Radial vs. Femoral Access for Percutaneous Coronary Artery Intervention in Patients With ST-Elevation Myocardial Infarction.

BACKGROUND: We aimed to compare the safety and efficacy of transradial vs transfemoral access for coronary angiography and intervention in patients presenting with ST-segment elevation myocardial infarction (STEMI) without cardiogenic shock. METHODS: PubMed, Embase and Cochrane Central were searched for randomized controlled trials (RCTs) comparing outcomes of STEMI patients who underwent transradial angiography (TRA) compared to transfemoral angiography (TFA). Our outcomes of interest were major adverse cardiac events (MACE), all-cause mortality, severe bleeding, access site bleeding, myocardial infarction, stroke, and major vascular complications. Summary statistics are reported as odds ratios (OR) with 95% confidence intervals (CI). RESULTS: In a pooled analysis of 17 RCTs with 12,118 randomized patients, the use of transradial compared to transfemoral approach in STEMI patients without cardiogenic shock was associated with a significant reduction in MACE [OR 0.85 (95% CI 0.73-0.99; p = 0.04; NNT = 111; I2 = 0%)] and all-cause mortality [OR 0.71 (95% CI 0.57-0.88; p < 0.01; NNT = 111; I2 = 0%)]. Severe bleeding [OR 0.57 (95% CI 0.44-0.74; p < 0.01; NNT = 77; I2 = 0%)], access-site bleeding [OR 0.39 (95% CI 0.26-0.59; p < 0.01; NNT = 67; I2 = 24%)], and major vascular complications [OR of 0.31 (95% CI 0.17-0.55; p < 0.01; NNT = 125; I2 = 0%)] were lower in TRA compared to TFA. There was no difference in stroke (0.6% vs 0.5%) or recurrent myocardial infarction (2.01% vs 2.02%) between the two approaches. CONCLUSIONS: For coronary intervention in STEMI patients without cardiogenic shock, there is a clear mortality benefit with the TRA over TFA. Further studies are needed to see if this mortality benefit persists over the long-term.

Meta-analysis of Dual Antiplatelet Therapy Versus Monotherapy With P2Y12 Inhibitors in Patients After Percutaneous Coronary Intervention.

The optimal duration of dual antiplatelet therapy (DAPT) in the era of second-generation drug-eluting stents is a matter of considerable debate with more data suggesting a shorter period of DAPT is feasible. We performed a meta-analysis to evaluate DAPT compared with monotherapy with a P2Y12 inhibitor after a percutaneous coronary intervention (PCI). PubMed, Embase, and Cochrane Central were searched from inception to October 2019 to identify randomized controlled trials that compared outcomes of patients treated with either DAPT or monotherapy with a P2Y12 inhibitor following PCI. Primary outcomes of interest included major bleeding, ischemic events (myocardial infarction, stroke, stent thrombosis, major adverse cardiac events), and both all-cause and cardiovascular mortality. Event rates were extracted, and the Mantel-Haenszel fixed-effects model was used to perform a meta-analysis. Summary statistics are reported as odds ratios with 95% confidence intervals. Subgroup analyses were performed using the generic inverse method. We identified four trials with 29,089 randomized patients. Use of P2Y12 monotherapy was associated with 30% lower odds of major bleeding 0.70 (0.60-0.81; p <0.01). Ischemic and mortality outcomes were similar in the two groups. For the outcome of major bleeding the results favor the use of P2Y12 monotherapy in the subgroups of age, sex, diabetes, chronic kidney disease, acute coronary syndrome, and multivessel disease. The present meta-analysis provides the most updated data on the use of DAPT duration. Following an initial period of short-term DAPT, monotherapy with a P2Y12 inhibitor appears to be the superior strategy for optimization of bleeding and thrombotic risk after PCI.

Valve-in-Valve Transcatheter Implantation Versus Redo Surgical Aortic Valve Replacement.

Valve-in-valve (ViV) transcatheter aortic valve implantation (TAVI) for a failing prosthesis is an appealing alternative to redo surgical AVR. We utilized data from the US National Inpatient Sample for the period 2012 to 2016 to identify hospitalizations for either ViV-TAVI or redo-SAVR. The primary outcomes of interest were in-hospital adverse events composite outcome (comprising of mortality, myocardial infarction, stroke, or acute kidney injury) and all-cause mortality. We used propensity score matching to adjust for the baseline differences between ViV-TAVI and redo-SAVR cohorts. Survey techniques were employed to compare the 2 groups. Over 5 years, there has been a considerable increase in both interventions for prosthetic aortic valve failure, with significantly higher utilization of ViV-TAVI compared to redo-SAVR (p <0.01). Out of the 3,305 hospitalizations for prosthetic aortic valve failure, 1,420 in matched pairs underwent either ViV-TAVI (n = 710) or redo-SAVR (n = 710). ViV-TAVI was associated with lower in-hospital composite adverse outcomes (14.1% vs 25.4%, p = 0.018), and numerically lower but statistically insignificant mortality (<1.0% vs 5.2%; p = 0.06). ViV-TAVI was associated with a decreased length of hospitalization (mean 6.6 vs 9.7 days; p <0.01). In the matched cohort, postoperative bleeding and transfusions were significantly lower for ViV-TAVI compared with redo-SAVR (17.6% vs 31.0% and 12% vs 31% respectively, p <0.01 for both). Acute kidney injury, sepsis, permanent pacemaker implantation, and vascular complications, although numerically better, did not differ between 2 strategies. In conclusion, ViV-TAVI is associated with lower in-hospital MACE rates and reduced length of hospitalization compared with redo-SAVR.