Paclitaxel-Coated Balloon Versus Uncoated Balloon Angioplasty For Coronary In-Stent Restenosis: A Systematic Review And Meta-Analysis Of Randomized Controlled Trials.

In-stent restenosis (ISR) accounts for 10% of percutaneous coronary intervention (PCI) in the Unites States. Paclitaxel coated balloons (PCBs) have been evaluated as a therapy for coronary ISR in multiple randomized controlled trials (RCTs). We searched PubMed/MEDLINE, Cochrane library, and ClinicalTrials.gov (from inception to April 1, 2024) for RCTs evaluating PCBs versus uncoated balloon angioplasty (BA) in patients with coronary ISR. The outcomes of interest were target lesion revascularization (TLR), major adverse cardiovascular events (MACE), all-cause mortality, cardiovascular mortality, myocardial infarction (MI), and stent thrombosis. We pooled the estimates using inverse variance random-effects model. The effect sizes were reported as risk ratio (RR) with 95% confidence interval (CI). A total of 6 RCTs with 1,343 patients were included. At a follow-up ranging from 6-12 months from randomization, use of PCBs was associated with a statistically significant decrease in TLR (RR 0.28; 95% CI 0.11 to 0.68), and MACE (RR 0.35; 95% CI 0.20 to 0.64) when compared with BA for coronary ISR. However, there was no significant difference in risk between PCBs and BA in terms of all-cause mortality (RR 0.56; 95% CI 0.14 to 2.31), cardiovascular mortality (RR 0.61; 95% CI 0.02 to 16.85), MI (RR 0.60; 95% CI 0.27 to 1.31), and stent thrombosis (RR 0.13; 95% CI 0.00 to 5.06). In conclusion, this meta-analysis suggests that PCBs compared with uncoated BA for treatment of coronary ISR at intermediate term follow-up of one-year was associated with significant decrease in TLR, and MACE without any difference in mortality, MI, or stent thrombosis.

Outcomes following TAVR in patients with cardiogenic shock: A systematic review and meta-analysis.

BACKGROUND: While transcatheter aortic valve replacement (TAVR) has broadened treatment options for critically ill patients, outcomes among those with concomitant cardiogenic shock (CS) are not well-explored. METHODS: We conducted a comprehensive search of major databases for studies comparing outcomes following TAVR in patients with and without CS since inception up to October 31, 2023. Our meta-analysis included five non-randomized observational. Dichotomous outcomes were assessed using the Mantel-Haenszel method (risk ratio, 95 % CI), and continuous outcomes were evaluated using mean difference and 95 % CI with the inverse variance method. Statistical heterogeneity was determined using the inconsistency test (I2). RESULTS: Among 26,283 patients across five studies, 30-day mortality was higher in the CS group (7267 patients; 27.6 %) compared to those without CS (OR 3.41, 95 % CI [2.01, 5.76], p < 0.01), as well as 30-day major vascular complications (OR 1.72, 95 % CI [1.54, 1.92], p < 0.01). At 1-year follow-up, there was no statistically significant difference in mortality rates between the compared groups (OR 2.68, 95 % CI [0.53, 13.46], p = 0.12). No significant between-group differences were observed in the likelihood of 30-day aortic valve reintervention (OR 3.20, 95 % CI [0.63, 16.22], p = 0.09) or post-TAVR aortic insufficiency (OR 0.91, 95 % CI [0.33, 2.51], p = 0.73). Furthermore, 30-day stroke, pacemaker implantation, and in-hospital major bleeding were comparable between both cohorts. CONCLUSION: Among patients undergoing TAVR, short-term mortality is higher but one-year outcomes are similar when comparing those with, to those without, CS. Future studies should examine whether TAVR outcomes are improved when the procedure is delayed to optimize CS and when delay is not possible, whether particular management strategies lead to more favorable periprocedural outcomes.

Transjugular Transcatheter Tricuspid Valve Replacement: Early Compassionate Use Outcomes.

BACKGROUND: Data on procedural and early outcomes after transjugular transcatheter tricuspid valve replacement (TTVR) are limited. OBJECTIVES: This study sought to evaluate first-in-man procedural and clinical outcomes after transjugular TTVR with a special focus on patients who received large device sizes in whom TTVR outcomes have been questioned. METHODS: The retrospective registry included patients who underwent TTVR using the LuX-Valve Plus system (Jenscare Biotechnology Co Ltd) for symptomatic tricuspid regurgitation (TR) from January 2022 until February 2024 at 15 international centers in a compassionate use setting. The endpoints were procedural TR reduction, in-hospital death, adverse events, and 1-month survival. We further stratified results according to the size of the implanted device (<55 vs ≥55 mm). RESULTS: The registry included a total of 76 patients at a median age of 78 years (Q1-Q3: 72-83 years, 47.4% women). TR was reduced to ≤2+ and ≤1+ in 94.7% and 90.8% of patients (75.0% of patients received TTVR devices ≥55 mm) with well-sustained results at 1-month follow-up (TR ≤2+ in 95.0% and ≤1+ 86.8%). Residual TR was paravalvular in all cases. In-hospital death occurred in 4 patients (5.3%). Four patients (5.3%) underwent cardiac surgery during index hospitalization. Major in-hospital bleeding events occurred in 5 patients (6.6%). New in-hospital pacemaker implantation was required in 3.9% of patients in the overall cohort (5.7% in "pacemaker-naive" individuals). No cases of valve thrombosis, stroke, myocardial infarction, or pulmonary embolism were observed. At 1-month follow-up, survival was 94.4%, and NYHA functional class significantly improved. One further patient received a pacemaker, 1 further bleeding event occurred, and 2 patients underwent reintervention or surgery within the first 30 days after TTVR. No differences in procedural outcomes or adverse events were observed after stratification for valve size. CONCLUSIONS: Transjugular TTVR appears to be a safe and effective treatment option for patients with severe TR with comparable outcomes in very large tricuspid anatomies.

Use of biliary stents for large coronary arteries.

Dedicated coronary artery drug-eluting stents may be inadequate in coronary arteries >6 mm in diameter, due to the risk of stent undersizing if the stent is not fully expanded or to loss of radial strength or damage to the drug coating if the stent is expanded >6 mm. We present two patients with large coronary arteries who were successfully treated with biliary balloon expandable stents.

Obesity Paradox in Transcatheter Aortic Valve Replacement.

BACKGROUND: Obesity paradox in cardiovascular risk prediction has gained increasing attention in recent years. We aimed to investigate the impact of BMI on mortality following transcatheter aortic valve replacement (TAVR). METHODS: We performed a multi-center retrospective analysis of patients with severe aortic stenosis undergoing TAVR. Patients were categorized into: Underweight (BMI < 18.5), normal weight (18.5 ≤ BMI < 25), overweight (25 ≤ BMI < 30) and obese (BMI ≥ 30). Multivariate cox-proportional hazard model was used to compare all-cause mortality. RESULTS: Total of 6688 patients included (175 underweight, 2252 normal weight, 2368 overweight and 1893 with obesity). Mean age of patients was 81 ± 8 years with 55% males. Patients with obesity had higher prevalence of comorbidities but a lower overall STS score. Mortality at 30-days post-TAVR was lower in the obese population compared to underweight, normal weight, and overweight patients (1.6% vs. 6.9%, 3.6%, and 2.8%, respectively, p < 0.001). Similarly, 3-year mortality was lowest in patients with obesity (17.1% vs. 28.9%, 24.5% and 18.6%, respectively, p < 0.001). On multivariate analysis, long term all-cause mortality at 3-years remained significantly lower in patients with obesity compared to underweight (HR 1.74, 95% CI: 1.30-2.40, p < 0.001) and normal weight (HR: 1.41, 95% CI:1.21-1.63, p < 0.001) but not in overweight patients (HR: 1.10, 95% CI:0.94-1.28, p = 0.240). CONCLUSION: In conclusion, patients with obesity have improved short and long term mortality following TAVR with an observed progressive increase in mortality with lower BMI ranges.

Echocardiographic Differences in Women Across Subtypes of Hypertensive Disorders of Pregnancy.

Background: Hypertensive disorders of pregnancy (HDP) can be classified into gestational hypertension, preeclampsia (PRE), and chronic hypertension with superimposed preeclampsia (SPE). Objectives: The purpose of this study was to retrospectively examine the echocardiographic differences in biventricular structure and function in 3 HDP groups of women in comparison to normotensive pregnant controls. Methods: Women with an echocardiogram during or within the first year of pregnancy were identified within our integrated health network. Exclusion criteria included age <18 years, diagnosis of pulmonary embolism, malignancy, autoimmune disease, and structural heart disease. Results: We identified a total of 706 subjects (cases: n = 427, normotensive controls: n = 279). Cases were divided into 3 groups: gestational hypertension (n = 57), PRE (n = 291), and SPE (n = 79). In adjusted analyses, echocardiographic parameters demonstrated a graded difference in left ventricular (LV) mass index, relative wall thickness, mitral inflow E, mitral inflow A, septal e', lateral e', E/e', left atrial volume index, tricuspid velocity, and lateral e' velocities with the most profound findings noted in the SPE group. Specifically, adjusted LV mass index (adjusted ß = 14.45, 95% CI: 9.00-19.90) and E/e' (adjusted ß = 2.97, 95% CI: 2.27-3.68) was highest in the SPE group in comparison to controls (P < 0.001). Conclusions: LV remodeling and diastolic filling abnormalities are more common in HDP and are most evident in SPE and PRE. Echocardiography during or immediately after pregnancy may be useful in these high-risk women to identify these abnormalities. The long-term implications of these echocardiographic abnormalities require further study.

Efficacy and safety of TAVR versus SAVR in patients with small aortic annuli: A systematic review and meta-analysis.

INTRODUCTION: Patients with a small aortic annulus (SAA) undergoing aortic valve replacement are at increased risk of patient-prosthesis mismatch (PPM), which adversely affects outcomes. Transcatheter aortic valve replacement (TAVR) has shown promise in mitigating PPM compared to surgical aortic valve replacement (SAVR). METHODS: We conducted a systematic review and meta-analysis following PRISMA guidelines to compare clinical outcomes, mortality, and PPM between SAA patients undergoing TAVR and SAVR. Eligible studies were identified through comprehensive literature searches and assessed for quality and relevance. RESULTS: Nine studies with a total of 2476 patients were included. There was no significant difference in 30-day Mortality between TAVR vs SAVR groups (OR = 0.65, 95% CI [ 0.09-4.61], P = 0.22). There was no difference between both groups regarding myocardial infarction at 30 days (OR = 0.63, 95% CI [0.1-3.89], P = 0.62). TAVR was associated with a significantly lower 30-day major bleeding and 2-year major bleeding, Pooled studies were homogeneous (OR = 0.44, 95% CI [0.31-0.64], P < 0.01, I2 = 0, P = 0.89), (OR = 0.4 ,95% CI [0.21-0.77], P = 0.03, I2 = 0%, P = 0.62) respectively. TAVR was associated with a lower rate of moderate PPM (OR = 0.6, 95% CI [ 0.44-0.84], p value = 0.01, i2 = 0%, p value = 0.44). The overall effect estimate did not favor any of the two groups regarding short-term Mild AR (OR = 5.44, 95% CI [1.02-28.91], P = 0.05) and Moderate/severe AR (OR = 4.08, 95% CI [ 0.79-21.02], P = 0.08, I2 = 0%, P = 0.59). CONCLUSION: Our findings suggest that both TAVR and SAVR are viable options for treating AS in patients with a small aortic annulus. TAVR offers advantages in reducing PPM and major bleeding, while SAVR performs better in terms of pacemaker implantation. Future studies should focus on comparing newer generation TAVR techniques and devices with SAVR. Consideration of patient characteristics is crucial in selecting the optimal treatment approach for AS.

The various perioperative issues of structural heart diseases and cardiogenic shock.

Up to 20 % of patients presenting with acute heart failure and cardiogenic shock have a structural etiology. Despite efforts in timely management, mortality rates remain alarmingly high, ranging from 50 % to 80 %. Surgical intervention is often the definitive treatment for structural heart disease; however, many patients are considered high risk or unsuitable candidates for such procedures. Consequently, there has been a paradigm shift towards the development of novel percutaneous management strategies and temporizing interventions. This article aims to provide a comprehensive review of the pathophysiology of valvular and structural heart conditions presenting in cardiogenic shock, focusing on the evolving landscape of mechanical circulatory support devices and other management modalities.

Hypertrophic cardiomyopathy in pregnancy: Nationwide analysis of patients characteristics and outcomes.

INTRODUCTION: Hypertrophic cardiomyopathy (HCM) poses unique challenges in the management of pregnant patients due to the complex interplay of physiological changes of pregnancy. Despite its relatively low prevalence among pregnant women, HCM can significantly impact maternal and fetal outcomes. This study aims to enhance understanding of pregnant patients with HCM and the associated outcomes through a nationwide analysis of patient characteristics and outcomes. METHODS: A retrospective analysis was conducted using data obtained from the Agency for Healthcare Research in Quality (AHRQ) Nationwide Inpatient Sample (NIS) database from January 2016 to December 2020. 3,599,855 pregnant patients without HCM and 187 pregnant patients with HCM were identified using International Classification of Disease (ICD) codes, and baseline characteristics, medical comorbidities, and outcomes were compared between the two groups. RESULTS: Significant differences were observed in baseline characteristics, including age distribution, racial composition, and prevalence of systemic organ disease, between pregnant women with and without HCM. Women with HCM had higher odds of experiencing maternal complications, such as acute heart failure and peripartum cardiomyopathy, as well as higher rates of fetal distress and obstetric interventions, including preterm delivery and caesarean section. CONCLUSION: Comprehensive cardiovascular assessment and risk stratification are essential in pregnant women with HCM to optimize maternal and fetal outcomes. Moreover, disparities in baseline characteristics and outcomes among black pregnant women with HCM highlight the need for a multifactorial approach to addressing pregnancy-related complications.

Maternal and Fetal Outcomes in Pulmonary Hypertension During Pregnancy: A Contemporary Nationwide Analysis.

Pulmonary hypertension (PH) disproportionately affects women, presenting challenges during pregnancy. Historically, patients with PH are advised to avoid pregnancy; however, recent reports have indicated that the incidence of adverse events in pregnant patients with PH may be lower than previously reported. We conducted a retrospective cohort study in pregnant patients with PH using the National Readmission Database from January 1, 2016, to December 31, 2020. PH was categorized according to the World Health Organization classification. Primary end points include maternal mortality and 30-day nonelective readmission rate. Other adverse short-term maternal (cardiovascular and obstetric) and fetal outcomes were also analyzed. Of 9,922,142 pregnant women, 3,532 (0.04%) had PH, with Group 1 PH noted in 1,833 (51.9%), Group 2 PH in 676 (19.1%), Group 3 PH in 604 (17.1%), Group 4 PH in 23 (0.7%), Group 5 PH in 98 (2.8%), and multifactorial PH in 298 (8.4%). PH patients exhibited higher rates of adverse cardiovascular events (15.7% vs 0.3% without PH, p <0.001) and mortality (0.9% vs 0.01% without PH, p <0.001). Mixed PH and Group 2 PH had the highest prevalence of adverse cardiovascular events in the World Health Organization PH groups. Patients with PH had a significantly higher nonelective 30-day readmission rate (10.4% vs 2.3%) and maternal adverse obstetric events (24.2% vs 9.1%) compared with those without PH (p <0.001) (Figure 1). In conclusion, pregnant women with PH had significantly higher adverse event rates, including in-hospital maternal mortality (85-fold), compared with those without PH.

Intravenous iron therapy for patients with iron deficiency and heart failure: a systematic review and meta-analysis of randomized controlled trials.

Introduction: Heart failure (HF) presents a significant health challenge, with intravenous (IV) iron therapy considered a potential treatment avenue. Method: We assessed IV iron therapy's efficacy in HF patients with concurrent iron deficiency versus standard of care. Primary outcomes included the composite of HF hospitalizations or cardiovascular-related mortality, HF hospitalizations, and all-cause, HF, and cardiovascular mortality rates. Secondary measures encompassed improvements in New York Heart Association functional classification, quality of life, 6-minute walk test, left ventricular ejection fraction, and adverse events. We used a random-effects model to compute relative risk (RR) or mean difference (MD) with 95% confidence intervals (CIs). Results: Based on an analysis of 14 randomized controlled trials involving 6614 patients, IV iron therapy significantly reduced composite outcome (RR: 0.84, 95% CI: 0.73, 0.96; P = 0.01) and HF hospitalizations (RR: 0.74, 95% CI: 0.61, 0.89; P = 0.002) compared to standard of care. Mortality rates showed no significant difference. IV iron therapy improved New York Heart Association functional classification, quality of life, and 6-minute walk test, with no major impact on left ventricular ejection fraction. Adverse events remained stable. Conclusions: IV iron therapy holds promise for diminishing HF hospitalizations and enhancing quality of life and 6-minute walk test in HF patients. Yet, its effect on all-cause or cardiovascular mortalities appears limited.

Early pandemic in-hospital outcomes and mortality risk factors in COVID-19 solid organ transplant patients.

Background: Solid organ transplant (SOT) recipients with COVID-19 have a higher risk of mortality than those without COVID-19. However, it is unclear how SOT patient outcomes compare to the general population without SOT who contract COVID-19. Methods: We used the National Inpatient Sample from January to December 2020 to investigate inpatient outcomes seen in SOT recipients after contracting COVID-19 compared to nontransplant patients. We identified our study sample using ICD-10 CM and excluded those <18 years of age and those with dual organ transplants. Inpatient outcomes were compared in SOT and non-SOT COVID cohorts, and we further evaluated predictors of mortality in the SOT with COVID population. Results: Out of the 1,416,445 COVID-19 admissions included in the study, 8315 (0.59%) were single SOT recipients. Our analysis that adjusted for multiple baseline characteristics and comorbidities demonstrated that COVID-19 in SOT patients was associated with higher rates of acute kidney injury (adjusted odds ratio [aOR] 2.34, 95% confidence interval [CI] 1.81-3.02, P < 0.01), lower rates of acute respiratory distress syndrome (aOR 0.68, 95% CI 0.54-0.85, P < 0.01), and similar rates of cardiac arrest, pulmonary embolism, circulatory shock, cerebrovascular events, and in-hospital mortality. Age >65 was associated with mortality in SOT patients. Conclusion: In this nationally representative sample, SOT patients presenting with COVID-19 experienced similar rates of mortality compared to those without SOT. SOT patients were more likely to develop acute kidney injury. Further research is needed to understand the complex relationship between transplant patient outcomes and COVID-19.

Cerebral embolic protection device utilization and outcomes in transcatheter aortic valve replacement: A nationally representative propensity matched analysis.

INTRODUCTION: In patients undergoing transcatheter aortic valve replacement (TAVR), cerebral embolic protection devices (CEPD) are used to possibly diminish the risk of periprocedural stroke. Trends and outcomes of CEPD usage in TAVR are not well characterized. METHODS: National readmission databases (NRD) 2017-2019 was used to identify hospital admissions for TAVR using ICD-10 codes, with versus without Sentinel CEPD. Primary outcomes of the study were in-hospital and 30-day stroke. Secondary outcomes include in-hospital mortality, 30-day mortality, 30-day readmission rate, and other procedural complications. We matched both cohorts using propensity score matching (PSM) and performed logistic regression to compute the odds ratios (ORs) and corresponding 95 % confidence intervals (CI). RESULTS: Out of 190,837 TAVR admissions in the United States, 10,643 (5.6 %) patients had TAVR with Sentinel CEPD. After propensity score matching, our cohort included 10,503 patients with CEPD and 10,541 without CEPD. Trends in CEPD utilization are noted in Fig. 1. In the PSM cohort, Sentinel CEPD was not associated with decreased risk of in-hospital stroke (1.9 % vs. 1.8 %, OR: 0.98, 95 % CI: 0.76-1.26, p = 0.88), 30-day stroke (2.1 % vs. 2.1 %, OR: 1.01, 95 % CI: 0.78-1.30, p = 0.96), or 30-day mortality (1.3 % vs. 1.0 %, OR: 0.74, 95 % CI: 0.51-1.07, p = 0.11) when compared to TAVR without CEPD. Other in-hospital and short-term outcomes post-TAVR were not impacted by Sentinel CEPD usage, including acute kidney injury, vascular complications, paravalvular leak, cardiogenic shock, circulatory support, or permanent pacemaker (Table 1). CONCLUSION: In this nationally representative cohort, Sentinel CEPD utilization during transfemoral TAVR for stroke prevention was not associated with reduced odds of in-hospital stroke, 30-day stroke, or 30-day mortality. Future studies should focus on optimizing patient selection for CEPD and establishing predictive models to identify the subset of TAVR patients with higher risk for periprocedural stroke who might benefit from CEPD.

Burden of cardiovascular disease in Sub-Saharan Africa, 1990-2019: An analysis of the Global Burden of Disease Study.

INTRODUCTION: The rise in cardiovascular disease (CVD) in Sub-Saharan Africa (SSA) reflects a major shift from communicable to noncommunicable diseases as primary health challenges. Consequently, this study aims to explore the burden of CVD and associated risk factors in SSA using data from the Global Burden of Disease (GBD) database. METHODS: This study utilized data from the GBD 1990 to 2019 to examine CVD prevalence in 46 SSA countries. We employed Bayesian regression models, demographic techniques, and mortality-to-incidence ratios to analyze both prevalence and mortality rates. Additionally, disability-adjusted life years (DALYs) were computed, and various risk factors were examined using the GBD's comparative risk assessment framework. RESULTS: Between 1990 and 2019, CVD raw counts in SSA rose by 131.7 %, with a 2.1 % increase in age-standardized prevalence rates. The most prevalent conditions were ischemic heart disease, stroke, and rheumatic heart disease. During the same period, the age-standardized CVD deaths per 100,000 individuals decreased from 314 (1990) to 269 (2019), reflecting a -14.4 % decline. Age-standardized CVD DALY rates also showed a decrease from 6,755 in 1990 to 5,476 in 2019, with translates to 18.9 % reduction. By 2019, the Central African Republic, Madagascar, and Lesotho were the countries with the highest age-standardized DALY rates for all CVDs. CONCLUSIONS: The study highlights a contrasting trend in SSA's CVD landscape: a decrease in age-standardized mortality and DALYs contrasts with increasing CVD prevalence, emphasizing the need for targeted public health strategies that balance treatment advancements with intensified prevention and control measures.

Inpatient outcomes of inflammatory bowel disease in hospitalized patients with COVID-19: analysis of a nationally representative sample.

Purpose: To compare the risks of adverse outcomes, including mortality, gastrointestinal bleeding, and venous thromboembolism, between COVID-19 patients with inflammatory bowel disease (IBD) and those without IBD. Methods: We analyzed data from the National Inpatient Sample between January and December 2020. The study included adult patients with Crohn's disease (CD) and ulcerative colitis (UC) who contracted COVID-19. Inpatient outcomes were compared between the IBD and non-IBD COVID-19 cohorts. Results: Out of 1,050,045 COVID-19 hospitalizations, 0.28% had CD (2954 patients) and 0.26% had UC (2794 patients). After adjusting for confounding factors, UC patients had a significantly higher risk of deep vein thrombosis compared to non-IBD patients, with an adjusted odds ratio (aOR) of 2.55 (P < 0.001). However, CD patients did not show a significant association with deep vein thrombosis (aOR 1.29, P = 0.329). There were no significant associations between IBD patients (both UC and CD) and pulmonary embolism, nonvariceal gastrointestinal bleeding, or in-hospital mortality. UC patients had a longer average hospital stay (8.25 days) compared to non-IBD patients (adjusted mean difference 0.89, P = 0.007). Healthcare resource utilization was similar among the three groups. Conclusion: Our national study on COVID-19 hospitalizations indicates that patients with IBD have comparable rates of gastrointestinal bleeding, pulmonary embolism, and mortality as those without IBD. However, patients with UC hospitalized with COVID-19 have a higher risk of deep vein thrombosis than COVID-19 patients hospitalized without UC. Further research is needed to better understand the relationship between COVID-19 and IBD.

Mechanical Circulatory Support for High-Risk Percutaneous Coronary Intervention.

PURPOSE OF REVIEW: This review will focus on the indications of mechanical circulatory support (MCS) for high-risk percutaneous coronary intervention (PCI) and then analyze in detail all MCS devices available to the operator, evaluating their mechanisms of action, pros and cons, contraindications, and clinical data supporting their use. RECENT FINDINGS: Over the last decade, the interventional cardiology arena has witnessed an increase in the complexity profile of the patients and lesions treated in the catheterization laboratory. Patients with significant comorbidity burden, left ventricular dysfunction, impaired hemodynamics, and/or complex coronary anatomy often cannot tolerate extensive percutaneous revascularization. Therefore, a variety of MCS devices have been developed and adopted for high-risk PCI. Despite the variety of MCS available to date, a detailed characterization of the patient requiring MCS is still lacking. A precise selection of patients who can benefit from MCS support during high-risk PCI and the choice of the most appropriate MCS device in each case are imperative to provide extensive revascularization and improve patient outcomes. Several new devices are being tested in early feasibility studies and randomized clinical trials and the experience gained in this context will allow us to provide precise answers to these questions in the coming years.

Bivalirudin versus unfractionated heparin in patients with myocardial infarction undergoing percutaneous coronary intervention: A systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Bivalirudin is an alternative accepted therapy to unfractionated heparin for patients with myocardial infarction (MI) undergoing percutaneous coronary intervention (PCI). We aimed in this meta-analysis to compare bivalirudin versus unfractionated heparin in patients with MI undergoing PCI. METHODS: We have screened PubMed/MEDLINE, Cochrane Library, and ClinicalTrials.gov (inception through January 8th, 2023) for randomized controlled trials (RCTs) evaluating bivalirudin versus unfractionated heparin in patients with MI undergoing PCI. The DerSimonian and Laird method was used for estimation of tau2 to calculate the risk ratio (RR) and 95 % confidence interval (CI). RESULTS: Ten RCTs with a total of 40,069 participants were included in our analysis. Bivalirudin as compared with unfractionated heparin was associated with significant decrease in major bleeding (RR 0.64 [0.52 to 0.79]; p < 0.01; I2 = 69 %) and cardiovascular mortality (RR 0.79 [0.67 to 0.92]; p < 0.01; I2 = 0 %). There was no significant difference between bivalirudin and unfractionated heparin groups in terms of major adverse cardiovascular events (RR 1.02 [0.91 to 1.14]; p = 0.73; I2 = 52 %), all-cause mortality (RR 0.89 [0.77 to 1.04]; p = 0.15; I2 = 23 %), MI (RR 1.02 [0.87 to 1.19]; p = 0.80; I2 = 36 %), stent thrombosis (RR 1.12 [0.52 to 2.40]; p = 0.77; I2 = 82 %), or stroke (RR 0.97 [0.73 to 1.29]; p = 0.85; I2 = 0 %). CONCLUSION: Our meta-analysis suggests that bivalirudin compared with unfractionated heparin in patients with MI undergoing PCI was associated with lower rates of major bleeding and cardiovascular mortality without a significant difference in major adverse cardiovascular events, all-cause mortality, MI, stroke, or stent thrombosis.

Liberal versus conservative transfusion strategy for patients with acute myocardial infarction and anemia: A systematic review and meta-analysis.

BACKGROUND: A hemoglobin (Hb) level goal of 7-8 g/dL is a standard care threshold, prompting blood transfusion. The debate over whether acute myocardial infarction (MI) patients benefit from a more liberal transfusion strategy prompted a meta-analysis of relevant trials. METHODS: We performed a meta-analysis of randomized controlled trials (RCTs) comparing liberal and restrictive transfusion strategies in anemic MI patients. Primary outcomes were recurrent MI and death/MI, while secondary outcomes included stroke, revascularization, heart failure, and all-cause mortality. Due to the limited trials, we utilized the Paul-Mendele method with Hartung Knapp adjustment. RESULTS: Involving 2155 patients with liberal transfusion and 2170 with conservative transfusion across four RCTs, liberal transfusion did not significantly reduce MI (relative risk [RR] 0.85; 95 % CI 0.72 - 1.02, p = 0.07) or death/MI (RR 0.88; 95 % CI 0.45 - 1.71, p = 0.57). No significant differences were observed in all-cause mortality (RR 0.82; 95 % CI 0.25 - 2.68, p = 0.63), stroke (RR 0.89; 95 % CI 0.48 - 1.64, p = 0.50), revascularization (RR 0.93; 95 % CI 0.48 - 1.80, p = 0.68), or heart failure (RR 1.14; 95 % CI 0.04 - 28.84, p = 0.88). CONCLUSION: Our meta-analysis supports current medical guidelines, reinforcing the practice of limiting transfusions in acute MI patients to those with an Hb level of 7 or 8 g/dL. Liberal transfusion strategies did not show improved clinical outcomes.