Transradial intervention in dialysis patients undergoing percutaneous coronary intervention: a Japanese nationwide registry study.

Aims: Transradial intervention (TRI) for percutaneous coronary intervention (PCI) is used to reduce periprocedural complications. However, its effectiveness and safety for patients on dialysis are not well established. We aimed to investigate the association of TRI with in-hospital complications in dialysis patients undergoing PCI. Methods and results: We included 44 462 patients on dialysis who underwent PCI using Japanese nationwide PCI registry data (2019-21) regardless of acute or chronic coronary syndrome. Patients were categorized based on access site: TRI, transfemoral intervention (TFI). Periprocedural access site bleeding complication requiring transfusion was the primary outcome and in-hospital death, and other periprocedural complications were the secondary outcomes. Matched weighted analysis was performed for TRI and TFI. Here, 8267 (18.6%) underwent TRI, and 36 195 (81.4%) underwent TFI. Patients who received TRI were older and had lower rates of comorbidities than those who received TFI. Access site bleeding rate and in-hospital death were significantly lower in the TRI group (0.1% vs. 0.7%, P < 0.001; 1.8% vs. 3.2%, P < 0.001, respectively). After adjustment, TRI was associated with a lower risk of access site bleeding (odds ratio [OR] [95% confidence interval (CI)]: 0.19 [0.099-0.38]; P < 0.001) and in-hospital death (OR [95% CI]: 0.79 [0.65-0.96]; P = 0.02). Other periprocedural complications between TRI and TFI were not significantly different. Conclusion: In patients undergoing dialysis and PCI, TRI had a lower risk of access site bleeding and in-hospital death than TFI. This suggests that TRI may be safer for this patient population.

Ipsilateral snare technique for the safe delivery of the Evolut PRO transcatheter aortic valve system: a case report.

Background: Transcatheter aortic valve implantation (TAVI) requires several bail-out techniques for safe valve delivery and deployment. Particularly in cases of challenging aortic anatomy, the snare technique from the contralateral side of the surgical site can facilitate delivery of the transcatheter heart valve (THV) system. However, there are no previous reports of the snare technique from the ipsilateral side of the surgical site in TAVI cases. Case summary: A 77-year-old woman presented with severe aortic stenosis and congestive heart failure. As computed tomography showed a heavily calcified aortic arch, we performed TAVI using the ipsilateral snare technique to control the direction of the Evolut THV system. There was no haematoma or excessive bleeding at the surgical site during the procedure, and the patient was discharged without complications. Discussion: In cases with challenging anatomy of the aorta, the ipsilateral snare technique may be useful for the safe delivery of the Evolut system.

Procedural Volume and Outcomes of Transfemoral Transcatheter Aortic Valve Replacement: From a Japanese Nationwide Registry.

The impact of procedural volume on transcatheter aortic valve replacement (TAVR) outcomes in Japan remains uncertain. Japan has carefully introduced TAVR after the establishment of techniques in Western countries and therefore may not exhibit volume-outcome relations after TAVR. Data on transfemoral TAVR was collected from the Japan Transcatheter Valve Therapy (J-TVT) registry between 2018 and 2020. Hospitals were categorized into quartiles (lowest, lower, high, and highest) based on annual TAVR volume. The primary analysis compared 30-day mortality among different TAVR volume hospitals. A multivariable adjustment analysis was performed to calculate the adjusted odds ratio (aOR) and 95% confidence intervals (CIs) of 30-day all-cause mortality with highest-volume hospital as the reference. A total of 2,741 transfemoral TAVR cases from 172 hospitals were included in the analysis. Median hospital TAVR volume was 38 (interquartile range 27 to 60) per year. Unadjusted 30-day mortality was 0.46%, 0.69%, 1.17%, and 1.18% from the lowest to the highest quartile of hospitals, respectively. There was no significant difference in 30-day mortality rates for lowest-volume hospitals (aOR 0.51, 95% CI 0.24 to 1.05, p = 0.07), low-volume hospitals (aOR 0.76, 95% CI 0.46 to 1.26, p = 0.29), or high-volume hospitals (aOR 1.11, 95% CI 0.74 to 1.67, p = 0.60). An analysis from the contemporary national registry in Japan did not find an obvious inverse relation between annual hospital volume and 30-day mortality. Our results suggest that TAVR has now reached a level of procedural maturity, with standardized outcomes observed across hospitals regardless of their annual procedural volume.

Access Site-Stratified Analysis of the Incidence, Predictors, and Outcomes of Impella-Supported Patients With Cardiogenic Shock.

This study aimed to evaluate the incidence, predictors, and outcomes of Impella-assisted patients with cardiogenic shock, stratified by the access site-transaxillary (TX) or trans-subclavian (TS) versus the conventional transfemoral (TF) approach. For this study, we analyzed the cases entered into the Japanese Percutaneous Ventricular Assist Device registry between February 2020 and December 2021. A multivariable logistic regression analysis was conducted to calculate the adjusted odds ratio (aOR) and 95% confidence intervals (CIs) to identify the predictors of the TX/TS approach, with reference to those who received the conventional TF approach. A log-rank test was performed to compare the 30-day mortality between the 2 approaches. A total of 2,564 cases of Impella were included in the study, of which 167 (6.5%) were accessed by way of the TX/TS approach. TX/TS approach cases were younger and had a higher percentage of concomitant use of extracorporeal membrane oxygenation or an intra-aortic balloon pump. The predictors of the TX/TS approach included a presentation with the acute coronary syndrome (aOR 0.32, 95% CI 0.16 to 0.63, p <0.001), cardiac arrest (aOR 0.10, 95% CI 0.02 to 0.36, p = 0.003), cardiogenic shock (aOR 0.51, 95% CI 0.33 to 0.79, p = 0.002), and inotropic use (aOR 1.88, 95% CI 1.08 to 3.49, p = 0.033). The 30-day mortality was comparable between TX/TS and TF approaches (29.3% vs 29.6%, respectively; log-rank, p = 0.64). Our analysis revealed that approximately 6% of the Impella-assisted patients with cardiogenic shock received the TX/TS approach as their first access site. These results suggest that the TX/TS approach may be a viable alternative to the TF approach in certain patients requiring Impella support.

Volume-outcome relationship in complication-related mortality after percutaneous coronary interventions: an analysis on the failure-to-rescue rate in the Japanese Nationwide Registry.

In-hospital mortality following percutaneous coronary intervention (PCI) varies across institutions with different annual PCI volumes. The failure to rescue (FTR) rate, defined as the mortality rate following PCI-related complications, may account for the volume-outcome relationship. The Japanese Nationwide PCI Registry, a consecutive, nationally mandated registry between 2019 and 2020, was queried. The FTR rate is defined as 'the number of patients who died following PCI-related complications' divided by 'the number of patients who experienced at least one PCI-related complication.' Multivariate analysis was used to calculate the risk-adjusted odds ratio (aOR) of the FTR rates among hospitals stratified into tertiles as low (≤ 236/year), medium (237-405/year), and high (≥ 406/year). A total of 465,716 PCIs and 1007 institutions were included. A volume-outcome relationship was observed for in-hospital mortality, and the medium-volume (aOR 0.90, 95% confidence interval [CI] 0.85-0.96), as well as high-volume (aOR 0.84, 95% CI 0.79-0.89) hospitals, had significantly lower in-hospital mortality than low-volume hospitals. Complication rates were lower at high-volume centers (1.9%, 2.2%, and 2.6% for high-, medium-, and low-volume centers, respectively; p < 0.001). The overall FTR rate was 19.0%. The FTR rates for the low-, medium-, and high-volume hospitals were 19.3%, 17.7%, and 20.6%, respectively. The medium-volume hospitals had a lower FTR rate (aOR 0.82, 95% [CI] 0.68-0.99), whereas the FTR rate was similar at the high-volume hospitals compared with that of the low-volume hospitals (aOR 1.02, 95% CI 0.83-1.26). In-hospital mortality was low after PCI in high-volume hospitals. However, the FTR rate in high-volume hospitals was not necessarily lower than that in low-volume hospitals. The FTR rate did not account for the volume-outcome relationship in PCI.

Impact of periprocedural bleeding on mid-term outcome in nonagenarians who underwent transcatheter aortic valve implantation: insights from LAPLACE registry.

Data from several recent studies have demonstrated the safety and efficacy of transcatheter aortic valve implantation (TAVI) for severe aortic stenosis (AS) even in nonagenarians. However, the impact of periprocedural bleeding following TAVI on their outcome remains unclear. In the aLliAnce for exPloring cLinical prospects of AortiC valvE disease (LAPLACE) registry, we compared outcomes between the bleeding and no-bleeding groups among 1953 patients < 90 years old (mean age, 83.0 ± 4.6 years old) and 316 nonagenarians (mean age, 91.7 ± 1.9 years old) who underwent TAVI with a median follow-up period of 628 days. The group with any periprocedural bleeding showed a higher 30-day mortality than the no-bleeding group in patients < 90 years old (3.3% vs. 0.5%, p = 0.001) and nonagenarians (7.9% vs. 0.7%, p = 0.001). In patients < 90 years old, severe periprocedural bleeding (n = 85) was associated with a higher mid-term all-cause mortality rate than no severe bleeding (n = 1,868), even after adjusting for covariates (hazard ratio [HR], 1.994; 95% confidence interval [CI] 1.287-2.937; p = 0.002). On the other hand, in nonagenarians, any periprocedural bleeding (n = 38) was associated with a higher mid-term cardiovascular (CV) mortality rate (21.1% vs. 4.3%, log-rank p = 0.014) than no bleeding (n = 278), even after adjusting for covariates (HR, 3.104; 95% CI 1.140-8.449; p = 0.027). In conclusion, any periprocedural bleeding after TAVI was associated with mid-term CV mortality in nonagenarians, whereas severe bleeding was associated with mid-term all-cause mortality in patients < 90 years old.

Effectiveness of high implantation of SAPIEN 3 in preventing pacemaker implantation: A propensity score analysis.

BACKGROUND: In transcatheter aortic valve implantation, high implantation on the aortic annulus may prevent conduction pathway injury, leading to a decrease in the rate of permanent pacemaker implantation. AIM: To assess the impact of high implantation of SAPIEN 3 on the prevention of permanent pacemaker implantation. METHODS: Since August 2020, we have performed high implantation by fluoroscopically positioning the lower part of the lucent line at the virtual basal ring line on a coplanar view before valve implantation. Patients treated before the adoption of this method were defined as the conventional group. We compared the high implantation group with the conventional group using propensity score analysis. RESULTS: Overall, the high implantation group (n=95) showed a significantly shorter ventricular strut length than the conventional group (n=85): median 1.3 (interquartile range 0.2-2.4) mm vs 2.8 (1.8-4.1) mm (P<0.001). The permanent pacemaker implantation rate was significantly lower in the high implantation group than in the conventional group (2.1% vs 11.8%; P=0.009). According to 100 propensity score analyses based on multiple imputation and the selection of appropriate covariates, the median P value for the comparison of permanent pacemaker implantation rates after transcatheter aortic valve implantation between the high implantation group and the conventional group ranged between 0.001 and 0.017, indicating a more significant reduction in the permanent pacemaker implantation rate in the high implantation group than in the conventional group. Neither valve dislodgement nor the need for a second valve was observed in either group. CONCLUSIONS: The high implantation of SAPIEN 3 successfully decreases ventricular strut length, reducing the permanent pacemaker implantation rate after transcatheter aortic valve implantation.

A novel "proximal first" Inoue balloon catheter for retrograde aortic valvuloplasty: Initial case report.

The Inoue balloon, invented for percutaneous transseptal mitral commissurotomy for mitral stenosis, is initially dilated in the distal portion and then the proximal portion, forming an hourglass shape that stabilizes the balloon at the mitral valve orifice with a pulling action. The device has been successfully applied to antegrade aortic valvuloplasty; the hourglass shape stabilizes the balloon across the aortic valve without rapid ventricular pacing. Subsequently, an Inoue balloon was developed for retrograde aortic valvuloplasty using the same design as the antegrade balloon. The hourglass-shaped balloon, however, has difficulty maintaining stability across the aortic valve because the distal portion of the balloon, which inflates first, directly receives systolic pressure from the left ventricle. A novel Inoue balloon was invented to overcome this issue by altering the manner of inflation: the proximal portion inflates first, followed by the distal portion. Theoretically, the proximal portion, which initially inflates just above the aortic valve, remains secure across the valve by applying a pressing force that counteracts the systolic forward pressure. Furthermore, a radiopaque marker is placed at the center of the balloon to enable rapid and precise balloon adjustment. We present a case involving a 65-year-old female hemodialysis patient with severe symptomatic aortic stenosis who we successfully treated with balloon aortic valvuloplasty using the novel Inoue balloon followed by transcatheter aortic valve implantation. The present case demonstrates the feasibility and effectiveness of the novel "proximal first" Inoue balloon for retrograde balloon aortic valvuloplasty for severe aortic stenosis.

Analysis of outcome of 6-month readmissions after percutaneous left atrial appendage occlusion.

OBJECTIVE: Percutaneous left atrial appendage occlusion (LAAO) is an alternative strategy for prevention of thromboembolic events in patients with atrial fibrillation and unsuitable for long-term oral anticoagulation. The study aimed to evaluate the causes and timing of readmissions within 6 months following percutaneous LAAO in a real-world setting. METHODS: We conducted a retrospective cohort study of percutaneous LAAO performed in the USA between January and June of 2016-2018 using the Nationwide Readmissions Database. RESULTS: Overall, 12 446 patients who underwent LAAO were included in the analyses and 3477 patients (28%) were readmitted within 6 months following the interventions. Readmitted patients were more often women (p=0.001). The index hospitalisation was characterised by longer duration of hospital stay (p<0.001) and complicated with acute kidney injury (p<0.001) among readmitted patients compared with those without readmissions. Readmissions within 6 months following the index intervention were mainly due to heart failure (13%) and gastrointestinal bleeding (12%). Characteristics associated with readmissions due to heart failure included previously known heart failure (HR 2.39; 95% CI 1.70 to 3.37), valvular heart disease (HR 1.39; 95% CI 1.05 to 1.84) and chronic kidney disease (HR 1.42; 95% CI 1.03 to 1.94). Readmissions due to gastrointestinal bleeding were associated with diabetes mellitus (HR 1.78; 95% CI 1.25 to 2.53), chronic kidney disease (HR 1.86; 95% CI 1.23 to 2.81) and previous anaemia (HR 2.41; 95% CI 1.54 to 3.77). CONCLUSIONS: After percutaneous LAAO, over a quarter of the patients in the USA required rehospitalisation within 6 months, mainly due to heart failure and gastrointestinal bleeding.

Clinical outcomes in nonagenarians undergoing transcatheter aortic valve implantation: a systematic review and meta-analysis.

To compare the risk of procedural complications and mortality after transcatheter aortic valve implantation (TAVI) in nonagenarians (age ≥ 90 years) compared to younger patients (< 90 years). Although TAVI could be considered as a treatment option in nonagenarians, several previous studies have shown conflicting outcomes between nonagenarians and younger patients who underwent TAVI. We conducted a comprehensive literature search through PubMed and EMBASE to investigate the clinical outcomes of nonagenarians after TAVI. The outcomes of interest were short- and long-term mortality and procedural complications. Our study identified 16 observational studies including a total of 179,565 patients (21,674 nonagenarian patients and 157,891 younger patients. Nonagenarians had a significantly higher rate of short- (hazard ratio [HR], 95% confidence interval [CI]: 1.48, 1.38-1.59; P < 0.001) and long-term mortality (HR, 95% CI: 1.34, 1.24-1.44; P < 0.001) than younger patients after TAVI. Furthermore, there were significant differences in major and/or life-threatening bleeding (risk ratio [RR], 95% CI: 1.21, 1.05-1.39; P = 0.008), stroke (HR, 95% CI: 1.24, 1.11-1.40; P < 0.001), and major vascular complication (RR, 95% CI: 2.15, 1.35-3.42; P = 0.001) between nonagenarians and younger patients after TAVI. Minor vascular complication, myocardial infarction and permanent pacemaker implantation rate were similar between the two groups. Nonagenarians had significantly higher rate of short- and long-term mortality, major and/or life-threatening bleeding, stroke, and major vascular complication after TAVI. Although TAVI is a treatment option in nonagenarians, careful and appropriate selection of patients is essential to improve clinical outcomes.

Hospital variation of 30-day readmission rate following transcatheter aortic valve implantation.

OBJECTIVES: Thirty-day readmission rate is one of the hospital quality metrics. Outcomes of transcatheter aortic valve implantation (TAVI) have improved significantly, but it remains unclear whether hospital-level variance in 30-day readmission rate exists in the contemporary TAVI era. METHODS: From the 2017 US Nationwide Readmission Database, endovascular TAVI were identified. The unadjusted 30-day readmission rate and 30-day risk-standardised readmission rate (RSRR) were calculated and we then conducted model testing to determine the relative contribution of hospital characteristics, patient-level covariates and economic status to the variation in readmission rates observed between the hospitals. RESULTS: A total of 44 899 TAVI from 338 hospitals were identified. The range of unadjusted 30-day readmission rate and 30-day RSRR was 2.0%-33.3% and 9.4%-15.3%, respectively. Median 30-day RSRR was 11.8% and there was a significant hospital-level variation (median OR 1.22, 95% CI 1.16 to 1.32, p<0.01) and this was similar in both readmissions caused due to major cardiac and non-cardiac conditions. Patient, hospital and economic factors accounted for 9.6%, 1.9% and 3.8% of the variability in hospital readmission rate, respectively. CONCLUSIONS: There was significant hospital-level variation in 30-day RSRR following TAVI. Further measures are required to mitigate this variance in the readmission rate.

Zero-fluoroscopy ablation for cardiac arrhythmias: A single-center experience in Japan.

BACKGROUND: Exposure to radiation during catheter ablation procedures poses a risk to the heath of both the patient and electrophysiology laboratory staff. Recently, the feasibility and effectiveness of zero-fluoroscopy ablation have been reported. However, studies on the outcomes of zero-fluoroscopy ablation in Japan remain limited. This study investigated the outcomes of zero-fluoroscopy ablation for cardiac arrhythmias at a Japanese institute. METHODS AND RESULTS: We present a retrospective analysis of the safety, efficacy, and feasibility data from 221 consecutive patients who underwent zero-fluoroscopy ablation. Of these patients, 181 had atrial fibrillation, 17 had paroxysmal supraventricular tachycardia, 13 had atrial tachycardia, 6 had ventricular tachycardia, and 4 had ventricular premature contractions. We performed zero-fluoroscopy ablation using three-dimensional electro-anatomical mapping systems and intracardiac echocardiography imaging. Ultrasound-guided sheath insertion was performed on all cases. Our experience includes exclusively endocardial cardiac ablations. The mean follow-up was 24 months. The recurrence rates were 25.4% for atrial fibrillation, 5.9% for paroxysmal supraventricular tachycardia, 15.4% for atrial tachycardia, 33.3% for ventricular tachycardia, and 25% for ventricular premature contraction. Complications occurred in two patients (0.9%), and there was no occurrence of death. A fluoroscopic guide was used in three cases for the confirmation of vascular access (one case) and for complications (two cases). CONCLUSIONS: Zero-fluoroscopy ablation was routinely performed without compromising on safety and efficacy. This approach may eliminate the exposure to radiation for all individuals involved in this procedure.

Catheter-based biopsy leading to early surgical intervention of the pulmonary artery intimal sarcoma.

Pulmonary artery intimal sarcoma (PAIS) is an extremely rare disease that portends a dismal prognosis. To reach a diagnosis, several diagnostic measures are performed but pathological confirmation is required for an ultimate diagnosis. We report a case where a catheter-based, less invasive approach led to the diagnosis and curative intervention for PAIS. .

Risk of Ischemic Stroke in Transcatheter Aortic Valve Implantation Versus Surgical Aortic Valve Replacement in Patients With Prior Stroke.

It has not been well studied whether transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR) have lower risk of ischemic stroke (IS) in those with prior history of IS. From the Nationwide Readmission Database from October 2015 to November 2017, TAVI and SAVR above age 50 were identified with the International Classification of Diseases, Tenth Revision, Clinical Modification/Procedure Coding System codes. Transapical TAVI and SAVR with concomitant bypass, mitral, or tricuspid surgery were excluded. The primary outcome was in-hospital IS. A total of 92,435 TAVI (13,292 with prior stroke) and 68,651 SAVR (5,365 with prior stroke) were identified. In-hospital IS was significantly lower in TAVI compared with SAVR (3.7% vs 8.0%, adjusted odds ratio 0.65, 95% confidence interval 0.47 to 0.89, p <0.01) with prior stroke whereas it was similar between TAVI and SAVR (1.7% vs 2.1%, adjusted odds ratio 0.97, 95% confidence interval 0.78 to 1.19, p = 0.75) in those without prior stroke (P interaction < 0.001). In-hospital mortality, acute kidney injury, and bleeding were lower in TAVI compared with SAVR in patients with and without prior stroke (P interaction > 0.05 for all). This analysis of a national claims database showed that TAVI was associated with a lower risk of in-hospital IS compared with SAVR among patients with prior stroke.

Duration of Antiplatelet Therapy Following Transcatheter Aortic Valve Replacement: Systematic Review and Network Meta-Analysis.

Background Although current guidelines recommend dual antiplatelet therapy (DAPT) for 3 to 6 months following transcatheter aortic valve replacement (TAVR), there are no studies directly comparing outcomes of different durations of DAPT following TAVR. Methods and Results PubMed, EMBASE, and Cochrane Database were searched through November 2020 to identify clinical studies that investigated single antiplatelet therapy versus DAPT use following TAVR. Studies using oral anticoagulants and antiplatelet therapy concomitantly were excluded. The DAPT group was subdivided by the duration of DAPT. We extracted the risk ratios (RRs) of major or life-threatening bleeding, stroke, and all-cause mortality. Four randomized controlled trials, 2 propensity-score matched studies, and 1 observational study were identified, yielding a total of 2498 patients who underwent TAVR assigned to the single antiplatelet therapy group (n=1249), 3-month DAPT group (n=485), or 6-month DAPT group (n=764). Pooled analyses demonstrated that when compared with the single antiplatelet therapy group, the rates of major or life-threatening bleeding were significantly higher in the 3- and 6-month DAPT groups (RR [95% CI]=2.13 [1.33-3.40], P=0.016; RR [95% CI]=2.54 [1.49-4.33], P=0.007, respectively) with no difference between the 3-month DAPT versus 6-month DAPT groups. The rates of stroke and all-cause mortality were similar among the 3 groups. Conclusions In this network meta-analysis of antiplatelet therapy following TAVR, single antiplatelet therapy with aspirin had lower bleeding without increasing stroke or death when compared with either 3- or 6-month DAPT.

Palliative care consultation in patients with Staphylococcus aureus bacteremia.

BACKGROUND: Palliative care consultation has shown benefits across a wide spectrum of diseases, but the utility in patients with Staphylococcus aureus bacteremia remains unclear despite its high mortality. AIM: To examine the frequency of palliative care consultation and factors associated with palliative care consult in Staphylococcus aureus bacteremia patients in the United States. DESIGN: A population-based retrospective analysis using the Nationwide Inpatient Sample database in 2014, compiled by the Healthcare Costs and Utilization Project of the Agency for Healthcare Research and Quality. SETTING/SUBJECTS: All inpatients with a discharge diagnosis of Staphylococcus aureus bacteremia (ICD-9-CM codes; 038.11 and 038.12). MEASUREMENTS: Palliative care consultation was identified using ICD-9-CM code V66.7. Patients' baseline characteristics and outcomes were compared between those with and without palliative care consult. RESULTS: A total of 111,320 Staphylococcus aureus bacteremia admissions were identified in 2014. Palliative care consult was observed in 8140 admissions (7.3%). Palliative care consultation was associated with advanced age, white race, comorbidities, higher income, teaching/urban hospitals, Midwest region, Methicillin-resistant Staphylococcus aureus bacteremia and the lack of echocardiogram. Palliative care consult was also associated with shorter but more expensive hospitalizations. Crude mortality was 53% (4314/8140) among admissions with palliative care consult and 8% (8357/10,3180) among those without palliative care consult (p < 0.001). CONCLUSIONS: Palliative care consultation was infrequent during the management of Staphylococcus aureus bacteremia, and a substantial number of patients died during their hospitalizations without palliative care consult. Given the reported benefit in other medical conditions, palliative care consultation may have a role in Staphylococcus aureus bacteremia. Selecting patients who may benefit the most should be explored.

Transcatheter Versus Surgical Aortic Valve Replacement in the United States (From the Nationwide Readmission Database).

Clinical outcomes of transcatheter aortic valve implantation (TAVI) have significantly improved with the accumulation of operator and institution experience as well as the wide use of newer generation devices. There is limited data on TAVI outcomes compared with surgical aortic valve replacement (SAVR) in contemporary practice in the United States. We queried the 2018 Nationwide Readmission Database of the United States. International Classification Diagnosis code 10 was used to extract TAVI and SAVR admissions. A propensity-matched cohort was created to compare TAVI and SAVR outcomes. A weighted 48,349 TAVI and 24,896 SAVR for aortic stenosis were included and 4.9% of TAVI were performed with an embolic protection device. In propensity-matched cohort (12,708 TAVI and 12,708 SAVR), TAVI conferred lower in-hospital mortality (1.7% vs 3.8%), acute kidney injury (11.3% vs 22.9%), and transfusion rate (5.9% vs. 20.6%) whereas new pacemaker rate was higher in TAVI compared with SAVR (10.5% vs. 7.0%) (all p values < 0.001). Stroke rate was similar between TAVI and SAVR (1.5% vs. 1.5%) (p value = 0.79). The routine discharge was more frequent (66.9% vs 25.8%) and length of stay was shorter (4.8 vs. 9.8 days) in TAVI than SAVR. Hospitalization cost was higher in SAVR than TAVI (51,962 vs 57,754 U.S. dollars) (all p values < 0.001). In-hospital mortality was also lower in TAVI compared with isolated SAVR. TAVI was performed more frequently than SAVR in 2018 in the United States with lower in-hospital mortality of TAVI compared with both SAVR and isolated SAVR.

Potent P2Y12 inhibitors versus Clopidogrel in elderly patients with acute coronary syndrome: Systematic review and meta-analysis.

BACKGROUND: Potent P2Y12 inhibitors reduce cardiovascular events but increase bleeding in patients presenting with acute coronary syndrome (ACS). Elderly patients are at increased risk of bleeding and whether the benefit-risk ratio of potent P2Y12 inhibitors remains favorable is not known. OBJECTIVES: To investigate the efficacy and safety of potent P2Y12 inhibitors versus clopidogrel in elderly patients with ACS. METHODS: PUBMED and EMBASE were searched through July 2020 for randomized control trials (RCTs) or subgroup analyses of RCTs investigating potent P2Y12 inhibitors (prasugrel or ticagrelor) or clopidogrel in elderly (age ≥ 65 years) patients with ACS. The primary outcome was major adverse cardiovascular events (MACE). RESULTS: Our search identified 9 RCTs with a total of 10,792 elderly patients. When compared with clopidogrel, potent P2Y12 inhibitors had similar risk of MACE (hazard ratio (HR): 0.94; 95%; confidence interval (CI) [0.85-1.06], P = .31, I2 = 9%), all-cause mortality (HR: 0.89; 95% CI [0.74-1.07], P = .22, I2 = 29%), reduced the risk of cardiovascular death (HR: 0.82; 95% CI [0.68-0.98], P = .03, I2 = 16%) but increased the risk of major bleeding (HR: 1.27; 95% CI [1.04-1.56], P = .02, I2 = 0%). In a subgroup analysis, ticagrelor reduced all-cause mortality (HR: 0.73; 95% CI [0.55-0.98]) and cardiovascular death (HR: 0.70; 95% CI [0.54-0.90]) compared with clopidogrel. CONCLUSIONS: Among elderly patients with ACS, potent P2Y12 inhibitors reduce cardiovascular death but increase bleeding with no difference in MACE or all-cause death when compared with clopidogrel. Further RCTs are needed to refine P2Y12 inhibitor selection for elderly patients with ACS.

Meta-analysis of impact of renin-angiotensin system inhibitors on survival after transcatheter aortic valve implantation.

INTRODUCTION: To determine whether renin-angiotensin system inhibitor (RASI) prescription is associated with better survival after transcatheter aortic valve implantation (TAVI), we performed the first meta-analysis of currently available studies. EVIDENCE ACQUISITION: To identify all studies reporting impact of RASI prescription on survival after TAVI, we searched PubMed, Web of Science, Google Scholar, etc. through October 2019. We extracted adjusted (if unavailable, unadjusted) hazard ratios (HRs) with their confidence intervals (CIs) of midterm (up to ≥6-month) all-cause mortality for RASI prescription from each study and combined study-specific estimates using inverse variance-weighted averages of logarithmic HRs in the random-effects model. EVIDENCE SYNTHESIS: We identified 13 eligible studies with a total of 26,132 TAVI patients and included them in the present meta-analysis. None was a randomized controlled trial, 5 were observational studies comparing patients with versus without RASI prescription (including 3 propensity score matched studies), and 8 were observational studies investigating RASI prescription as one of covariates. The primary meta-analysis of all studies demonstrated that RASI prescription was associated with significantly lower midterm mortality (HR=0.83; 95% CI: 0.76 to 0.92; P=0.0002). Although we identified significant funnel plot asymmetry (P=0.036 by the rank correlation test) suggesting publication bias, correcting for it using the trim-and-fill method did not substantially alter the result favoring RASI prescription (corrected HR=0.85; 95% CI: 0.76 to 0.95; P=0.004). CONCLUSIONS: RASI prescription may be associated with better midterm survival after TAVI.