Chronic kidney disease is associated with increased mortality and procedural complications in transcatheter aortic valve replacement: a systematic review and meta-analysis.

OBJECTIVE: We performed a systematic review and meta-analysis to explore the association between chronic kidney disease (CKD) and mortality and procedural complications in transcatheter aortic valve replacement (TAVR). BACKGROUND: The impact of varying stages of CKD or end-stage renal disease (ESRD) on patients receiving TAVR is not clearly identified. METHODS: We searched the databases of MEDLINE and EMBASE from inception to May 2018. Included studies were published TAVR studies that compared the risk of mortality and procedural complications in CKD patients compared to control patients. Data from each study were combined using the random-effects model. RESULTS: Twelve studies (42,703 CKD patients and 51,347 controls) were included. Compared with controls, CKD patients had a significantly higher risk of 30-day overall mortality (risk ratio [RR] = 1.56, 95% confidence interval [CI]: 1.34-1.80, I2 = 60.9), long-term cardiovascular mortality (RR = 1.44, 95% CI: 1.22-1.70, I2 = 36.2%), and long-term overall mortality (RR = 1.66, 95% CI: 1.45-1.91, I2 = 80.3), as well as procedural complications including pacemaker requirement (RR = 1.20, 95% CI: 1.03-1.39, I2 = 56.1%) and bleeding (RR = 1.60, 95% CI: 1.26-2.02, I2 = 86.0%). Risk of mortality and procedural complications increased with severity of CKD for stages 3, 4, and 5, respectively, in terms of long-term overall mortality (RR = 1.28, 1.82, and 2.12), 30-day overall mortality (RR = 1.26, 1.89, and 1.93), 30-day cardiovascular mortality (RR = 1.18, 1.75, and 2.50), and 30-day overall bleeding (RR = 1.19, 1.63, and 2.12). CONCLUSIONS: Our meta-analysis demonstrates a significant increased risk of mortality and procedural complications in patients with CKD who underwent TAVR compared to controls.

Red blood cell distribution width as an easily measurable biomarker of persistent inflammation and T cell dysregulation in antiretrovirally treated HIV-infected adults.

BACKGROUND: Chronic inflammation and immune dysfunction occur in human immunodeficiency virus (HIV)-infection despite stable antiretroviral therapy (ART). Red blood cell distribution width (RDW) has been shown to correlate with markers of inflammation in non-HIV conditions. The study objective was to determine associations between RDW with cellular markers of immune activation and immune dysfunction including soluble inflammatory mediators in ART treated HIV infection. METHODS: We performed a cross-sectional analysis of the Hawaii Aging with HIV-Cardiovascular study. RDW was defined as one standard deviation of RBC size divided by mean corpuscular volume multiplied by 100%. Correlations were analyzed between RDW, soluble inflammatory biomarkers and T cell activation (CD38 + HLA-DR+), senescence (CD28-CD57+), and immune exhaustion (PD-1, TIGIT, TIM-3 expression). RESULTS: Of 158 participants analyzed, median age was 50 years, duration of ART 12.6 years, virally suppressed 84.4%, and CD4 count 503 cells/mm3. Significant positive correlations were identified between RDW and soluble biomarkers including sICAM, IL-8, IL-6, SAA, TNF-α, sE-selection, fibrinogen, D-dimer, CRP, CD4/CD8 ratio, and frequency of multiple CD8 T-cell populations such as CD38 + HLA-DR + T-cells, single TIGIT+, and dual expressing of TIGIT + PD1+, TIGIT + TIM3+, and TIM3 + PD1+ CD8+ T-cell subsets (p < .05). Frequencies of CD38 + HLA-DR + CD8+ T-cells and TIGIT + CD8+ T-cells remained significant adjusting for baseline variables (p < .01). CONCLUSION: Our study revealed correlations between RDW with systemic inflammatory biomarkers and CD8+ T-cell populations related to immune activation and exhaustion in HIV-infected individuals on ART. Further studies are warranted to determine the utility of RDW as a marker of immune dysregulation in HIV.

Intracoronary thrombin injection using a microcatheter to treat guidewire-induced coronary artery perforation.

Coronary artery perforation (CAP) is an infrequent yet a very dangerous complication of percutaneous coronary intervention. We describe the successful treatment of a guidewire-induced distal coronary branch vessel perforation using localized distal injection of intracoronary thrombin with a microcatheter. This technique appears to be safe and effective for the treatment of life-threatening distal guidewire perforations, even in the smallest tertiary coronary branches.