Incidence of Early Atrial Fibrillation After Transcatheter versus Surgical Aortic Valve Replacement: A Meta-Analysis of Randomized Controlled Trials.

BACKGROUND: Post-operative atrial fibrillation (POAF) is common after aortic valve replacement (AVR) and is associated with worse outcomes. We performed a meta-analysis of randomized controlled trials comparing Surgical Aortic Valve Replacement (SAVR) and Transcatheter Aortic Valve Replacement (TAVR) for incidence of POAF at 30 days. METHODS: We searched databases from 1/1/1990 to 1/1/2020 for randomized studies comparing TAVR and SAVR. POAF was defined as either worsening or new-onset atrial fibrillation. Random effects model was used to estimate the risk of POAF with TAVR vs SAVR in all trials, and in subgroups (low, intermediate, high risk, and in self-expandable vs balloon expandable valves). Sensitivity analysis was performed including only studies reporting new-onset atrial fibrillation. RESULTS: Seven RCTs were identified that enrolled 7,934 patients (3,999 to TAVR and 3,935 to SAVR). The overall incidence of POAF was 9.7% after TAVR and 33.3% after SAVR. TAVR was associated with a lower risk of POAF compared with SAVR (OR 0.21 [0.18-0.24]; P < 0.0001). Compared with SAVR, TAVR was associated with a significantly lower risk of POAF in the high-risk cohort (OR 0.37 [0.27-0.49]; P < 0.0001), in the intermediate-risk cohort (OR 0.23 [0.19-0.28]; P < 0.0001), low-risk cohort (OR 0.13 [0.10-0.16]; P < 0.0001). Sensitivity analysis of 4 trials including only new-onset POAF showed similar summary estimates (OR 0.21, 95% CI [0.18-0.25]; P< 0.0001). CONCLUSIONS: TAVR is associated with a significantly lower risk of post-operative atrial fibrillation compared with SAVR in all strata. Further studies are needed to identify the contribution of post-operative atrial fibrillation to the differences in clinical outcomes after TAVR and SAVR.

New therapeutic perspectives with clevidipine: an ultra-short-acting intravenous Ca2+ channel blocker.

Intravenous antihypertensive agents are used in clinical situations in which the immediate, precise control of blood pressure is a clinical necessity. Clevidipine is a new, vascular-selective, dihyrdopyridine Ca(2+) channel blocker, which exerts its hemodynamic effects through selective arterial vasodilation without effects on the venous circulation. Because it is a potent coronary vasodilator, reduction in mean arterial pressure does not impair coronary perfusion. The unique properties of clevidipine include an ultra-short pharmacodynamic duration of action and a half-life after intravenous administration of approximately 2 min, resulting in very rapid onset and offset of antihypertensive effects. In clinical trials performed in patients undergoing cardiac surgery, clevidipine proved superior to nitroprusside and nitroglycerin in maintaining blood pressure within predetermined ranges during the perioperative period. Its safety profile is comparable to nicardipine and nitroglycerin and, in one study, was associated with reduced 30-day mortality compared with nitroprusside. Clevidipine constitutes a useful addition to available intravenous agents and could prove particularly valuable in circumstances that require the ability to rapidly terminate the blood pressure-lowering effects of administered agents.

Cardiovascular surgical outcomes in patients with the antiphospholipid syndrome--a case-series.

BACKGROUND: Patients with the antiphospholipid syndrome (APLS) have severe involvement of the cardiovascular apparatus and often need surgical interventions to correct these manifestations. Few studies that have looked at the outcomes of cardiothoracic surgeries in APLS patients have reported high rates of perioperative mortality and thromboembolic events. OBJECTIVE: Our goal was to examine the outcomes of adult APLS patients undergoing coronary artery bypass surgery (CABG) and/or valvular surgery. We also wanted to determine whether aggressive anticoagulation therapy could prevent life threatening thromboembolic complications in these patients. METHODS: We retrospectively reviewed medical records of nine patients with primary APLS undergoing cardiothoracic surgery between 1985 and 2005 at our institution. Patient demographics, operative procedures and one-year clinical outcomes were obtained. RESULTS: Forty-five percent of our patients had more than three cardiovascular risk factors other than APLS. There were no mortalities in our case series. However, 89% of our patients developed major complications. Despite aggressive anticoagulation, 37.5% developed thromboembolic events including cerebrovascular accidents, myocardial infarctions and vena caval thrombosis. Other complications included heparin-induced thrombocytopenia, redo of CABG surgery and sepsis. CONCLUSION: Despite aggressive anticoagulation and lack of significant pre-operative co-morbidities, APLS patients undergoing cardiothoracic surgery appear to have high rates of post-operative clinical events.

Isolated noncompaction of the ventricular myocardium: contemporary diagnosis and management.

Noncompaction of the ventricular myocardium is a rare form of cardiomyopathy that has been described since the early 1990s. However, noncompaction remains frequently overlooked, in part due to the limited awareness of its unique clinical and imaging characteristics. Contemporary diagnosis has been facilitated by the introduction of specific morphologic criteria by echocardiography and cardiac magnetic resonance. Management issues revolve around the management of heart failure, arrhythmias, and thromboembolic events in order to prevent the significant morbidity and even mortality that has been associated with this entity. Finally, the genetics of noncompaction have been diverse and an issue of clinical importance as it relates to screening of first-degree relatives of affected patients. Two recent cases are presented and many of the contemporary issues in diagnosis and management, based on an extensive review of the literature, are addressed.

New drugs for hypertension: what do they offer?

A new drug might make a positive contribution to existing therapies for hypertension by: 1) reducing blood pressure (BP) via a novel pharmacologic mechanism; 2) possessing pharmacologic or pharmacokinetic properties that make it superior to other members of its class; or 3) facilitating BP control in refractory patients. In this paper, we review four experimental agents that promise to advance therapeutics by one of these mechanisms. Aliskiren is the first in a new class of potent, orally effective renin inhibitors. Aliskiren produces dose-dependent BP reduction with few side effects and constitutes a novel pharmacologic approach to renin-angiotensin-aldosterone inhibition. Nebivolol is a third-generation, cardioselective beta-blocker that produces vasodilation and improves endothelial function via the l-arginine/nitric oxide pathway. Clevidipine is an ultra-short-acting, vascular-selective, dihydropyridine calcium antagonist that is being developed for intravenous use in acute hospitalized patients. Darusentan is an endothelin(A) selective endothelin receptor antagonist that is effective in achieving BP control in a significant percentage of patients who remain uncontrolled despite treatment with three or more antihypertensive drugs.

Sífilis congénita: artículo de revisión / Congenital syphilis: article of review

El resurgimiento de la sífilis en la población de edad fértil ha despertado nuevo interés por la sífilis congénita. La infección se adquiere en las últimas semanas del embarazo pero si la espiroquetemia no es tan intensa, pueden no identificarse en el nacimiento signos de enfermedad congénita, los cuales se manifestarán varias semanas más tarde. Por lo tanto la infección persistente puede ser sintomática o asintomática