Cardiovascular Revascularization Medicine最新文献

Background: More than half of NSTEACS patients are presented with multivessel CAD. Culprit vessel only or complete revascularization (CR) guided either by angiography or fractional flow reserve (FFR) is available percutaneous coronary intervention (PCI) options. This study aims to compare different PCI strategies in NSTEACS patients with multivessel CAD.

Methods: Observational and RCTs studies are selected and compared for short- and long-term outcomes of all-cause mortality, MACE, and repeat revascularization. Odds ratio (OR) and SUCRA ranking of 4 interventions; (A) culprit vessel only revascularization, (B) single stage CR guided by angiography, (C) single stage CR guided by FFR, and (D) multistage CR guided by angiography are reported as pairwise and pooled network frequentist analysis conducted using RevMan and R software.

Results: Thirty- six studies with 213,254 patients were included. Pairwise analysis of A vs B shows no significant difference in short term outcomes. Pooled network analysis demonstrates that B, C, and D resulted in a significantly lower odds of long-term all-cause mortality compared to A (OR 0.42-0.77, 95 % CrI: 0.19-0.91). SUCRA ranking shows that C is more favorable compared to other interventions to reduce long term all-cause mortality and MACE (SUCRA 0.932 and 0.953). Sensitivity analysis with only RCTs and propensity matched scoring observational studies retains the significance and ranking of the interventions.

Conclusion: CR is just as safe as culprit vessel revascularization and single stage CR guided by FFR is the most preferable strategy to reduce risk of all- cause mortality and MACE.

Prospero id: CRD42023491792.

Background: The impact of mitral annular calcification (MAC) on the clinical outcomes of patients undergoing mitral transcatheter edge-to-edge repair (MTEER) remains unclear. This meta-analysis aims to evaluate the clinical outcomes of MTEER among patients with moderate to severe MAC compared to those with mild or no MAC.

Methods: We systematically searched PubMed, EMBASE, and Cochrane CENTRAL databases through March 31st, 2024, comparing clinical outcomes of MTEER among patients with moderate/severe (MAC+) versus no/mild MAC (MAC-). We assessed pooled estimates for procedural success, all-cause mortality, residual mitral regurgitation (MR) ≤ moderate, and New York Heart Association (NYHA) class III/IV status at one year.

Results: Among five studies (2533 patients; mean age 76.4 ± 10.9 years, 39.8 % women), MAC+ patients were predominantly women (55.7 % vs 37.5 %, p < 0.001), older (87.9 ± 11.1 vs. 75.9 ± 9.1 years; mean difference (MD) = 3.99, p = 0.011) and had higher STS scores (7.7 ± 6.7 % vs. 4.9 ± 4.6 %; MD = 1.34, p < 0.001). MAC+ patients had comparable procedural success rates, residual MR < moderate, and NYHA III/IV at 1 year. However, all-cause mortality at 1 year was higher for MAC+ patients (Relative Risk = 1.56, 95 % CI = 1.06-2.29).

Conclusions: MTEER is a safe and feasible option for carefully selected patients with MAC and significant MR, offering durable MR reduction and functional status improvement. Significantly higher one-year mortality associated with MAC despite significant MR reduction suggests an increased risk unrelated to valvular dysfunction and highlights the need for further investigation into identifying patients who benefit the most from MTEER.

Background: Disparities in healthcare based on race, ethnicity, and socioeconomic status (SES) remain a public health crisis, especially in perioperative anesthetic management. This study applies a health equity lens to intraoperative pain and postoperative nausea and vomiting (PONV) for patients undergoing coronary artery bypass grafting (CABG).

Methods: This retrospective cohort study included 1404 adult patients who underwent coronary artery bypass grafting (CABG) between 2017 and 2022 at a single, multi-site, academic healthcare system. The primary outcomes were PONV as well as moderate-to-severe post-operative pain. Secondary outcomes were administration of prophylactic antiemetics, compliance with guideline-recommended antiemetic prophylaxis, and opioid morphine milligram equivalents (MME) administered intraoperatively. Independent variables included patient race and ethnicity, healthcare payor type, and community-level SES (using Area Deprivation Index [ADI]). Multivariable logistic regression models that controlled for relevant covariates were utilized.

Results: The findings showed no significant disparities in experiencing PONV, post-operative pain, or receiving high opioid MME based on race, ethnicity, payor type, and ADI. There were also no differences in the receipt of antiemetics nor compliance with guideline-recommended antiemetic prophylaxis.

Conclusions: Our study did not find racial, ethnic, or SES disparities in intraoperative anesthetic pain management, postoperative pain, nor PONV management. Applying a health equity lens to quality outcomes during the perioperative period is necessary to ensure equitable care among diverse populations.

Background: Embolic protection devices were developed to reduce the risk of common complications encountered during percutaneous coronary intervention (PCI) of saphenous vein grafts, however, in the setting of contemporary multi-modality medical management, their overall efficacy has been called into question. This study aimed to assess the evolving utilization and clinical outcomes associated with distal filter wire embolic protection devices in saphenous vein PCI.

Methods: Consecutive patients undergoing PCI to a saphenous vein graft in a registry were included. Peri-procedural and long-term outcomes including 12-month mortality and 30-day MACCE rates were compared between PCI using a distal filter wire embolic protection device and unprotected PCI.

Results: From 2005 to 2020, a total of 753 patients underwent PCI to a saphenous vein graft with 256 using a distal filter wire embolic protection device. At one year, the use of a distal filter wire embolic protection devices was not associated with a decrease in mortality (4.7 % vs 5.4 %, p = 0.19) and there was no difference in 30-day MACCE rates between protected and unprotected saphenous vein PCI (3.1 % vs 5.8 %, p = 0.10).

Conclusion: In this 12-month analysis of saphenous vein graft PCI, there was no evidence that distal filter wire embolic protection devices improved short term post procedural or long-term mortality outcomes.

Background: Bioprosthetic surgical aortic valve replacement (SAVR) using the Trifecta valve was frequently chosen because of its large opening area and low transvalvular gradient. However, long-term follow-up revealed the potential for early structural valve deterioration. To further assess the long-term clinical outcomes and management considerations for patients implanted with the Trifecta valve, a real-world study using Medicare fee-for-service claims data was conducted with a focus on Trifecta valve reintervention.

Methods: De-identified patients undergoing SAVR with the Trifecta™ valve (Abbott) in the U.S. between 1/1/2011-12/31/2021 were selected by ICD-9/10 procedure codes and then linked to a manufacturer device tracking database. All-cause mortality and freedom from Trifecta valve reintervention with repeat SAVR or valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) were evaluated at 10-years using the Kaplan Meier method. Independent predictors for reintervention and clinical outcomes following reintervention were assessed.

Results: Among 242,160 Medicare beneficiaries undergoing SAVR during the study period, 23,197 were implanted with the Trifecta valve. Mean age was 75.2 ± 7.4 years. At 10-years survival was 32.3 % (95 % CI, 31.4 %-33.3 %) and the freedom from valve reintervention was 82.4 % (95 % CI, 81.1 %-83.5 %). Independent predictors for reintervention included younger age, female, obesity, and implants with a small valve size (19 mm, 21 mm). Reintervention with ViV-TAVI (N = 796) was associated with better operative survival (3.8 % vs. 12.5 %, p < 0.001) than repeat SAVR (N = 577).

Conclusion: This real-world nationwide study of Medicare beneficiaries receiving the Trifecta valve demonstrates >80 % freedom from all-cause valve reintervention at 10-years post-implant with reintervention using ViV-TAVI having improved operative survival compared to repeat SAVR.

Background: Mechanical circulatory support with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has brought forward a paradigm shift in the management of cardiogenic shock. Neurological complications associated with VA-ECMO represent a significant source of morbidity and mortality and serve as a limiting factor in its application and duration of use.

Methods: We performed a single-center retrospective case-control study of patients who developed stroke while managed with peripheral VA-ECMO from January 2018 to September 2022 at a quaternary center. We included consecutive patients above the age of 18 who were admitted to the cardiac intensive care unit and were managed with peripheral VA-ECMO. All patients who developed a stroke while on VA-ECMO were included in the case cohort, and compared to those who did not suffer stroke. Multivariable logistic regression was performed to identify risk factors associated with stroke on VA-ECMO. In-hospital outcomes were assessed out to 30 days.

Results: A total 244 patients were included in the final analysis, 36 (14.7 %) of whom developed stroke on VA-ECMO. Ischemic stroke was seen in 20 patients (55.6 %) whereas hemorrhagic stroke was seen in 16 patients (44.4 %). The use of P2Y₁₂ antagonists (aOR 2.70, p = 0.019), limb ischemia (aOR 4.41, p = 0.002), and blood transfusion requirement (aOR 8.55, p = 0.041) were independently associated with development of stroke on VA-ECMO. Female sex trended towards statistical significance (aOR 2.19, p = 0.053) while age was not independently associated with development of stroke on VA-ECMO. There was no significant association between stroke development and outcomes of VA-ECMO duration, hospital length of stay, and all-cause mortality out to 30-days.

Conclusions: VA-ECMO carried a considerable risk of neurological complications. Mortality and duration of hemodynamic support was not associated with stroke risk. Awareness regarding stroke risk is imperative in facilitating early identification and management of ischemic and hemorrhagic stroke. Research involving clinical trials and multicenter studies are necessary to empower centers in mitigating this source of significant morbidity and mortality in patients on mechanical circulatory support.