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.

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.

Myxoid Liposarcoma Originating In The Anterior Mediastinum.

Myxoid liposarcomas of the head and neck are mostly metastatic in nature, with the primary lesion usually in lower extremities or retroperitoneum. Primary mediastinal liposarcomas are even rarer. Although there have been previous cases reporting their incidence, there is no evidence of any case comprising of both the neck and the mediastinal region yet. We here present a case of a 43 year old male with a primary liposarcoma of the myxoid subtype originating in the anterior mediastinum. This is the first time such a case has presented in literature. The patient presented with a right sided neck swelling associated with pain and shortness of breath upon lying down. CT neck revealed an enhancing mass extending from right cervical region to axilla and encasing the subclavian artery and involving a portion of the right lung. The patient underwent wide local excision of the mass along with chemoradiotherapy to prevent recurrence.