Outcomes of fractional flow reserve-guided percutaneous coronary interventions in patients with acute coronary syndrome.

INTRODUCTION: Fractional flow reserve (FFR) assessment has been validated as an effective tool to guide revascularization of stable coronary artery disease. The role of utilizing FFR in acute coronary syndrome (ACS) is less established. METHODS: The study population was extracted from the National Readmissions Data (NRD) 2014 using International Classification of Diseases, ninth edition, clinical modification (ICD-9-CM) codes for ACS, percutaneous coronary intervention (PCI), FFR, and periprocedural complications. Study endpoints included all-cause of in-hospital mortality, length of index hospital stay (LOS), acute kidney injury (AKI), bleeding, coronary dissection, total number of stents used, stroke, vascular complications (VCs), and the total charges of index hospitalization. RESULTS: A total of 304,548 discharges that had the diagnosis of ACS and treated invasively within the same index hospitalization (average age 65.1 years; 64% male) were identified. Among these, 7,832 had FFR guided invasive treatment (2.6%) which was associated with significantly lower in-hospital all-cause mortality (1.1 vs. 3.1%, p < .01), shorter LOS (4.6 vs. 5.3 days, p < .01), less AKI (12.5 vs. 14.6%, p < .01), less bleeding (7.0 vs. 8.5%, p < .01), and lower total charges ($99,805 vs. $105,736). There was no significant difference between both groups in terms of stroke (2.2 vs. 2.3%, p = .41), coronary dissection (0.7 vs. 0.8%, p = .34), VC (1.3 vs. 1.0% p = .01) or the total number of stents used (55.5 vs. 54.5% p = .34). CONCLUSION: In patients presenting with an ACS FFR- guided PCI, as compared to angiography guided PCI, was associated with lower rates of in-hospital mortality, shorter LOS, less AKI, bleeding and lower hospital charges. There was no significant difference in terms of the incidence of stroke, coronary dissection, VC or the total number of stents used.

Tibiopedal arterial minimally invasive retrograde revascularization (TAMI) in patients with peripheral arterial disease and critical limb ischemia. On behalf of the Peripheral Registry of Endovascular Clinical Outcomes (PRIME).

OBJECTIVES AND BACKGROUND: Complex peripheral arterial disease (PAD) and critical limb ischemia (CLI) are associated with high morbidity and mortality. Endovascular techniques have become prevalent in treatment of advanced PAD and CLI, and use of techniques such as tibiopedal minimally invasive revascularization (TAMI), have been proven safe in small, single-center series. However, its use has not been systematically compared to traditional approaches. METHODS AND RESULTS: This is a retrospective, multicenter analysis which enrolled 744 patients with advanced PAD and CLI who underwent 1,195 endovascular interventions between January 2013 and April 2018. Data was analyzed based on access used for revascularization: 840 performed via femoral access, 254 via dual access, and 101 via TAMI. The dual access group had the highest median Rutherford Class and lowest number of patent tibial vessels. Median fluoroscopy time, procedure time, hospital stay, and contrast volume were significantly lower in the TAMI access group when compared to both femoral/dual access groups. There was also a significant difference between all groups regarding location of target lesions: Femoropopliteal lesions were most commonly treated via femoral access; infrapopliteal lesions, via TAMI, and multilevel lesions via dual access. CONCLUSIONS: Stand-alone TAMI or tibial access as an integral part of a dual access treatment strategy, is safe and efficacious in the treatment of patients with advanced PAD and CLI who have infrapopliteal lesions. Larger prospective and randomized studies may be useful to further validate this approach.

Fractional flow reserve versus angiography guided percutaneous coronary intervention: An updated systematic review.

OBJECTIVES: To compare outcomes of fractional flow reserve (FFR) to angiography (ANGIO) guided percutaneous coronary intervention (PCI). BACKGROUND: The results of a recent randomized controlled trial reported unfavorable effects of routine measurement of FFR, thereby questioning its validity in improving clinical outcomes. METHODS: MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were queried from January, 2000 through December, 2016 and studies comparing FFR and ANGIO guided PCI were included. Clinical endpoints assessed during hospitalization and at follow-up (>9 months) included: myocardial infarction (MI), major adverse cardiovascular events (MACE), target lesion revascularization (TLR), and all-cause mortality. Additional endpoints included number of PCIs performed, procedure cost, procedure time, contrast volume, and fluoroscopy time. RESULTS: A total of 51,350 patients (age 65 years, 73% male) were included from 11 studies. The use of FFR was associated with significantly lower likelihood of MI during hospitalization (OR 0.54, 95% CI: 0.39 to 0.75, P = 0.0003) and at follow-up (OR 0.53, 95% CI: 0.40 to 0.70, P = 0.00001). Similarly, FFR-PCI was associated with lower in-hospital MACE (OR 0.51, 95% CI: 0.37 to 0.70, P = 0.0001) and follow-up MACE (OR 0.63, 95% CI: 0.47 to 0.86, P = 0.004). In-hospital TLR was lower in the FFR-PCI group (OR 0.62, 95% CI: 0.40 to 0.97, P = 0.04), but not at follow-up (OR 0.83, 95% CI: 0.50 to 1.37, P = 0.46). There was no difference of in-hospital (OR 0.58, 95% CI: 0.31 to 1.09, P = 0.09) or follow-up all-cause mortality (OR 0.84, 95%CI: 0.59 to 1.20, P = 0.34). FFR-PCI was associated with significantly less PCI (OR 0.04, 95% CI: 0.01 to 0.15, P = 0.00001) with lower procedure cost (Mean Difference -4.27, 95% CI: -6.61 to -1.92, P = 0.0004). However, no difference in procedure time (Mean Difference 0.79, 95% CI: -2.41 to 3.99, P = 0.63), contrast use (Mean Difference -8.28, 95% CI: -24.25 to 7.68, P = 0.31) or fluoroscopy time (Mean Difference 0.38, 95% CI: -2.54 to 3.31, P = 0.80) was observed. CONCLUSIONS: FFR-PCI as compared to ANGIO-PCI is associated with lower in-hospital and follow-up MI and MACE rates. Although, in-hospital TLR was lower in the FFR-PCI group, this benefit was not present after 9 months. FFR-PCI group was also associated with less PCI and lower procedure costs with no effect on procedure time, contrast volume or fluoroscopy time.

Thoracic endovascular repair versus medical management for acute uncomplicated type B aortic dissection.

BACKGROUND: Current treatment options and outcomes for acute uncomplicated thoracic Type-B aortic dissection (TBAD) remain unclear between medical management (MED) and thoracic endovascular aortic repair (TEVAR). In this study we aim to compare both strategies in terms of all-cause mortality, aortic dilation, and aortic rupture. METHODS: MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were queried from January 1990 through March 2017. Only studies comparing TEVAR to MED for acute uncomplicated TBAD were included. Random-effects meta-analysis was used to pool outcomes across studies. Study outcomes included short (1 month), intermediate (1 year), and mid-term (2-5 year) all-cause mortality. Additional outcomes included aortic dilation and rupture at 1 year. RESULTS: A total of 1,960 patients (64.3 years; 75.8% male) were included from six studies (one prospective and five retrospective). No difference was observed in short-term (odd ratio [OR] 0.73 with 95% confidence interval [CI] 0.47 to 1.12, P = 0.15), intermediate (OR 0.99 with 95% CI 0.56 to 1.73, P = 0.96), or mid-term all-cause mortality (OR 1.12 with 95% CI 0.54 to 2.32, P = 0.75). No difference in aortic dilation with either modality was noted at 1-year (OR 1.11 with 95% CI 0.76 to 1.64, P = 0.59). TEVAR was associated with a significantly lower 1-year risk of aortic rupture (OR 2.49 with 95% CI 1.23 to 5.06, P = 0.01). CONCLUSION: There were no short, intermediate, or mid-term differences in mortality between TEVAR or MED in patients with acute uncomplicated TBAD. Although the dilation rate was similar between both groups, TEVAR was associated with lower likelihood of aortic rupture at 1 year.

Chronic Total Occlusion Crossing Approach Based on Plaque Cap Morphology: The CTOP Classification.

PURPOSE: To present the chronic total occlusion (CTO) crossing approach based on plaque cap morphology (CTOP) classification system and assess its ability to predict successful lesion crossing. METHODS: A retrospective analysis was conducted of imaging and procedure data from 114 consecutive symptomatic patients (mean age 69±11 years; 84 men) with claudication (Rutherford category 3) or critical limb ischemia (Rutherford category 4-6) who underwent endovascular interventions for 142 CTOs. CTO cap morphology was determined from a review of angiography and duplex ultrasonography and classified into 4 types (I, II, III, or IV) based on the concave or convex shape of the proximal and distal caps. RESULTS: Statistically significant differences among groups were found in patients with rest pain, lesion length, and severe calcification. CTOP type II CTOs were most common and type III lesions the least common. Type I CTOs were most likely to be crossed antegrade and had a lower incidence of severe calcification. Type IV lesions were more likely to be crossed retrograde from a tibiopedal approach. CTOP type IV was least likely to be crossed in an antegrade fashion. Access conversion, or need for an alternate access, was commonly seen in types II, III, and IV lesions. Distinctive predictors of access conversion were CTO types II and III, lesion length, and severe calcification. CONCLUSION: CTOP type I lesions were easiest to cross in antegrade fashion and type IV the most difficult. Lesion length >10 cm, severe calcification, and CTO types II, III, and IV benefited from the addition of retrograde tibiopedal access.

Hemorrhagic and ischemic outcomes of Heparin vs. Bivalirudin in carotid artery stenting: A meta-analysis of studies.

INTRODUCTION: Bivalirudin, has been shown to have comparable efficacy and better safety profile when compared to unfractionated heparin (UFH) in percutaneous coronary interventions. Bivalirudin's safety in carotid artery stenting (CAS) was associated with better outcomes than heparin in some studies. In this Meta analysis we examine the hemorrhagic and ischemic outcomes associated with Bivalirudin compared to UFH during CAS. METHODS: A comprehensive literature search was conducted with the electronic databases MEDLINE, EMBASE, and CENTRAL. Random-effects meta-analysis method was used to pool risk ratio (RR) for both Heparin and Bivalirudin with 95% confidence interval (CI). Study outcomes included hemorrhagic complications; major/minor bleeding and intracranial hemorrhage (ICH) as well as ischemic complications including ischemic stroke, myocardial infarction, and 30 day mortality. RESULTS: A total of four studies were included enrolling 7,784 patients. Compared to UFH, Bivalirudin was associated with significantly lower major bleeding events with a relative risk (RR) of 0.53 (95% CI: 0.35-0.80; I2 = 0%). Minor bleeding events were significantly lower in the Bivalirudin group with a RR of 0.41 (95% CI: 0.2-0.82; I2 = 0%). Looking into other outcomes, there were no significant differences between anticoagulation strategies in terms of ischemic stroke (RR 0.8, with 95% CI: 0.60-1.06), intracranial hemorrhage (RR 0.73 with 95% CI: 0.27-1.98), myocardial infarction (RR 1.01 with 95% CI: 0.59-1.73) or 30 day mortality (RR 0.83 with 95% CI: 0.47-1.47). CONCLUSION: Compared to UFH, Bivalirudin is associated with lower bleeding risk when used during CAS. © 2016 Wiley Periodicals, Inc.

Proximal balloon occlusion versus distal filter protection in carotid artery stenting: A meta-analysis and review of the literature.

INTRODUCTION: Carotid artery stenting (CAS) is typically performed using embolic protection devices (EPDs) as a means to reduce the risk of procedure-related stroke. In this study, we compared procedural morbidity and mortality associated with distal (D-EPD) vs. proximal (P-EPD) protection. METHODS: MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were queried from January 1998 through May 2015. Only studies comparing (D-EPD) and (P-EPD) were included. Two independent reviewers selected and appraised studies and extracted data in duplicate. Random-effects meta-analysis was used to pool outcomes across studies. Heterogeneity of treatment effect among studies was assessed using the I2 statistics. Publication bias was assessed using inspection of funnel plots. The primary endpoints included 30-day mortality and stroke. Secondary endpoints included new cerebral lesions on diffusion-weighted magnetic resonance imaging (DW-MRI) and contralateral lesions on DW-MRI. RESULTS: A total of 12,281 patients were included from 18 studies (13 prospective and 5 retrospective) comparing (D-EPD) and (P-EPD) in the setting of CAS. The mean patient age was 69 years and 64% of patients were male. No evidence of publication bias was detected. There was no significant difference between the two modalities in terms of the risk of stroke (risk difference [RD] 0.0, 95% confidence interval [CI] -0.01 to 0.01) or mortality (RD 0.0, 95% CI -0.01 to 0.01) nor was there any difference in the incidence of new cerebral lesions on DW-MRI or contralateral DW-MRI lesions. CONCLUSIONS: In patients undergoing CAS, both D-EPD and P-EPD provide similar levels of protection from peri-procedural stroke and 30 days mortality. © 2016 Wiley Periodicals, Inc.

An open sarcolemmal adenosine triphosphate-sensitive potassium channel is necessary for detrimental myocyte swelling secondary to stress.

BACKGROUND: Stress (exposure to hyperkalemic cardioplegia, metabolic inhibition, or osmotic) results in significant myocyte swelling and reduced contractility. In contrast to wild-type mice, these detrimental consequences are not observed in mice lacking the Kir6.2 subunit of the sarcolemmal ATP-sensitive potassium (sK(ATP)) channel after exposure to hyperkalemic cardioplegia. The hypothesis for this study was that an open sK(ATP) channel (Kir6.2 and SUR2A subunits) is necessary for detrimental myocyte swelling to occur in response to stress. METHODS AND RESULTS: To investigate the role of the sK(ATP) channel in stress-induced myocyte swelling, high-dose pharmacological sK(ATP) channel blockade and genetic deletion (knockout of Kir6.2 subunit) were used. Myocytes were exposed sequentially to Tyrode control (20 minutes), test (stress) solution (20 minutes), and Tyrode control (20 minutes). To evaluate pharmacological channel blockade, myocytes were exposed to hyperkalemic cardioplegia (stress) with and without a K(ATP) channel blocker. To evaluate the effects of genetic deletion, wild-type and sK(ATP) knockout [Kir6.2(-/-)] myocytes were exposed to metabolic inhibition (stress). Myocyte volume was recorded using image-grabbing software. Detrimental myocyte swelling was prevented by high-dose sK(ATP) channel blockade (glibenclamide or HMR 1098) but not mitochondrial K(ATP) channel blockade (5-hydroxydecanoate) during exposure to hyperkalemic cardioplegia. Genetic deletion of the sK(ATP) channel prevented significant myocyte swelling in response to metabolic inhibition. CONCLUSIONS: K(ATP) channel openers prevent detrimental myocyte swelling and reduce contractility in response to stress through an unknown mechanism. Paradoxically, the present data support a role for sK(ATP) channel activation in myocyte volume derangement in response to stress.

Cardiovascular mortality in dialysis patients.

In their broad spectrum, cardiovascular diseases are, collectively, the major cause of death in patients on dialysis. The population of patients treated with peritoneal dialysis and hemodialysis are not only subject to the traditional risk factors for heart disease, but also to certain uremia-associated risk factors that are unique in this population. In the dialysis population, data regarding the effectiveness of routine pharmacologic and procedural interventions on cardiovascular outcomes are limited. Most dialysis patients are excluded from clinical trials, and so data from randomized controlled trials investigating outcomes in patients undergoing peritoneal dialysis or hemodialysis are almost absent. In this review, we discuss some of the major cardiovascular problems in the dialysis population, the impact of those problems on survival, and when data are available, the impact of therapeutic strategies.

The tale of mind & heart: psychiatric disorders & coronary heart disease.

The mind-body interaction has always intrigued humans. Most people, on the basis of either intuition or personal experience, believe that emotional stress can cause or alter the course of even major physical diseases. Sir William Osler described his typical patient with angina pectoris as 'a man whose engine is always set full speed ahead' and described his patients with cardiac disease as 'worriers'. In recent years there has been tangible evidence for the existence of this interaction however modern medicine is still trying to unravel its intricacies. In this article we review the current knowledge regarding the effect of depression, anxiety disorders and the detrimental effect it has on coronary heart disease. In addition we discuss some of the proven acute psychological triggers for acute coronary syndrome.

Outcomes of transcatheter aortic valve replacement in patients with mitral valve regurgitation.

INTRODUCTION: Transcatheter aortic valve replacement (TAVR) is currently considered a class I indication for patients with severe symptomatic aortic stenosis and high/prohibitive surgical risk. AIM: We describe the effect of concomitant mitral valve regurgitation (MR) on post-procedural TAVR outcomes. MATERIAL AND METHODS: The study population was extracted from the 2014 National Readmissions Data (NRD) using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for TAVR, MR and post-procedural outcomes. Propensity matching was used to extract a control group of TAVR patients without MR (TAVR-C) to the TAVR with concomitant MR group (TAVR-MR). Study outcomes included in-hospital all-cause mortality, in-hospital post-procedural stroke, acute myocardial infarction (AMI), bleeding, mechanical complications of prosthetic valve, vascular complications (VC), need for new permanent pacemaker implantation (PPM) and 30-day readmission rates. RESULTS: A total of 1511 patients were identified in each group (mean age: 81.7 years, 49.3% male); the two groups were comparable in terms of baseline characteristics and co-morbidities. When compared to TAVR-C, TAVR-MR was associated with lower post-procedural stroke (3.5% vs. 5.2%, p = 0.03). There was no significant difference between groups in terms of all-cause mortality (4.1% vs. 4.5%, p = 0.59), AMI (3.2% vs. 2.9%, p = 0.59), bleeding (33.4% vs. 35.6%, p = 0.19), mechanical complications of prosthetic valve (2.5% vs. 1.9%, p = 0.31), VC (3.2% vs. 4.4%, p = 0.06), the need for PPM (7.9% vs. 9.1%, p = 0.21) or 30-day readmission rates (19.0% vs. 19.1%, p = 0.95). CONCLUSIONS: TAVR-MR was associated with lower post-procedural stroke but comparable other in-hospital outcomes and 30-day readmission rates to TAVR-C.

Atherectomy-assisted versus percutaneous angioplasty interventions for treatment of symptomatic infra-inguinal peripheral arterial disease.

INTRODUCTION: The role of atherectomy (ATHERO) for the treatment of symptomatic infra-inguinal arterial lesions remains controversial. We evaluated the effectiveness and safety of atherectomy-assisted endovascular interventions in comparison with percutaneous angioplasty (PTA). MATERIAL AND METHODS: A systematic search utilizing MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials was conducted for studies comparing ATHERO with PTA from February 1995 to May 2018. Only studies comparing ATHERO to PTA for symptomatic infra-inguinal disease were included. Random-effects meta-analysis was used to pool the data and endpoints across studies. Study endpoints included vessel dissection, distal embolization, residual stenosis (> 30%), vessel patency at 6 months, target lesion revascularization (TLR) at 12 months and major amputation rates at 1, 6, and 12 months. RESULTS: A total of 2923 patients were included from 8 studies. PTA was associated with higher vessel dissection (OR = 4.00, 95% CI: 1.15-13.86) and lower 12-month major amputation rates (OR = 0.73, 95% CI: 0.59-0.90). There was no significant difference between ATHERO and PTA groups in terms of distal embolization (OR = 0.45, 95% CI: 0.04-4.63), residual stenosis (OR = 1.28, 95% CI: 0.58-2.80), vessel patency at 6 months (OR = 1.27, 95% CI: 0.50-3.22), TLR at 12 months (OR = 1.07, 95% CI: 0.46-2.51), or limb amputation at 1 month (OR = 0.69, 95% CI: 0.44-1.07) or 6 months (OR = 1.54, 95% CI: 0.38-6.15). CONCLUSIONS: In patients undergoing infra-inguinal endovascular interventions, PTA was associated with higher peri-procedural vessel dissection and lower 12-month major amputation rates. Both modalities were associated with similar distal embolization, residual stenosis, and 6-month vessel patency and amputation rates.

Percutaneous angioplasty versus atherectomy for treatment of symptomatic infra-popliteal arterial disease.

BACKGROUND: Outcomes for debulking by atherectomy (ATH) for adjunctive treatment of below the knee (BTK) symptomatic arterial disease compared to percutaneous transluminal angioplasty alone (PTA) are unclear. METHODS: MEDLINE, EMBASE, PubMed and the Cochrane Central Register of Controlled Trials were queried from between 2000 and 2017 including studies comparing PTA alone to PTA-ATH. Random effect meta-analysis model was used to pool the data across the studies. Study endpoints included: vessel dissection, residual stenosis (<30%), mortality at 12months and amputation rates at 1 and 12months. RESULTS: A total of 2587 patients (72.9years; 63% male) were included from 4 studies (2 prospective, one of which was randomized, and 2 retrospective) comparing PTA alone to ATH-PTA in patients with symptomatic infra-popliteal disease. There was no significant difference between the two approaches in terms of vessel dissection [OR 3.73 with 95% CI 0.83 to 16.64, p=0.08] or residual stenosis [OR 0.41 with 95% CI 0.11 to 1.60, p=0.18]. Clinical outcomes did not differ in terms of 12month mortality [OR 3.47 with 95% CI 0.15 to 81.37, p=0.44], or limb amputation at 1month [OR 1.23 with 95% CI 0.91 to 1.67, p=0.18] or 12months [OR: 1.02 with 95% CI 0.83 to 1.26, p=0.83]. CONCLUSION: In patients undergoing (BTK) intervention, PTA alone and ATH-PTA was associated with similar outcomes in terms of vessel dissection and residual stenosis, mortality at 12months, and limb amputation at 1 or 12months.

Bivalirudin versus unfractionated heparin in peripheral vascular interventions.

BACKGROUND: A number of studies suggest that bivalirudin (BIV) is associated with similar efficacy but reduced bleeding when compared with unfractionated heparin (UFH) in patients undergoing peripheral vascular interventions (PVI). METHODS: A comprehensive literature search was conducted with the electronic databases MEDLINE, EMBASE and CENTRAL. These were queried to identify studies comparing BIV with UFH in PVI. Study endpoints included total bleeding events, major and minor bleeding events and procedural success. Random-effects meta-analysis method was used to pool endpoint odds ratios (OR) for both UFH and BIV with 95% confidence intervals (CI). RESULTS: A total of 12,335 patients (70.6 years; 59.7% male) were included from seven observational cohort studies (two prospective and five retrospective) comparing outcomes between BIV and UFH during PVI between January 2000 and May 2017. Compared with BIV, UFH was associated with significantly higher total bleeding, (OR 1.52 with 95% CI 1.11 to 2.09, p = 0.009), major bleeding (OR 1.38 with 95% CI 1.13 to 1.68, p = 0.002), and minor bleeding (OR 1.51 with 95% CI 1.09 to 2.08, p = 0.01). Procedural success rates were not different between the two groups (BIV vs HEP: OR 0.90 with 95% CI 0.49 to 1.64, p = 0.72) CONCLUSION: Compared with BIV, UFH was associated with more bleeding when used during PVI. There was no significant difference in procedural success between the two anticoagulation strategies.

Endovascular versus surgical treatment for acute limb ischemia: a systematic review and meta-analysis of clinical trials.

BACKGROUND: A number of small studies have suggested that outcomes following endovascular (ENDO) therapy are comparable to those following surgical (SURG) revascularization for patients presenting with acute limb ischemia (ALI). We sought to compare mortality, limb amputation and recurrent ischemia across both revascularization strategies. METHODS: A comprehensive database search of MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL) electronic databases from January 1990 through January 2016 was performed to identify studies of ENDO versus SURG for ALI. Two independent reviewers selected studies and extracted the data. Random-effects meta-analysis was used to pool results across studies. Heterogeneity of treatment effect among trials was assessed using the I2 statistics. The primary endpoints were mortality and limb amputation at 1 month, 6 and 12 months. Secondary endpoint was recurrent ischemia at one year. RESULTS: A total of 1,773 patients were included from six studies (five randomized prospective and one observational retrospective) comparing ENDO and SURG in the setting of ALI. The mean age was 67 years and 65% of patients were male. There were no differences in mortality between the two groups at 1 month [risk ratio (RR) for ENDO vs. SURG is 0.70; 95% confidence interval (CI), 0.33 to 1.50], 6 months (RR 1.12; CI, 0.78 to 1.61) or 12 months (RR 0.74; CI, 0.29 to 1.85). Similarly, there was no significant difference in amputation rates between ENDO and SURG at 1 month (RR 0.75; CI, 0.40 to 1.42), 6 months (RR 0.87; CI, 0.52 to 1.48) or 12 months (RR 0.81; CI, 0.55 to 1.18). When looking into secondary outcomes, recurrent ischemia was not different between the two groups (RR 1.12; CI, 0.75 to 1.67). CONCLUSIONS: In patients presenting with ALI (<2 weeks of duration), ENDO and SURG approaches have similar rates of short-term and 12 month mortality, limb amputation and recurrent ischemia.

Comparison of Outcomes of ST-Elevation Myocardial Infarction Treated by Percutaneous Coronary Intervention During Off-Hours Versus On-Hours.

Previous studies have reported worse outcomes and longer door-to-balloon times (DBTs) in patients presenting with ST-elevation myocardial infarction (STEMI) after normal working hours, during weekends, and on holidays (off-hours) compared with normal business hours (on-hours). Recent studies, however, have reported similar outcomes regardless of presentation time. MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were queried from January 1990 through December 2016. Only studies comparing STEMI outcomes during off-hours versus on-hours with percutaneous coronary intervention were included. A random-effects meta-analysis model was used to pool outcomes across the studies. Clinical end points included short- (<30 days of presentation), intermediate- (at 1 to 2 years), and long-term (at 3 to 4 years) stent thrombosis, mortality, recurrent myocardial infarction (MI), and major adverse cardiovascular events (MACEs). A total of 86,776 patients (62 years and 74.5% male) were identified from 39 studies. There was no significant difference between both groups with regard to mean DBT (odds ratio [OR] 0.74, 95% confidence interval [CI] -2.73 to 4.22, p = 0.67) or median DBT (p = 0.19). There was no significant difference between the 2 groups for short-term end points including mortality (OR 1.11, 95% CI 0.99 to 1.25, p = 0.08), MI (OR 1.25, 95% CI 0.90 to 1.74, p = 0.18), MACE (OR 1.06, 95% CI 0.93 to 1.20, p = 0.40), or stent thrombosis (OR 1.23, 95% CI 0.83 to 1.82, p = 0.31). Similarly, intermediate-term end points were not statistically different for mortality (OR 0.97, 95% CI 0.89 to 1.05, p = 0.46), MI (OR 0.86, 95% CI 0.73 to 1.02, p = 0.08), or MACE (OR 1.00, 95% CI 0.92 to 1.08, p = 0.98). Long-term end points did not differ statistically between groups for mortality (OR 0.95, 95% CI 0.83 to 1.09, p = 0.46), MI (OR 1.19, 95% CI 0.77 to 1.84, p = 0.44), or MACE (OR 0.98, 95% CI 0.89 to 1.08, p = 0.67). In conclusion, patients presenting with STEMI during off-hours and treated with percutaneous coronary intervention had similar short-, intermediate-, and long-term outcomes compared with patients presenting during on-hours. DBT was not affected by the time of presentation.

Transcatheter versus surgical aortic valve replacement in patients with non-high surgical risk severe aortic stenosis: A systematic review.

OBJECTIVE: Transcatether aortic valve replacement (TAVR) has emerged as an acceptable alternative to surgical aortic valve replacement (SAVR) in patients with high-risk surgical profile. In this analysis, we compare both approaches in non-high surgical risk severe aortic stenosis. METHODS: Only studies comparing SAVR and TAVR and enrolling patients with low-intermediate risk were included from January 2000 through May 2016. Primary endpoints were assessed at 1 and 12months including: mortality, cerebrovascular accident (CVA) and myocardial infarction (MI). Secondary endpoints at 1month included: bleeding, acute kidney injury, new permanent pacemaker implantation and vascular access site complications. RESULTS: A total of 5223 patients from 8 studies were included (4 prospective and 4 retrospective). There were no significant differences between TAVR and SAVR at one month in terms of mortality (risk ratio RR 0.91, 95% CI: 0.68 to 1.20), or CVA (RR 0.91, 95% CI 0.68 to 1.21). However, MI was lower in the TAVR group (RR 0.58, 95% CI 0.34 to 0.99). At 12months, there was no significant difference between strategies in terms of mortality (RR 0.98, 95% CI 0.84-1.13), CVA (RR1.07, 95% CI 0.85-1.33) or MI (RR 0.78, 95% CI 0.53-1.15). With regard to secondary outcomes, TAVR was associated with lower rates of bleeding (RR 0.44, 95% CI 0.22-0.88) and acute kidney injury (RR 0.54, 95% CI 0.31-0.93) but higher need for new permanent pacemaker implantation (RR 2.99, 95% CI 1.51-5.94) and high rate of vascular access site complications (RR 9.08, 95% CI 2.03-40.66). CONCLUSION: In severe AS patients with non-high surgical risk, TAVR has lower risk of MI at one month, but both TAVR and SAVR yielded similar outcomes at one month in terms of mortality and CVA and at 12months in terms of mortality, CVA and MI. In regard to secondary outcomes at one month, TAVR has lower rates of bleeding and acute kidney injury, and higher rates of need for new permanent pacemakers and high rate of vascular access site complications.

Dyslipidemia in patients with chronic and end-stage kidney disease.

In this review, we discuss the physiology, diagnosis and treatment of dyslipidemia in patients with chronic and end-stage renal disease. The recent important clinical trials in patients with chronic kidney disease and dyslipidemia are reviewed. Because of the lack of evidence in treating lipid abnormalities in this specific patient population, we propose that future studies should focus on the pathophysiological mechanisms and treatment of dyslipidemia in this special patient population.

Diazoxide maintains human myocyte volume homeostasis during stress.

BACKGROUND: Exposure to hypothermic hyperkalemic cardioplegia, hyposmotic stress, or metabolic inhibition results in significant animal myocyte swelling (6% to10%) and subsequent reduced contractility (10% to 20%). Both are eliminated by the adenosine triphosphate-sensitive potassium channel opener diazoxide (DZX). The relationship between swelling and reduced contractility suggests that the structural change may represent one mechanism of postoperative myocardial stunning. This study evaluated human myocyte volume during stress to investigate if similar phenomena exist in human myocytes. METHODS AND RESULTS: Human atrial myocytes isolated from tissue obtained during cardiac surgery were perfused with Tyrode's physiological solution (20 minutes, 37°C), test solution (20 minutes), and Tyrode's (37°C, 20 minutes). Test solutions (n=6 to 12 myocytes each) included Tyrode's (37°C or 9°C), Tyrode's+DZX (9°C), hyperkalemic cardioplegia (9°C)±DZX, cardioplegia+DZX+HMR 1098 (sarcolemmal adenosine triphosphate-sensitive potassium channel inhibitor, 9°C), cardioplegia+DZX+5-hydroxydeconoate (mitochondrial adenosine triphosphate-sensitive potassium channel inhibitor, 9°C), mild hyposmotic solution±DZX, metabolic inhibition±DZX, and metabolic inhibition+DZX+5-hydroxydeconoate. Myocyte volume was recorded every 5 minutes. Exposure to hypothermic hyperkalemic cardioplegia, hyposmotic stress, or metabolic inhibition resulted in significant human myocyte swelling (8%, 7%, and 6%, respectively; all P<0.05 vs control). In all groups, the swelling was eliminated or lessened by DZX. The addition of channel inhibitors did not significantly alter results. CONCLUSIONS: DZX maintains human myocyte volume homeostasis during stress via an unknown mechanism. DZX may prove to be clinically useful following the elucidation of its specific mechanism of action. (J Am Heart Assoc. 2012;1:jah3-e000778 doi: 10.1161/JAHA.112.000778.).