Alkhouli, Mohamad

Abstract Aims To compare early de-escalation of dual antiplatelet therapy (DAPT) (1–3 months) to monotherapy with either P2Y12 inhibitor or aspirin vs. 12 months DAPT after percutaneous coronary intervention (PCI) with drug-eluting stent (DES). Methods and results Electronic databases of Medline, Embase, and Cochrane library were searched through February 2020 to identify randomized controlled trials. A Bayesian network meta-analysis was conducted with random effects model. The main endpoints of interest were cardiovascular mortality and total bleeding events. Among seven trials (35 821 patients), 52.6% patients were presented with acute coronary syndrome. A total of 3359 patients and 14 530 patients were de-escalated to aspirin and P2Y12 inhibitor monotherapy, respectively. At a median follow-up of 12 months, compared with 12 months of DAPT, there was no significant difference in cardiovascular mortality between 1-month DAPT followed by P2Y12 inhibitor monotherapy [hazard ratio (HR) 0.84 (95% credible interval 0.29–2.43)], 3 months of DAPT followed by P2Y12 inhibitor monotherapy [HR 0.74 (0.39–1.46)], or 3 months of DAPT [HR 1.00 (0.54–1.86)] followed by aspirin monotherapy. Except for de-escalation of DAPT to aspirin monotherapy after 3 months [HR 0.75 (0.43–1.20)], de-escalation to P2Y12 inhibitor monotherapy after 1 month [HR 0.28 (0.10–0.83)], or 3 months [HR 0.57 (0.33–0.98)] were associated with significant decrease in total bleeding events. There were no significant differences in terms of ischaemic endpoints among different DAPT strategies. Conclusion Early de-escalation of DAPT (1–3 months) to monotherapy with a P2Y12 inhibitor instead of aspirin might be a safer and equally effective approach compared with 12 months of DAPT in patients with PCI and DES.

Abstract

AbstractBackgroundTranscatheter edge‐to‐edge repair with MitraClip is only approved for treatment of mitral regurgitation but is increasingly used to treat concomitant tricuspid regurgitation (TR) due to its common coexistence and association with poor outcomes. This study aimed to describe the learning curve associated with the challenge of off‐label treatment of concomitant TR.MethodsThis is a retrospective review of initial and consecutive patients who underwent combined edge‐to‐edge repair of mitral and tricuspid valves (TVs) at our institution from August 2017 to October 2019.ResultsRepair of both valves with MitraClip was performed in 22 patients (median age 81.5 years, 32% female). Mean procedure time was 176 ± 47 min; mean fluoroscopy time was 65 ± 24 min. Procedure duration in the first tertile was significantly longer (223 ± 13 min) than in the third tertile (143 ± 23 min, p = .0003). Median number of total clips placed per case was 3; in 15 patients (68%), the anterior and septal leaflets of the TV were clipped. The average changes in mean right atrial (RA) and left atrial (LA) pressures were −1.7 ± 2.5 mmHg (p = .0080) and −3.2 ± 4.6 mmHg (p = .0045), respectively. The average changes in RA and LA V‐wave heights were −3.3 ± 4.0 mmHg (p = .0009) and −8.1 ± 9.9 mmHg (p = .038), respectively. There was a significant trend toward decreasing residual TR over the course of the series (p = .046). At 30 days, survival was 100% and mean NYHA class decreased from 2.8 to 1.8 (p < .0001).ConclusionsCombined edge‐to‐edge tricuspid and mitral valve repair is safe and feasible. With experience, procedure duration and residual TR decreased.

Objective A subset of patients at the time of transcatheter mitral valve repair (TMVR) will have normal left atrial pressure (LAP) (<13 mm Hg) despite having severe mitral regurgitation (MR). The goal of this study was to determine clinical characteristics and outcomes in patients with normal LAP undergoing TMVR. Methods A single-centre retrospective cohort of consecutive patients who underwent transcatheter edge-to-edge mitral valve clip and continuous LAP monitoring between 5/1/2014 and 5/1/2018 was analysed. One-year mortality was compared by Kaplan–Meier survival curves. Multivariable analysis was performed to identify predictors of normal LAP and 1 year mortality. Results Of the 204 patients undergoing TMVR, 65% were men and the mean age was 81. Of these patients, 31 (15%) had normal LAP (mean LAP 10.5 mm Hg, mean V wave 16.5 mm Hg) and 173 had elevated LAP (mean LAP 19 mm Hg, mean V wave 32.5 mm Hg). The prevalence of severe MR was not different between groups, although the normal LAP group had significantly lower effective regurgitant orifice area and regurgitant volume. Other notable baseline characteristics including prior cardiac surgery, atrial fibrillation, hypertension, diabetes, congestive heart failure, body mass index, mechanism of MR and ejection fraction were similar between groups. However, there was an increased prevalence of chronic lung disease (CLD) (45.2% vs 17.3%, p<0.001) in the normal LAP group. On multivariate analysis, the only significant predictor of normal LAP was the presence of CLD (OR 4.79 (1.83–12.36), p=0.001) and 1-year mortality was significantly higher in the normal LAP group (32.3% vs 12.7%, p=0.006). After adjustment for comorbidities, normal LAP was no longer a predictor of 1-year mortality (RR 1.62 (0.64–4.06), p=0.32); however, CLD (RR 3.44 (1.37–8.67), p=0.01) remained a statistically significant predictor. Conclusion Normal LAP at the time of TMVR is associated with a higher incidence of CLD which independently predicts increased 1-year mortality. In patients with CLD and apparently severe MR, measurement of LAP may help identify those with lower likelihood of benefit from TMVR.

Abstract Background Studies assessing the association between surgical volume and coronary artery bypass grafting (CABG) outcomes yielded conflicting results. Given the substantial recent decrease in CABG volume, we sough to examine the volume‐outcomes effect in contemporary practice. Methods The National Readmission Database was queried to identify patients undergoing CABG between January 1, 2015 and December 31, 2016. Risk‐adjusted in‐hospital morbidity, mortality, length‐of‐stay, cost, and 30‐day readmission were compared between low‐, intermediate‐, and high‐volume centers. Results A total of 411 159 CABG hospitalizations at 1558 hospitals were included. Hospitals were classified into three tertiles (high > 250, intermediate 100‐250, and low‐volume < 100). Hospitals in the highest tertile (n = 568) performed 73.9% of all CABG operations, while those in the intermediate (n = 452), and low (n = 538) volume tertiles performed only 21.7% and 4.4% of all CABGs, respectively. The median number of CABGs performed at high‐, intermediate‐, and low‐volume hospitals was 45 316 335, respectively. After risk adjustment, undergoing CABG at low‐ or intermediate‐ volume hospital (vs high‐volume hospitals) was associated with higher in‐hospital death (odd ratio [OR] = 1.31, 95% confidence interval [CI], 1.19‐1.44, and OR = 1.11, 95% CI, 1.05‐1.17, respectively, P < .001). Similarly, adjusted odds of stroke, acute kidney injury, and blood transfusion were higher at low‐ and intermediate‐volume centers compared with high‐volume centers. Undergoing CABG at a low‐volume center was associated with 50% higher adjusted cost and 77% higher adjusted 30‐day readmissions. Conclusions In contemporary practice, in which one‐third of CABG‐capable hospitals perform < 100 CABG operations annually, a strong relationship is observed between surgical volume and adjusted in‐hospital morbidity, mortality, cost, and 30‐day readmission.