Ezenna, Chidubem

ABSTRACT Background Percutaneous left atrial appendage occlusion (LAAO) is an alternative strategy for stroke prevention in patients with nonvalvular atrial fibrillation (AF) with contraindications to long‐term oral anticoagulation therapy. However, evidence comparing the long‐term outcomes of LAAO with those of direct oral anticoagulants (DOAC) remains limited. Methods A systematic search was conducted across PubMed, Scopus, and the Cochrane databases through April 2026. Co‐primary outcomes were major adverse cardiovascular and cerebrovascular events (MACCE; composite of cardiac death, stroke, or systemic embolism) and net adverse clinical events (NACE; composite of MACCE and non‐procedure‐related bleeding). Secondary endpoints included individual components of co‐primary endpoints, ischemic and hemorrhagic stroke, all‐cause death, major or clinically significant bleeding (procedure + non‐procedure related), and stroke or systemic embolism. The random‐effects model was used to generate risk ratios (RRs) and 95% CIs. Results Four randomized controlled trials comprising 5890 AF patients and a median follow‐up of 3 years were included. There was no significant difference between LAAO and DOAC therapy in the risk of MACCE (RR 1.17; 95%CI 0.96–1.41; I 2 = 0%) or NACE (RR 0.89; 95%CI 0.65–1.24; I 2 = 85%). Both LAAO and DOAC therapy were similar in risk of cardiac death, stroke, systemic embolism, hemorrhagic stroke, ischemic stroke, all‐cause mortality, stroke or systemic embolism, and pericardial effusion. LAAO was associated with a lower risk of non‐procedure‐related bleeding (RR 0.60; 95%CI 0.47–0.76; I 2 = 59%). Conclusion LAAO demonstrated efficacy comparable to DOAC therapy in reducing the risk of MACCE, NACE, and ischemic events, while significantly reducing the risk of non‐procedure‐related bleeding. Our findings support a tailored approach to stroke prevention in AF, wherein LAAO serves as an effective alternative for patients with contraindications to DOAC therapy.

Background Older adults undergoing percutaneous coronary intervention (PCI) face unique challenges due to complex anatomy and comorbidities. Intravascular imaging [including intravascular ultrasound (IVUS) and optical coherence tomography (OCT)] has been shown to improve PCI outcomes, but its benefits in older adults are less well established. We conducted a meta-analysis of randomized controlled trials (RCTs) to compare intravascular imaging with angiography alone to guide PCI in older adults. Methods Cochrane, PubMed, and Scopus were searched for RCTs comparing intravascular imaging (IVUS or OCT) vs. angiography alone in adults aged ≥65 years. The outcome of interest was major adverse cardiovascular events (MACE) at the longest follow-up, as defined by each trial. Subgroup analyses were performed based on intravascular imaging modality, age group, and lesion complexity. Data were pooled using random-effects models, and heterogeneity was assessed using Higgins’ I ² statistic. Results Nine RCTs ( n = 7164, intravascular imaging = 3703, angiography alone = 3461) met the inclusion criteria. Intravascular imaging significantly reduced MACE compared with angiography alone [relative risk (RR) 0.66, 95% confidence interval (CI) 0.56–0.77; P < 0.001; I ² = 0%]. IVUS demonstrated superiority over angiography alone (RR 0.55, 95% CI 0.43–0.72; P < 0.001; I ² = 0%), while OCT demonstrated only a trend toward MACE reduction (RR 0.80, 95% CI 0.62–1.02). Subgroup analyses indicated consistent benefits with intravascular imaging for adults aged ≥65 and ≥70 years, respectively, and among those with complex coronary lesions (RR 0.65, 95% CI 0.53–0.79; P < 0.001). Conclusion Intravascular imaging guidance, especially IVUS, reduces MACE in older adults undergoing PCI compared with angiography alone.

Background Treatment of in-stent restenosis (ISR) accounts for 10% of percutaneous coronary interventions in the USA. Paclitaxel-coated balloons (PCBs) are an alternative to uncoated balloons (UCBs) for ISR. Methods We systematically searched PubMed, Scopus, and Cochrane Central for studies comparing PCB with UCB in treating ISR. Outcomes included late lumen loss, binary restenosis, target lesion revascularization (TLR), and major adverse cardiovascular events (MACE). Results Eight trials including 1410 patients [PCB in 865 (61%), follow-up 6 months to 10 years) were identified. Angiographic outcomes of late lumen loss [mean difference: −0.50 mm; 95% confidence interval (CI): −0.66 to −0.33; P < 0.01] and binary restenosis [relative risk (RR): 0.22; 95% CI: 0.13–0.40; P < 0.01] at 6–8 months were lower with PCB. TLR at 6 months (RR: 0.16; 95% CI: 0.06–0.40; P < 0.001) and 1 year (RR: 0.45; 95% CI: 0.31–0.66; P < 0.001), MACE at 6 months (RR: 0.25; 95% CI: 0.16–0.38; P < 0.001), MACE at 3–5 years (RR: 0.54; 95% CI: 0.37–0.80; P = 0.002), and TLR at 3–5 years (RR: 0.51; 95% CI: 0.29–0.90; P = 0.021) were lower with PCB. Meta-regression revealed that ISR lesions in the left anterior descending artery were associated with lower rates of binary restenosis while the opposite was observed for left circumflex lesions. Conclusion Revascularization of coronary ISR with PCB is associated with reduced late lumen loss, binary restenosis, TLR, CCE, and MACE. PCB may be a preferred strategy for coronary ISR.