Left atrial appendage closure device outcomes among cirrhosis patients with atrial fibrillation: a United States National Cohort Study.

AIMS: Literature regarding outcomes associated with atrial fibrillation among cirrhosis patients who had left atrial appendage occlusion (LAAO) device procedure is limited. We aim to evaluate the in-hospital clinical outcomes and 30-day readmissions among LAAO with and without cirrhosis. METHODS AND RESULTS: We performed a retrospective study of all hospitalizations associated with the LAAO procedure, using the Nationwide Readmissions Database for the years 2016-19. Primary outcomes were in-hospital clinical outcomes and 30-day readmissions. A total of 54 897 index hospitalizations for LAAO (female 41.8%) were reported. Of these, 905(1.65%) had cirrhosis. Gastrointestinal (GI) bleeding was reported in 44 (4.9%) vs. 1606 (2.97%) and coagulopathy in 21 (2.3%) vs. 521 (0.96%) in cirrhosis and without-cirrhosis groups, respectively. A total of 872 (1.59%) patients needed blood transfusion, 24 (2.7%) vs. 848(1.57%) in cirrhosis vs. without-cirrhosis groups (P = 0.047). Fresh frozen plasma (FFP) transfusion was reported among 888 (1.62%), with cirrhosis 26 (3%) vs. without cirrhosis 862 (1.6%) (P = 0.05). On adjusted multivariate logistic regression analysis, acute kidney injury, coagulopathy, FFP transfusion, and blood transfusion were strongly associated with cirrhosis, and GI bleeding, ischaemic stroke, and intracranial haemorrhage were not associated with cirrhosis. Readmissions in 30 days were 5028 (9.18%), 167 (18.5%) in the cirrhosis group and 4861 (9%) without-cirrhosis group (P = 0.01). On multivariate Cox regression, CHA2DS2-Vasc score of six was significantly associated with 30-day readmission compared with other scores [hazard ratio 2.24; 95% confidence interval (1.58-3.16); P < 0.001]. CONCLUSION: Left atrial appendage occlusion procedure in patients with cirrhosis had relatively similar GI bleeding and stroke rates, however, had higher rates of 30-day readmission. A higher CHA2DS2-Vasc score was more likely to be associated with 30-day readmissions and hence would help in discharge planning. The long-term safety and efficacy of LAAO in the cirrhosis population need to be demonstrated.

Transcatheter Versus Surgical Aortic Valve Replacement in Low-Surgical-Risk Patients: A Meta-Analysis of Randomized-Controlled Trials and Propensity-Matched Studies.

BACKGROUND: We performed a meta-analysis of randomized trials (RCT) and propensity-matched (PSM) studies comparing transcatheter aortic valve implantation (TAVI) with surgical aortic valve replacement (SAVR) in low surgical risk patients. METHODS: Published studies including low-risk patients who underwent TAVI (n = 9068) or SAVR (n = 17,388) were included. Outcomes of interest were short-term (30-day) and mid-term (1-year) mortality and major complications. RESULTS: Short-term mortality was lower with TAVI vs. SAVR (1.8% vs. 2.8%, RR = 0.67, [0.56-0.80]). TAVI was associated with lower risk of atrial fibrillation (7.4% vs. 36.5%, RR = 0.21, [0.14-0.31]), and kidney injury (5.3% vs. 9%, RR = 0.45, [0.26-0.80]), but had higher incidence of vascular complications (5.5% vs. 1.4%, RR = 4.88 [1.47-16.18]), and permanent pacemaker implantation (14.9% vs. 3.4%, RR = 4.94 [3.03-8.08]). Stroke rates were similar between both interventions (1.7% vs. 2.2%, RR = 0.80 [0.54-1.18]). Mid-term all-cause mortality was similar in the pooled analysis for TAVI vs. SAVR (8.6% vs. 8.4%, RR = 0.90 [0.66-1.24]), but was lower with TAVI in RCTs (2.1% vs. 3.5%, RR = 0.61 [0.39-0.95]). Cardiovascular mortality was lower with TAVI (1.6% vs. 2.9%, RR = 0.55 [0.33-0.90]), but stroke (3% vs. 4.2%, RR = 0.69, [0.45-1.06]) and valve re-interventions rates (0.8% vs. 0.6%, RR = 1.28 [0.52-3.17]) were similar between both strategies. CONCLUSION: TAVI in low surgical risk patients is associated with lower short-term morbidity and mortality compared with SAVR.

Meta-analysis Evaluating the Safety and Efficacy of Transcarotid Transcatheter Aortic Valve Implantation.

We performed a systemic review and meta-analysis of studies evaluating transcarotid vascular access for transcatheter aortic valve implantation (TAVI). Published studies evaluating transcarotid vascular access for TAVI were included in this analysis. Outcomes of interest included 30-day mortality, stroke/transient ischemic attack (TIA), new pacemaker implantation, acute kidney injury (AKI), major vascular complication, major bleeding, and myocardial infarction. Pooled estimate for 30-day mortality was 5.3% (95% confidence interval [CI] 4.0% to 6.8%; I2 = 4%), stroke/TIA was 3.4% (95% CI 2.4% to 4.6%; I2 = 0%), new pacemaker implantation was 15.3% (95% CI 10.8% to 19.7%; I2 = 72%), AKI was 3.4% (95% CI 1.3% to 6.5%; I2 = 58%), major vascular complication was 2.4% (95% CI 1.1% to 3.7%; I2 = 46%), major bleeding was 4.3% (95% CI 2.8% to 6.1%; I2 = 11%), and myocardial infarction was 1.1% (95% CI 0.4% to 2.0%; I2 = 0%). Metaregression was carried out to study the association of effect size with the continuous study-level covariates that included average age, proportion of males, and mean STS score. In this regard, mean STS score showed association with major vascular complications (coefficient: 0.008; p = 0.049). Cumulative meta-analysis carried out showed that there was temporal trend of decreasing incidence of stroke/TIA, major vascular complications, and AKI for transcarotid TAVI. In conclusion, transcarotid access for TAVI is a reasonable choice in patients requiring alternate access to transfemoral route.

Safety and efficacy of transcatheter aortic valve replacement for native aortic valve regurgitation: A systematic review and meta-analysis.

OBJECTIVE: The objective of this study was to analyze the available literature on using transcatheter aortic valve replacement (TAVR) for native aortic regurgitation (AR). BACKGROUND: Surgical aortic valve replacement is the gold standard therapy for native AR. TAVR has emerged as an alternative approach in high-risk patients. METHODS: MEDLINE, Scopus, and Cochrane CENTRAL were searched for reports of at least 5 patients undergoing TAVR for native AR. Outcomes included 30-day mortality, myocardial infarction, stroke, major bleeding, postprocedural moderate to severe AR, and device success. Pooled estimates were calculated using a random-effects model. Subgroup analysis and a meta-regression were performed to study the effects of study level covariates on outcomes. RESULTS: Nineteen studies (n =998 patients) were included. The rate of procedural success per Valve Academic Research Consortium - 2 (VARC-2) criteria was 86.2% (78.8%-92.2%]. Thirty-day mortality was 11.9% (9.4%-14.7%). Subgroup analysis showed the use of new generation valves was associated with lower 30-day mortality (P = 0.02) and higher device success (P = 0.009) compared with early generation valves. There was no significant difference (P = 0.13) in the rate of 30-day mortality between patients receiving purpose-specific [8.2% (4.3%-13.1%); I2 = 0%] and nonpurpose specific valves [13.0% (8.2%-18.6%); I2 = 25%]. However, device success was higher (P = 0.02) in patients who received purpose-specific valves [96.3% (92.2%-98.9%); I2 = 0%] compared with nonpurpose specific valves [84.4% (75%-91.9%); I2 =46%]. CONCLUSION: TAVR for native AR is associated with acceptable procedural success but increased early mortality. However, the safety and the efficacy of the procedure increased with newer valves.

Sodium-glucose co-transporter 2 inhibitors and cardiovascular outcomes: A systematic review and meta-analysis.

Background The risks and benefits of sodium-glucose co-transporter 2 (SGLT2) inhibitors on cardiovascular outcomes have not been well established. We pooled evidence from all available clinical trials to assess the cardiovascular effects of this drug. Design A systematic review and meta-analysis of randomised controlled trials. Methods We queried electronic databases (MEDLINE, Scopus, CENTRAL and clinicaltrials.gov) from their inception to July 2017 for published and unpublished placebo controlled trials of SGLT2 inhibitors. Only studies with a follow-up period of at least 24 weeks and reporting at least one cardiovascular outcome were included. Results from trials were presented as odds ratios (ORs) with 95% confidence intervals (CIs) and were pooled using a random-effects model. Results Thirty-five eligible studies (canagliflozin, nine; empagliflozin, eight; dapagliflozin, 18), consisting of 34,987 patients with type 2 diabetes mellitus were included. Pooled results show that SGLT2 inhibitors, when compared to placebo, significantly reduce all-cause mortality (OR 0.79, 95% CI 0.70-0.89; P < 0.001), major adverse cardiac events (OR 0.8, 95% CI 0.76-0.92; P < 0.001), non-fatal myocardial infarction (OR 0.85, 95% CI 0.73-0.98; P = 0.03) and heart failure/hospitalisation for heart failure (OR 0.67, 95% CI 0.59-0.76; P < 0.001) in patients with type 2 diabetes mellitus. No significant difference was noted in the occurrence of stroke (OR 1.02, 95% CI 0.85-1.21; P = 0.87), atrial fibrillation (OR 0.61, 95% CI 0.31-1.19; P = 0.15) or unstable angina (OR 0.95, 95% CI 0.73-1.25; P = 0.73). In addition, there was no heterogeneity between different drugs in the SGLT2 inhibitor class for all of the clinical outcomes studied ( I2 = 0). Conclusions SGLT2 inhibitors significantly reduce the incidence of mortality, major adverse cardiac events, non-fatal myocardial infarction and heart failure in patients with type 2 diabetes mellitus. Subtypes of SGLT2 inhibitors appear to have similar cardiovascular effects.

Risk of ventricular tachyarrhythmias following improvement of left ventricular ejection fraction in patients with implantable cardiac defibrillators implanted for primary prevention of sudden cardiac death.

PURPOSE: In patients who undergo implantable cardiac defibrillator (ICD) implantation for primary prevention of sudden cardiac death (SCD), data is unclear whether their ICD generator needs to be replaced at end of life if their left ventricular ejection fraction (EF) improves. Despite improvement in EF, the underlying scar may represent a potential substrate for ventricular arrhythmias. METHODS: Data on 280 patients who underwent ICD implantation for primary prevention of SCD was obtained from two centers. Patients were followed for any improvement in EF to ≥35%. All arrhythmic events during follow-up, including appropriate and inappropriate shocks/ATP, were recorded. RESULTS: Thirty percent (n = 86/280) of patients improved their EF to >35% of which 41% (n = 37) underwent a generator change by the study ending period with the rest not yet at ERI. Mean baseline EF in patients with and without target EF improvement was 26 ± 7 and 23 ± 7% (p = 0.2). After excluding patients whose arrhythmic events data were unavailable, the final sample consisted of 62 patients in the EF improvement group and 156 patients in the group without EF improvement. In the group with EF improvement, appropriate events (shock + ATP) were noted in 19% of patients (n = 12/62) and inappropriate shocks and ATP in 6% of (n = 4/62) patients after their EF improved to >35%. Four patients received appropriate therapies when their EF was low prior to improvement. In contrast, in patients who had no improvement in EF, 27% (n = 43/156) received an appropriate therapy (p = 0.6) while 11% (n = 18/156) (p = 0.2) received inappropriate shocks and ATP. All-cause mortality was higher in patients without subsequent improvement in EF versus those with EF improvement (31 vs. 15% (p = .005). CONCLUSIONS: There was no significant difference in the number of appropriate therapies received by each group. Patients continue to be at high risk for sudden cardiac death despite improvement in EF.

Hemodynamic Support With a Microaxial Percutaneous Left Ventricular Assist Device (Impella) Protects Against Acute Kidney Injury in Patients Undergoing High-Risk Percutaneous Coronary Intervention.

RATIONALE: Acute kidney injury (AKI) is common during high-risk percutaneous coronary intervention (PCI), particularly in those with severely reduced left ventricular ejection fraction. The impact of partial hemodynamic support with a microaxial percutaneous left ventricular assist device (pLVAD) on renal function after high-risk PCI remains unknown. OBJECTIVE: We tested the hypothesis that partial hemodynamic support with the Impella 2.5 microaxial pLVAD during high-risk PCI protected against AKI. METHODS AND RESULTS: In this retrospective, single-center study, we analyzed data from 230 patients (115 consecutive pLVAD-supported and 115 unsupported matched-controls) undergoing high-risk PCI with ejection fraction ≤35%. The primary outcome was incidence of in-hospital AKI according to AKI network criteria. Logistic regression analysis determined the predictors of AKI. Overall, 5.2% (6) of pLVAD-supported patients versus 27.8% (32) of unsupported control patients developed AKI (P<0.001). Similarly, 0.9% (1) versus 6.1% (7) required postprocedural hemodialysis (P<0.05). Microaxial pLVAD support during high-risk PCI was independently associated with a significant reduction in AKI (adjusted odds ratio, 0.13; 95% confidence intervals, 0.09-0.31; P<0.001). Despite preexisting CKD or a lower ejection fraction, pLVAD support protection against AKI persisted (adjusted odds ratio, 0.63; 95% confidence intervals, 0.25-0.83; P=0.04 and adjusted odds ratio, 0.16; 95% confidence intervals, 0.12-0.28; P<0.001, respectively). CONCLUSIONS: Impella 2.5 (pLVAD) support protected against AKI during high-risk PCI. This renal protective effect persisted despite the presence of underlying CKD and decreasing ejection fraction.

Predictive Model for Blood Product Use in Coronary Artery Bypass Grafting.

OBJECTIVE: To build a clinical predictive model to determine the need for transfusing blood and its products in coronary artery bypass grafting (CABG) procedures in South East Asian population. STUDY DESIGN: Analytical study. PLACE AND DURATION OF STUDY: Section of Cardiothoracic Surgery, Aga Khan University Hospital, Karachi, from January 2006 to October 2014. METHODOLOGY: Information on pre-, intra- and postoperative variables were collected for all adult patients who underwent on-pump CABG. The patients grouped into those who received blood and its components, and those who did not. Aunivariate as well as multivariate logistic model was built to determine the predictors of transfusion. RESULTS: A total of 3,550 patients underwent CABG and males were dominant in both groups (75 vs. 93%). The transfusion rate was 56.4% (n=2001). Age (adjusted OR 1.03, p < 0.001), obesity (1.50, p=0.001), tobacco use (1.29, p=0.001), and male gender (4.51, p < 0.001) found to be a stronger predictor. Among preoperative comorbidities, diabetes (1.20, p=0.016), myocardial infarction (1.22, p=0.009), preoperative creatinine (1.12, p=0.033), and left main vessel disease of > 50% (1.49, p < 0.001) were independently associated with the outcome. Compared to elective cases, transfusion rates were high in urgent and emergent cases (OR: 1.93 and 3.36 respectively, p < 0.001 for both). CONCLUSION: Age, male gender, obesity, tobacco use, diabetes, myocardial infarction, high creatinine, urgent and emergent cases were independent predictors of transfusion in CABG procedure. This model can be utilized for preoperative risk stratification of patients and their management to improve the outcomes.

Successful tricuspid valvectomy in a septic patient with tricuspid valve endocarditis.

Endocarditis is characterized by vegetations, which is a mass of platelets, fibrin, micro-colonies of micro-organisms, and inflammatory cells, in the endocardium. Over the past three decades, the incidence of right-sided endocarditis has risen dramatically in Pakistan. We report a 36-year woman with a history of repeated intravenous analgesic injections for low back pain, presenting with high grade fever, sepsis and a white cell count of 44,000 with 90% neutrophils. Echocardiography showed large mobile vegetations on Tricuspid Valve (TV). Tricuspid Valve Endocarditis (TVE) is generally responsive to medical treatment; however, about 25% of TVE patients require surgical intervention. Long-term survival of a patient is possible without a prosthetic TV replacement, particularly if the pulmonary artery pressure is normal.

Predictors and clinical impact of pre-existing and acquired thrombocytopenia following transcatheter aortic valve replacement.

BACKGROUND: Data are limited regarding transcatheter aortic valve replacement (TAVR)-related thrombocytopenia (TP). We sought to thoroughly characterize the presence, clinical impact, and severity of TP associated with TAVR. METHODS AND RESULTS: Data were collected from 90 patients who underwent TAVR using the Edwards SAPIEN valve (59 TF, 29 TA, 2 Tao). Platelet counts were evaluated peri-procedurally and for 8 days following TAVR. Platelet levels were compared and patients were divided into a no TP (No-TP) group 1, acquired (new) TP (NTP) group 2, pre-existing (pre-TAVR) TP (PTP) group 3, and further stratified based on the severity of TP: mild (M) TP (100-149 × 10(3) cell/µL) and moderate-severe (MS) TP (<100 × 10(3) cell/µL). Pre-TAVR point prevalence and post-TAVR incidence of TP were 40% and 79%, respectively (P < 0.001); nadir platelet count in all groups occurred day 4 post-TAVR. Baseline predictors for developing MS TP in groups 2-3 included baseline TP, leaner body mass, smaller pre-procedural aortic valve area, higher peak aortic jet velocity, and worsening baseline renal function. Development of "major" TP (nadir platelet count <100 × 103 cell/µL, ≥50% decrease) predicted a higher risk of major vascular complications (OR 2.78 [95% CI, 1.58-3.82]) and major bleeding (OR 3.18 [95% CI, 1.33-5.42]) in group 3. CONCLUSION: TAVR-related TP is predictable and classification by PTP and TP severity prior to TAVR allows for better risk stratification in predicting in-hospital clinical outcomes. Major TP in the presence of worsening TP is predictable and is associated with worse clinical outcomes. © 2014 Wiley Periodicals, Inc.

Diagnostic dilemma: Takotsubo cardiomyopathy versus acute coronary syndrome.

Takotsubo cardiomyopathy is a kind of non-ischemic cardiomyopathy characterized by transient apical ballooning of the heart. This often results from sudden, temporary weakening of the myocardium. Initially defined in the absence of coronary artery disease, it has since expanded to involve patients with coronary artery disease. This inclusion is not free of challenges now faced at distinguishing between the two when they occur concomitantly, impacting the therapeutic interventions. We present a case of takotsubo cardiomyopathy with simultaneous coronary artery disease that responded well to conservative management and resulted in complete recovery of the patient. This reiterates the principle that a case-by-case evaluation of patients with takotsubo cardiomyopathy with underlying coronary artery disease needs to be made before an individualized therapeutic approach can be taken.

Rarity revisited: cryptococcal peritonitis.

Cryptococcal peritonitis is a rare disease. Although the respiratory tract is considered to be the usual port of entry for the organism, the gastrointestinal tract can also serve as the potential site of entry. Here, we present a case of cryptococcal peritonitis that developed in an HIV-negative patient with underlying liver cirrhosis. We reviewed the literature and a total of 61 cases of cryptococcal peritonitis were identified. Liver cirrhosis, HIV/AIDS and end-stage renal disease on continuous ambulatory peritoneal dialysis were the major risk factors for developing crytococcal peritonitis.

Dyspnoea and the ovaries: a rare presentation of Krukenberg tumour.

Krukenberg tumour is a metastatic signet-ring adenocarcinoma of the ovary, usually with a gastrointestinal primary detected metachronously or synchronously. We present here a case of a 48 year-old woman who presented with a prolonged history of dyspnoea on exertion. Workup had revealed a pelvic mass. Thoracocentesis of her pleural effusion, with cytology, and pathology reports from her total abdominal hysterectomy with bilateral salpingo-oophorectomy revealed a carcinoma with signet-ring cells. Immunostains were positive for CDX2, CK7 and CK20, which was highly suggestive of a gastric primary. Colonoscopy was negative, and an oesophagogastroduodenoscopy revealed a few small crater ulcers, the biopsy of which was negative for cancer. A right-sided pleurodesis was performed for the unremitting malignant effusion, and a PleurX catheter was placed in her left pleural space. She was discharged home with a very poor prognosis.

Genetic backgrounds of the Plasmodium falciparum chloroquine resistant transporter (pfcrt) alleles in Pakistan.

Chloroquine (CQ) resistance in Plasmodium falciparum has been associated with point mutations in the P. falciparum CQ resistance transporter gene (pfcrt). Previous studies have shown 4-5 independent origins for CQ resistant pfcrt alleles globally, two in South America, one each in Southeast Asia, Papua New Guinea (PNG) and Philippines. In Asia, at least two different alleles corresponding to amino acids 72-76 (CVIET and SVMNT) have been found. The CVIET allele originated in Southeast Asia and then spread to Asia and Africa as well. The SVMNT allele, originating from PNG, has been found in India. This study was undertaken to investigate the genetic background of the CQ resistant pfcrt haplotypes in Pakistan. We genotyped microsatellite markers surrounding the pfcrt gene (six different markers at -12.3, -4.8, -1, 1.5, 3.9, 18.8 kb) in 114 clinical isolates of P. falciparum collected from different regions in Pakistan. Microsatellite analysis showed a significant reduction in genetic variation among the mutant SVMNT pfcrt alleles when compared to wild type alleles. The predominant SVMNT haplotype found in this study shared the same microsatellite haplotype found in both PNG and India. Two isolates with CVIET haplotypes showed similar microsatellite background to those found in Africa and Asia. In conclusion, this study suggests that CQ resistant SVMNT haplotypes in India and Pakistan have a common ancestral origin similar to that of Papua New Guinean isolates.

Secondary prevention of heart disease--knowledge among cardiologists and omega-3 (omega-3) fatty acid prescribing behaviors in Karachi, Pakistan.

BACKGROUND: The use of omega-3 fatty acids is a currently proven strategy for secondary prevention of heart disease. The prescription practices for this important nutraceutical is not currently known. It is imperative to assess the knowledge of cardiologists regarding the benefits of omega-3 fatty acids and to determine the frequency of its prescription. The aim of the study was to determine the practices and associations of dietary fish prescribing among cardiologists of Karachi and to assess their knowledge of fish oil supplementation and attitudes toward dietary practices. METHODS: A cross sectional survey was conducted during the period of January to March, 2008. A self report questionnaire was employed. All practicing cardiologists of Karachi were included in the study. Multiple logistic regression analysis was performed to determine the independent factors associated with high fish prescribers. RESULTS: The sample comprised of a total of 163 cardiologists practicing in Karachi, Pakistan. Most (73.6%) of the cardiologists fell in the age range of 28-45 years and were male (90.8%). High fish prescribers only comprised 36.2% of the respondents. After adjusting for age and gender, multivariate analysis revealed that only the variable of knowledge about fish oil's role in reducing sudden cardiac death was independently associated with high fish prescribers OR = 6.38 [95% CI 2.58-15.78]. CONCLUSION: The level of knowledge about the benefits of omega-3 fatty acids is high and the cardiologists harbor a favorable attitude towards dispensing dietary fish advice. However, the prescription practices are less than optimal and not concordant with recommendations of organisations such as the American Heart Association and National Heart Foundation of Australia. The knowledge of prevention of sudden cardiac death in CVD patients has been identified as an important predictor of high fish prescription. This particular life-saving property of omega-3 fatty acids should be the focus of any implemented educational strategy targeted to improve secondary CVD prevention via omega-3 fatty acid supplementation.