Reducing neurosurgical theatre start time delays by seventy minutes through application of the 'Golden Patient' initiative.

BACKGROUND: This project's focus was on improving neurosurgical theatre efficiency through the application of Javed et al's Golden Patient initiative to the emergency theatre setting. This initiative has not previously been used in neurosurgery, so we have had to consider how to adapt it. Phase I's primary objective was to quantify theatre start time delays. Phase II assessed whether introducing the initiative reduced the delays. METHODOLOGY: We performed an observational retrospective service evaluation project. Data was collected on weekday theatre start times over 12-week periods pre- and post-initiative. We quantified the delay in theatre start times and recorded the reasons for delays. Following the initiative's introduction, we repeated the evaluation process. Mean and median theatre start times were compared. An ANOVA test was used to confirm statistical significance. RESULTS: Data was collected on 49 days and on 48 days over 12-week periods in both Phase I and II respectively. Phase I of this project identified that there was on average an 86.7 minute delay in starting the theatre each day. The theatre start time was delayed in 91.7% of cases. A 72.3 minute reduction in the theatre start time delay was noted following the initiative's introduction (p < .0005), with an improvement in the average emergency theatre start time from 09:56 to 08:44 (08:30 is the recognised theatre start time). We have identified hospital-wide and doctor-related contributing factors which require further attention, most notably, relating to issues around transferring patients from the ward to theatre. CONCLUSIONS: We have identified a statistically significant improvement in reducing theatre start time delays following the introduction of the initiative. This relatively simple intervention improved communication amongst the multidisciplinary team and led to a notable improvement in the service provided to patients by reducing start time delays. Through tackling identified areas, we hope to further reduce theatre start time delays leading not only to financial savings but also to further improvements in the quality of care provided to our neurosurgical patients.

Complications after Transfemoral Transcatheter Aortic Valve Replacement with a Balloon-Expandable Prosthesis: The Importance of Preventative Measures and Contingency Planning.

Transcatheter aortic valve replacement (TAVR) with balloon-expandable Edwards-SAPIEN valve was superior to standard therapy in inoperable patients and noninferior to surgical aortic valve replacement in high surgical-risk, but operable patients, with severe symptomatic aortic stenosis in the randomized controlled PARTNER trial. Since the first case of TAVR with a balloon-expandable valve in 2002, several groups have reported their experience with balloon-expandable valves with high-procedural success. In the United States, the balloon-expandable Edwards-SAPIEN valve is the only transcatheter heart valve approved by the FDA for commercial use. Moreover, this is only in high-risk inoperable patients. Despite increasing experience with the TAVR procedure, it can be associated with complications, which can be technically challenging, even for an experienced operator. Complications associated with TAVR include vascular complications, valve malpositioning, regurgitation, embolization, coronary compromise, conduction abnormalities, stroke/transient ischemic attack, acute kidney injury, cardiac tamponade, and hemodynamic collapse. A thorough understanding of the procedure is essential for pre-emptive planning for procedural complications and early identification and management of complications are necessary for procedural success. We hereby review our experience of transfemoral TAVR with balloon-expandable valves, offer practical tips to maximize the likelihood of procedural success, describe pre-emptive strategies to prevent peri-procedural complications and bailout measures to manage them, should they occur. © 2018 Wiley Periodicals, Inc.

Clinical Impact of Diabetes Mellitus on Outcomes After Transcatheter Aortic Valve Replacement: Insights From the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry.

BACKGROUND: Diabetes mellitus (DM) adversely affects morbidity and mortality for cardiovascular diseases and procedures. Data evaluating the outcomes of transcatheter aortic valve replacement (TAVR) in diabetic patients are limited by small sample size and contradictory results. We aimed to establish the magnitude of risk and the incremental influence of insulin dependency by examining short- and long-term adverse outcomes according to DM status and therapy in the world's largest TAVR registry. METHODS AND RESULTS: We analyzed data from the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry. In-hospital mortality, 30-day mortality, and 1-year mortality after TAVR in patients with and without DM were evaluated using multivariate modeling. Among 47 643 patients treated with TAVR from November 2011 through September 2015 at 394 US hospitals, there were 17 849 (37.5%) patients with DM. Overall, 6600 of the diabetic patients were insulin treated (IT). Thirty-day mortality was 5.0% in patients with DM (6.1% in IT DM and 4.4% in non-IT DM; P<0.001) versus 5.9% in patients without DM (P<0.001). Overall, 1-year mortality was 21.8% in patients with DM (24.8% in IT DM and 20.1% in non-IT DM; P<0.001) versus 21.2% in patients without DM (P=0.274). In a multivariable model, DM was associated with increased 1-year mortality (hazard ratio, 1.30; 95% confidence interval, 1.13-1.49; P<0.001). Subgroup multivariable analysis showed stronger mortality association in IT diabetics (hazard ratio, 1.57; 95% confidence interval, 1.28-1.91; P<0.001) than in non-IT diabetics (hazard ratio, 1.17; 95% confidence interval, 1.00-1.38; P=0.052). CONCLUSIONS: Our data establish the magnitude of short- and long-term risk conferred by DM and the incremental risk conferred by insulin dependency in the performance of TAVR. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01737528.

Administration of cells with thermosensitive hydrogel enhances the functional recovery in ischemic rat heart.

The lack of cell retention clearly represents a potentially serious limitation for therapeutic efficacy of stem cells. To enhance the efficacy, we developed a novel hydrogel that is thermosensitive and biodegradable and possesses desirable stiffness in a solid form. Immediately after induction of myocardial infarction of male rat, cardiac outgrowth cells embedded in hydrogel (HG) or saline (CO) were injected directly into the peri-infarct area. Left ventricular ejection fraction, cell retention rate, and a spectrum of biochemical markers were measured to evaluate the effect of the treatment. Left ventricular ejection fraction was significantly higher in the cell-injected groups (HG and CO) than in the control group at 1 week after treatment. This functional benefit was continued only in the HG group, accompanied with more retained cells. Furthermore, the expression of insulin-like growth factor-1 was significantly higher in the HG group with less progression of cell apoptosis.

Ovariectomy due to a dermoid cyst in an orangutan (Pongo pygmaeus).

A large abdominal mass was identified during an elective preventative health examination in a 25-yr-old female hybrid orangutan (Pongo pygmaeus). Sonographically, the mass was fluid-filled and a presumptive diagnosis of a dermoid cyst or cystic teratoma of an ovary was made. Exploratory laparotomy, after assembly of a surgical team, confirmed that the 2.5-kg cystic mass was associated with the left ovary. Following ovariectomy, perioperative dissection of the mass revealed hair components, confirming the working diagnosis. Because the right ovary was slightly nodular and firmer than expected, and these germ cell tumors sometimes occur bilaterally, excision of the contralateral ovary was elected. Histopathology confirmed the left ovarian mass was a dermoid cyst; the right ovary contained a corpus hemorrhagicum but no evidence of neoplasia. Recovery was uneventful and the orangutan was prescribed hormone replacement therapy to mitigate potential problems associated with a chronic lack of estrogen and progesterone. This case report demonstrates the importance of elective examinations under anesthesia, even in well-trained great apes.

Transfemoral access assessment for transcatheter aortic valve replacement: evidence-based application of computed tomography over invasive angiography.

BACKGROUND: Although computed tomography (CT) is commonly used for iliofemoral evaluation for transfemoral transcatheter aortic valve replacement, many centers worldwide use invasive angiography alone for this purpose. No study to date has evaluated the value of CT over angiography for the prediction of vascular complications. In addition, no data exist for the value of noncontrast CT. METHODS AND RESULTS: Of the 588 transcatheter aortic valve replacement patients, we reviewed 496 consecutive transfemoral cases. Vessel diameters were measured by CT or angiography. Sheath-related complication (SRC) was defined as an iliofemoral arterial injury not including a cannulation site. Receiver operating characteristic models were generated using sheath-to-iliofemoral artery ratios as a variable and SRC as an end point. In patients undergoing both contrast CT and angiography (n=283; 35 SRCs), contrast CT showed a greater predictive value than angiography by area under the curve P<0.001): 0.87 (95% confidence interval: 0.82-0.91) versus 0.72 (95% confidence interval: 0.66-0.77). In patients undergoing both noncontrast CT and angiography (n=103; 17 SRCs), there was no difference between noncontrast CT and angiography: 0.79 (95% confidence interval: 0.70-0.86) versus 0.73 (95% confidence interval: 0.63-0.81). Three-dimensional assessments of calcification and tortuosity provided limited additional value for SRC prediction. CONCLUSIONS: Contrast CT has a greater predictive value for post-transcatheter aortic valve replacement vascular complications than angiography. Because these complications increase mortality, an accurate assessment of the vasculature is a critical component of proper access selection.

Intrinsic cardiac origin of human cardiosphere-derived cells.

AIMS: Cardiosphere-derived cells (CDCs) are in clinical development as a regenerative cell product which can be expanded ex vivo from patient cardiac biopsies. Cardiosphere-derived cells are clonogenic, exhibit multilineage differentiation, and exert functional benefits in preclinical models of heart failure. The origin of CDCs remains unclear: are these cells endogenous to the heart, or do they arise from cells that populate the heart via blood-borne seeding? METHODS AND RESULTS: Right ventricular endomyocardial biopsies were obtained from cardiac transplant recipients (n = 10, age 57 ± 15 years), and CDCs expanded from each biopsy. Donor-recipient mismatches were used to probe the origin of CDCs in three complementary ways. First, DNA analysis of short-tandem nucleotide repeats (STRs) was performed on genomic DNA from donor and recipient, then compared with the STR pattern of CDCs. Second, in two cases where the donor was male and the recipient female, CDCs were examined for the presence of X and Y chromosomes by fluorescence in situ hybridization. Finally, in two cases, quantitative PCR (qPCR) was performed for individual-specific polymorphisms of a major histocompatability locus to quantify the contribution of recipient cells to CDCs. In no case was recipient DNA detectable in the CDCs by STR analysis. In the two cases in which a female patient had received a male heart, all CDCs examined had an X and Y chromosome, similarly indicating exclusively donor origin. Likewise, qPCR on CDCs did not detect any recipient DNA. CONCLUSION: Cardiosphere-derived cells are of endogenous cardiac origin, with no detectable contribution from extra-cardiac seeding.

Meta-analysis of complications in aortic valve replacement: comparison of Medtronic-Corevalve, Edwards-Sapien and surgical aortic valve replacement in 8,536 patients.

BACKGROUND: We sought to establish the complication rates following transcatheter aortic valve replacement (TAVR) in the context of high risk and octogenarian surgical aortic valve replacement (SAVR) in the contemporary literature, and to critically analyze population characteristics and outcomes. METHODS: TAVR studies were selected from nonoverlapping series and SAVR studies for comparison if they met similar entry criteria. Bayesian meta-analytic methods were employed. RESULTS: For the 5024 TAVR and 3512 SAVR patients included in the study, TAVR subjects had greater baseline renal impairment (P < 0.001), a higher incidence of prior myocardial infarction (P = 0.032) and respiratory disease (P = 0.005) and a higher logistic EuroSCORE (P = 0.039). There were no significant differences observed in complications studied in SAVR and TAVR: 30 day mortality (9% vs 8.5%, P = 0.31), 1 year mortality (18.4% vs 22.8%, P = 0.65), 30 day stroke (2.4% vs 2.6%, P = 0.72), new permanent pacemaker (5.9% vs 12.1%, P = 0.055) and dialysis inception (2.4% vs 4.1%, P = 0.70). We also compared demographics and outcomes between the two types of transcatheter valves. Apart from some variation in functional status, there were no significant differences at baseline with different TAVR designs. The only difference in complications was the need for pacemaker insertion, higher with the Medtronic-Corevalve than with the Edwards-Sapien design (24.5% vs 5.9% P < 0.0001). CONCLUSIONS: Complications for elderly and high risk aortic stenosis patients being treated by TAVR appear comparable to those selected for SAVR in the real-world.

A novel regimen of alternate day clopidogrel would provide a cost-effective strategy to prevent very late stent thrombosis.

BACKGROUND/OBJECTIVES: ACC/AHA/SCAI recommendations include dual anti-platelet therapy (aspirin and clopidogrel) for 12 months after drug-eluting stent percutaneous coronary intervention (DES PCI). Numerous case reports have emerged of "very late stent thrombosis" (VLST) (>1 year post-DES-PCI) even 1-5 years after DES-PCI manifesting with myocardial infarction and death when clopidogrel therapy was interrupted or stopped. HYPOTHESIS: We hypothesize that a novel regimen of alternate day clopidogrel would provide a cost-effective strategy to prevent VLST taking into account the known facts about clopidogrel pharmacodynamics, stent endothelialization and stent thrombosis. We hypothesized that the degree of anti-platelet effect required to prevent VLST decreases with time as the stent endothelializes-that is the "therapeutic threshold" required to prevent VLST decreases with time. The anti-platelet effect of clopidogrel lasts for 5-7 days. Typically, stent thrombosis on interruption of clopidogrel (with bare metal stents within first 30 days) occurs after 3-4 days signifying recovery of enough platelet function to produce stent thrombosis--recovery of platelet inhibition beyond the therapeutic threshold. Since the therapeutic threshold required to prevent VLST in DES after 1 year is much lower, this degree of platelet inhibition can be conceivably achieved with just administering clopidogrel on alternate days. EMPIRICAL DATA: We studied efficacy and safety of regimen of daily aspirin 81 mg and alternate-day clopidogrel 75 mg beyond 12 months after PCI with DES for prevention of VLST by following 347 patients for occurrence of death, myocardial infarction (MI), VLST, target vessel revascularization (TVR) and bleeding. There were no occurrence of major bleeding, VLST events or death. CONCLUSIONS: Long term dual anti-platelet therapy with aspirin 81 mg daily and clopidogrel 75 mg every other day beyond 12 months after PCI with DES may be a safe and efficacious cost-saving strategy to prevent VLST.

Comparison of long-term outcomes of drug-eluting stents and bare metal stents for saphenous vein graft stenosis.

OBJECTIVE: Our aim was to compare the long-term outcomes between drug-eluting stents and bare-metal stents for saphenous vein graft stenosis. BACKGROUND: The ideal type of stent to treat saphenous vein graft stenosis has not been clearly established. Short-term randomized controlled trial results comparing drug-eluting stents with bare-metal stents for saphenous vein graft stenosis are conflicting, intermediate-term retrospective studies and meta-analyses at two years suggest no difference in outcomes, and there are no long term follow-up studies. The need for long term follow-up data has become emerged with concern over late stent thrombosis. METHODS: 246 saphenous vein graft patients undergoing stenting from August 2002-December 2008 were studied. Overall survival and event-free survival were compared by Kaplan-Meier method. Hazard ratios (HR) were calculated by Cox-proportional hazards models. RESULTS: We treated 133 patients with DES (median follow-up four years) and 113 patients with BMS (median follow-up four years) for SVG stenosis. Overall survival (77.0% ± 3.9% vs. 70.6% ± 4.6%, log-rank P = 0.60) and MACE-free survival (57.5% ± 4.6% vs. 56.8% ± 4.9, log-rank P = 0.70) were not significantly different between the DES and BMS groups. Although BMS was associated with increased risk of target lesion revascularization (TLR) (freedom from TLR 85.2% ± 3.5% vs. 90.0% ± 3.0%, HR 2.07, 95% CI 0.97-4.42, log-rank P = 0.05), there was no significant difference in the freedom from myocardial infarction (86.7% ± 3.3% vs. 88.7% ± 3.2%, log-rank P = 0.39) or target vessel revascularization (77.1% ± 4.2% vs. 76.1% ± 4.2%, log-rank P = 0.33) between the two groups. CONCLUSIONS: Although mortality is not statistically different between DES and BMS for SVG stenosis, BMS is associated with increased risk of revascularization, thus suggesting the superiority of DES over BMS in the long term.

Predictive accuracy of SYNTAX score for predicting long-term outcomes of unprotected left main coronary artery revascularization.

The American College of Cardiology/American Heart Association recently updated recommendations for percutaneous coronary intervention (PCI) of unprotected left main coronary artery (ULMCA) disease from class III to II(b) according to the results of the SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery (SYNTAX) trial. The SYNTAX score is an angiographic tool using solely the coronary anatomy. We studied the effect of co-morbidities (Parsonnet's score) on the ability of the SYNTAX score to predict long-term outcomes in patients with ULMCA disease treated by revascularization. A total of 328 patients underwent revascularization of ULMCA from April 2003 to February 2007. Of the 328 patients, 120 underwent PCI (median follow-up 973 days) and 208 underwent coronary artery bypass grafting (CABG) (median follow-up 1,298 days). The ability of the SYNTAX score to predict outcomes was assessed using the Cox proportional hazards model. The outcomes between the PCI and CABG groups were compared by propensity analysis. The median SYNTAX score was 26 in the PCI and 28 in the CABG group (p = 0.5). In the PCI group, greater quartiles were associated with worse survival (62.1% at SYNTAX score of ≥36 vs 82.4% at SYNTAX score of <36, p = 0.03) and all-cause mortality, myocardial infarction, cerebrovascular events, and target vessel revascularization-free (MACCE) survival (47.7%, SYNTAX score ≥20 vs 76.6%, SYNTAX score <20, p = 0.02). Using the Parsonnet score as a covariate, the SYNTAX score continued to be an independent predictor of MACCE and demonstrated a trend toward predicting mortality in the PCI group. In contrast, the SYNTAX score did not predict the outcomes for the CABG group. No difference was found in mortality between the PCI and CABG groups for ULMCA disease, regardless of coronary complexity; although greater SYNTAX scores were associated with increased MACCE rates with PCI compared to CABG. Both the coronary anatomy (SYNTAX score) and co-morbidities (Parsonnet's score) predicted long-term outcomes for PCI of ULMCA disease. In contrast, the SYNTAX score did not predict the outcomes after CABG. In conclusion, the ideal scoring system to guide an appropriate revascularization decision for ULMCA disease should take into account both the coronary anatomy and the co-morbidities.

Review article: current status of myocardial regeneration: new cell sources and new strategies.

Clinical trials of stem cell therapy in cardiology are based upon a reasonably solid foundation in animal laboratory research. The most widely used cell source in clinical trials has been the patient's own reconstituted bone marrow cell (BMC) aspirate. Cell sources in human bone marrow include hematopoietic stem cells, mesenchymal progenitor cells, and other cell types with many desirable characteristics. In vitro, they can be induced to become typical sarcomeres with centrally positioned nuclei and abundant mitochondria and to express atrial natriuretic peptide (ANP), brain natriuretic peptide (BNP), and contractile proteins including myosin heavy chain, myosin light chain, and alpha actin. Intracoronary BMC infusion significantly decreases infarct size, increases myocardial perfusion, and improves regional and global cardiac function. Meta-analyses of clinical trials of intracoronary autologous BMC infusion following acute myocardial infarction (MI) report that the mean absolute increase in ejection fraction (EF) is approximately 3% to 4%. This modest improvement in function appears to persist for 1 year. Some trials have shown that clinical events are reduced at 12 months, but others have reported no long-term clinical benefit, and the only 5-year follow-up suggests persistent benefit with decreased mortality, but also little evidence of significant myocardial regeneration in humans. These results have led to efforts to identify better cell sources and to create more conducive myocardial environment for cell proliferation. Among the cell types are skeletal myoblasts, cardiac stem cells, and induced pluripotent stem cells. Environmental modifiers are designed to increase cell survival, persistence, and proliferation.

Meta-analysis of incidence, clinical characteristics and implications of stent fracture.

A meta-analysis of published studies was conducted to evaluate the incidence, predictors, and clinical outcomes of stent fractures. Eight studies with 108 stent fractures in 5,321 patients were analyzed using the Bayesian method. Study end points included in-stent restenosis (ISR) and target lesion revascularization (TLR). The mean incidence of stent fracture per patient was 4.0% (95% confidence interval 0.4% to 16.3%). All cases, except 1, were reported with sirolimus-eluting stents. The incidence of stent fracture was 30.4% in the left anterior descending coronary artery, 10.9% in the left circumflex coronary artery, 56.4% in the right coronary artery, < 0.01% in the left main coronary artery, and 1.7% in saphenous vein grafts. The probability of stent fracture was significantly higher in the right coronary artery than in the left anterior descending and left circumflex lesions (p < 0.01). Left main stents were less likely to fracture compared to those in all other vessels (p < 0.01). The probability of stent fracture was significantly increased in overlapping stents (7.5% vs 2.1%, p = 0.01) and long stents (46 vs 32.5 mm, p < 0.01). Lesions with stent fractures had higher rates of ISR (38% vs 8.2%, p < 0.01) and TLR (17% vs 5.6%, p < 0.01). Conversely, the probability of stent fractures was higher in patients with ISR (12.8% vs 2.1%, p < 0.01) and TLR (8.8% vs 2.7%, p < 0.01). In conclusion, although not always associated with clinical sequelae, the probability of ISR and TLR is increased with stent fracture. Conversely, the probability of stent fractures is increased in lesions with ISR or TLR, thus raising the need for surveillance and management guidelines for at-risk patients.

KIF6 polymorphism as a predictor of risk of coronary events and of clinical event reduction by statin therapy.

Evidence from multiple large prospective studies suggests that a common polymorphism that encodes an arginine (Arg)-to-tryptophan substitution at position 719 in the KIF6 gene is associated with coronary heart disease (CHD) and reduction in coronary events from statin therapy. Carriers of the 719Arg allele were at greater risk for primary and secondary CHD events, and statin therapy significantly reduced coronary events in 719Arg carriers but not in noncarriers. The number needed to treat to prevent a single CHD event ranged from 10 to 20 for 719Arg carriers, compared to >80 for noncarriers in the Cholesterol and Recurrent Events (CARE) study, the West of Scotland Coronary Prevention Study (WOSCOPS), the Prospective Study of Pravastatin in the Elderly at Risk (PROSPER), and the Pravastatin or Atorvastatin Evaluation and Infection Therapy-Thrombolysis In Myocardial Infarction 22 (PROVE IT-TIMI22) study. In conclusion, assessment of 719Arg carrier status holds promise for stratification of coronary event risk and for selection of optimal therapy in primary and secondary CHD prevention.

Redefining normal low-density lipoprotein cholesterol: a strategy to unseat coronary disease as the nation's leading killer.

The new Adult Treatment Panel guidelines will be published in 2011. This paper suggests the consideration of major changes in the existing management guidelines for low-density lipoprotein cholesterol management based on 2 fundamental principles: return the low-density lipoprotein cholesterol level to the normal range and begin treatment closer to disease onset. These principles suggest the value of rethinking all 3 of the principal features of the Adult Treatment Panel III guidelines for low-density lipoprotein cholesterol management: the initiation criteria, the use of variable targets, and the level of the treatment target. Because the principal issue surrounding guideline change is likely to be uncertainty concerning cost and toxicity, the text of new guidelines would have to completely satisfy this concern by strong emphasis on a prudent conservative approach to implementation and would include both cautionary data and caveats concerning the tradeoffs between the potency, cost, and toxicity of statins. The proposed changes in the guidelines, if combined with effective implementation, would likely lead to the displacement of atherosclerotic disease as the nation's number 1 killer. This review provides a logical rationale and discusses the pros and cons for each of the proposed changes.

Meta-analysis of prognostic value of stress testing in patients with asymptomatic severe aortic stenosis.

The management strategy in asymptomatic patients with severe aortic stenosis (AS) is controversial. Aortic valve replacement has significant morbidity and mortality, while there is a risk for sudden cardiac death with conservative management. There is no consensus on the prognostic value of stress testing to stratify management. A pooled analysis of studies in patients with severe AS was performed to assess the prognostic value of stress testing for adverse events, including angina, dyspnea, acute heart failure, sudden death, and symptoms requiring aortic valve replacement. A search of published research was performed using the terms "stress test" and "asymptomatic aortic stenosis." A random-effects model was used to calculate pooled odds ratios and 95% confidence intervals. Data from 7 studies were included (491 patients with asymptomatic severe AS). None of the patients experienced any complications during or after stress testing. There were no sudden deaths in the patients with normal stress test results after 1 year of follow-up, while 5% with abnormal stress test results had sudden cardiac death. Overall, 52 of 253 patients (21%) with normal stress test results had adverse cardiac events, compared with 156 of 238 (66%) with abnormal stress test results (odds ratio 0.12, 95% confidence interval 0.07 to 0.21, p <0.001). In conclusion, stress testing in asymptomatic patients with severe AS is safe and identifies patients at risk for adverse cardiac events and sudden cardiac death. These data suggest that stress tests can be used for risk stratification and for deciding on the timing of aortic valve replacement in asymptomatic patients with severe AS.

A meta-analysis of 3,773 patients treated with percutaneous coronary intervention or surgery for unprotected left main coronary artery stenosis.

OBJECTIVES: This study sought to understand the total weight of evidence regarding outcomes in coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) in unprotected left main coronary artery (ULMCA) stenosis. BACKGROUND: Following a diagnosis of significant ULMCA stenosis in an individual that is a candidate for surgery, CABG is recommended by the American College of Cardiology/American Heart Association guidelines, whereas PCI is not recommended (Class III). METHODS: Databases were searched for clinical studies that reported outcomes after PCI and CABG for the treatment of ULMCA stenosis. Ten studies were identified that included a total of 3,773 patients. RESULTS: Meta-analysis showed that death, myocardial infarction, and stroke (major adverse cardiovascular or cerebrovascular events) were similar in the PCI- and CABG-treated patients at 1 year (odds ratio [OR]: 0.84 [95% confidence interval: 0.57 to 1.22]), 2 years (OR: 1.25 [95% CI: 0.81 to 1.94]), and 3 years (OR: 1.16 [95% CI: 0.68 to 1.98]). Target vessel revascularization was significantly higher in the PCI group at 1 year (OR: 4.36 [95% CI: 2.60 to 7.32]), 2 years (OR: 4.20 [95% CI: 2.21 to 7.97]), and 3 years (OR: 3.30 [95% CI: 0.96 to 11.33]). There was no difference in mortality in PCI- versus CABG-treated patients at 1 year (OR: 1.00 [95% CI: 0.70 to 1.41]), 2 years (OR: 1.27 [95% CI: 0.83 to 1.94]), and 3 years (OR: 1.11 [95% CI: 0.66 to 1.86]). CONCLUSIONS: Our analysis reveals no difference in mortality or major adverse cardiovascular or cerebrovascular events, for up to 3 years, between PCI and CABG for the treatment of ULMCA stenosis. However, PCI patients had a significantly higher risk of target vessel revascularization. In selected patients with ULMCA stenosis, PCI is emerging as an acceptable option.