Long-term outcomes of the frozen elephant trunk procedure: a systematic review.

BACKGROUND: The frozen elephant trunk (FET) procedure remains an increasingly popular approach to address complex multi-segmental aortic pathologies, owing to their ability to promote false lumen thrombosis and reduce the need for second-stage operations. While the short-term outcomes of such procedures have been shown to be acceptable, much less is known regarding long-term outcomes. This systematic review evaluates long-term outcomes of the FET procedure. METHODS: Studies with at least 12 months follow-up data on FETs were identified in four electronic databases. All studies were reviewed by two independent researchers and relevant data extracted. Long-term outcomes, including overall survival, freedom from reintervention, and freedom from aortic events, were evaluated using patient data recreated from digitized Kaplan-Meier curves. RESULTS: Thirty-seven studies with 4,178 patients were identified. The majority of the studies focused solely on acute dissections. Average follow-up was 3.2 years. Overall survival at 1-, 3-, and 5-year was 89.6%, 85.2%, and 82.0%, respectively. Freedom from reintervention at the same timepoints were 93.9%, 89.3%, and 86.8%, respectively. Mortality, permanent neurological deficit and spinal cord injury were 10.2%, 7.7%, and 6.5%, respectively. CONCLUSIONS: Survival after the FET procedure is favorable, though ongoing close serial monitoring is essential to assess for the need for further reintervention. Larger multi-institutional registries are required to provide more robust evidence to better elucidate the patient cohort that would most benefit from the FET.

Systematic Review of Defibrillation Threshold Testing at De Novo Implantation.

BACKGROUND: Recent results from the largest multicenter randomized trial (Shockless IMPLant Evaluation [SIMPLE]) on defibrillation threshold (DFT) testing suggest that while shock testing seems safe, it does not reduce the risk of failed shocks or prolong survival. A contemporary systematic review of DFT versus no-DFT testing at the time of implantable cardioverter-defibrillator implantation was performed to evaluate the current evidence and to assess the impact of the SIMPLE study. METHODS AND RESULTS: Electronic searches were performed using 6 databases from their inception to March 2014. Relevant studies investigating implant DFT were identified. Data were extracted and analyzed according to predefined clinical end points. Predefined outcomes for interrogation were all-cause mortality, composite end point of implantable cardioverter-defibrillator efficacy (arrhythmic deaths and ineffective shocks), and composite safety end point (the sum of complications recorded at 30 days). Meta-analysis was performed including 13 studies and 9740 patients. No significant differences between DFT versus no-DFT cohorts were found in terms of all-cause mortality (risk ratio, 0.90; 95% confidence interval, 0.71-1.15; P=0.41), composite efficacy outcome (risk ratio, 1.24; 95% confidence interval, 0.65-3.37; P=0.51), and 30-day postimplant complications (risk ratio, 1.18; 95% confidence interval, 0.87-1.60; P=0.29). No significant difference was found in the trends observed when the results of the SIMPLE study were excluded or included. CONCLUSIONS: This systematic review of contemporary data suggests a modest average effect of DFT, if any, in terms of mortality, shock efficacy, or safety. Therefore, DFT testing should no longer be compulsory during de novo implantation. However, DFT testing may still be clinically relevant in specific patient populations.

Meta-Analysis of Contemporary Atrial Fibrillation Ablation Strategies: Irrigated Radiofrequency Versus Duty-Cycled Phased Radiofrequency Versus Cryoballoon Ablation.

OBJECTIVES: Using data from published studies, we performed a comparison of the 3 most commonly used atrial fibrillation (AF) ablation technologies in terms of efficacy and procedural duration. BACKGROUND: Catheter ablation is an effective treatment of atrial fibrillation (AF). Until recently, it has been performed with point-by-point delivery of irrigated radiofrequency energy (IRF). Phased duty-cycled radiofrequency (PRF) and cryoballoon ablation (CBA) have been introduced as alternatives to simplify AF ablation. METHODS: Electronic searches of 6 databases was performed, and eligible studies with IRF, PRF, or CBA as cohort arms were included. These ablation strategies were compared directly by using conventional frequentist meta-analysis and indirectly by using network meta-analysis, with outcomes graded using rank probability analysis. RESULTS: Direct conventional meta-analysis using all available published data showed that PRF was associated with an apparently higher freedom from AF than IRF (66.4% vs. 58%, respectively, p = 0.007), whereas CBA was comparable with IRF (64.8% vs. 62%, respectively, p = 0.99). PRF was associated with shorter procedural time (p < 0.0001), whereas there was a trend toward shorter procedural time with CBA than with IRF (p = 0.10). Indirect network meta-analysis using all available published data showed that PRF was associated with higher freedom from AF than CBA and IRF (odds ratio: 1.51; 95% confidence interval [CI]: 1.12 to 1.92) while having the shortest procedural time (weighted mean difference: 40.8 min; 95% CI: -63.31 to -18.11). Rank probability analysis also suggested that PRF was superior to CBA in terms of efficacy and procedural duration. However, when the meta-analysis was repeated using randomized controlled trial data alone, IRF and PRF were comparable in terms of freedom from AF (p = 0.35) over a mean follow-up of 9 months, but PRF was associated with significantly shorter procedural time (p = 0.006). There was a higher freedom from AF with IRF than with CBA (p = 0.04) over a mean follow-up of 12 months, whereas both techniques demonstrated similar procedural time (p = 0.47). CONCLUSIONS: Although preliminary meta-analysis of pooled data suggested the highest efficacy with PRF, this was not replicated when analysis was limited to randomized data. Therefore, there was insufficient evidence to suggest that one ablation modality is more efficacious than another. However, there was a consistent reduction in procedural duration associated with PRF in all analyses. The present meta-analysis highlights the critical need for further randomized studies comparing available ablation technologies in terms of efficacy and safety.

Catheter ablation for atrial fibrillation in hypertrophic cardiomyopathy patients: a systematic review.

PURPOSE: The primary aim of this systematic review was to assess the efficacy of catheter ablation of atrial fibrillation (AF) in patients with hypertrophic cardiomyopathy (HCM). Differentiation based off catheter ablation modalities was not considered due to the limited scope of the current field. Studies that employed alcohol septal ablation for the treatment of AF in HCM patients were excluded as were abstracts, case reports, conference presentations, editorials, reviews, and expert opinions METHODS: Electronic searches were performed in six databases from their inception until January 2014. Relevant studies regarding catheter ablation for AF in HCM populations were identified. Data was extracted and analyzed according to pre-defined clinical endpoints RESULTS: A review was undertaken of eight studies in which 241 HCM patients underwent catheter ablation for AF. Overall AF-free survival at last follow-up ranged from 47 to 77% (64-67%). Sinus rhythm was maintained at last follow-up in 47-82% (median 64-67%). AF recurrence ranged from 0 to 66% (median 35-40%). CONCLUSION: A review of the current evidence suggests that catheter ablation of AF in HCM patients is effective with suitable efficacy and is justified in select patients. Future adequately powered randomized studies should be undertaken aimed at addressing long-term efficacy and complications associated with procedural outcomes.

Hepatic resection for malignant liver tumours in the elderly: a systematic review and meta-analysis.

BACKGROUND: The number of elderly patients undergoing hepatic resection for surgical treatment of benign and malignant cancers is increasing. However, there is limited clinical data on the complications and long-term survival rates associated with liver surgery in the elderly patients (≥70 years) versus younger patients for malignant liver conditions. METHODS: Six electronic databases were searched for original published studies comparing elderly (≥70) versus younger (<70) cohorts for malignant liver tumours. Data were extracted and analysed according to predefined clinical endpoints. RESULTS: Twenty-seven comparative studies were identified, including 4769 elderly patients versus 15,855 younger patients (n = 20,624). There was significantly higher 30-day mortality in the elderly colorectal liver metastasis group (P < 0.00002) and significant difference between elderly and young in terms of overall survival (hazard ration (HR), 1.10; P = 0.02). However, there was no difference in disease-free survival (HR, 1.05; P = 0.27). Post-operative pneumonia, renal failure and infection were more frequent in the elderly group. CONCLUSIONS: Liver resection for malignant hepatic tumours in the elderly is associated with a greater 30-day mortality and overall mortality when compared with younger cohorts, but similar disease-free survival. Length of stay and transfusions were not significantly different while pneumonia, renal failure and infections were more frequent in the elderly group.

Frailty in advanced heart failure: a systematic review.

Frailty is a common geriatric syndrome of increased vulnerability to adverse events. The prevalence of frailty among chronic heart failure (CHF) is high and confers a greater risk of adverse events including falls, hospitalisation and mortality. There have been few studies assessing frailty in CHF. A review of the key databases was conducted from 2004 to 2014 including the key search terms 'frail elderly' and 'heart failure'. The following electronic databases were searched: Medline, Cumulative Index for Nursing and Allied Health and Academic Search Complete, with reference lists being manually searched. Articles were included if frailty was assessed using a valid measuring tool in a population with a confirmed diagnosis of CHF. The search yielded a total of 393 articles with 8 articles being selected for review. The prevalence of frailty among those with CHF was high, ranging from 18 to 54 %. The frailty phenotype and geriatric assessments tools were the most common frailty measures utilised; high rates of co-morbidity, hospitalisation and mortality were identified. Frailty is common in CHF and is associated with adverse outcomes.

Transcatheter Aortic Valve Implantation (TAVI) in Patients With Bicuspid Aortic Valve Stenosis--Systematic Review and Meta-Analysis.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is a feasible interventional technique for severe aortic stenosis in patients who are deemed inoperable or at high surgical risk. There is limited evidence for the safety and efficacy of TAVI in patients with bicuspid aortic valves (BAV), the most common congenital valve abnormality. In many TAVI trials, patients with BAV have been contraindicated due to concerns surrounding abnormal valve geometry, leading to malfunction or malpositioning. A systematic review and meta-analysis was conducted in order to assess the current evidence and relative merits of TAVI in aortic stenosis patients with BAV. METHOD: From six electronic databases, seven articles including 149 BAV and 2096 non-BAV patients undergoing TAVI were analysed. RESULTS: Between the BAV and no-BAV cohorts, there was no difference in 30-day mortality (8.3% vs 9.0%; P=0.68), post-TAVI mean peak gradients (weighted mean difference, 0.36 mmHg; P=0.55), moderate or severe paravalvular leak (25.7% vs 19.9%; P=0.29), pacemaker implantations (18.5% vs 27.9%; P=0.52), life-threatening bleeding (8.2% vs 13.9%; P=0.33), major bleeding (20% vs 16.8%; P=0.88), conversion to conventional surgery (1.9% vs 1.2%; P=0.18) and vascular complications (8.6% vs 10.1%; P=0.32). CONCLUSIONS: Preliminary short and mid-term pooled data from observation studies suggest that TAVI is feasible and safe in older patients with BAV. While future randomised trials are not likely, larger adequately-powered multi-institutional studies are warranted to assess the long-term durability and complications associated with TAVI in older BAV patients with severe aortic stenosis.

Early hemodynamic performance of the third generation St Jude Trifecta aortic prosthesis: A systematic review and meta-analysis.

OBJECTIVE: The Trifecta aortic prosthesis is a latest-generation trileaflet stented pericardial valve designed for supra-annular placement in the aortic position. Robust clinical evidence and long-term follow-up data for this new prosthesis are lacking; a systematic review was conducted to assess current evidence. METHODS: A comprehensive search from 6 electronic databases was performed, with time period parameters dating from database inception to January 2014. Results utilizing Trifecta prosthesis for aortic valve replacement (AVR) were identified. RESULTS: A total of 13 studies with 2549 patients undergoing AVR with this prosthesis were included in this review. The mean proportion of patients with aortic stenosis was 82.4%, with a mean gradient of 47.4 mm Hg, and a pooled effective orifice area (EOA) of 0.74 cm(2). Valve sizes of 21 mm and 23 mm were implanted in 71.3% of patients. The pooled rates of 30-day mortality, cerebrovascular accidents, and acute kidney injuries were 2.7%, 1.9%, and 2.6%, respectively. After implantation, the pooled mean gradient decreased to 9.2 mm Hg, whereas discharge EOA increased to 1.8 cm(2), compared with preoperative parameters. Among included studies with significant heterogeneity detected, most patients had satisfactory patient-prosthesis mismatch, with 2.7% having severe mismatch. CONCLUSIONS: The present systematic review demonstrated that short-term AVR with this prosthesis provided excellent early safety and hemodynamic outcomes with acceptable mean gradients and EOA. Long-term follow-up and randomized controlled trials are warranted to confirm the early results.

New-onset atrial fibrillation following coronary bypass surgery predicts long-term mortality: a systematic review and meta-analysis.

Atrial fibrillation (AF) is one of the most common postoperative complications following cardiac surgery. Recent evidence suggests that postoperative atrial fibrillation (POAF) may be more 'malignant' than previously thought, associated with follow-up mortality and morbidity. To evaluate the long-term survival of POAF versus No-POAF cohorts following coronary bypass surgery, the current meta-analysis with reconstructed individual patient data was performed. Electronic searches were performed using six databases from their inception to August 2014. Relevant studies with long-term survival data presented for POAF versus No-POAF were identified. Data were extracted by two independent reviewers and analysed according to predefined clinical endpoints. The pooled hazard ratio (HR) significantly favoured higher survival in No-POAF over POAF (HR 1.28; 95% CI, 1.19-1.37; I(2) = 96%; P < 0.00001). Individual patient data of 69 518 patients were available for inverted Kaplan-Meier survival curve analysis. Analysis of aggregate data using Kaplan-Meier curve methods for POAF versus No-POAF groups determined survival rates at the 1-year (95.7 vs 98%), 2-year (92.3 vs 95.4%), 3-year (88.7 vs 93.9%), 5-year (82.6 vs 89.4%) and 10-year (65.5 vs 75.3%) follow-up. Other complications including 30-day mortality, strokes, respiratory failure, pneumonia and hospitalization were significantly higher in the POAF group. New-onset AF following coronary bypass surgery is associated with significantly higher risk of mortality in short- and long-term follow-up. Current evidence suggests the need for stricter surveillance and monitoring of POAF following coronary bypass surgery.