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Vishwanath V, Akseer S, Frankfurter C, Reza S, Farrell A, Horlick E, Abrahamyan L. Comparative effectiveness of devices for transcatheter closure of atrial septal defects: Systematic review and network meta-analysis. Arch Cardiovasc Dis 2022; 115:664-674. [PMID: 36336619 DOI: 10.1016/j.acvd.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 09/08/2022] [Accepted: 09/13/2022] [Indexed: 12/15/2022]
Abstract
Atrial septal defect is a common congenital heart disease, producing a left-to-right shunt in the atrial septum; the current preferred treatment is transcatheter device closure. The aim is to conduct a systematic review to synthesize information on the comparative effectiveness and safety of atrial septal defect closure devices. The methods used: a comprehensive search of Ovid MEDLINE®, Embase, and Cochrane Central databases was conducted. Studies comparing procedural and follow-up outcomes of atrial septal defect devices were included. Network meta-analyses were conducted to generate direct and indirect evidence for comparative effectiveness and safety outcomes between devices. The results are as follows: Twelve studies met our inclusion criteria and were compared in network meta-analyses. The meta-analyses evaluated contemporary devices: the AMPLATZER Septal Occluder; the GORE CARDIOFORM Septal Occluder; the Figulla Flexible II Occluder; the CeraFlex Septal Occluder; and the HELEX Septal Occluder. These studies represented 3998 patients. The primary safety and efficacy outcomes were device embolization and follow-up residual shunt, respectively. Secondary clinical outcomes included procedural success and major and minor complications. No differences were found between devices in terms of device embolization and secondary clinical outcomes. Follow-up residual shunt was higher with the HELEX Septal Occluder compared with the AMPLATZER Septal Occluder (odds ratio 2.92, 95% confidence interval 1.12-7.61). To conclude: although most outcomes were similar between devices, evidence was largely based on observational low-quality studies. There were inconsistencies in outcome reporting and definitions; this merits future studies, with head-to-head device comparisons and standardization of outcomes.
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Affiliation(s)
- Varnita Vishwanath
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre (PMCC), University Health Network, ON M5G 2N2 Toronto, Canada
| | - Selai Akseer
- Toronto General Hospital Research Institute, University Health Network, 10th Floor Eaton North, Room 237, 200, Elizabeth Street, ON M5G 2C4 Toronto, Canada; Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto ON M5T 3M6, Canada
| | - Claudia Frankfurter
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre (PMCC), University Health Network, ON M5G 2N2 Toronto, Canada
| | - Seleman Reza
- Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto ON M5T 3M6, Canada
| | - Ashley Farrell
- Library & Information Services, University Health Network, Toronto ON M5G 2C4, Canada
| | - Eric Horlick
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre (PMCC), University Health Network, ON M5G 2N2 Toronto, Canada
| | - Lusine Abrahamyan
- Toronto General Hospital Research Institute, University Health Network, 10th Floor Eaton North, Room 237, 200, Elizabeth Street, ON M5G 2C4 Toronto, Canada; Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto ON M5T 3M6, Canada.
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Hobbes B, Akseer S, Pikula A, Huszti E, Devereaux PJ, Horlick E, Abrahamyan L. Risk of Perioperative Stroke in Patients with Patent Foramen Ovale: A Systematic Review and Meta-Analysis. Can J Cardiol 2022; 38:1189-1200. [PMID: 35247468 DOI: 10.1016/j.cjca.2022.02.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 02/23/2022] [Accepted: 02/24/2022] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Patent foramen ovale (PFO) is a common congenital cardiac abnormality. Risk of stroke increases perioperatively; however, the association of PFO with perioperative stroke risk remains unclear. We conducted a systematic review to inform the risk of perioperative stroke in patients with PFO undergoing surgery. METHODS EMBASE, MEDLINE, and Cochrane databases were searched from inception to January 2020. We described methods used for establishing PFO and perioperative stroke diagnosis. We conducted meta-analyses to obtain pooled estimates for risk of stroke in patients with and without PFO in different surgical populations. RESULTS Ten articles with a total of 20,858,011 patients met the eligibility criteria. Prevalence of PFO ranged from 0.06-1.4% based on ICD code diagnosis and 10.4-40.4% based on echocardiography diagnosis. Perioperative stroke was observed in 0-25% of patients with PFO, and 0-16.7% without PFO. Studies that use echocardiography to diagnose PFO found no association between PFO and perioperative stroke. Studies that used ICD codes, found strong association but were highly heterogenous. PFO was not associated with a risk of perioperative stroke in cardiac and transplant surgeries. While the adjusted odds ratios for stroke were substantial for orthopedic, general, genitourinary, neuro, and thoracic surgeries (with PFO status established based on ICD codes), data heterogeneity and quality of data create significant uncertainty. CONCLUSION In conclusion, PFO is likely a risk factor for perioperative stroke in select types of surgeries. However, this is based on a very low-quality evidence. Rigorous, prospective studies are needed to further investigate this relationship.
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Affiliation(s)
- Benjamin Hobbes
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Selai Akseer
- Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, Ontario, Canada
| | - Aleksandra Pikula
- Division of Neurology, Toronto Western Hospital, University Health Network (UHN), Toronto, ON, Canada
| | - Ella Huszti
- Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, Ontario, Canada; Biostatistics Research Unit, UHN, Toronto, Ontario, Canada
| | - P J Devereaux
- Population Health Research Institute, Hamilton, ON, Canada; Departments of Medicine, and Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Eric Horlick
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre (PMCC), UHN, Toronto, Ontario, Canada
| | - Lusine Abrahamyan
- Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, Ontario, Canada; Toronto General Hospital Research Institute, UHN, Toronto, Ontario, Canada.
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Akseer S, Abrahamyan L, Lee DS, Huszti E, Meier LM, Osten M, Benson L, Horlick E. Long-Term Outcomes in Adult Patients With Pulmonary Hypertension After Percutaneous Closure of Atrial Septal Defects. Circ Cardiovasc Interv 2021; 15:e011110. [PMID: 34911355 DOI: 10.1161/circinterventions.121.011110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pulmonary hypertension (PH), recently redefined as mean pulmonary arterial pressure >20 mm Hg (PH20), may be observed in patients with atrial septal defects (ASD). We aimed to determine the effect of preprocedural PH20 status on outcomes among patients undergoing ASD closure. METHODS Study population was selected from a retrospective registry of adult patients who underwent percutaneous ASD closure from 1998 to 2016 from a single center and had right heart catheterizations during the procedure. The clinical registry was linked to administrative databases to capture short- and long-term outcomes. RESULTS We included a total of 632 ASD closure patients of whom 359 (56.8%) had PH20. The mean follow-up length was 7.6±4.6 years. Patients with PH20 were older (mean age 56.5 versus 43.1 years, P<0.001) and a higher prevalence of comorbidities including hypertension (54.3% versus 21.6%, P<0.001) and diabetes (18.1% versus 5.9%, P<0.001) than those without PH. In a Cox proportional hazards model after covariate adjustment, patients with PH had a significantly higher risk of developing major adverse cardiac and cerebrovascular events (heart failure, stroke, myocardial infarction, or cardiovascular mortality), with hazards ratio 2.45 (95% CI, 1.4-4.4). When applying the prior, mean pulmonary arterial pressure ≥25 mm Hg (PH25) cutoff, a significantly higher hazard of developing major adverse cardiac and cerebrovascular events was observed in PH versus non-PH patients. CONCLUSIONS ASD patients with PH undergoing closure suffer from more comorbidities and worse long-term major adverse cardiac and cerebrovascular events outcomes, compared with patients without PH. The use of the new PH20 definition potentially dilutes the effect of this serious condition on outcomes in this population.
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Affiliation(s)
- Selai Akseer
- Toronto General Hospital Research Institute, University Health Network (UHN), Ontario, Canada (S.A., L.A., D.S.L., E.H.).,Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Ontario, Canada. (S.A., L.A., D.S.L., E.H.)
| | - Lusine Abrahamyan
- Toronto General Hospital Research Institute, University Health Network (UHN), Ontario, Canada (S.A., L.A., D.S.L., E.H.).,Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Ontario, Canada. (S.A., L.A., D.S.L., E.H.)
| | - Douglas S Lee
- Toronto General Hospital Research Institute, University Health Network (UHN), Ontario, Canada (S.A., L.A., D.S.L., E.H.).,Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Ontario, Canada. (S.A., L.A., D.S.L., E.H.).,ICES, Toronto, Ontario, Canada (D.S.L.)
| | - Ella Huszti
- Toronto General Hospital Research Institute, University Health Network (UHN), Ontario, Canada (S.A., L.A., D.S.L., E.H.).,Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Ontario, Canada. (S.A., L.A., D.S.L., E.H.).,Biostatistics Research Unit, UHN, Toronto, Ontario, Canada (E.H.)
| | - Lukas M Meier
- Adult Congenital Heart Disease Program, University Heart Center, University Hospital Zurich, University of Zurich, Switzerland (L.M.M.)
| | - Mark Osten
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, UHN, Toronto, Ontario, Canada (M.O., E.H.)
| | - Lee Benson
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Ontario, Canada. (L.B.).,Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada (L.B.)
| | - Eric Horlick
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, UHN, Toronto, Ontario, Canada (M.O., E.H.)
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Akseer S, Horlick E, Vishwanath V, Hobbes B, Huszti E, Mak S, Lee DS, Abrahamyan L. Prevalence and outcomes of pulmonary hypertension after percutaneous closure of atrial septal defect: a systematic review and meta-analysis. Eur Respir Rev 2020; 29:29/158/200099. [PMID: 33328279 DOI: 10.1183/16000617.0099-2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 06/29/2020] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Atrial septal defect (ASD) is a common form of congenital heart disease. Significant shunts may increase the risk of developing pulmonary hypertension (PH). We aimed to describe current PH definitions, evaluate PH prevalence and the effect of PH on outcomes in patients undergoing percutaneous ASD closure. METHODS EMBASE, MEDLINE and Cochrane databases were systematically searched. Studies reporting PH prevalence or mean systolic pulmonary arterial pressure (sPAP) before and after percutaneous ASD closure in adults were included. We conducted meta-analyses to obtain summary estimates for PH prevalence and mean sPAP. RESULTS 15 articles with a total of 1073 patients met the eligibility criteria. Studies applied variable PH definitions. PH prevalence and mean sPAP levels decreased in all studies after closure. The pooled PH prevalence decreased from 44% (95% CI 29-60%) to 18% (95% CI 8-27%). The overall standardised mean difference in sPAP was 1.12 (95% CI 0.81-1.44) and 1.62 (95% CI 1.00-2.23) in cohort and case-series studies respectively indicating a large decrease. The pooled standard mean difference among the younger and older patients were different, 1.25 (95% CI 0.78-1.71) and 0.91 (95% CI 0.56-1.27), respectively. A high degree of between-study heterogeneity was noted. CONCLUSIONS Both PH prevalence and mean sPAP decrease after ASD closure. Larger, prospective studies with consistent PH definitions using the recommended measurement modality are warranted.
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Affiliation(s)
- Selai Akseer
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, ON, Canada
| | - Eric Horlick
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre (PMCC), University Health Network, Toronto, ON, Canada
| | - Varnita Vishwanath
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre (PMCC), University Health Network, Toronto, ON, Canada
| | - Benjamin Hobbes
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre (PMCC), University Health Network, Toronto, ON, Canada
| | - Ella Huszti
- Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, ON, Canada.,Biostatistics Research Unit, University Health Network, Toronto, ON, Canada
| | - Susanna Mak
- Division of Cardiology, Mount Sinai Hospital, Toronto, ON, Canada
| | - Douglas S Lee
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, ON, Canada.,ICES, Toronto, ON, Canada
| | - Lusine Abrahamyan
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada .,Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, ON, Canada
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Vaivada T, Akseer N, Akseer S, Somaskandan A, Stefopulos M, Bhutta ZA. Stunting in childhood: an overview of global burden, trends, determinants, and drivers of decline. Am J Clin Nutr 2020; 112:777S-791S. [PMID: 32860401 PMCID: PMC7487433 DOI: 10.1093/ajcn/nqaa159] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 05/29/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Progress has been made worldwide in reducing chronic undernutrition and rates of linear growth stunting in children under 5 y of age, although rates still remain high in many regions. Policies, programs, and interventions supporting maternal and child health and nutrition have the potential to improve child growth and development. OBJECTIVE This article synthesizes the available global evidence on the drivers of national declines in stunting prevalence and compares the relative effect of major drivers of stunting decline between countries. METHODS We conducted a systematic review of published peer-reviewed and gray literature analyzing the relation between changes in key determinants of child linear growth and contemporaneous changes in linear growth outcomes over time. RESULTS Among the basic determinants of stunting assessed within regression-decomposition analyses, improvement in asset index score was a consistent and strong driver of improved linear growth outcomes. Increased parental education was also a strong predictor of improved child growth. Of the underlying determinants of stunting, reduced rates of open defecation, improved sanitation infrastructure, and improved access to key maternal health services, including optimal antenatal care and delivery in a health facility or with a skilled birth attendant, all accounted for substantially improved child growth, although the magnitude of variation explained by each differed substantially between countries. At the immediate level, changes in several maternal characteristics predicted modest stunting reductions, including parity, interpregnancy interval, and maternal height. CONCLUSIONS Unique sets of stunting determinants predicted stunting reduction within countries that have reduced stunting. Several common drivers emerge at the basic, underlying, and immediate levels, including improvements in maternal and paternal education, household socioeconomic status, sanitation conditions, maternal health services access, and family planning. Further data collection and in-depth mixed-methods research are required to strengthen recommendations for those countries where the stunting burden remains unacceptably high.
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Affiliation(s)
- Tyler Vaivada
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | - Nadia Akseer
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Selai Akseer
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | - Ahalya Somaskandan
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | | | - Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Center of Excellence in Women and Child Health, the Aga Khan University, Karachi, Pakistan
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