Transcatheter, sutureless and conventional aortic-valve replacement: a network meta-analysis of 16,432 patients.

BACKGROUND: Minimally invasive surgical techniques pose alternatives to conventional surgery for the treatment of aortic stenosis (AS). We present a Bayesian network analysis comparing Valve Academic Research Consortium-2 clinical outcomes between transcatheter aortic valve implantation (TAVI), sutureless (SL-AVR) and conventional aortic valve replacement (CAVR). METHODS: Electronic searches of databases were conducted and seven two-arm randomized-controlled trials and 25 propensity-score-matched studies comparing clinical outcomes of TAVI, SL-AVR and CAVR for treatment of AS were identified. Bayesian Markov chain Monte Carlo modelling was used to analyze clinical outcomes. RESULTS: The analysis included 16,432 patients who underwent TAVI [7,056], SL-AVR [1,238] or CAVR [8,138]. Compared to CAVR, TAVI and SL-AVR were associated with reduced postoperative major bleeding of 59% (OR 0.41, 95% CI: 0.28-0.59) and 44% (OR 0.56, 95% CI: 0.30-0.99) respectively. TAVI had a 41% reduction in postoperative myocardial infarction (OR 0.59, 95% CI: 0.40-0.86) and SL-AVR had a 40% reduction in postoperative acute kidney injury (AKI) (OR 0.62, 95% CI: 0.42-0.86). Compared to TAVI, CAVR and SL-AVR had a reduction in moderate/severe paravalvular regurgitation of 89% (OR 0.11, 95% CI: 0.07-0.16) and 92% (OR 0.08, 95% CI: 0.03-0.17). CAVR had a 67% decreased postoperative permanent pacemaker (PPM) implantation compared to TAVI (OR 0.33, 95% CI: 0.24-0.45) and a 63% reduction compared to SL-AVR (OR 0.37, 95% CI: 0.22-0.61). There were no differences in 30-day mortality or postoperative stroke between the groups. CONCLUSIONS: In selected patients, minimally invasive surgical interventions including TAVI and SL-AVR for severe AS are viable alternatives to conventional surgery. However, TAVI is associated with increased paravalvular regurgitation, whereas TAVI and SL-AVR are associated with increased conduction disturbances compared to CAVR.

Direct endovascular thrombectomy and bridging strategies for acute ischemic stroke: a network meta-analysis.

OBJECTIVES: The present Bayesian network meta-analysis aimed to compare the various strategies for acute ischemic stroke: direct endovascular thrombectomy within the thrombolysis window in patients with no contraindications to thrombolysis (DEVT); (2) direct endovascular thrombectomy secondary to contraindications to thrombolysis (DEVTc); (3) endovascular thrombectomy in addition to thrombolysis (IVEVT); and (4) thrombolysis without thrombectomy (IVT). METHODS: Six electronic databases were searched from their dates of inception to May 2017 to identify randomized controlled trials (RCTs) comparing IVT versus IVEVT, and prospective registry studies comparing IVEVT versus DEVT or IVEVT versus DEVTc. Network meta-analyses were performed using ORs and 95% CIs as the summary statistic. RESULTS: We identified 12 studies (5 RCTs, 7 prospective cohort) with a total of 3161 patients for analysis. There was no significant difference in good functional outcome at 90 days (modified Rankin Scale score ≤2) between DEVT and IVEVT. There was no significant difference in mortality between all treatment groups. DEVT was associated with a 49% reduction in intracranial hemorrhage (ICH) compared with IVEVT (OR 0.51; 95% CI 0.33 to 0.79), due to reduction in rates of asymptomatic ICH (OR 0.47; 95% CI 0.29 to 0.76). Patients treated with DEVT had higher rates of reperfusion compared with IVEVT (OR 1.73; 95% CI 1.04 to 2.94). CONCLUSIONS: To our knowledge, this is the first network meta-analysis to be performed in the era of contemporary mechanical thrombectomy comparing DEVT and DEVTc. Our analysis suggests the addition of thrombolysis prior to thrombectomy for large vessel occlusions may not be associated with improved outcomes.

Intraocular bleeding in patients managed with novel oral anticoagulation and traditional anticoagulation: a network meta-analysis and systematic review.

BACKGROUND/AIM: To clarify the nature of the relationship between novel oral anticoagulants (NOACs) and traditional anticoagulation in respect to intraocular bleeding. METHODS: A comprehensive literature search up to October 2017 yielded 12 randomised controlled trials. Bayesian Markov chain Monte Carlo analysis was employed to investigate the relationship across multiple trials with varying NOACs. Random effects (informative priors) ORs were applied for the risk of intraocular bleeding due to various treatment measures. Mantel-Haenszel pairwise analyses were also performed. A total of 102 617 participants from 12 different randomised controlled trials. 11 746 received apixaban, 16 074 received dabigatran, 18 132 received edoxaban, 11 893 received rivaroxaban and 44 764 received warfarin. RESULTS: Edoxaban was significantly associated with a reduced risk of intraocular bleeding in comparison to warfarin (OR 0.59; 95% CI 0.34 to 0.98). All other findings were non-significant; however, apixaban was the only NOAC to trend with an increased event rate against warfarin. The Bayesian Markov chain Monte Carlo modelling indicated that edoxaban had the greatest chance of producing the lowest rate of bleeding (surface under the cumulative ranking curve 0.8642). Pooled pairwise analysis supported the network analysis results favouring edoxaban against warfarin (OR 0.59; 95% CI 0.39 to 0.90; p=0.02) as well as subgroup analysis of low-dose edoxaban versus warfarin (OR 0.43; 95% CI 0.24 to 0.78). CONCLUSION: The analysis suggests that edoxaban may be the paramount agent in reducing intraocular bleeding rates. Given a paucity of reporting data for this rare event, future research and confirmation is strongly recommended.

Epidural Steroids at Closure After Microdiscectomy/Laminectomy for Reduction of Postoperative Analgesia: Systematic Review and Meta-Analysis.

BACKGROUND: This review assessed the efficacy of epidural steroid administration on the reduction of pain, hospital stay time, and use of opioid analgesics postoperatively. METHODS: We searched Medline, PubMed, Embase, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews for studies using epidural steroids through any route after lumbar surgery. The primary study outcomes included preoperative and postoperative pain as assessed with a visual analogue scale (VAS), length of hospital stay (LOS), and postoperative use of opioid analgesics. The data were extracted and stratified according to the steroid administered. Data were then assessed for heterogeneity, subgroup differences, and ultimately tabulated in a Forest plot. RESULTS: A total of 17 randomized controlled trials were included in this review, with 16 undergoing quantitative analysis. Steroids were shown to be superior in terms of VAS outcome at 24 hours, with triamcinolone and dexamethasone performing similarly. Methylprednisolone paradoxically performed worse at the 24-hour mark. At 1 month, all steroids illustrated superiority in terms of VAS outcome. Steroids also proved superior in reducing LOS and postoperative use of opioid analgesia. CONCLUSIONS: Intraoperative or perioperative epidural administration of steroids offers significant benefits in terms of pain control, reduction in LOS, and use of postoperative opioid analgesia. Before steroids are routinely used by spinal surgeons, however, significantly more research is required. A particular emphasis should be placed on quality study protocols and data recording, to allow for more thorough analyses in the future.