Prophylactic use of the implantable cardioverter-defibrillator and its effect on the long-term survival, cardiovascular and sudden cardiac death in nonischemic cardiomyopathy patients-a systematic review and meta-analysis.

Implantable cardioverter-defibrillator (ICD) has shown to reduce sudden cardiac death and overall mortality in patients with dilated cardiomyopathy. The recently published DANISH trial has shown conflicting outcomes on the long-term survival in patients with prophylactic implantation of ICD in Non-Ischemic Cardiomyopathy (NICM). Two independent reviewers searched MEDLINE, PUBMED, Ovid, CINAHL, clinicaltrials.gov , and Cochrane Registry for randomized control trials (RCT's) comparing ICD to medical treatment (MT). Six RCT's enrolling 3389 patients (ICD = 1554 and MT = 1835) were included for final analysis. The primary outcomes were mortality comparing ICD to MT, 231 vs 337 (OR = 0.74, CI = 0.62-0.90, p = 0.002, and I2 = 0%) favoring ICD. On comparing to amiodarone only, there were 47 deaths in the ICD arm vs 71 deaths in amiodarone arm, (OR = 0.66, CI = 0.44-0.98, p = 0.04, I2 0%), to placebo and usual care only (excluding amiodarone); there were 225 deaths in ICD patients compared to 266 in the placebo and usual care arm, (OR = 0.73, CI = 0.59-0.92, p = 0.007, I2 = 15%). The results of our analysis from these six RCTs clearly support the ongoing benefit of prophylactic ICD implantation and support current recommendations for ICD implantation in NICM patients. More RCT's at a larger scale are needed to further elucidate benefits of both ICD and CRT-D in this post PARADIGM era where MT is at a pinnacle in reducing morbidity and mortality in heart failure patients.

Readmission rate after ultrafiltration in acute decompensated heart failure: a systematic review and meta-analysis.

Significance of ultrafiltration in acute decompensated heart failure remains unclear. We performed meta-analysis to determine its role in reducing readmissions after acute decompensated heart failure. MEDLINE was searched using PUBMED from inception to March 22, 2017 for prospective randomized control trials comparing ultrafiltration to diuretics in acute decompensated heart failure. Five hundred ninety studies were found; nine studies with 820 patients were included. Studies with renal replacement therapy bar ultrafiltration, chronic decompensated heart failure, and non-English language were excluded. RevMan Version 5.3 was used for analysis. The primary outcomes analyzed were cumulative and 90 days readmissions secondary to heart failure and all-cause readmissions. Baseline characteristics were similar. One hundred eighty-eight patients were readmitted with heart failure, 77 vs 111 favoring ultrafiltration; risk ratio (RR) = 0.71 (95% confidence interval (CI), 0.49-1.02, p = 0.07, I 2  = 47%). Ninety days readmissions were 43 vs 67 favoring ultrafiltration; RR = 0.65 (95%CI, 0.47-0.90, p = 0.01, I 2  = 0%). Ultrafiltration showed significantly higher fluid removal and weight loss. Hypotension was common in ultrafiltration (24 vs 13, OR = 2.06, 95%CI = 0.98-4.32, p = 0.06, I 2  = 0%). Ultrafiltration showed reduced 90 days heart failure readmissions and trend towards reduced cumulative hospital readmissions. Renal and cardiovascular outcomes and hospital stay were similar.

Anti-thrombotic therapy strategies with long-term anticoagulation after percutaneous coronary intervention - a systematic review and meta-analysis.

Background: Long-term oral anticoagulants (OAC) increases bleeding risk after the percutaneous coronary intervention (PCI) with dual antiplatelet therapy (DAPT) with Aspirin and P2Y12 inhibitors. We hypothesize that dual anti-thrombotic therapy (DATT) reduces bleeding without increased cardiovascular events. Objectives: DATT does not increase adverse cardiovascular events compared to triple anti-thrombotic therapy (TATT). Method: We searched MEDLINE, PUBMED, Google Scholar, Cochrane and EMBASE from inception to 6 April 2019 for randomized control trials (RCTs) comparing DATT to TATT after PCI. Results: We identified 641 citations (411 after excluding duplicates). Four RCTs with 5,317 patients (3,039 on DATT vs 2,278 on TATT) were included. DATT arm showed significantly reduced [total bleeding, 731 vs. 784, odds ratio [OR] = 0.51, Confidence Interval [CI] = 0.39-0.67, p < 0.00001, I2 = 71% (I2 = 0% without WOEST study)], [TIIMI major bleeding 60 vs. 80, OR = 0.56, CI = 0.4-0.79, p = 0.0009, I2 = 0%], and [TIIMI minor bleeding, 70 vs 126, OR = 0.43, CI = 0.32-0.59, p < 0.00001, I2 = 0%]. There was no difference in subsequent strokes, myocardial infarction, stent thrombosis, and mortality. A trend towards decreased non-cardiac deaths with DATT was observed, 14 vs 26, OR = 0.55, CI = 0.27-1.10, p = 0.09, I2 = 6%. Conclusions: DATT is associated with significantly reduced bleeding and a trend towards reduced non-cardiac death with no difference in adverse cardiovascular outcomes.

Impact of Hyoscine Bromide Use on Polyp Detection Rate During Colonoscopy: A Systematic Review and Meta-Analysis.

BACKGROUND: Colorectal cancer (CRC) is a leading cause of death worldwide. Polyp detection rate (PDR) and adenoma detection rate (ADR) are key focus in endoscopic research for CRC screening and prevention. Use of anti-spasmodic agents during colonoscopy to help identify adenomas and polyps has remained a controversial topic. Hyoscine butyl bromide (HBB) is the most commonly used anti-spasmodic agent in patients undergoing colonoscopy. Some randomized controlled trials (RCTs) have questioned the clinical efficacy and safety of routine use of HBB for polyp and adenoma detection rates. METHODS: We conducted a systematic search in PubMed and MEDLINE from inception until February 10, 2018, for studies which compared HBB with placebo. We used RevMan version 5.3 for analysis. Procedural end-points were polyps, adenomas, and advanced adenoma detection rates, mean number of polyps detected and cecal intubation time. RESULTS: We included seven RCTs with 2,588 patients in our analysis. A total of 1,301 patients were randomized to HBB arm and 1,287 to the placebo arm. There was no significant difference in the primary outcome of polyp detection rate, 654 in HBB group vs. 616 in the placebo group, (odds ratio (OR) = 1.11, confidence interval (CI) = 0.93 - 1.34, P = 0.25). There was no difference in secondary outcomes of adenoma detection rate, 430 in HBB group vs. 396 in the placebo group, (OR = 1.06, CI = 0.89 - 1.26, P = 0.51), advanced adenoma detection rate, 92 in HBB vs. 95 in placebo group (OR = 0.95, CI = 0.70 - 1.30, P = 0.76), mean number of polyps detected (point estimate = 0.12, CI = 0.00 - 0.23, P = 0.05), adenomatous polyps (OR = 0.84, CI = 0.39 - 1.81, P = 0.65) and cecal intubation time (point estimate = 0.73, CI = -1.98 - 0.52, P = 0.25) between the two groups. CONCLUSIONS: The use of HBB in patients undergoing colonoscopy does not appear to improve polyp or adenoma detection rates. It showed a non-significant trend of increased mean number of polyps detected with HBB.

Reduced Stroke After Transcatheter Patent Foramen Ovale Closure: A Systematic Review and Meta-analysis.

BACKGROUND: Recent randomized control trials (RCTs) have suggested benefit with transcatheter patent foramen ovale (PFO) closure plus antiplatelet therapy over medical treatment alone for secondary stroke prevention. MATERIAL AND METHODS: Data sources: we searched PubMed and Ovid MEDLINE from the inception until November 10, 2017 for RCTs comparing TPFO closure to medical therapy in patients with a PFO and a history of cryptogenic stroke. RESULTS: Five RCTs with 3,627 patients (TPFO closure = 1,829 versus medical therapy =1,798) were included. There was a decreased number of post-TPFO closure strokes compared to the medical therapy arm; 53 versus 80 strokes (odds ratio [OR] = 0.61, CI: 0.39-0.94, P = 0.03, I2 = 17%). Transient ischemic attacks occurred in 43 patients after TPFO closure versus 60 patients in the medical therapy group (OR = 0.80, CI: 0.53-1.19, P = 0.26, I2 = 0%). There was a higher incidence of atrial fibrillation in the TPFO closure group, which occurred in 75 patients, compared to 12 patients in the medical therapy group (OR = 5.23, CI: 2.17-12.59, P = 0.0002, I2 = 43%). There was a trend toward a decreased number of neuropsychiatric events in the TPFO closure closure group compared to the medical therapy group; 42 versus 67 neuropsychiatric events (OR = 0.71, CI: 0.48-1.06, P = 0.09, I2 = 0%). CONCLUSIONS: TPFO closure plus antiplatelet therapy is superior to medical therapy in patients with a PFO and cryptogenic stroke. PFO closure is associated with new-onset atrial fibrillation and a trend toward reduced neuropsychiatric events.

Double Trouble - Severe Hypernatremia Secondary to Central Diabetes Insipidus Complicated by Hypercalcemic Nephrogenic Diabetes Insipidus: A Case Report.

BACKGROUND Patients with malignancies often have electrolyte abnormalities. We present a case of a patient with central diabetes insipidus secondary to metastatic pituitary invasion complicated by hypercalcemic nephrogenic diabetes insipidus. CASE REPORT We present a case of 40-year-old female with a history of stage IV breast cancer with skeletal and leptomeningeal metastasis, who was admitted with polyuria, polydipsia, and recent onset of confusion. The patient was found to have profound hypernatremia and severe hypercalcemia with normal parathyroid and vitamin D serum levels. Urine studies showed low urine osmolality and high urine output, despite the higher serum osmolality. The patient received 5% dextrose for rehydration, 1 dose of intravenous (IV) pamidronate, 1 dose of IV desmopressin, and 4 days of subcutaneous calcitonin 200 international units Q12H. Initially, her urine output in the hospital was in the range of 350-400 milliliters/hour, which responded well to 1 dose of 1-desamino-8d-arginine vasopressin (DDAVP). In the subsequent days, her confusion resolved with normalization of serum sodium and calcium, but she died because of the extensive malignancy. CONCLUSIONS Our case emphasizes the importance of identification of causes and complications of electrolyte abnormalities associated with metastatic cancers. These electrolyte abnormalities can be primary or paraneoplastic and should be actively pursued and treated in such cases.

Meta-Analysis Comparing Outcomes and Need for Renal Replacement Therapy of Transcatheter Aortic Valve Implantation Versus Surgical Aortic Valve Replacement.

Acute kidney injury (AKI) is commonly associated with aortic valve replacement. Surgical aortic valve replacement (SAVR) is a known risk factor for AKI but little is known about the short- and long-term effects of transcatheter aortic valve implantation (TAVI). The purpose of our analysis is to identify the short- and long-term effect of TAVI on renal outcomes. We searched Medline and PUBMED from January 1, 2000 to November 6, 2017 for randomized control trials (RCTs) comparing TAVI to SAVR in patients with severe aortic stenosis. Three hundred sixty-nine trials were identified, 6 RCTs were included in our analysis. RevMan version 5.3 was used for statistical analysis. Heterogeneity is calculated using I2 statistics. Primary outcomes were AKI within 30 days and 1 year of TAVI, and requirement for renal replacement therapy. We included 5,536 patients (2,796 in TAVI and 2,740 in SAVR arm) from 6 RCTs. Baseline characteristics were similar. There was reduced incidence of AKI at 30 days of TAVI compared with SAVR, 57 versus 133 (odds ratio [OR] 0.40, confidence interval [CI] 0.28 to 0.56, p <0.00001, I2 = 7%) with no difference at 1 year (OR 0.65, CI 0.32 to 1.32, p = 0.23, I2 = 76%) and need for renal replacement therapy OR 0.95, CI 0.50 to 1.80, p = 0.87, I2 = 0%). Permanent pacemaker was more frequent in the TAVI arm compared with SAVR arm, 379 versus 110, (OR 3.75, CI 1.67 to 8.42, p = 0.001, I2 = 89%). In conclusion, TAVI is associated with a reduction in AKIs at 30 days despite the exposure to contrast and higher incidence of new permanent pacemaker placement.

An Atypical Case of Silent Aortic Dissection in a Peritoneal Dialysis Patient: A Case Report and Review of Literature.

BACKGROUND Aortic dissection presents with acute chest or back pain and is associated with high mortality. We present a case of aortic dissection with an atypical presentation in a peritoneal dialysis patient, and the challenges met with peritoneal dialysis. CASE REPORT A 53-year-old African American male presented with progressively worsening exertional dyspnea and orthopnea for 3 days without any history of chest pain. His chest x-ray showed mild pulmonary edema. He was admitted with a diagnosis of heart failure. Bedside echocardiogram revealed severe aortic regurgitation and concern for possible aortic dissection. Computed tomography of chest with contrast showed Stanford type-A aortic dissection extending from the aortic valve to the level of the left subclavian artery. Emergent surgery was performed. Postoperatively, the patient was managed in surgical and trauma intensive care unit to keep the blood pressure in the desired range. Initially, he was started on continuous veno-venous hemodialysis and later on transitioned to intermittent hemodialysis. He was switched back to peritoneal dialysis after 6 weeks of surgery. CONCLUSIONS Atypical presentation of a silent aortic dissection without chest pain in the setting of renal failure and other co-morbidities emphasizes that dialysis patients are different from the general population. Sometimes the management needs to be modified from the conventional ways to achieve the high level of success.

Left Renal Vein Compression Syndrome: Cracking the Nut of Clinical Dilemmas - Three Cases and Review of Literature.

BACKGROUND The term nutcracker phenomenon (NCP) elucidates anatomical structure and hemodynamics, whereas nutcracker syndrome (NCS) refers to clinical manifestations. We present three cases of similar clinical features of hematuria and flank pain with different clinical outcomes. CASE REPORT Case 1: A 36-year-old Caucasian female with a past medical history (PMH) of HIV infection presented for evaluation of hematuria. Computed tomography (CT) without contrast showed pelvic venous congestion and narrowing of the extra-renal left renal vein (LRV). After the failure of conservative management, renal auto-transplantation was attempted but failed because of extensive venous collateral; the patient subsequently required a total hysterectomy due to recurrence of symptoms. Case 2: A 41-year-old Caucasian female with extensive PMH presented with chronic abdominal pain. A CT scan of the abdomen and pelvis showed pelvic venous congestion. The patient underwent angioplasty and stent placement of the LRV. Subsequently, a left ovarian vein embolization was performed. On follow-up visits, her symptoms improved. Case 3: A 36-year-old female with PMH of HIV infection, gastroesophageal reflux disease, and hypertension presented with hematuria and flank pain. Her venogram revealed 1 mm Hg pressure gradient across stenosis, suggestive of LRV hypertension. Over the months of her follow-up after discharge, her hematuria gradually decreased from daily to intermittent non-daily frequency, without any intervention. CONCLUSIONS The treatment of NCS includes observation, percutaneous angioplasty, open or endovascular surgery, or nephrectomy. In patients younger than 18 years of age, the best option is a conservative approach with observation for at least two years, as approximately 75% of patients have complete resolution of hematuria.

Vegetation Attached to the Left Interatrial Septal Surface at the Congenital Location of the Foramen Ovale: A Rare Occurrence.

BACKGROUND Non-valvular mural infective endocarditis (IE) is a rare bacterial growth on cardiac walls. Several risk factors have been reported. Echocardiography is an important diagnostic modality for diagnosing vegetation attached to the intracardiac walls. CASE REPORT We present the case of a 57-year-old man admitted with Staphylococcus aureus bacteremia due to an infected tunnelled hemodialyses catheter. Transthoracic echocardiogram did not show any abnormality, but transesophageal echocardiogram (TEE) revealed a 1.7×0.8 cm mobile echo-density attached to the surface of the interatrial septum in the left atrium, where the foramen ovale (FO) exists in utero. The patient was transferred to another facility for re-do sternotomy cardiac surgery, where these findings were confirmed intraoperatively. A biopsy of the mass was taken, which confirmed it to be a vegetation attached to the FO. CONCLUSIONS We report the first case in the literature of vegetation attached to the surface of the interatrial septum in the left atrium at the congenital location of the foramen ovale. There have been no previously reported cases in the literature with such novel imaging findings.

Left Atrial to Esophageal Fistula: A Case Report and Literature Review.

BACKGROUND Left atrial to esophageal fistula (LAEF) is a rare fatal complication of radiofrequency ablation (RFA) for atrial fibrillation and is associated with high mortality. Clinical features can be nonspecific and include fever, dysphagia, upper gastrointestinal (GI) bleeding, sepsis, and embolic stroke a after recent history of RFA for atrial fibrillation. CASE REPORT  A 57-year-old Caucasian male was brought to the emergency department (ED) by his family because of an altered mental status. He had undergone a radiofrequency ablation for paroxysmal atrial fibrillation three weeks earlier. Several hours after admission to the ED, the patient transiently became unresponsive and had a right sided hemiplegia. A brain MRI revealed multiple cerebral infarcts. On the following day, the patient had an episode of melena, and an esophagogastroduodenoscopy (EGD) was performed which did not reveal any source of bleeding. While the patient was being monitored in the intensive care unit (ICU), he had an episode of hematemesis and went into cardiac arrest from which he was successfully resuscitated and transferred to another facility. He had another EGD, which uncovered a flap of mucosa covering the lower third of his esophagus and a 1 cm fistulous opening was seen with fresh blood oozing out of it. The patient had another cardiac arrest during the endoscopy and died despite all measures. CONCLUSIONS We present this case to stress the importance of early diagnosis of LAEF. LAEF can be fatal if diagnosis is delayed or missed. Early surgical intervention can reduce LAEF morbidity and mortality. Newer diagnostic modalities such as endoscopic ultrasound (EUS) can be helpful in cases where conventional imaging is unclear.