Efficacy and safety of TAVR versus SAVR in patients with small aortic annuli: A systematic review and meta-analysis.

INTRODUCTION: Patients with a small aortic annulus (SAA) undergoing aortic valve replacement are at increased risk of patient-prosthesis mismatch (PPM), which adversely affects outcomes. Transcatheter aortic valve replacement (TAVR) has shown promise in mitigating PPM compared to surgical aortic valve replacement (SAVR). METHODS: We conducted a systematic review and meta-analysis following PRISMA guidelines to compare clinical outcomes, mortality, and PPM between SAA patients undergoing TAVR and SAVR. Eligible studies were identified through comprehensive literature searches and assessed for quality and relevance. RESULTS: Nine studies with a total of 2476 patients were included. There was no significant difference in 30-day Mortality between TAVR vs SAVR groups (OR = 0.65, 95% CI [ 0.09-4.61], P = 0.22). There was no difference between both groups regarding myocardial infarction at 30 days (OR = 0.63, 95% CI [0.1-3.89], P = 0.62). TAVR was associated with a significantly lower 30-day major bleeding and 2-year major bleeding, Pooled studies were homogeneous (OR = 0.44, 95% CI [0.31-0.64], P < 0.01, I2 = 0, P = 0.89), (OR = 0.4 ,95% CI [0.21-0.77], P = 0.03, I2 = 0%, P = 0.62) respectively. TAVR was associated with a lower rate of moderate PPM (OR = 0.6, 95% CI [ 0.44-0.84], p value = 0.01, i2 = 0%, p value = 0.44). The overall effect estimate did not favor any of the two groups regarding short-term Mild AR (OR = 5.44, 95% CI [1.02-28.91], P = 0.05) and Moderate/severe AR (OR = 4.08, 95% CI [ 0.79-21.02], P = 0.08, I2 = 0%, P = 0.59). CONCLUSION: Our findings suggest that both TAVR and SAVR are viable options for treating AS in patients with a small aortic annulus. TAVR offers advantages in reducing PPM and major bleeding, while SAVR performs better in terms of pacemaker implantation. Future studies should focus on comparing newer generation TAVR techniques and devices with SAVR. Consideration of patient characteristics is crucial in selecting the optimal treatment approach for AS.

Relationship Between Body Mass Index and Outcomes in Acute Myocardial Infarction.

Background: The prevalence of obesity in the United States is high. Obesity is one of the leading risk factors in the development of acute myocardial infarction (AMI). Nevertheless, how obesity impacts AMI in-hospital outcomes remains controversial. Methods: Using National Inpatient Sample (NIS) database, we identified patients diagnosed with AMI from the year 2015 to 2018. We divided these patients into five subgroups based on their body mass index (BMI). We compared outcomes such as mortality, length of inpatient stay, and inpatient complications between our subgroups. Statistical analysis was done using the program STATA. Our nationally representative analysis included 561,535 patients who had an AMI event across various weight classes. Results: Most of our sample was obese (BMI > 30 kg/m2) and male. Obese patients were significantly younger than the rest. Length of stay (LOS) for AMI was highest for those with a BMI of less than 24 kg/m2. In-hospital mortality is highest for those with a BMI of < 30 kg/m2 and lowest for those with a BMI of 30 - 40 kg/m2. Inpatient complications are highest in the lower BMI population (BMI < 24 kg/m2). Conclusion: The current analysis of a nationally representative sample showed the clinical implications of BMI in patients with AMI. Patients with a BMI of 30 - 40 kg/m2 had more favorable LOS, inpatient complications, and in-hospital mortality when compared to those with an ideal body weight. Hence, this supports and expands on the concept of the "obesity paradox". Further studies are needed to further investigate the possible mechanism behind this.

A Case of Burnt-Out Cardiac Sarcoidosis Presenting With Sustained Ventricular Tachycardia.

Cardiac sarcoidosis is a challenging clinical entity in terms of diagnosis and management. Cardiac involvement is the most common cause of death in patients with sarcoidosis. Recently, there have been new advancements in the imaging modalities that aid in the diagnosis of this condition, including cardiac MRI and PET scan. These tools can help identify and determine the extent of the progression of sarcoidosis, which can have diagnostic and therapeutic implications. In this report, we present the case of a 74-year-old man with no history of sarcoidosis who presented with sustained ventricular tachycardia (VT) and was subsequently found to have findings consistent with burnt-out sarcoidosis on imaging. This case highlights the differences in the management of various stages of cardiac sarcoid involvement to reduce adverse outcomes.

Ortner's syndrome: A rare case of hoarseness secondary to chronic aortic dissection.

Ortner's syndrome, also known as cardiovocal syndrome, is a rare presentation of aortic dissection. Symptoms occur as a result of recurrent laryngeal nerve compression. Our report describes a case of a patient who complained of hoarseness for a few months and was eventually diagnosed with chronic aortic dissection.

Impact of Digoxin Use on Guideline-Directed Medical Therapy in Patients With Heart Failure With Reduced Ejection Fraction.

Background: Digoxin was one of the first agents used in the management of heart failure with reduced ejection fraction (HFrEF). Concerns over its safety, efficacy, and the introduction of guideline-directed medical therapy (GDMT) have relegated it to a secondary role. The efficacy of digoxin is still under debate, and its use in patients on GDMT remains unclear. We aim to evaluate whether patients with HFrEF on digoxin can tolerate higher doses of a ß-blocker (BB), angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blocker (ARB), mineralocorticoid receptor antagonists (MRAs), and angiotensin receptor-neprilysin inhibitor (ARNI). Methods: A retrospective chart review was performed on 233 patients with HFrEF managed at a tertiary care center in Cleveland, Ohio. A bivariate analysis was performed to compare patients on digoxin with patients not on digoxin in terms of ability to progress the dosing of BB, ACEI, MRA, ARB, or ARNI. Results: Thirty-four (14.6%) of our 233 patients were receiving digoxin at baseline visit. The digoxin group was more likely to have lower initial and last systolic blood pressure, initial diastolic blood pressure, and left ventricular ejection fraction. Mean follow-up duration and baseline sodium level were higher in the digoxin group. There was no significant difference between the two groups in terms of patients receiving higher doses of BB (P = 0.235), ACEI/ARB (P = 0.903), MRA (P = 0.331), or ARNI (P = 0.717). Conclusions: There was no significant difference between the doses of BB, ACEI, ARB, MRA, or ARNI among HFrEF patients on digoxin compared to those that were not. Randomized control trials with a larger sample are needed to establish our findings of digoxin not significantly affecting the ability to up titrate GDMT in HFrEF patients.

Right Coronary Artery to Right Atrial Fistula: Role of Multi-Modality Imaging and Percutaneous Closure.

Coronary artery fistula (CAF) is a connection between a coronary artery and a cardiac chamber or nearby vessel. Our case represents a fistula arising from the right coronary artery and terminating in the right atrium, presenting as atrial fibrillation. CAF closure options include surgical and percutaneous approaches.

Disparities in the Prescription of Statins in the Primary Care Setting: A Retrospective Observational Study.

Despite the high disease burden of atherosclerosis, evidence exists for the disparity in the prescription of guideline-indicated medications between genders, racial groups, socioeconomic groups, and ages. We aim to perform a retrospective study looking at the disparity in statin prescription for primary and secondary prevention in these groups. Data were collected from a single center and included patients with an LDL level >190 mg/dL, diagnosis of diabetes mellitus with LDL level >70 mg/dL, and diagnosis of cardiovascular disease regardless of LDL level. Patients older than 75 or younger than 21 were excluded from the study. Complex samples multivariable logistic and linear regression models were used to calculate the adjusted odds ratio and 95% confidence interval. The total study population was n = 56,995. Of those, 57.89% (n = 32,992) were female. Only 59.56 % of these patients for whom statin therapy was indicated received it. Most patients were White (53.21%) followed by African Americans (35.98%), Asians (2.43%), American Indian/Native Alaskans (0.40%), and Native Hawaiian/Pacific Islander (0.18%). There is a clear disparity in statin prescription favoring males, the elderly, and people of white ethnicity. Interestingly, Asians were more likely to be prescribed statins as opposed to whites. Self-pay patients were more likely to receive statins than patients on Medicare.Despite being indicated, Statins are under prescribed. Disparities based on race, gender, and insurance type mirror previous trends in the literature. Some results have shown a reversal in trends such as the higher prescription for Asian-Americans. Multiple patient-specific, provider-related, institutional factors might explain these disparities and must be investigated.

Demographic Undertones for Sepsis Mortality in a Community-Based Hospital.

BACKGROUND: Sepsis continues to take main stage in healthcare. Therefore, it remains crucial to elucidate contributors to sepsis mortality. The aim of this study is to determine the impact of race, insurance type, and code status on sepsis mortality in a community health system. METHODS: We conducted a retrospective cohort study of inpatient adults of any sex, race, and insurance type with a diagnosis of sepsis, severe sepsis, septic shock, or pneumonia. RESULTS: We included 913 patients, with an average age of 69 years for expired patients and 62 years for non-expiring patients (P < 0.0001). After controlling for other variables, patients who presented as comfort care arrest were 4.3 (95% confidence interval (CI): 1.8 to 9.9, P = 0.0007) times more likely to have died than full code patients. Those who were comfort care only were 10.6 (95% CI: 0.8 to 140.6, P = 0.0741) times more likely to have died than the full code, although this was not statistically significant. CONCLUSIONS: The results suggest that patients who are comfort care arrest have an increased risk of sepsis mortality. The results show no impact of insurance type or race on sepsis mortality, which is in contrast to some existing literature. The study suggests that institutions may need to investigate internal variables related to sepsis mortality.