Synchronous Carotid Endarterectomy and Coronary Artery Bypass Graft versus Staged Carotid Artery Stenting and Coronary Artery Bypass Graft for Patients with Concomitant Severe Coronary and Carotid Stenosis: A Systematic Review and Meta-analysis.

BACKGROUND: Owing to the systemic nature of atherosclerosis, medium and large arteries at different sites are commonly simultaneously affected. As a result, severe coronary artery disease (CAD) requiring coronary artery bypass graft (CABG) frequently coexists with significant carotid stenosis that warrants revascularization. The aim of this study was to compare synchronous carotid endarterectomy (CEA) and CABG vs. staged carotid artery stenting (CAS) and CABG for patients with concomitant CAD and carotid artery stenosis in terms of perioperative (30-day) outcomes. METHODS: This study was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Eligible studies were identified through a search of PubMed, Scopus, and Cochrane until July 2018. A meta-analysis was conducted with the use of a random-effects model. The I-square statistic was used to assess heterogeneity. RESULTS: Five studies comprising 16,712 patients were included in this meta-analysis. Perioperative stroke (odds ratio [OR]: 0.84; 95% confidence interval [CI]: 0.43-1.64; I2 = 39.1%), transient ischemic attack (TIA; OR: 0.32; 95% CI: 0.04-2.67; I2 = 27.6%), and myocardial infarction (MI) rates (OR: 0.56; 95% CI: 0.08-3.85; I2 = 68.9%) were similar between the two groups. However, patients who underwent simultaneous CEA and CABG were at a statistically significant higher risk for perioperative mortality (OR: 1.80; 95% CI: 1.05-3.06; I2 = 0.0%). CONCLUSIONS: The current meta-analysis did not detect statistically significant differences in the rates of perioperative stroke, TIA, and MI between the groups. However, patients in the simultaneous CEA and CABG group had a significantly higher risk of 30-day mortality. Future randomized trials or prospective cohorts are needed to validate our results.

Association between Public Reporting of Outcomes and the Use of Mechanical Circulatory Support in Patients with Cardiogenic Shock.

Risk-averse behavior has been reported among physicians and facilities treating cardiogenic shock in states with public reporting. Our objective was to evaluate if public reporting leads to a lower use of mechanical circulatory support in cardiogenic shock. We conducted a retrospective study with the use of the National Inpatient Sample from 2005 to 2011. Hospitalizations of patients ≥18 years old with a diagnosis of cardiogenic shock were included. A regional comparison was performed to identify differences between reporting and nonreporting states. The main outcome of interest was the use of mechanical circulatory support. A total of 13043 hospitalizations for cardiogenic shock were identified of which 9664 occurred in reporting and 3379 in nonreporting states (age 69.9 ± 0.4 years, 56.8% men). Use of mechanical circulatory support was 32.8% in this high-risk population. Odds of receiving mechanical circulatory support were lower (OR 0.50; 95% CI 0.43-0.57; p < 0.01) and in-hospital mortality higher (OR 1.19; 95% CI 1.06-1.34; p < 0.01) in reporting states. Use of mechanical circulatory support was also lower in the subgroup of patients with acute myocardial infarction and cardiogenic shock in reporting states (OR 0.61; 95% CI 0.51-0.72; p < 0.01). In conclusion, patients with cardiogenic shock in reporting states are less likely to receive mechanical circulatory support than patients in nonreporting states.

Predictors of 90-Day Readmission and in-Hospital Mortality in Takotsubo Cardiomyopathy: An Analysis of 28,079 Index Admissions.

BACKGROUND: Takotsubo cardiomyopathy (TC) is diagnosed in 1% to 2% of patients presenting with suspected acute coronary syndromes. Readmission patterns after TC have been less studied. Thus, we sought to perform a study to evaluate the etiologies, trends, and predictors of 90-day readmission in TC. METHODS: The Nationwide Readmissions Database (NRD), 2014, was used to select the study cohort. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic code 429.83 was used to identify TC. Admissions within 90 days of index admission were considered early readmissions. Readmission etiologies were identified by an ICD-9-CM code. Hierarchical multivariate models were used to evaluate predictors of early readmission. RESULTS: A total of 28,079 patients were identified during the study period, of whom 24.3% (n = 6841) were readmitted within 90 days of discharge. In-hospital mortality during index admissions was 5.69%. The most common etiologies for readmission were cardiac (18.56%), respiratory (17.20%), and infections (13.12%). Among cardiac complications, acute heart failure was the most common etiology (7.48%). The highest number of readmissions happened on the first day after discharge (n = 125). On multivariate analysis, the age of 50-64 years, diabetes, heart failure, chronic pulmonary disease, peripheral vascular disease, anemia, and malignancy were shown to be significant predictors of readmission. Patients of female gender are less likely to be readmitted and have lower in-hospital mortality. CONCLUSIONS: Patients with TC are highly likely to be readmitted within the first month after discharge, most likely with secondary to cardiac or respiratory complications. These findings warrant close post-discharge transition to reduce morbidity and improve healthcare outcomes. SUMMARY: This analysis from the Nationwide Readmission Database outlines a detailed analysis on etiologies, trends, and predictors of 90-day readmission for patients presenting with takotsubo cardiomyopathy.

Meta-Analysis of Transthoracic Echocardiography Versus Cardiac Magnetic Resonance for the Assessment of Aortic Regurgitation After Transcatheter Aortic Valve Implantation.

Residual aortic regurgitation (AR) is a major complication after transcatheter aortic valve implantation (TAVI). Although the echocardiographic assessment of post-TAVI AR remains challenging, cardiac magnetic resonance (CMR) allows direct quantification of AR. The aim of this study was to review the level of agreement between 2-dimensional transthoracic echocardiography (2D TTE) and CMR on grading the severity of AR after TAVI, and determine the accuracy of TTE in detecting moderate or severe AR. Electronic databases were searched in order to identify studies comparing 2D TTE to CMR for post-TAVI AR assessment. Kappa coefficient was used to determine the level of agreement between the 2 imaging modalities. CMR was used as the reference standard in order to assess the diagnostic accuracy of 2D TTE. Seven studies were included in this systematic review. Six studies reported a low correlation between 2D TTE and CMR (kappa coefficient ranging from -0.02 to 0.41), whereas one study showed good agreement with a kappa coefficient of 0.72. Given the heterogeneity in the included studies the diagnostic accuracy of TTE was evaluated by estimating the hierarchical summary receiver operator characteristic curve. The area under the curve for detection of moderate or severe AR with TTE was 0.83 (95% confidence interval 0.79 to 0.86). In conclusion, despite the reported significant disconcordance between TTE and CMR grading of AR, TTE has sufficient ability to discriminate moderate or severe AR from mild or none AR after TAVI in the clinical setting. CMR should be considered when TTE results are equivocal.

Risk Factors for Restenosis After Carotid Revascularization: A Meta-Analysis of Hazard Ratios.

BACKGROUND: Carotid artery restenosis after carotid endarterectomy (CEA) or carotid artery stenting (CAS) will occur in 3%-30% of cases. Restenosis can lead to more frequent clinical and imaging monitoring and the potential for reoperation. We sought to define the demographic, clinical, and radiographic characteristics that influence the restenosis risk after carotid revascularization. METHODS: The present study was performed in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines. A random effects model meta-analysis of hazard ratios (HRs) was conducted. RESULTS: Eighteen studies with 17,106 patients were included. Diabetes (HR, 1.68; 95% confidence interval [CI], 1.00-2.83; I2, 76.7%), dyslipidemia (HR, 1.77; 95% CI, 1.08-2.91; I2, 22.5%), female gender (HR, 1.50; 95% CI, 1.14-1.98, I2, 0%), chronic kidney disease (HR, 4.15; 95% CI, 1.69-10.19; I2, 44.5%), hypertension (HR, 1.99; 95% CI, 1.07-3.72; I2, 68%), smoking (HR, 1.65; 95% CI, 1.15-2.37; I2, 54.3%), and pretreatment stenosis >70% (HR, 1.04; 95% CI, 1.0-1.08; I2, 0%) showed a statistically significant increase in restenosis risk after carotid revascularization. Subgroup analyses of CEA and CAS showed that female gender and smoking status were significantly associated with recurrent stenosis after CEA but not after CAS. In contrast, hypertension was associated with restenosis after CAS but not after CEA. Patch endarterectomy (HR, 0.33; 95% CI, 0.22-0.50; I2, 0%) and symptomatic status at presentation in the CAS group (HR, 0.61; 95% CI, 0.41-0.90; I2, 0%) were associated with a decreased risk of restenosis. Antiplatelet use and coronary artery disease were not associated with restenosis risk. CONCLUSIONS: Diabetes, dyslipidemia, female gender, renal failure, hypertension, and smoking were associated with an increased risk of restenosis, and patch endarterectomy and symptomatic status at presentation were associated with a decreased risk of carotid restenosis. Both female gender and current smoking status were only associated with recurrent stenosis after CEA, and hypertension was only associated with restenosis after CAS.

Reversal of Novel Anticoagulants in Emergent Surgery and Trauma: A Comprehensive Review and Proposed Management Algorithm.

Non-vitamin K oral anticoagulants (NOACs), including dabigatran, rivaroxaban, apixaban, and edoxaban, are increasingly used for thromboembolism prevention. Contrary to older anticoagulants, such as coumadin, when antidotes existed and were broadly used in cases of emergent surgery and bleeding, antidotes for NOACs have not been developed until recently. Moreover, the monitoring of NOAC's anticoagulant effect varies across different hospital settings and the absence of a single test that can accurately predict the degree of anticoagulation achieved increases the uncertainty. These uncertainties often result in management dilemmas for clinicians when patients who are on NOACs need a reversal of anticoagulation. Until recently, available antidotes for NOACs included only prothrombin complex concentrate (PCC), activated prothrombin complex concentrate (aPCC) and recombinant activated factor VII and the less optimal fresh frozen plasma (FFP). Recently though, novel antidotes for NOACs have been developed, including idarucizumab, which is a monoclonal antibody fragment that binds dabigatran, and andexanet alfa, a modified decoy form of the activated factor X (FXa) that binds FXa inhibitors and AT III. Another option, ciraparantag, which is a small molecule that binds to heparin, thrombin inhibitors and FXa inhibitors, is still in phase I development. In this review, we summarize the current evidence and present the available bypassing and novel reversal agents. Finally, we propose an algorithm for the management of patients who take NOACs and present to the emergency department with either trauma and active bleeding or need for emergent surgery.

Frequency of Complications Including Death from Coronary Artery Bypass Grafting in Patients With Hepatic Cirrhosis.

Advanced liver disease is a risk factor for cardiac surgery. However, liver dysfunction is not included in cardiac risk assessment models. We sought to identify trends in utilization, complications, and outcomes of patients with cirrhosis who underwent coronary artery bypass graft surgery (CABG). Using the National Inpatient Sample database, we identified patients with cirrhosis who underwent CABG from 2002 to 2014. Propensity-score matching was used to identify differences in in-hospital mortality and postoperative complications in cirrhosis and noncirrhosis patients. We identified a total of 698,799 CABG admissions of which 2,231 (0.3%) had cirrhosis (mean age 63.6 ± 9.6 years, 74% men, 63% white, mean Charlson co-morbidity index 3.3 ± 1.8). Cardiopulmonary bypass was used in 71% of patients. Mean length of stay was 13.7 ± 11.4 days and hospitalization cost $67,744.6 ± 58,320.4. One or more complications occurred in 44% of cases. After propensity-score matching, patients with cirrhosis had a higher rate of complications (43.9% vs 38.93%; p < 0.001) and in-hospital mortality (7.2% vs 4.07%; p < 0.001) than noncirrhosis patients. On multivariate analysis, cirrhosis and ascites were associated with increased in-hospital mortality (odds ratio 2.87; 95% confidence intervals 2.37 to 3.48) and postoperative complications (odds ratio 5.11; 95% confidence intervals 3.88 to 6.72). In conclusion, patients with cirrhosis constitute a small portion of patients who underwent CABG in the United States but have a higher rate of complications and in-hospital mortality compared with noncirrhosis patients. In-hospital mortality remains high for this subset of patients but has decreased in recent years.

Preoperative Use of Statins in Carotid Artery Stenting: A Systematic Review and Meta-analysis.

PURPOSE: To determine through meta-analysis whether administration of statins before carotid artery stenting (CAS) is associated with fewer periprocedural adverse events. METHODS: All randomized and observational English-language studies of periprocedural statin administration prior to CAS that reported the outcomes of interest (stroke, transient ischemic attack, myocardial infarction, and death at 30 days) were included in a random-effects meta-analysis. The I2 statistic was used to assess heterogeneity. Meta-regression analysis was performed to determine whether an association of statin treatment with risk of outcome events was influenced by other trial-level baseline characteristics of statin-treated and untreated patients. RESULTS: Eleven studies comprising 4088 patients were included. Patients who received statins prior to CAS had a significantly lower risk of stroke (OR 0.39, 95% CI 0.27 to 0.58, p<0.01; I2=0%) and death (OR 0.30, 95% CI 0.10 to 0.96, p=0.042; I2=0%). Statin use was not associated with a reduced risk of transient ischemic attack or myocardial infarction. In meta-regression analysis, other trial-level baseline characteristics had no significant influence on the association of statin treatment with death or stroke. CONCLUSION: Statin therapy prior to CAS is associated with decreased risk of perioperative stroke and death without any effect on the rates of transient ischemic attack or myocardial infarction.

Carotid Artery Endarterectomy versus Carotid Artery Stenting for Restenosis After Carotid Artery Endarterectomy: A Systematic Review and Meta-Analysis.

OBJECTIVE: Carotid artery restenosis may occur after ipsilateral carotid endarterectomy (CEA). The aim of this study was to determine whether carotid artery stenting (CAS) or redo CEA is the optimal treatment for postendarterectomy carotid restenosis. METHODS: Eligible studies for meta-analysis were identified through a search of PubMed, Scopus, and Cochrane up to July 20, 2017. A meta-analysis was conducted with the use of random effects modeling. I2 was used to assess for heterogeneity. RESULTS: Thirteen studies comprising 4163 patients were included. Risk for any type of cranial nerve injury was higher in the redo CEA group (odds ratio = 13.61; 95% confidence interval, 5.43-34.16; I2 = 3.3%). Periprocedural and/or short-term (within 30 days) stroke, transient ischemic attack, myocardial infarction, temporary cranial nerve injury, and death rates were similar between the 2 revascularization approaches. During median follow-up of 28 months, CAS was associated with significantly lower risk for long-term recurrent carotid artery restenosis when defined as stenosis >60% (odds ratio = 2.16; 95% confidence interval, 1.13-4.12; I2 = 0%) or >70% (odds ratio = 2.31; 95% confidence interval, 1.13-4.72; I2 = 0%). No difference was identified in long-term target lesion revascularization rates between redo CEA and CAS. CONCLUSIONS: Patients with carotid restenosis after CEA can safely undergo both CAS and CEA with similar risks of periprocedural stroke, transient ischemic attack, myocardial infarction, and death. However, patients treated with CAS have a lower risk for a new restenosis and periprocedural cranial nerve injury.

Assessment of hypertension control and clinical course of patients excluded from the SYMPLICITY HTN-3 trial.

The screening of patients referred for the Symplicity Renal-Denervation Catheter Therapy on Resistant Hypertension (SYMPLICITY HTN-3) trial was rigorous, with many found not eligible to participate. We investigate patients who were not included in the trial and evaluate their current hypertensive (HTN) therapy, control and clinical status. A retrospective review and telephone interview was performed 8-10 months postscreening on 45 patients and their referring providers who were ultimately not included. Patients were grouped into 4 categories: (1) noninterest; (2) excluded (not meeting inclusion criteria); (3) screen failure (excluded during screening visits due to adequate blood pressure control guided by HTN specialist); or (4) referred after enrollment closure. Primary outcomes evaluated included current anti-HTN management and clinical outcomes. This population consisted of 42% males, mean age 65 ± 5 years, 78% African American, 64% diabetic, and 21% chronic kidney disease. Primary referral basis included cardiology (44%), nephrology (30%), and primary care (26%). At time of follow-up, 20% had continued resistant HTN while most of the patients had controlled HTN (60%); with highest success rates among the screen failure group (88%) who also had the lowest average systolic blood pressure (137 ± 11 mm of Hg) when compared to other groups (P = .04). Average number of medications was lowest in the screen failure group (2.8 ± 1.6, P = .07). Resistant and/or uncontrolled HTN was most prevalent in the noninterest or excluded groups, as were hospitalization for cardiovascular and HTN urgency/emergency. This study highlights the disparity of HTN control and treatment in daily practice compared with clinical trials, and confirms a need for vigilant screening of those considered candidates for renal denervation.