Contemporary Management of Severely Calcified Coronary Lesions.

Coronary artery calcification is increasingly prevalent in our patient population. It significantly limits the procedural success of percutaneous coronary intervention and is associated with a higher risk of adverse cardiovascular events both in the short-term and long-term. There are several modalities for modifying calcified plaque, such as balloon angioplasty (including specialty balloons), coronary atheroablative therapy (rotational, orbital, and laser atherectomy), and intravascular lithotripsy. We discuss each modality's relative advantages and disadvantages and the data supporting their use. This review also highlights the importance of intravascular imaging to characterize coronary calcification and presents an algorithm to tailor the calcium modification therapy based on specific coronary lesion characteristics.

The efficacy of posterior wall isolation in atrial fibrillation ablation: A systematic review and meta-analysis of randomized controlled trials.

Background: Posterior wall isolation (PWI) is an emerging approach in atrial fibrillation (AF) ablation, yet its efficacy remains controversial. This is the first meta-analysis of randomized controlled trials (RCT) to evaluate the efficacy of PWI in AF ablation. Objective: To assess the efficacy of PWI in reducing atrial arrhythmia recurrence following initial AF ablation at long-term follow-ups when compared to conventional methods. Methods: We conducted a literature search from inception through September 2021 in EMBASE and MEDLINE databases. We included RCTs that compared outcomes in PWI and conventional approaches of AF ablation. Data from each study were combined using the random-effects, generic inverse variance method of DerSimonian and Laird to calculate odds ratio (OR), and 95% confidence interval (CI). Results: Eight RCT from 2009 to 2020, including 1024 AF patients, were included. PWI did not decrease overall atrial arrhythmias recurrence (RR 0.96, 95% CI:0.88-1.05, I 2 = 31.6%, p-value 0.393). However, the pooled analysis showed a significant decrease in AF recurrence in PWI compared to controlled approaches (RR 0.88, 95% CI:0.81-0.96, I 2 = 48.2%, p-value .004). In the subgroup analysis, PWI significantly decreased AF recurrence in the studies that included only persistent AF (RR = 0.89, 95% CI:0.80-0.98, I 2 = 65.2%, p-value .014). PWI significantly decreased AF recurrence when compared to PVI with roof line (RR 0.84, 95% CI 0.74-0.95, I 2 0.00%, p-value .008). Conclusion: Our study suggests that adding PWI significantly decreased AF recurrence in patients with persistent AF compared to controlled approaches. It highlights the importance of considering PWI during the initial procedure in this patient population.

Gender difference in outcomes of patients undergoing MitraClip therapy: A systematic review and meta-analysis.

INTRODUCTION: Transcatheter edge-to-edge repair (TEER) of the mitral valve with MitraClip therapy is an emerging treatment in selected patients with severe mitral regurgitation. Identifying the patient with increased risk of poorer outcomes, including mortality, is crucial in these patients. Recent studies suggested conflicting data regarding the effects of gender on outcome in this patient population. We evaluate the impact of gender on the outcome of patients undergoing MitraClip therapy by systematic review and meta-analysis. METHODS: The authors comprehensively searched the databases of EMBASE and MEDLINE from inception to April 2021. Included studies were published cohorts reporting univariate or multivariate analysis of the effects of gender on in-hospital and overall mortality among patients undergoing MitraClip therapy. Data from each study were combined using the random-effects, generic inverse variance method of DerSimonioan and Laird. RESULTS: A total of nine studies were included in this meta-analysis, including 9062 patients. Male gender is associated with higher in-hospital mortality with pooled OR 1.81 (95% confidence interval 1.01-3.22, p-value 0.045) and overall mortality with pooled OR 1.19 (95% CI 1.06-1.33, p-value 0.003). CONCLUSIONS: According to our meta-analysis, the male gender increases the risk of in-hospital mortality up to 1.81 folds and overall mortality up to 1.19 folds.

Zero fluoroscopy approach versus fluoroscopy approach for cardiac arrhythmia ablations: A systematic review and meta-analysis.

BACKGROUND: Radiofrequency catheter ablation for cardiac arrhythmias has traditionally been guided by fluoroscopy. Fluoroscopy exposes the patient, operator, and staff to ionizing radiation which has no safe dose void of stochastic and deterministic biologic risks. Zero fluoroscopy (ZF) approaches for catheter ablation have been advocated to eliminate these risks. We conducted a meta-analysis comparing acute procedure success, recurrence-free survival, complications, and procedure times between the approaches. METHODS: We conducted a literature search from inception through December 2020 in the databases of EMBASE and MEDLINE. We included randomized controlled trials and cohorts that compared the outcomes of interest in ZF and conventional/low fluoroscopy (CF/LF) approaches. The outcomes sought were acute procedure success, recurrence-free survival, complications, and procedure times. Effect estimates were combined, using the random-effects, generic inverse variance method of DerSimonian and Laird. RESULTS: Sixteen studies from 2013 to 2020, including 6052 patients (2219 ZF, 3833 CF/LF) were included. There were no significant differences in acute procedure success rate (odds ratio [OR]: 1.10, 95% confidence interval [CI]: 0.75-1.59), recurrence-free survival (OR: 1.08, 95% CI: 0.78-1.49), periprocedural complication rate (OR: 0.72, 95% CI: 0.45-1.16), or total procedure time (weighted mean difference 2.32 min, 95% CI: -2.85-7.50) between ZF and CF/LF approaches, respectively. Overall, only 1.26% of patients crossed over from ZF to CF/LF arm. CONCLUSIONS: Periprocedural and postprocedural outcomes with a ZF approach compared favorably with traditional fluoroscopic guidance without increasing procedural times. As comfort with ZF grows, coupled with evolving mapping technologies, this method has potential to become the standard approach for catheter ablation.

The effects of marital status on outcome of heart failure population: a systematic review and meta-analysis.

BACKGROUND: Traditional risk factors for worse outcome in heart failure (HF) are well-established. However, there are still many unknown risk factors for worse outcome in this population. Several studies have shown that unmarried status is associated with an increased risk of rehospitalization and mortality in HF patients. However, there is no systematic review or meta-analysis to confirm this association. We performed a systematic review and meta-analysis to explore the effect of marital status on outcome regarding mortality and rehospitalization in HF population. METHODS: We searched the databases of MEDLINE and EMBASE from inception to July 2019. Included studies were published cohort studies or randomised controlled trials reporting rates of mortality and/or rehospitalization in HF patients, married and unmarried. Data from each study were combined using the random-effects model. RESULTS: Ten studies were included in our meta-analysis. We found that unmarried status is associated with increased risk of mortality (pooled OR = 1.52, 95%CI = 1.30-1.78, p < .001), increased risk of rehospitalization (pooled OR = 1.80, 95%CI = 1.18-2.74, p = .007), and increased risk of combined endpoint of mortality and rehospitalization (pooled OR = 1.72, 95%CI = 1.36-2.17, p < .001). CONCLUSIONS: Our meta-analysis demonstrated that being unmarried, divorced, and widowed is associated with a worse outcome in HF population regarding mortality and rehospitalization rate.

Therapeutic implications of statins in heart failure with reduced ejection fraction and heart failure with preserved ejection fraction: a review of current literature.

Statins are one of the standard treatments to prevent cardiovascular events such as coronary artery disease and heart failure (HF). However, data on the use of statins to improve clinical outcomes in patients with established HF remains controversial. We summarized available clinical studies which investigated the effects of statins on clinical outcomes in patients with HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF). Statins possess many pleiotropic effects in addition to lipid-lowering properties that positively affect the pathophysiology of HF. In HFrEF, data from two large randomized placebo-controlled trials did not show benefits of statins on mortality of patients with HFrEF. However, more recent prospective cohort studies and meta-analyses have shown decreased risk of mortality as well as cardiovascular hospitalization with statins treatment. In HFpEF, most prospective and retrospective cohort studies as well as meta analyses have consistently reported positive effects of statins, including reducing mortality and improving other clinical outcomes. Current evidence also suggests better outcomes with lipophilic statins in patients with HF. In summary, statins might be effective in improving survival and other clinical outcomes in patients with HF, especially for patients with HFpEF. Lipophilic statins might also be more beneficial for HF patients. Based on current evidence, statins did not cause harm and should be continued in HF patients who are already taking the medication. Further randomized controlled trials are needed to clarify the benefits of statins in HF patients.

High-power short duration and low-power long duration in atrial fibrillation ablation: A meta-analysis.

BACKGROUND: Multiple strategies have advocation for power titration and catheter movement during atrial fibrillation (AF) ablation. Comparative favoring evidence regarding the efficacy, logistics, and safety of a higher-power, shorter duration (HPSD) ablation strategy compared to a lower-power, longer duration (LPLD) ablation strategy is insubstantial. We performed a meta-analysis to compare arrhythmia-free survival, procedure times, and complication rates between the two strategies. METHODS: We searched MEDLINE, EMBASE, and Cochrane Library from inception to September 2020. We included studies comparing patients who underwent HPSD and LPLD strategies for AF ablation and reporting either of the following outcomes: Freedom from atrial tachyarrhythmia (AT) including AF and atrial flutter, procedure time, or periprocedural complications. We combined data using the random-effects model to calculate the odds ratio (OR) and weight mean difference (WMD) with a 95% confidence interval (CI). RESULTS: Ten studies from 2006 to 2020 involving 2274 patients were included (1393 patients underwent HPSD strategy and 881 patients underwent LPLD strategy). HPSD strategy was not associated with increased freedom from AT at 12-month follow-up (OR = 1.54, 95% CI: 0.99 to 2.40, p = .054). In the subgroup analysis of the randomized controlled trial, the HPSD strategy was associated with increased freedom from AT compared to the LPLD strategy (OR = 3.12, 95% CI: 1.18 to 8.20, p = .02). There was a significant reduction in the HPSD group for the total procedure (WMD = 49.60, 95% CI: 29.76 to 69.44) and ablation (WMD = 17.92, 95% CI: 13.63 to 22.22) times, but not for fluoroscopy time (WMD = 1.15, 95% CI: -0.67 to 2.97). HPSD was not associated with a reduction in esophageal ulcer/atrioesophageal fistula (OR = 0.35, 95% CI: 0.12 to 1.06) or pericardial effusion/cardiac tamponade rates (OR = 1.16, 95% CI: 0.35 to 3.81). CONCLUSIONS: When compared to the LPLD strategy, the HPSD strategy does not improve recurrent AT nor reduce periprocedural complication risks. However, subgroup analysis of the randomized controlled trial showed that HPSD significantly reduces AT recurrence. An HPSD strategy can significantly reduce total procedure and ablation times.

Treatment outcomes of bumetanide continuous infusion: A systematic review and meta-analysis.

The clinical use of continuous bumetanide infusion for acute heart failure and volume overload is common. However, there is not enough supporting evidence for the use of continuous bumetanide infusion. Thus, we conducted this systematic review and meta-analysis aiming to describe the treatment outcomes of continuous bumetanide infusion. We searched Ovid MEDLINE, EMBASE and the Cochrane Library for eligible publications. Inclusion criteria were patients age ≥18 years with bumetanide infusion for heart failure, acute kidney injury (AKI) or volume overload. From 1564 citations, three studies (n = 94 patients) were included in the systematic review and meta-analysis. The mean dose of bumetanide was 1.08 ± 0.43 mg/hour with a mean treatment duration of 45.09 ± 10.12 hours. Mean urine output in response to continuous bumetanide infusion was 1.88 mL/kg/hour (95% confidence interval [CI], 1.72-2.05). The incidence of AKI with continuous bumetanide infusion was 24.7% (95% CI, 8.2-54.6). By using Pearson's correlation coefficient, increasing doses of bumetanide were correlated with increased urine output (P = .026) and increased incidence of AKI (P < .01). There was no correlation between increasing urine output and the incidence of AKI (P = .739). In conclusion, with available evidence, continuous bumetanide infusion may be used in the treatment of acute heart failure or volume overload with close monitoring for new-onset or worsening AKI.

Wide QRS complex and the risk of major arrhythmic events in Brugada syndrome patients: A systematic review and meta-analysis.

BACKGROUND: Brugada syndrome (BrS) is an inherited arrhythmic disease associated with an increased risk of major arrhythmic events (MAE). Previous studies reported that a wide QRS complex may be useful as a predictor of MAE in BrS patients. We aimed to assess the correlation of wide QRS complex with MAE by a systematic review and meta-analysis. METHODS: We comprehensively searched the databases of MEDLINE and EMBASE from inception to June 2019. Included studies were cohort and case control studies that reported QRS duration and the relationship between wide QRS complex (>120 milliseconds) and MAE (sudden cardiac death, sudden cardiac arrest, ventricular fibrillation, sustained ventricular tachycardia, or appropriate shock). Data from each study were combined using the random-effects model. RESULTS: Twenty-two studies from 2007 to 2018 were included in this meta-analysis involving 4,814 BrS patients. The mean age was 46.1 ± 12.8 years. The patients were predominately men (77.6%). Wide QRS duration was an independent predictor of MAE (pooled risk ratio 1.55, 95% confidence interval: 1.04-2.30, P = .30, I 2 = 38.4%). QRS duration was wider in BrS who had history of MAE (weight mean difference = 8.12 milliseconds, 95% confidence interval: 5.75-10.51 milliseconds). CONCLUSIONS: Our study demonstrated that QRS duration is wider in BrS who had history of MAE, and a wide QRS complex is associated with 1.55 times higher risk of MAE in BrS populations. Wide QRS complex can be considered for risk stratification in prediction of MAE in patients with BrS, especially when considering implantable cardioverter-defibrillator placement in asymptomatic patients.

Cognitive impairment and 30-day rehospitalization rate in patients with acute heart failure: A systematic review and meta-analysis.

BACKGROUND: Heart failure (HF) is one of the world leading causes of hospitalization and rehospitalization. Cognitive impairment has been identified as a risk factor for rehospitalization in patients with heart failure. However, previous studies reported mixed results. Therefore, we conducted a systematic review and meta-analysis to assess the association between cognitive impairment and 30-day rehospitalization in patients with HF. METHOD: We performed a comprehensive literature search through July 2018 in the databases of MEDLINE and EMBASE. Included studies were cohort studies, case-control studies, cross-sectional studies or randomized controlled trials that compared the risk of 30-day rehospitalization in HF patients with cognitive impairment and those without. We calculated pooled relative risk (RR) with 95% confidence intervals (CI) and I2 statistic using the random-effects model. RESULTS: Five studies with a total of 2,342 participants (1,004 participants had cognitive impairment) were included for meta-analysis. In random-effect model, cognitive impairment significantly increased the risk of 30-day rehospitalization in HF participants (pooled RR=1.63, 95%CI: 1.19-2.24], I2=64.2%, p=0.002). Subgroup analysis was performed on the studies that excluded patients with dementia. The results also showed that cognitive impairment significantly increased the risk of 30-day rehospitalization in participants with HF (pooled RR=1.29, 95%CI: 1.05-1.59, I2=0.0%, p=0.016), which was consistent with our overall analysis. CONCLUSION: Our meta-analysis demonstrated that the presence of cognitive impairment is associated with 30-day rehospitalization in patients with HF.