Systematic review and meta-analysis of early aortic valve replacement versus conservative therapy in patients with asymptomatic aortic valve stenosis with preserved left ventricle systolic function.

BACKGROUND: A quarter of patients with severe aortic stenosis (AS) were asymptomatic, and only a third of them survived at the end of 4 years. Only a select subset of these patients was recommended for aortic valve replacement (AVR) by the current American College of Cardiology/American Heart Association guidelines. We intended to study the effect of early AVR (eAVR) in this subset of asymptomatic patients with preserved left ventricle function. METHODS AND RESULTS: We searched PubMed and Embase for randomised and observational studies comparing the effect of eAVR versus conservative therapy in patients with severe, asymptomatic AS and normal left ventricular function. The primary outcome was all-cause mortality. The secondary outcomes were composite major adverse cardiac events (MACE) (study defined), myocardial infarction (MI), stroke, cardiac death, sudden death, the development of symptoms, heart failure hospitalisations and major bleeding. We used GRADEPro to assess the certainty of the evidence. In the randomised controlled trial (RCT) only analysis, we found no significant difference in all-cause mortality between the early aortic intervention group versus the conservative arm (CA) (incidence rate ratio, IRR (CI): 0.5 (0.2 to 1.1), I2=31%, p=0.09). However, in the overall cohort, we found mortality benefit for eAVR over CA (IRR (CI): 0.4 (0.3 to 0.7), I2=84%, p<0.01). There were significantly lower MACE, cardiac death, sudden death, development of symptoms and heart failure hospitalisations in the eAVR group. We noticed no difference in MI, stroke and major bleeding. CONCLUSION: We conclude that there is no reduction in all-cause mortality in the eAVR arm in patients with asymptomatic AS with preserved ejection fraction. However, eAVR reduces heart failure related hospitalisations and death or heart failure hospitalisations. PROSPERO REGISTRATION NUMBER: CRD42022306132.

Trans-radial approach versus trans-femoral approach in patients with acute coronary syndrome undergoing percutaneous coronary intervention: An updated meta-analysis of randomized controlled trials.

INTRODUCTION: Trans-radial approach (TRA) is recommended over trans-femoral approach (TFA) in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). We intended to study the effect of access on all-cause mortality. METHODS AND RESULTS: We searched PubMed and EMBASE for randomized studies on patients with ACS undergoing PCI. The primary outcome was all-cause mortality at 30-days. The secondary outcomes included in-hospital mortality, major adverse cardiac or cerebrovascular event (MACE) as defined by the study, net adverse clinical event (NACE), non-fatal myocardial infarction, non-fatal stroke, stent thrombosis, study-defined major bleeding, and minor bleeding, vascular complications, hematoma, pseudoaneurysm, non-access site bleeding, need for transfusion, access site cross-over, contrast volume, procedure duration, and hospital stay duration. We studied 20,122 ACS patients, including 10,037 and 10,085 patients undergoing trans-radial and trans-femoral approaches, respectively. We found mortality benefit in patients with ACS for the trans-radial approach [(1.7% vs. 2.3%; RR: 0.75; 95% CI: 0.62-0.91; P = 0.004; I2 = 0%). Out of 10,465 patients with STEMI, 5,189 patients had TRA and 5,276 had TFA procedures. A similar benefit was observed in patients with STEMI alone [(2.3% vs. 3.3%; RR: 0.71; 95% CI: 0.56-0.90; P = 0.004; I2 = 0%). We observed reduced MACE, NACE, major bleeding, vascular complications, and pseudoaneurysms. No difference in re-infarction, stroke, and serious bleeding requiring blood transfusions were noted. We noticed a small decrease in contrast volume(ml) {mean difference (95% CI): -4.6 [-8.5 to -0.7]}, small but significantly increase in procedural time {mean difference (95% CI) 1.2 [0.1 to 2.3]}and fluoroscopy time {mean difference (95% CI) 0.8 [0.3 to1.4] min} in the trans-radial group. CONCLUSION: TRA has significantly reduced 30-day all-cause mortality among patients undergoing PCI for ACS. TRA should be the preferred vascular access in patients with ACS.

Successful extraction of refractory thrombus from an ectatic coronary artery using stent retriever during primary angioplasty for acute myocardial infarction: a case report.

BACKGROUND: Ectatic coronary segments are nidi for thrombus formation due to altered flow dynamics and stasis-an important component of Virchow's triad. Ectasia accompanied by an adjacent coronary stenosis with or without a plaque event can lead to acute myocardial infarctions complicated by huge thrombus burden. CASE SUMMARY: Here, we present a case of a young male with acute inferior wall myocardial infarction complicated by Type IV coronary artery ectasia of the right coronary artery and huge thrombus burden that was refractory to conventional methods of thrombus management like thrombo-suction and intracoronary cocktails including tenecteplase. After a stormy course of transient complete heart block and recurrent ventricular tachycardia, the thrombus was successfully extracted using a stent retriever to achieve thrombolysis in myocardial infarction (TIMI) II plus flow distally. The lesion just distal to the ectasia was stented 24 h later to achieve TIMI III flow and the patient had an uneventful recovery subsequently. DISCUSSION: Angiographically visible thrombus that is refractory to intracoronary medications and aspiration thrombectomy can be successfully managed using a stent retriever.

The prevalence of myocardial bridging on multidetector computed tomography and its relation to coronary plaques.

PURPOSE: To test the hypothesis that the prevalence of myocardial bridging varies between ethnic groups, and that the segment proximal to the myocardial bridge is more prone to plaque formation. MATERIAL AND METHODS: A total of 4500 patients who had undergone computerised tomography (CT) coronary angiography at our institute were studied for myocardial bridging. Data on the clinical profile and indication for CT coronary angiography in myocardial bridging were collected. Patients with and without proximal disease were compared using the chi-square test for ordinal variables and Student's t-test for continuous variables. The length to depth ratio (RA-MA ratio) of the bridged segment was determined. RESULTS: The prevalence of atherosclerotic plaques in the segment proximal to the bridged segment was 37.8%, which was lower than the prevalence of 48.7% for plaques in the corresponding segments among patients without myocardial bridging. The average length of the bridged segment was 15.5 ± 5 mm, and that for patients with and without proximal plaques was 13 ± 4 and 16 ± 6 mm (p = 0.1), respectively. Similarly, the average depth of the segments with and without proximal plaques was 1.8 ± 0.6 mm and 1.4 ± 0.5 mm (p = 0.06), respectively. Only the RA-MA ratio (8 ± 3 vs. 13 ± 6, p = 0.01) was significantly lower in patients with atherosclerotic plaques. CONCLUSIONS: The prevalence in our study population was 10%, with mid left anterior descending artery (LAD) being the most common segment involved. Moreover, the prevalence and distribution of coronary plaques in LAD were similar in patients with and without myocardial bridging.

Incidence, predictors, and long term clinical outcome of angiographic definite stent thrombosis in real world scenario - A prospective cohort study.

BACKGROUND: The occurrence of stent thrombosis (ST) in real world scenario is far different from that mentioned in the literature. Our study identifies the various parameters of ST. METHODS: This is a prospective observational-cohort study where-in consecutive patients who received successful percutaneous transluminal angioplasty (PTCA) over the study period of 1-year was included and were followed for 1-year from the primary procedure. RESULTS: The overall incidence of definite ST was 1.4% and 1.7% at 30 days and 1 year respectively. The most common mode of presentation of ST was ST-elevation myocardial infarction (82.6%). The history of prior PTCA, multi-vessel disease, emergent PTCA, acute coronary syndrome and type B2/C lesions were found to be the independent predictors for definite ST. The incidence of late ST was significantly higher with bare metal stent (BMS) than drug-eluting stent (DES) (OR-2.4, 95% CI:1.3-4.5). At mean follow-up of 13.9 months after ST, the overall mortality was 36.9%. The independent predictors of mortality after ST were post-PTCA thrombolysis in myocardial infarction (TIMI) flow grade < 3, and cardiogenic shock at the time of presentation. CONCLUSION: The overall incidence of definite ST is high in the real world scenario and the DES fared better than BMS. ST carries a bad prognosis especially so if the patients present in cardiogenic shock, or unable to achieve TIMI-3 flow after PTCA.

SYNTAX Score in Patients with High Computed Tomography Coronary Calcium Score.

OBJECTIVES: To study the conventional coronary angiogram ( CA) findings in patients with high coronary calcium on multidetector computed tomogram. MATERIALS AND METHODS: Fifty patients with coronary calcium high enough in its extent and location to interfere with the interpretation of a contrast-filled coronary artery for a significant lesion were studied with conventional CA. Framingham risk score (FRS), computed tomography (CT) coronary calcium score (CCS), and SYNTAX score (SS) from the CA were calculated by separate investigators who were blinded to other scores. Effectively, 250 coronary arteries (left main, left anterior descending, left circumflex, and right coronary artery and posterior descending artery in each subject) with calcium scores were studied for lesions on CA. RESULTS: Thirty-five subjects had high FRS, 10 had intermediate FRS, and 5 had low FRS. Eight subjects of 25 (32%) with CCS between 350 and 1000 had no significant coronary artery disease (CAD). Overall, the CCS and the SS had a strong agreement with each other (r = 0.68, P < 0.01) that persisted in those with very high scores >1000 (r = 0.55, P < 0.01, n = 30), but only a nonsignificant weak correlation with scores between 350 and 1000 (r = 0.1, P = 0.62, n = 20). Individual vessel calcium scores correlated strongly for the presence of any lesion (r = 0.52, P < 0.01) in the same artery but only weakly for a significant lesion (r = 0.29, P = 0.05). CONCLUSION: High CT CCS in this cohort of intermediate to high (Framingham score) risk patients correlated strongly with the subject's global burden of the CAD as derived by the SS, more so for subjects with very high scores. Similarly, CCS correlated strongly with the presence of any lesion but only weakly for a significant stenosis; also, about one-third of patients with CCS between 350 and 1000 may not have significant disease on conventional CA.

Prevalence of parameters of suboptimal scaffold deployment following angiographic guided bioresorbable vascular scaffold implantation in real world practice - an optical coherence tomography analysis.

AIM: To assess the prevalence of suboptimal bioresorbable vascular scaffold (BVS, Abbott Vascular, Santa Clara, California) deployment in real world practice with intracoronary optical coherence tomography (OCT) imaging. METHODS: Consecutive patients who underwent percutaneous coronary intervention using BVS and the final optimization assessed with OCT imaging in two tertiary care centers between December 2012 and February 2015 were evaluated for parameters of suboptimal scaffold deployment by OCT. RESULTS: Overall, 36 scaffolds were implanted in 27 patients during this period. Mean age of the population was 54.7±8.2years and 19 (70.4%) were type B2/C lesions. The prevalence of parameters of suboptimal scaffold deployment were: underexpansion-22(61.1%), geographic miss-3(8.3%), tissue prolapse-7(25.9%), scaffold pattern irregularity-1(2.8%), longitudinal elongation-7(38.8%). Of the 7 overlaps imaged: excessive overlap was observed in 3 and scaffold gap in one. The median duration of follow up was 679days (range 193-963days). There were four events during this period. None were associated with suboptimal scaffold deployment. CONCLUSION: OCT based parameters of suboptimal scaffold deployment are common in real world scenario and were not associated with adverse outcomes on long term follow up. These findings need to be confirmed in larger studies.

Percutaneous Coronary Intervention for Coronary Thrombo-embolism during Balloon Mitral Valvuloplasty in a Pregnant Woman.

Coronary embolism as a cause of acute myocardial infarction is considered rarer than it actually is because of the difficulties associated with its documentation. Equally rare is the event of a clot embolising to the coronary artery during balloon mitral valvuloplasty (BMV). We had a unique and a rare opportunity to encounter, recognise, document and successfully manage this rare complication during BMV in a pregnant woman.

Clinical usefulness and cost effectiveness of fractional flow reserve among Indian patients (FIND study).

OBJECTIVES: To study the clinical usefulness, cost benefit, and medium term outcome of fractional flow reserve (FFR) based management of coronary artery disease of intermediate severity. BACKGROUND: In spite of the advantages of FFR there is paucity of data in Indian population who have frequent diffuse, small and multivessel disease where it would probably be more beneficial in terms of cost and outcome. METHODS: The treating cardiologist's management decision with both FFR and angiographic data was compared with that of a reviewing cardiologist decision based on a retrospective analysis of angiogram alone. RESULTS: Eighty-one vessels with intermediate lesions in 59 patients required 26 stents lesser when FFR data was added to the angiogram. The concordance of management decision was about 58% which means that >40% of intermediate lesions would be misclassified as significant based on angiography alone. There were no major events at a mean follow up of 11 ± 5 months. The net cost benefit in favor of FFR based management was INR 8,57,600 (USD 15,600) in our centre. CONCLUSION: Indians with more severe form of CAD benefit from a FFR based management plan for intermediate lesions, both clinically and economically. © 2014 Wiley Periodicals, Inc.