Carotid access for transcatheter aortic valve replacement: A meta-analysis.

OBJECTIVE: We sought to evaluate the feasibility and safety of carotid access transcatheter aortic valve replacement (TAVR) by performing a meta-analysis of published cases. BACKGROUND: Several case series and regional data have provided initial basis for carotid access TAVR in patients with prohibitive femoral approach. We performed this meta-analysis to provide further evidence of feasibility and safety of carotid TAVR. METHODS: We searched PubMed, EMBASE, CINAHL, and Cochrane CENTRAL for any study on carotid access TAVR involving ⩾5 patients since inception till March 1, 2020. Random-effects model was used to compute overall effects. The outcomes analyzed were all-cause mortality, Transient ischemic attack (TIA)/stroke, need for permanent pacemaker (PPM) implantation, pericardial tamponade, access site complications, major bleeding, and length of stay. RESULTS: There was a total of 17 retrospective studies (n = 2082) with a median follow-up of 1 month. Mean age of the patient was 80 years. Mean Euroscore and STS scores were 15 ± 6.2 and 7.9 ± 3.3, respectively. The procedural success rate was 99%. The rate of all-cause mortality was 6.7% (range 4.6-9.7%, p < .001, I2 = 67%). Incidence of TIA/stroke was 3.9% (range 3.1-4.8%, p < .001, I2 = 0%) and PPM implantation was 16.7% (range 12.5-21.9%, p < .001, I2 = 56%). Rate of pericardial tamponade, vascular complication, and major bleeding were 1.7, 2.5, and 7%, respectively. Average length of hospital stay was 7.7 days. CONCLUSION: Our results show that transcarotid approach is a feasible option in patients with prohibitive femoral access for TAVR.

Baseline thrombocytopenia in women with coronary heart disease increases incident acute coronary syndrome: insights from national inpatient database.

There are paucity of data on gender-based differences in the effect of thrombocytopenia and coronary heart disease (CHD) towards development of acute coronary syndrome (ACS). We used National Inpatient Sample (NIS) database of the United States to assess the gender-based differences in the association of thrombocytopenia with CHD and the impact of thrombocytopenia on mortality, length of stay and hospitalization costs on ACS subgroup of CHD. Our analysis found that thrombocytopenia was associated with increased odds of CHD on univariate (odds ratio [OR] 1.31 (95% CI 1.30-1.32) p < 0.001) and multivariate (OR 1.36 (95% CI 1.34-1.38) p < 0.001) analyses. Thrombocytopenic CHD patients had increased odds of developing ACS only in women (OR 1.15, 95% CI 1.12-1.17, p < 0.001). Thrombocytopenia was found to be associated with poor short-term outcome in ACS subgroup of CHD with higher in-hospital mortality (OR 1.64, CI 1.58 to 1.71, p < 0.001), length of stay (3.4 days, CI 3.30-3.52, p < 0.001), and cost of hospitalization ($55,652, CI 53,717-57,587, p < 0.001). Thrombocytopenic women with ACS have greater odds of mortality compared to men. Our study suggests that thrombocytopenia among women with CHD is associated with increased odds of developing ACS. Women with ACS have greater mortality compared to men. Thrombocytopenic ACS patients have worse in-hospital outcome compared to patients with normal platelet count. We demonstrated association only and is not possible to establish causality with our study.

Periprocedural and long-term outcomes of endovascular abdominal aortic aneurysm repair in cardiology practice.

BACKGROUND: Endovascular repair of abdominal aortic aneurysm (AAA) has recently been made a class I indication in the treatment of AAA. In comparison to the conventional open surgical treatment, endovascular AAA repair (EVAR) is associated with equivalent long-term morbidity and mortality rates. Vascular surgeons perform majority of EVAR. There are no reports for the long-term results of this intervention performed by interventional cardiologists. We present one of the first reports of periprocedural and long-term outcomes of EVAR performed by interventional cardiologists. METHODS: Retrospective chart review on patients with attempted EVAR between September 2005 and January 2011 was performed. Included cases were all consecutive patients who had attempted EVAR by interventional cardiologists. RESULTS: During the study period EVAR was attempted in 170 patients, with 27% being women. The mean age was 74 years (range 52-93). The endovascular graft placement was successful in 96% (163/170) of patients. Procedure failures were more common in women (6 of 46 vs 1 of 124, P = 0.003). The 30-day mortality was 1.8 % (3 of 170). In patients with successful EVAR the mean follow-up was 30 months and mean length of hospital stay was 3.5 ± 3.2 days. Major periprocedural complications were noted in 9% patients (15 of 167). During follow-up, six patients (3.5%) required re-intervention and additional 16 patients died with no aneurysm related deaths. CONCLUSION: EVAR primarily performed by interventional cardiologists demonstrates high periprocedural and long-term success rates. A higher EVAR failure rate has been observed in women.

12-month primary patency rates of contemporary endovascular device therapy for femoro-popliteal occlusive disease in 6,024 patients: beyond balloon angioplasty.

BACKGROUND: Endovascular approach to superficial femoral artery (SFA) disease, the most common cause of symptomatic peripheral arterial disease, remains fraught with high failure rates. Newer devices including second-generation nitinol stents, drug-coated stents, drug-coated balloons, covered stents, cryo-therapy, LASER, and directional atherectomy have shown promising results. Clinical equipoise still persists regarding the optimal selection of devices, largely attributable to the different inclusion criteria, study population, length of lesions treated, definition of "patency" and "restenosis," and follow-up methods in the pivotal trials. METHODS: A prospective protocol was developed. We performed a literature search using PubMed from January 2006 to November 2013. Published articles including endovascular interventions in SFA or popliteal arteries with reported 12-month "primary patency" or "binary restenosis" rates as endpoints were included. RESULTS: We identified 6,024 patients in 61 trials reporting 12-month primary patency rates in patients with femoropoliteal disease. Primary patency rates were (weighted average) 77.2% for nitinol stents, 68.8% for covered stents, 84% for drug eluting stents, 78.2% for drug eluting/coated balloon, 60.7% for cryoballoon, 51.1% for LASER atherectomy, 63.5% for directional atherectomy and 70.2% with a combination of endovascular devices. CONCLUSION: The most frequently used endovascular devices yielded various 12-month primary patency rates ranging from 51% to 85%. The increased variation in inclusion criteria, length, and complexity of lesions between studies does not allow direct comparison between them. Larger randomized trials in specific patient populations comparing those modalities is needed before we can make safe recommendation of the superiority of one device over the other.

Decreased readmissions and improved quality of care with the use of an inexpensive checklist in heart failure.

Providing effective discharge instructions, appropriate dose uptitration, education regarding heart failure (HF) monitoring, and strict follow-up have all been shown to decrease readmissions for HF but are all underutilized. The authors developed and evaluated the impact of a quality-improvement HF checklist as a tool to remind physicians to improve quality of care in HF patients. The checklist was used in randomly selected patients admitted with a primary diagnosis of acute decompensated HF. It included documentation regarding medications and dose uptitration, relevant counseling, and follow-up instructions at discharge. The checklist was used in 48 patients, and this checklist group was compared with 48 patients as a randomly selected control group. Higher proportions of patients were taking angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) in the checklist group compared with the control group (40 of 48 vs 23 of 48, P<.001). Compared with the controls, the rate of dose uptitration for ß-blockers and/or ACE inhibitors/ARBs was more common in the checklist group (4 of 48 vs 21 of 48, P<.001). Both 30-day (19% to 6%) and 6-month (42% to 23%) readmissions were lower in the checklist group. The use of an HF checklist was associated with better quality of care and decreased readmission rates for patients admitted with HF.

Safety and feasibility of orbital atherectomy for the treatment of calcified coronary lesions: the ORBIT I trial.

OBJECTIVE: The ORBIT I trial evaluated the safety and performance of an orbital atherectomy system (OAS) for the treatment of de novo calcified coronary lesions. BACKGROUND: Severely calcified coronary arteries pose an ongoing treatment challenge. Stent placement in calcified lesions can result in stent under expansion, malapposition, and procedural complications. OAS treatment may change calcified lesion compliance to reduce procedural complications and facilitate stent placement. METHODS: The ORBIT I trial, a prospective, nonrandomized study, was conducted in two centers in India. Fifty patients with de novo calcified coronary lesions were enrolled. Patients were treated with the OAS followed by stent placement. RESULTS: The average age of the patients was 57.4 years and 90% were male. Mean lesion length was 13.4 mm. The average number of OAS devices used per patient was 1.3. Device success was 98%, and procedural success was 94%. The cumulative major adverse cardiac event rate was 4% in-hospital (two non-Q-wave myocardial infarctions), 6% at 30 days (one additional non-Q-wave myocardial infarction leading to target lesion revascularization), and 8% at 6 months (one additional event of cardiac death). Angiographic complications were observed in seven patients (six dissections and one perforation). CONCLUSION: The ORBIT I trial suggests that the OAS may offer an effective method to change compliance of calcified coronary lesions to facilitate optimal stent placement in these difficult to treat patients. A larger trial is required to establish safety and overall effectiveness of the OAS in treating calcified coronary lesions.

No Racial Disparities in the Treatment of ST Elevation Myocardial Infarction - A Community-based Experience.

Whether racial disparities exist in the treatment of ST elevation myocardial infarction (STEMI) is not exactly known. We report a retrospective chart review of patients with first event of STEMI, in two groups separated by one decade. Results revealed that hospital mortality in the 2007 and 1997 groups for African Americans versus Caucasians was one of 22 versus 21 of 170, 95 % confidence interval (CI) -0.178 to 0.022, p=0.48 and four of 41 versus 39 of 402, 95 % CI -0.095 to 0.096, p=1.00, respectively. The mean length of stay (LOS) for African Americans and Caucasians in the 2007 and 1997 groups was 5.7 versus 4.1 days (p=0.09) and 7.3 versus 6.6 days (p=0.42), respectively. During follow-up, a total of 40 patients needed re-intervention in the 2007 group. The re-intervention rate in African American patients being 13.6 % (three of 22) versus 21.2 % (36 of 170) in Caucasians, 95 % CI -0.231 to 0.081, with p=0.57. In conclusion, there was no evidence of racial disparity in the treatment of STEMI in terms of hospital mortality, length of hospital stay and re-intervention rate.

Carotid stenting in high-risk patients: early and late outcomes.

PURPOSE: Some patients with severe carotid stenosis have anatomical or clinical comorbidities that place them at high risk for carotid endarterectomy (CEA). The early and late outcomes after carotid artery stenting (CAS) were evaluated in patients at high risk for CEA. METHODS: Between 2002 and 2009, 186 patients were enrolled in a high-risk CAS institutional registry. The primary outcome was major adverse cardiac and cerberovascular events (MACCEs) at 30 days, including death, stroke, and myocardial infarction. Secondary outcomes were technical, procedural, and clinical success; nonstroke neurological events; and death and ipsilateral stroke at 5 years. RESULTS: Twenty-five patients (13.2%) were symptomatic. Thirty day MACCE occurred in 2.6%, including death in 1 (0.5%), stroke in 3 (1.6%), and myocardial infraction in 1 (0.5%) patient. Strokes were nonfatal in 3 (1.6%), major in 2 (1.1%), and minor in 1 (0.5%) patients. Other neurological events included transient ischemic attack in 9 (4.7%) and retinal artery occlusion in 2 (1.1%) patients. After stroke, 2 patients had complete resolution of neurological deficit within 30 days, and 1 patient had improvement in neurological deficit. By Kaplan--Meier analysis, all-cause mortality was 47.5% and ipsilateral stroke was 4.5% at 5 years. CONCLUSIONS: In patients who are high risk for CEA, CAS can be performed with low MACCE at 30 days and ipsilateral stroke at 5 years. However, nearly half of these patients die within 5 years from causes unrelated to stroke.

Endovascular abdominal aortic aneurysm repair by interventional cardiologists--a community-based experience.

INTRODUCTION: Endovascular repair of abdominal aortic aneurysm (AAA) is a relatively recent technology. In comparison to the conventional open surgical treatment for AAA, endovascular AAA repair (EVAR) combines a less-invasive approach with lower morbidity and mortality. There have been few studies regarding the performance of this procedure in a community-based setting. We report our experience of EVAR performed primarily by interventional cardiologists in a community hospital. METHODS: In our community hospital setting, between September 2005 and November 2007, we included all patients who underwent EVAR by interventional cardiologists, with available on-site vascular surgical support. Clinical and serial computed angiographic imaging outcomes were followed by a retrospective chart review. Data collection tools included demographic and clinical characteristics, anatomical aneurysm features, length of stay, peri- and postprocedural complications, and mortality. RESULTS: A total of 71 consecutive patients had EVAR attempted. The endovascular stent placement was successful in 67 (93%) patients. Thirty-day mortality in this study was 1 of 71 (1.4%). All four procedural failures and the single periprocedural mortality occurred in women. Mean follow-up was 12 months. There were a total of six mortalities and among these four were women (P ≤ 0.001); however, multivariate analysis revealed loss of significant difference in mortality (P = 0.16). Major complications following EVAR were noted in 10 of 71 (14%) patients. CONCLUSION: EVAR can be successfully performed by experienced interventional cardiologists with vascular surgical support in a community-based setting. In our experience, there is acceptable rate of complications and mortality in a carefully selected patient population.