Abstract 373: Meta-analysis of Clinical Outcomes Comparing Use of Transesophageal Echocardiography versus No Transesophageal Echocardiogram During Transcatheter Aortic Valve Replacement

Background: Transesophageal echocardiography (TEE) is routinely used for intraoperative guidance for TAVR procedures. TAVR is also done with minimal imaging or no TEE guidance (minimal imaging approach). The clinical benefits of intraprocedure TEE during TAVR compared to minimal imaging approach has not been well established.

Aim: To perform a meta-analysis of available trials comparing effectiveness of intraprocedural TEE versus minimal imaging approach during TAVR procedure.

Hypothesis: TAVR with intraprocedural TEE is associated with better clinical outcomes compared with minimalist imaging approach.

Methods: 8 retrospective observational studies were identified via a comprehensive literature search that incorporated Embase, MEDLINE, and CENTRAL. Each selected study reported on the comparison between TAVR performed with TEE guidance or with no TEE (minimalist strategy) during the procedure. Studies were screened for risk of bias using a quality assessment tool. Outcomes studied included all-cause mortality, cardiovascular mortality, paravalvular leak as defined by the original trial, readmission within 30 days, stroke, myocardial infarction (MI) , and acute kidney injury (AKI). For each outcome, estimates were pooled and reported as a risk ratio with 95% confidence interval (CI).

Results: A total of 2057 patients were divided into TEE (n=1115) vs. non-TEE (n=942) cohorts. No significant difference was seen between TEE vs non-TEE groups in reducing cardiovascular mortality (RR=2.06 [95%CI: 0.91- 4.67], p=0.08 ), all cause mortality (RR= 0.63 [95% CI: 0.21- 1.90], p=0.41), readmission within 30 days (RR=0.49 [95% CI: 0.06-4.41], p=0.53), stroke (RR=0.97 [95% CI: 0.27- 3.47], p=0.96), MI (RR=0.92 [95%CI: 0.26- 3.29], p=0.90), and AKI (RR=1.24 [95% CI: 0.16-9.35], p=0.83). A significant increase in paravalvular leak was observed within the non-TEE group (RR=1.19 [95% CI: 1.01-1.39], p=0.04) in comparison to the TEE group.

Conclusion: TEE guidance during TAVR is associated with reduced paravalvular leak when compared with minimal imaging approach. No other clinical difference was observed between the two approaches. Further studies are needed to validate these findings.

Timing of Percutaneous Coronary Intervention in Non-ST Elevation Acute Coronary Syndrome - Meta-Analysis and Systematic Review of Literature

BACKGROUND

Percutaneous coronary intervention (PCI) is the standard procedure of care for most patients with non-ST elevation acute coronary syndrome (NSTE-ACS). However, the timing of PCI remains unclear. We performed this meta-analysis with available randomized controlled trials (RCTs) to compare early versus late coronary intervention in patients with NSTE-ACS.

METHOD

A total of 13 RCTs were selected through PubMed/MEDLINE via OVID, EMBASE via OVID and Cochrane Central Register of Controlled Trials (inception to October 2018) search. Outcomes were analyzed using the relative risk (RR) and 95% CI. Pooled RRs were determined using M-H random-effects model, which can account for between study heterogeneity.

RESULTS

We included 13 RCTs with 11,972 patients were included. There were 7101 patients were randomized into early invasive group and 4871 in late invasive group. There was a significant decrease in myocardial infarction with long-term follow up in early invasive group compared to the delayed invasive group (RR 0.847 [95% CI 0.74-0.95], p = 0.009) with no difference in mortality between early and late invasive group (5.41% vs 6.49%, RR 0.882 [95% CI, 0.76-1.02]). On subgroup analysis, data was available from 6 RCTs for GRACE (Global Registry of Acute Coronary Events) score and 8 RCTs for elevated troponin. Early intervention led to decrease in adverse events in patients with elevated GRACE score > 140 (Mantel-Haenszel pooled RR 0.88 [95% CI 0.82-0.95], p-value 0.002) but no difference was seen in patients with elevated troponin.

CONCLUSION

It can be postulated from these results that early invasive strategy leads to decrease in myocardial infarction but without significant decrease in mortality. In patients with elevated GRACE score (>140), early intervention did show a trend towards decrease in major adverse cardiac events, whereas in patients with elevated troponin alone, similar association was not observed. However, adequately powered randomized controlled trial is necessary to validate these findings.

Network Meta-Analysis of Percutaneous Intervention-Based Revascularization Strategies for ST-Elevation Myocardial Infarction and Concomitant Multi-Vessel Disease

BACKGROUND

In patients with ST elevation myocardial infarction (STEMI) and concomitant multi-vessel disease (MVD), primary percutaneous coronary intervention (PCI) of the culprit vessel is the preferred reperfusion strategy. However, optimum timing of revascularization for non-culprit artery is unclear. In this Bayesian network meta-analysis (NMA), we compared different PCI-based revascularization strategies in STEMI patients with MVD.

METHODS

11 randomized controlled trials (RCTs) were selected using MEDLINE, EMBASE and CENTRAL (Inception to September 2017). For all outcomes, median estimate of odds ratio from posterior distribution with corresponding 95% credible interval was calculated. The Surface under the Cumulative Ranking Curve (SUCRA) metric was used to estimate the relative ranking probability of each intervention. Sensitivity analysis was conducted by excluding the RCTs in which the staged intervention was performed after two weeks of the index procedure or post discharge.

RESULTS

In this NMA of 3172 patients, CR-I (instant complete revascularization) was associated with 40% relative risk reduction in all-cause mortality compared with IRA (infarct related artery) [0.60 (0.31-0.89)]. CR-I was superior to CR-S (staged complete revascularization) [0.42 (0.22-0.70)] and IRA [0.50(0.29-0.72)] in reducing the risk of re- infarction. Both CR-I and CR-S significantly reduced the risk of repeat revascularization compared to IRA, whereas the risk of CIN (contrast induced nephropathy) and major bleeding was similar across all interventions. Sensitivity analysis showed, that CR-I was a better strategy compared with CR-S [0.34 (0.12-0.74)] and IRA (0.60 [0.36-0.97]) in reducing all-cause mortality.

CONCLUSIONS

In this NMA, CR-I was associated with reduction in all-cause mortality and re- infarction compared with IRA.

A Bayesian network meta-analysis of preventive strategies for contrast-induced nephropathy after cardiac catheterization

BACKGROUND

The optimal preventive strategy for contrast induced acute kidney injury (CIAKI) in patients undergoing cardiac catheterization remains uncertain.

OBJECTIVE

We conducted Bayesian network meta-analysis (NMA) to compare different preventive strategies for CIAKI in these cohorts.

METHODS

Forty-nine randomized controlled trials were extracted using MEDLINE, EMBASE and CENTRAL data bases (inception-1st December 2017). We calculated median of the odds ratio (OR) with the corresponding 95% credible interval (CrI). The ranking probability of each treatment was based on SUCRA (surface under the cumulative ranking curve).

RESULTS

In NMA of 28,063 patients [normal saline (NS: 9716 patients), sodium bicarbonate (NaHCO3: 4484 patients), statin (2542 patients), N-acetylcysteine (NAC: 3006 patients), NAC + NaHCO3 (774 patients), NS + NAC (3807 patients), NS + NaHCO3 (135 patients) and placebo (3599 patients)], statins reduced the relative risk of CIAKI compared with NS (OR: 0.50; 95% CrI, 0.25-0.99), and placebo (OR: 0.44; 95% CrI, 0.24-0.83). Subgroup analyses showed that in patients receiving low osmolar contrast, statins reduced the relative risk of CIAKI by 58% versus NS, and 51% versus placebo. There were no significant differences across all the treatments in terms of risk of hemodialysis or all-cause mortality. Statins had the highest probability for reducing the risk of CIAKI (SUCRA, 0.86), risk of hemodialysis (SUCRA, 0.88) and all-cause mortality (SUCRA, 0.81).

CONCLUSION

Statins were the superior preventive strategy for reducing the risk of CIAKI compared with NS alone and placebo.