. The aim of this document is to provide the reader with a synopsis of current evidence regarding the use or non-use of TEVAR in acute and chronic thoracic aortic disease, to share latest recommendations for a modified terminology and for reporting standards and finally to provide a glimpse into future developments.

Impact of the COVID-19 pandemic on cardiovascular mortality and catherization activity during the lockdown in central Germany: an observational study.

AIMS: During the COVID-19 pandemic, hospital admissions for cardiac care have declined. However, effects on mortality are unclear. Thus, we sought to evaluate the impact of the lockdown period in central Germany on overall and cardiovascular deaths. Simultaneously we looked at catheterization activities in the same region. METHODS AND RESULTS: Data from 22 of 24 public health-authorities in central Germany were aggregated during the pandemic related lockdown period and compared to the same time period in 2019. Information on the total number of deaths and causes of death, including cardiovascular mortality, were collected. Additionally, we compared rates of hospitalization (n = 5178) for chronic coronary syndrome (CCS), acute coronary syndrome (ACS), and out of hospital cardiac arrest (OHCA) in 26 hospitals in this area. Data on 5,984 deaths occurring between March 23, 2020 and April 26, 2020 were evaluated. In comparison to the reference non-pandemic period in 2019 (deaths: n = 5832), there was a non-significant increase in all-cause mortality of 2.6% [incidence rate ratio (IRR) 1.03, 95% confidence interval (CI) 0.99-1.06; p = 0.16]. Cardiovascular and cardiac mortality increased significantly by 7.6% (IRR 1.08, 95%-CI 1.01-1.14; p = 0.02) and by 11.8% (IRR 1.12, 95%-CI 1.05-1.19; p < 0.001), respectively. During the same period, our data revealed a drop in cardiac catherization procedures. CONCLUSION: During the COVID-19-related lockdown a significant increase in cardiovascular mortality was observed in central Germany, whereas catherization activities were reduced. The mechanisms underlying both of these observations should be investigated further in order to better understand the effects of a pandemic-related lockdown and social-distancing restrictions on cardiovascular care and mortality.

Distal Stent Graft-Induced New Entry After TEVAR or FET: Insights Into a New Disease From EuREC.

BACKGROUND: The study sought to learn about incidence and reasons for distal stent graft-induced new entry (dSINE) after thoracic endovascular aortic repair (TEVAR) or after frozen elephant trunk (FET) implantation, and develop prevention algorithms. METHODS: In an analysis of an international multicenter registry (EuREC [European Registry of Endovascular Aortic Repair Complications] registry), we found 69 dSINE patients of 1430 (4.8%) TEVAR patients with type B aortic dissection and 6 dSINE patients of 100 (6%) patients after the FET procedure for aortic dissection with secondary morphological comparison. RESULTS: The underlying aortic pathology was acute type B aortic dissection in 33 (44%) patients, subacute or chronic type B aortic dissection in 34 (45%) patients, acute type A aortic dissection in 3 patients and remaining dissection after type A repair in 3 (8%) patients, and acute type B intramural hematoma in 2 (3%) patients. dSINE occurred in 4.4% of patients in the acute setting and in 4.9% of patients in the subacute or chronic setting after TEVAR. After the FET procedure, dSINE occurred in 5.3% of patients in the acute setting and in 6.5% of patients in the chronic setting. The interval between TEVAR or FET and the diagnosis of dSINE was 489 ± 681 days. Follow-up after dSINE was 1340 ± 1151 days, and 4 (5%) patients developed recurrence of dSINE. Morphological analysis between patients after TEVAR with and without dSINE showed a smaller true lumen diameter, a more accentuated oval true lumen morphology, and a higher degree of stent graft oversizing in patients who developed dSINE. CONCLUSIONS: dSINE after TEVAR or FET is not rare and occurs with similar incidence after acute and chronic aortic dissection (early and late). Avoiding oversizing in the acute and chronic settings as well as carefully selecting patients for TEVAR in postdissection aneurysmal formation will aid in reducing the incidence of dSINE to a minimum.

Impact of left atrial diameter on outcome in patients undergoing edge-to-edge mitral valve repair: results from the German TRAnscatheter Mitral valve Interventions (TRAMI) registry.

BACKGROUND: Left atrial (LA) dimension is a marker of disease severity and outcome in primary and secondary mitral regurgitation. In transcatheter mitral valve repair, LA enlargement might additionally impact on device handling and technical success through an altered anatomy and atrial annular dilatation. METHODS AND RESULTS: Data from the multicentre German TRAnscatheter Mitral valve Interventions registry (TRAMI) were used to analyse the association of baseline LA diameter by tertiles with efficacy, safety and long-term clinical outcome in patients undergoing edge-to-edge repair with MitraClip. In 520 of 843 patients prospectively enrolled in TRAMI, baseline LA diameter were reported [median (interquartile range) LA diameter in tertiles: 44 (40-46) mm, 51 (48-53) mm and 60 (55-66) mm]. Larger LA diameters were significantly associated with secondary aetiology of mitral regurgitation, lower ejection fraction, larger left ventricle, male sex and atrial fibrillation (all P < 0.05). Technical success was not different across tertiles (96%, 95.4% and 98.4%, respectively; P = 0.43) as were major in-hospital cardiovascular and cerebral adverse events (mortality, myocardial infarction or stroke: 1.8%, 1.2% and 4.4%, respectively; P = 0.11 across tertiles). However, 4-year mortality significantly increased with larger LA diameter (32.9%, 46.4% and 51.7%, respectively; P < 0.01), as did hospitalization in survivors (60%, 67.6% and 78.9%, respectively; P < 0.05). The association between LA diameter and outcome remained significant after multivariable adjustment including baseline left ventricular end-diastolic diameter. CONCLUSION: Left atrial enlargement is a strong and independent predictor of adverse long-term outcome after transcatheter mitral valve repair. Further study is warranted to examine whether timely intervention may have the potential to modify outcome.

Underweight is associated with inferior short and long-term outcomes after MitraClip implantation: Results from the German TRAnscatheter mitral valve interventions (TRAMI) registry.

BACKGROUND: Underweight and obesity represent classical risk factors for adverse outcome in patients treated for cardiovascular disease. AIMS: The current analysis examines the impact of underweight, overweight and obesity on intra-hospital, short and long-term outcomes in patients treated by MitraClip therapy. METHODS AND RESULTS: From August 2010 until July 2013, 799 patients (age 75.3 ±â€¯8.6 years, male gender 60.7%, median logistic EuroSCORE 20% [12; 31], functional mitral regurgitation (MR): 69.3%) were prospectively enrolled into the multicenter German Transcatheter Mitral Valve Interventions registry. Patients were stratified according to body mass index (BMI) into 4 groups: BMI <20 kg/m2 (underweight), BMI 20.0 to <25.0 kg/m2 (normal weight, reference group), BMI 25.0 to <30.0 kg/m2 (overweight) and BMI ≥30 kg/m2 (obese). Significant increased rates of procedural failure, transfusion/bleeding, sepsis or multiorgan failure and low cardiac output failure were found for underweight patients only. Kaplan-Meier survival curves demonstrated inferior survival for underweight patients, but comparable outcomes for all other patients (global log rank test, P < .01). Multivariable Cox-regression analysis (adjusted for age, gender, creatinine ≥1.5 mg/dL, diabetes, left ventricular ejection fraction <30% and chronic obstructive pulmonary disease) confirmed underweight (as compared to normal weight) as an independent risk factor of death (hazard ratio [HR]: 1.58, 95% confidence interval (CI): 1.01-2.46, P = .044) and overweight as protective against death (HR: 0.71; 95%-CI: 0.55-0.93; P = .011). CONCLUSIONS: Compared to other weight groups, underweight patients undergoing MitraClip implantation are exposed to increased rates of procedural failure, bleeding and low cardiac output as well as increased short- and long-term mortality rates and should therefore be carefully discussed in the heart-team.

Combined Tricuspid and Mitral Versus Isolated Mitral Valve Repair for Severe MR and TR: An Analysis From the TriValve and TRAMI Registries.

OBJECTIVES: The aim of this study was to retrospectively compare the characteristics, procedural courses, and outcomes of patients presenting with concomitant mitral regurgitation (MR) and tricuspid regurgitation (TR) in the TriValve (Transcatheter Tricuspid Valve Therapies) and TRAMI (Transcatheter Mitral Valve Interventions) registries. BACKGROUND: Transcatheter mitral edge-to-edge valve repair (TMVR) has been shown to be successful in patients with severe MR. Lately, edge-to-edge repair has also emerged as a possible treatment for severe TR in patients at high risk for cardiac surgery. In patients with both severe MR and TR, the yield of concomitant transcatheter mitral and tricuspid valve repair (TMTVR) for patients at high surgical risk is unknown. METHODS: The characteristics, procedural data, and 1-year outcomes of all patients in the international multicenter TriValve registry and the German multicenter TRAMI registry, who presented with both severe MR and TR, were retrospectively compared. Patients in TRAMI (n = 106) underwent isolated TMVR, while those in TriValve (n = 122) additionally underwent concurrent TMTVR in compassionate and/or off-label use. RESULTS: All 228 patients (mean age 77 ± 8 years, 44.3% women) presented with significant dyspnea at baseline (New York Heart Association functional class III or IV in 93.9%), without any differences in the rates of pulmonary hypertension and chronic pulmonary disease. The proportion of patients with left ventricular ejection fraction <30% was higher in the TMVR group (34.9% vs. 18.0%; p < 0.001), while patients in the TMTVR group had lower glomerular filtration rates. At discharge, MR was comparably reduced in both groups. At 1 year, overall all-cause mortality was 34.0% in the TMVR group and 16.4% in the TMTVR group (p = 0.035, Cox regression). On multivariate analysis, TMTVR was associated with a 2-fold lower mortality rate (hazard ratio: 0.52; p = 0.02). The rate of patients in New York Heart Association functional class ≤II at 1 year did not differ (69.4% vs. 67.0%; p = 0.54). CONCLUSIONS: Concurrent TMTVR was associated with a higher 1-year survival rate compared with isolated TMVR in patients with both MR and TR. Further randomized trials are needed to confirm these results.

Outcomes Following Transcatheter Aortic Valve Replacement for Degenerative Stentless Versus Stented Bioprostheses.

OBJECTIVES: A large comprehensive analysis of transcatheter aortic valve replacement (TAVR) was performed for failed stentless bioprostheses. BACKGROUND: Valve-in-valve (ViV) transcatheter aortic replacement (TAVR) is an alternative to redo surgery for patients with a failing aortic bioprosthesis. METHODS: Unadjusted outcome data were collected from the VIVID (Valve-in-Valve International Data) registry between 2007 and 2016 from a total of 1,598 aortic ViV procedures (291 stentless, 1,307 stented bioprostheses). RESULTS: Bioprosthetic failure was secondary to aortic regurgitation in 56% of stentless and 20% stented devices (p < 0.001). ViV-TAVR access was transfemoral in 71.1% stentless and 74.2% stented ViV-TAVR. Self-expanding devices were more frequently used in stentless ViV-TAVR (56.0% vs. 39.9%; p = 0.05), but there was no difference between balloon-expanding and self-expanding TAVR devices for stented ViV-TAVR (48.6% vs. 45.1%). The degree of oversizing for all mechanisms of bioprosthesis failure was 9 ± 10% for stentless ViV-TAVR vs. 6 ± 9% for stented ViV-TAVR (and 8 ± 10% for stentless ViV-TAVR vs. 3 ± 9% for stented ViV-TAVR in patients with predominant aortic regurgitation; both p < 0.001). Initial device malposition (10.3% vs. 6.2%; p = 0.014), second transcatheter device (7.9% vs. 3.4%), coronary obstruction (6.0% vs. 1.5%), and paravalvular leak occurred more frequently in stentless ViV-TAVR (all p < 0.001). Hospital stay duration (median 7 days) was no different, and 30-day (6.6% vs. 4.4%; p = 0.12) and 1-year mortality year (15.8% vs. 12.6%; p = 0.15) were numerically higher, but not statistically different, after stentless ViV-TAVR. CONCLUSIONS: Stentless ViV-TAVR is associated with greater periprocedural complications (initial device malposition, second transcatheter device, coronary obstruction, paravalvular leak), but no difference in 30-day and 1-year outcome.

Incidence and outcome of peri-procedural transcatheter heart valve embolization and migration: the TRAVEL registry (TranscatheteR HeArt Valve EmboLization and Migration).

AIMS: Peri-procedural transcatheter valve embolization and migration (TVEM) is a rare but potentially devastating complication of transcatheter aortic valve implantation (TAVI). We sought to assess the incidence, causes, and outcome of TVEM in a large multicentre cohort. METHODS AND RESULTS: We recorded cases of peri-procedural TVEM in patients undergoing TAVI between January 2010 and December 2017 from 26 international sites. Peri-procedural TVEM occurred in 273/29 636 (0.92%) TAVI cases (age 80.8 ± 7.3 years; 53.8% female), of which 217 were to the ascending aorta and 56 to the left ventricle. The use of self-expanding or first-generation prostheses and presence of a bicuspid aortic valve were independent predictors of TVEM. Bail-out measures included repositioning attempts using snares or miscellaneous tools (41.0%), multiple valve implantations (83.2%), and conversion to surgery (19.0%). Using 1:4-propensity matching, we identified a cohort of 235 patients with TVEM (TVEMPS) and 932 patients without TVEM (non-TVEMPS). In the matched cohort, all-cause mortality was higher in TVEMPS than in non-TVEMPS at 30 days (18.6% vs. 4.9%; P < 0.001) and after 1 year (30.5% vs. 16.6%; P < 0.001). Major stroke was more frequent in TVEMPS at 30 days (10.6% vs. 2.8%; P < 0.001), but not at 1 year (4.6% vs. 1.9%; P = 0.17). The need for emergent cardiopulmonary support, major stroke at 30 days, and acute kidney injury Stages 2 and 3 increased the risk of 1-year mortality, whereas a better renal function at baseline was protective. CONCLUSION: Transcatheter valve embolization and migration occurred in approximately 1% and was associated with increased morbidity and mortality.

Meta-analysis of fractional flow reserve guided complete revascularization versus infarct related artery only revascularization in patients with ST-elevation myocardial infarction and multivessel coronary artery disease.

BACKGROUND: Multivessel coronary artery disease is found in 30-50% of patients with ST-elevation myocardial infarction (MI) and is associated with adverse outcomes. It is not yet clear if outcomes are improved by utilizing fractional flow reserve (FFR) guided percutaneous coronary intervention (PCI) of noninfarct related artery (non-IRA) along with primary PCI. METHODS AND RESULTS: To evaluate this, we performed a metanalysis of published randomized controlled trials by performing systematic search of PubMed, Medline, Google Scholar and Cochrane Central. Three studies met the inclusion criteria, with total of 1633 patients; 689 underwent FFR-guided complete revascularization and 944 underwent IRA only revascularization. FFR-guided PCI of non-IRA along with primary PCI led to significant reduction of major adverse cardiovascular events (composite of death, MI and repeat revascularization) compared to PCI of IRA only [odds ratio (OR) = 0.55; 95% confidence interval (CI) = 0.42-0.72; P < 0.001]. This difference was primarily due to significant reduction in repeat revascularization (OR = 0.37; 95% CI = 0.26-0.53; P < 0.001). The rates of all-cause mortality (OR = 1.24; 95% CI = 0.65-2.35; P = 0.51) and MI (OR = 0.79; 95% CI = 0.46-1.36; P = 0.48) were similar in two groups. CONCLUSION: This meta-analysis demonstrated that FFR-guided PCI of non-IRA along with primary PCI was associated with lower rate of major adverse cardiovascular events compared with PCI of IRA-only in patients with ST-elevation MI and multivessel disease. The difference was driven by lower rate of repeat revascularization in FFR-guided PCI of non-IRA group.

Long-term outcome, survival and predictors of mortality after MitraClip therapy: Results from the German Transcatheter Mitral Valve Interventions (TRAMI) registry.

BACKGROUND: MitraClip therapy is increasingly used in patients deemed inoperable to treat severe mitral regurgitation (MR), but long-tern data is scarce. AIMS: The multicentre, industry-independent German Transcatheter Mitral Valve Interventions (TRAMI) registry comprises the largest prospectively enrolled cohort of patients treated by MitraClip therapy. The current analysis is focusing on long-term mortality rates, cardiac rehospitalization and reintervention. METHODS AND RESULTS: Long-term follow-up (median time 1037 days) in the TRAMI registry was available for 722 patients treated at 20 German centres. Improvements in New York Heart Association (NYHA) functional class (I/II long-term: 65% vs. 1-year follow-up: 63.3%) and self-rated health-status (EuroQuol visual analogue scale [EQ VAS] long-term: 60 [50-70] vs. 1-year follow-up: 60 [50; 70]) were pertained over time. Estimated mortality rates by Kaplan-Meier method were 19.7% for 1-year, 31.9% for 2-year and 53.1% for 4-year follow-up without differences found for MR aetiology. Multivariable Cox-regression analysis identified previous aortic valve implantation (hazard ratio [HR] = 2.21; p < 0.0001), NYHA class IV (HR = 1.78; p < 0.001), prior cardiac decompensation (HR = 1.63; p < 0.001), creatinine > 1.5 mg/dl (HR = 1.63; p < 0.0001) and left ventricular ejection fraction < 30% (HR = 1.60; p < 0.001) as most predictive for long-term mortality. CONCLUSIONS: Long-term outcome in the TRAMI registry confirmed lasting clinical improvements and low intervention rates. Long-term mortality was strongly influenced by cardiac and non-cardiac co-morbidities and was found comparable for both MR aetiologies.

Meta-analysis of drug eluting stents compared with bare metal stents in high bleeding risk patients undergoing percutaneous coronary interventions.

OBJECTIVES: To determine the efficacy and safety of drug-eluting stents (DESs) and bare metal stents (BMSs) when used with short or tailored dual antiplatelet therapy (DAPT) in high bleeding risk (HBR) patients. BACKGROUND: DES have been shown to reduce target lesion revascularization (TLR) as well as stent thrombosis (ST) compared to BMS in patients undergoing percutaneous coronary intervention (PCI). However, patients at HBR continue to receive BMS given the fear of bleeding or ST from premature discontinuation of DAPT in patients receiving DES. METHODS: We performed a meta-analysis of randomized controlled trials by performing systematic search for studies comparing DES with BMS in HBR patients using PUBMED, MEDLINE, and Cochrane Central, reported until March 1, 2018. RESULTS: Three randomized controlled studies met the inclusion criteria with total of 4,460 patients; 50% received DES. Major adverse cardiovascular event (MACE); composite of death, myocardial infarction (MI), and TLR, at 1 year was significantly lower (RR = 0.63, 95% CI 0.50-0.80) in DES group compared to BMS. This difference was primarily driven by lower TLR (RR = 0.46, 95% CI 0.35-0.61) in DES group. Definite or probable ST (RR = 0.59, 95% CI = 0.32-1.08) and major (RR = 0.94, 95% CI = 0.74-1.20) bleeding were similar. CONCLUSIONS: DES was associated with lower MACE without increased risk of bleeding or ST compared to BMS when used with short or tailored DAPT in patients with HBR.