Association Between Clinical Trial Participation Status and Outcomes With Mitral Transcatheter Edge-to-Edge Repair

BACKGROUND

Clinical trials have demonstrated the efficacy and safety of mitral transcatheter edge-to-edge repair (M-TEER) for selected patients with severe mitral regurgitation. However, the generalizability of trial results to real-world patients remains uncertain.

OBJECTIVES

The authors aimed to compare baseline characteristics and in-hospital outcomes among trial participants with nonparticipants undergoing M-TEER.

METHODS

Using the National Inpatient Sample database years 2016-2020, M-TEER admissions were identified and categorized into trial participants vs none. We also identified a cohort of trial noneligible patients based on clinical exclusion criteria from pivotal trials. Multivariate regression analysis was performed to compare in-hospital outcomes. The primary outcome was in-hospital mortality, and secondary outcomes included in-hospital complications, length of stay, and hospitalization cost.

RESULTS

Among 38,770 M-TEER admissions from 2016 to 2020, 11,450 (29.5%) were trial participants, 22,975 (59.3%) were eligible nonparticipants, and 2,960 (7.6%) were noneligible. Baseline characteristics and comorbidity profiles were mostly similar between trial participants vs eligible nonparticipants. In-hospital mortality (adjusted OR [aOR]: 0.98; 95% CI: 0.60-1.62), cardiogenic shock (aOR: 1.06; 95% CI: 0.80-1.42), mechanical circulatory support (aOR: 0.91; 95% CI: 0.58-1.41), mechanical ventilation (aOR: 1.03; 95% CI: 0.74-1.42), and conversion to mitral valve surgery (aOR: 1.08; 95% CI: 0.57-2.03) were not different between both groups. Conversely, M-TEER for noneligible patients was associated with higher rates of mortality (aOR: 6.27; 95% CI: 3.75-10.45) and complications.

CONCLUSIONS

The majority of real-world M-TEER patients would have been eligible for clinical trial participation and had comparable clinical profiles and in-hospital outcomes to trial participants. However, noneligible patients had worse in-hospital outcomes compared with trial participants.

Sex differences in myocarditis hospitalizations: Rates, outcomes, and hospital characteristics in the National Readmission Database

Inflammation of the myocardium, or myocarditis, presents with varied severity, from mild to life-threatening such as cardiogenic shock or ventricular tachycardia storm. Existing data on sex-related differences in its presentation and outcomes are scarce. Using the Nationwide Readmission Database (2016-2019), we identified myocarditis hospitalizations and stratified them according to sex to either males or females. Multivariable regression analyses were used to determine the association between sex and myocarditis outcomes. The primary outcome was in-hospital mortality, and the secondary outcomes included sudden cardiac death (SCD), cardiogenic shock (CS), use of mechanical circulatory support (MCS), and 90-day readmissions. We found a total of 12,997 myocarditis hospitalizations, among which 4,884 (37.6 %) were females. Compared to males, females were older (51 ± 15.6 years vs. 41.9 ± 14.8 in males) and more likely to have connective tissue disease, obesity, and a history of coronary artery disease. No differences were noted between the two groups with regards to in-hospital mortality (adjusted odds ratio [aOR] 1.20; confidence interval [CI] 0.93-1.53; P = 0.16), SCD (aOR:1.18; CI 0.84-1.64; P = 0.34), CS (aOR: 1.01; CI 0.85-1.20;P = 0.87), or use of MCS (aOR: 1.07; CI:0.86-1.34; P = 0.56). In terms of interventional procedures, females had lower rates of coronary angiography (aOR: 0.78; CI 0.70-0.88; P < 0.01), however, similar rates of right heart catheterization (aOR 0.93; CI:0.79-1.09; P = 0.36) and myocardial biopsy (aOR: 1.16; CI:0.83-1.62; P = 0.38) compared to males. Additionally, females had a higher risk of 90-day all-cause readmission (aOR: 1.25; CI: 1.16-1.56; P < 0.01) and myocarditis readmission (aOR:1.58; CI 1.02-2.44; P = 0.04). Specific predictors of readmission included essential hypertension, congestive heart failure, malignancy, and peripheral vascular disease. In conclusion, females admitted with myocarditis tend to have similar in-hospital outcomes with males; however, they are at higher risk of readmission within 90 days from hospitalization. Further studies are needed to identify those at higher risk of readmission.

Disparities in Acute Coronary Syndrome Outcomes in Individuals With Intellectual Disabilities: A Propensity-Matched Analysis of National Inpatient Sample

BACKGROUND

Individuals with intellectual disabilities (IDs) are at similar risk of acute coronary syndrome (ACS) as compared to general population. However, there is a paucity of real-world data evaluating outcomes of ACS in this population. We sought to study ACS outcomes in individuals with IDs using a large national database.

METHODS

Adult admissions with a primary diagnosis of ACS were identified from the national inpatient sample of years 2016-2019. Cohort was stratified according to presence of IDs. A 1 to 1 nearest neighbor propensity score matching using 16 patient variables. Outcomes evaluated were in-hospital mortality, coronary angiography (CA), timing of CA (early [day 0] vs. late [>day0]), and revascularization.

RESULTS

A total of 5110 admissions (2555 in each group) were included in our matched cohort. IDs admissions had higher rates of in-hospital mortality (9 % vs. 4 %, aOR: 2.84, 95 % CI [1.66-4.86], P < 0.001), and were less likely to receive CA (52 % vs. 71 %, aOR: 0.44, 95 % CI [0.34-0.58], P < 0.001) and revascularization (33 % vs. 52 %, aOR: 0.45, 95 % CI [0.35-0.58], P < 0.001). In-Hospital mortality was higher in the ID admissions whether invasive coronary treatment (CA or revascularization) was performed (6 % vs. 3 %, aOR: 2.34, 95 % CI [1.09-5.06], P = 0.03) or not (13 % vs. 5 %, aOR: 2.56, 95 % CI [1.14-5.78], P = 0.023).

CONCLUSION

Significant disparities exist in ACS outcomes and management in individuals with IDs. More research is needed to understand the reasons for these disparities and develop interventions to improve quality of care in this population.

Outcomes of Coronary Artery Bypass Grafting in Patients With Previous Mediastinal Radiation

Studies have shown that patients with radiation therapy-associated coronary artery disease tend to have worse outcomes with percutaneous revascularization. Previous irradiation has been linked with future internal mammary artery graft disease. Studies investigating the outcomes of coronary artery bypass surgery (CABG) among patients with previous radiation are limited. The Nationwide Readmission Database for the years 2016 to 2019 was queried for hospitalizations with CABG and history of mediastinal radiation. Complex samples multivariable logistic and linear regression models were used to determine the association between the history of mediastinal radiation and in-hospital mortality, 90 days all-cause unplanned readmission rates, and acute coronary syndrome readmission rates. A total of 533,702 hospitalizations (2,070 in the irradiation history group and 531,632 in the control group) were included in this analysis. Patients with radiation therapy history were less likely to have traditional coronary artery disease risk factors and more likely to have associated valvular disease. Patients with a history of irradiation had similar in-hospital mortality and 90-day readmission risk at the expense of higher hospitalizations costs (β coefficient: $2,764; p = 0.005). They had a higher likelihood of readmission with acute coronary syndrome within 90 days (adjusted odds ratio 1.67, p = 0.02). In a conclusion, a history of mediastinal irradiation is not associated with increased rates of short-term mortality or increased all-cause readmission risk after CABG. However, it may be associated with increased acute coronary syndrome readmission rates.

Mechanical Thrombectomy for Acute Ischemic Stroke in Metastatic Cancer Patients: A Nationwide Cross-Sectional Analysis

BACKGROUND AND PURPOSE

Mechanical thrombectomy (MT) is the standard treatment for large vessel occlusion (LVO) acute ischemic stroke. Patients with active malignancy have an increased risk of stroke but were excluded from MT trials.

METHODS

We searched the National Readmission Database for LVO patients treated with MT between 2016-2018 and compared the characteristics and outcomes of cancer-free patients to those with metastatic cancer (MC). Primary outcomes were all-cause in-hospital mortality and favorable outcome, defined as a routine discharge to home (regardless of whether home services were provided or not). Multivariate regression was used to adjust for confounders.

RESULTS

Of 40,537 LVO patients treated with MT, 933 (2.3%) had MC diagnosis. Compared to cancer-free patients, MC patients were similar in age and stroke severity but had greater overall disease severity. Hospital complications that occurred more frequently in MC included pneumonia, sepsis, acute coronary syndrome, deep vein thrombosis, and pulmonary embolism (P<0.001). Patients with MC had similar rates of intracerebral hemorrhage (20% vs. 21%) but were less likely to receive tissue plasminogen activator (13% vs. 23%, P<0.001). In unadjusted analysis, MC patients as compared to cancer-free patients had a higher in-hospital mortality rate and were less likely to be discharged to home (36% vs. 42%, P=0.014). On multivariate regression adjusting for confounders, mortality was the only outcome that was significantly higher in the MC group than in the cancerfree group (P<0.001).

CONCLUSION

LVO patients with MC have higher mortality and more infectious and thrombotic complications than cancer-free patients. MT nonetheless can result in survival with good outcome in slightly over one-third of patients.

Differences According to Sex in Short-term Clinical Outcomes After Supraventricular Tachycardia Catheter Ablation: Insights from the Nationwide Readmission Database

Catheter ablation is indicated for the management of supraventricular tachycardias (SVTs). We investigated the effect of sex on short-term outcomes after catheter ablation for SVTs other than atrial fibrillation (AF). Using the Healthcare Cost and Utilization Project Nationwide Readmission Database for the years 2016-2018, SVT patients who underwent catheter ablation were identified using the appropriate International Classification of Diseases, 10th Revision, codes. The primary outcome was 30-day readmissions. Secondary outcomes included 30-day readmissions for SVT, postprocedural bleeding, acute myocardial infarction, transient ischemic attack, stroke, hemopericardium, cardiac tamponade, length of stay (LOS) in the hospital, and total hospital charges (in USD). Female sex was not associated with an increased risk of the primary outcome (P = .168) but was associated with a significantly decreased risk of postprocedural revascularization (P = .001), LOS (P = .003), and total hospital charges (P = .002). There were no significant differences in other secondary outcomes. Among patients admitted for catheter ablation for SVTs (other than AF), female sex was associated with decreased LOS and total hospital charges, which may be attributed to increased comorbidity rates in men and gender-based biases.

Abstract P066: Short-term Outcomes Of Hypertensive Crises In Patients With Orthostatic Hypotension

Introduction: Current recommendations in management of supine hypertension-orthostatic hypotension disease (SH-OH) are mainly derived from outpatient studies with the aim of controlling SH while minimizing OH symptoms rather than targeting a specific standing blood pressure value. Data on short term outcomes of patients with OH who are hospitalized with hypertensive (HTN) crises is lacking.

Methods: The Nationwide Readmission Database 2016-2019 was queried for all hospitalizations of HTN crises. Hospitalizations were stratified according to whether OH was present or not. We employed propensity score to match hospitalizations for patients with OH to those without, at 1:1 ratio. Outcomes evaluated were 30-days readmission with HTN crises or falls, as well as hospital outcomes of in-hospital mortality, acute kidney injury (AKI), acute congestive heart failure (CHF), acute coronary syndrome (ACS), type 2 myocardial infarction (T2MI), aortic dissection, stroke, length of stay (LOS), discharge to nursing home and hospitalization costs.

Results: We included a total of 9,451 hospitalization (4,735 in the OH group vs 4,716 in the control group). OH group was more likely to be readmitted with falls (Odds ratio [OR]:3.27, p<0.01) but not with HTN crises(p=0.05). Both groups had similar likelihood of developing AKI (p=0.08), stroke/TIA (p=p=0.52), and aortic dissection(p=0.66). Alternatively, OH group were less likely to develop acute CHF (OR:0.54, p<0.01) or ACS (OR:0.39,p<0.01) in the setting of HTN crises than non-OH group. OH group were more likely to have longer LOS and have higher hospitalization costs.

Conclusion: Patients with OH who are admitted with HTN crises tend to have similar or lower HTN-related complications to non-OH group while having higher likelihood of readmission with falls, LOS and hospitalization costs. Further randomized studies are needed to confirm such findings

Impact of Chronic Obstructive Pulmonary Disease on Atrial Fibrillation Ablation Outcomes According to the National Readmission Database

Chronic obstructive pulmonary disease (COPD) is a risk factor for the development of atrial fibrillation (AF). There is a paucity of contemporary data studying the association between COPD and outcomes of AF ablation. The objective of this study was to investigate the impact of COPD on AF ablation outcomes using a large nationwide database. This study was a retrospective analysis of the National Readmission Database for the years 2016-2018 and included patients admitted with a diagnosis of AF who underwent catheter ablation. Admissions were stratified according to COPD diagnosis using International Classification of Diseases, 10th Revision, Clinical Modification codes. Multivariate, linear, Cox, and logistic regressions were performed to study the impact of COPD on AF ablation. A total of 18,224 admissions (mean age, 68 years; standard deviation, 10 years) were included, of whom 3,494 (19%) had a diagnosis of COPD. The COPD group was older (72 ± 8 vs. 67 ± 11 years, P < .001) and more likely to have congestive heart failure (73% vs. 44%, P < .001) and renal failure (31% vs. 17%, P < .001). COPD was associated with an increased risk of readmission (adjusted hazard ratio [aHR], 1.40; 95% confidence interval [CI], 1.26-1.56; P < .001) and all-cause in-hospital mortality (adjusted odds ratio, 2.83; 95% CI, 1.74-4.60; P < .001). However, COPD was not associated with an increased risk of readmission due to recurrent AF (aHR, 0.97; 95% CI, 0.75-1.27; P = .844) or the need for re-ablation (aHR, 0.85; 95% CI, 0.44-1.65; P = .639), respectively. In conclusion, COPD was not associated with an increased risk of recurrent AF after ablation despite higher periprocedural risks. The present study contributes to a better understanding of this high-risk subgroup of patients undergoing AF ablation.

Early versus late discharge after transcatheter aortic valve replacement and readmissions for permanent pacemaker implantation

OBJECTIVE

To examine the rate of readmission for permanent pacemaker (PPM) implantation with early versus late discharge after transcatheter aortic valve replacement (TAVR).

BACKGROUND

There is a current trend toward early discharge after TAVR. However, paucity of data exists on the impact of such practice on readmissions for PPM implantation.

METHODS

The Nationwide Readmission Database 2016-2018 was queried for all hospitalizations where patients underwent TAVR. Hospitalizations were stratified into early (Days 0 and 1) versus late (≥Day 2) discharge groups. Observations in which PPM was required in the index admission were excluded. Multivariable regression analyses involving patient- and hospital-related variables were utilized. The primary outcome was 90-day readmission for PPM implantation.

RESULTS

The final analysis included 68,482 TAVR hospitalizations, 20,261 (29.6%) with early versus 48,221 (70.4%) with late discharge. Early discharge after TAVR increased over the study period (16.2% in 2016 vs. 37.9% in 2018, P_trend  < 0.01). Nevertheless, 90-day readmission for PPM implantation remained stable (1.8% in 2016 vs. 2.0% in 2018, P_trend  = 0.32). The 90-day readmission rate for PPM implantation (2.0% vs. 1.8%; adjusted odds ratio: 1.15; 95% confidence interval: 0.95-1.39; p = 0.15) and median time-to-readmission (5 days [interquartile range, IQR 3-9] vs. 5 days [IQR 3-14], p = 0.92) were similar with early versus late discharge. Similar rates were observed regardless of whether readmission was elective versus not. Early discharge was associated with lower hospitalization cost ($39,990 ± $13,681 vs. $46,750 ± $18,218, p < 0.01) compared with late discharge.

CONCLUSION

In patients who did not require PPM during the index TAVR hospitalization, the rate of readmission for PPM implantation was similar with early versus late discharge.

Adjunctive Vein of Marshall Ethanol Infusion During Atrial Fibrillation Ablation: A Systematic Review and Meta-Analysis

Introduction

Catheter ablation (CA) for atrial fibrillation (AF) can be associated with limited efficacy. Due to its autonomic innervation, the vein of Marshall (VOM) is an attractive target during AF ablation. In this meta-analysis, we aimed to evaluate the efficacy and safety of adjunctive ethanol infusion of VOM (VOM-EI) in AF ablation.

Methods

We performed a comprehensive literature search for studies that evaluated the efficacy and safety of VOM-EI in AF ablation compared to AF catheter ablation alone. The primary outcome of interest was late (≥3 months) AF or atrial tachycardia (AT) recurrence. The secondary outcomes included acute mitral isthmus bidirectional block (MIBB) and procedural complications (pericardial effusion, stroke, or atrio-esophageal fistula). Pooled relative risk (RR) and corresponding 95% confidence intervals (CIs) were calculated using the random-effects model.

Results

A total of four studies, including 804 AF patients (68.2% with persistent AF, the mean age of 63.5±9.9 years, 401 patients underwent VOM-EI plus CA vs. 403 patients who had CA alone), were included in the final analysis. VOM-EI group was associated with a lower risk of late AF/AT recurrence (RR:0.63; 95% CI:0.46-0.87; P = 0.005), and increased probability to achieve acute MIBB (RR:1.39; 95% CI:1.08-1.79; P = 0.009) without an increase in procedural complications (RR:1.05; 95% CI:0.57-1.94; P = 0.87).

Conclusions

Our meta-analysis demonstrated that adjunctive VOM-EI strategy is more effective than conventional catheter ablation with similar safety profiles.

Relation of Type 2 Myocardial Infarction and Readmission With Type 1 Myocardial Infarction in Hypertensive Crises (from a Nationwide Analysis)

Type 2 myocardial infarction (T2MI) is an ischemic injury that occurs due to a mismatch between myocardial oxygen supply and demand. T2MI can occur with hypertensive crisis. Nevertheless, the impact of T2MI on hypertensive crisis outcome is poorly understood due to limited data. This study was a retrospective analysis of the National Readmission Database year 2018. Patients were included if the primary diagnosis was hypertensive crisis, hypertensive urgency, or hypertensive emergency. Patients were excluded if they had type 1 myocardial infarction (T1MI), severe sepsis, septic shock, gastrointestinal bleeding, or hemorrhagic anemia at index admission. The primary outcome was 90-day readmission with T1MI. Secondary outcomes were in-hospital mortality, length of stay, resource utilization, and all-cause 90-day readmission. Subgroup analysis was done according to urgency and emergency presentation. A total of 101,211 index hospitalizations were included in our cohort, of whom 3,644 (3.6%) received a diagnosis of T2MI. A total of 912 patients were readmitted within 90 days with T1MI. T2MI was an independent predictor of 90-day readmission with T1MI (adjusted odds ratio [aOR] 2.64, 95% confidence interval [CI] 1.90 to 3.66, p <0.01). Subgroup analysis including only hypertensive urgency and hypertensive emergency yielded similar results (aOR 2.80, 95% CI 1.56 to 5.01, p <0.01 and aOR 2.28, 95% CI 1.59 to 3.27, p <0.01, respectively). In conclusion, T2MI was an independent predictor of poor outcome in patients presenting with hypertensive crisis. Further studies are needed to guide the management of T2MI in this population.

Sex-based differences in clinical outcomes and resource utilization of type 2 myocardial infarction

Background

Sex-based differences in clinical outcomes have been previously well described in type 1 myocardial infarction (MI). However, type 2 MI is common in contemporary practice with scarce data regarding sex-based differences of clinical outcomes and resource utilization.

Purpose

To examine the association of sex category with clinical outcomes and resource utilization in hospitalizations with type 2 MI.

Methods

The Nationwide Readmission Database 2018 was queried for hospitalizations within the United States with type 2 MI using The International Classification of Diseases, Tenth Revision (ICD-10) diagnosis code I21.A1. Comorbidities and outcomes were identified using the corresponding ICD-10 codes. Complex samples multivariable logistic and linear regression models were used to determine the association between type 2 MI and outcomes (in-hospital mortality, index length of stay [LOS], hospital costs, discharge to nursing facility, and 30-day all-cause readmissions) in females compared to males with type 2 MI.

Results

A total of 252,641 hospitalizations [119,783 (47.4%) females and 132,858 (52.6%) males] were included in this analysis. Females with type 2 MI were more likely to be older (72.8 years vs. 69.7 years; P&lt;0.001), admitted on the weekend (26.5% vs. 25.9%; P=0.02), and have a higher prevalence of chronic pulmonary disease (35.6% vs. 32.0%; P&lt;0.001), obesity (17.9% vs. 15.7%; P&lt;0.001), neurological disorders (22.9% vs. 22.3%; P=0.02), deficiency anemias (7.5% vs. 6.6%; P&lt;0.001), and hypothyroidism (22.1% vs. 10.1%; P&lt;0.001) compared to males with type 2 MI. Female with type 2 MI was associated with lower in-hospital mortality, shorter LOS, less hospital costs, and increased nursing home discharge compared to males with type 2 MI. Females and males with type 2 MI had similar rates of 30-day all-cause readmission [Table 1].

Conclusion

Among type 2 MI hospitalizations, females have lower in-hospital mortality, less hospitalization cost, shorter LOS, but increased rates of nursing home discharge compared to males. Thirty-day all-cause readmission was similar between males and females with type 2 MI.

Funding Acknowledgement

Type of funding sources: None.

Short versus standard peroral endoscopic myotomy for esophageal achalasia: a systematic review and meta-analysis

Background

Peroral endoscopic myotomy (POEM) is increasingly used to treat esophageal achalasia, but is associated with a high rate of gastroesophageal reflux disease (GERD). The aim of our meta-analysis was to compare short and standard POEM in terms of clinical success and postoperative GERD.

Methods

We conducted a systematic review and meta-analysis of studies that compared POEM using short myotomy with standard myotomy. The primary outcome was clinical success. Secondary outcomes were postoperative GERD, perioperative complications, operation time, and length of hospital stay. A random-effects model was used to calculate the risk ratios (RR), mean differences (MD), and confidence intervals (CI). A P-value <0.05 was considered statistically significant.

Results

We included 5 studies involving 474 esophageal achalasia patients. Short and standard myotomies were similar in terms of clinical success (RR 1.02, 95%CI 0.97-1.09), perioperative complications (RR 0.68, 95%CI 0.26-1.75), and length of hospital stay (MD 0.25 days, 95%CI -0.14-0.63). Operation time was shorter for short myotomy (MD -15.01 mins, 95%CI -20.34 - -9.67). Although reflux symptoms were similar (RR 0.94, 95%CI 0.51-1.74), short myotomy had a lower risk of reflux esophagitis on endoscopy (RR 0.61, 95%CI 0.39-0.98), and pathologic acid exposure on pH monitoring (RR 0.58, 95%CI 0.36-0.94).

Conclusions

POEM using a shorter myotomy is comparable with standard myotomy in terms of efficacy and safety in the short-term setting. A short myotomy requires a shorter operation time and might reduce the occurrence of postoperative GERD.

Sex-based differences in clinical outcomes and resource utilization of type 2 myocardial infarction

BACKGROUND

Sex-based differences in clinical outcomes have been previously well described in type 1 myocardial infarction (T1MI). However, type 2 myocardial infarction (T2MI) is more common in contemporary practice, with scarce data regarding sex-based differences of outcomes.

METHODS

The Nationwide Readmission Database 2018 was queried for hospitalizations with T2MI as a primary or secondary diagnosis. Complex samples multivariable logistic and linear regression models were used to determine the association between T2MI and outcomes (in-hospital mortality, index length of stay [LOS], hospital costs, discharge to nursing facility, and 30-day all-cause readmissions) in females compared to males with T2MI.

RESULTS

A total of 252,641 hospitalizations [119,783 (47.4%) females and 132,858 (52.6%) males] were included in this analysis. Females with T2MI was associated with lower in-hospital mortality (adjusted odds ratio [aOR] 0.92; 95% confidence interval [CI] 0.88-0.96; P < 0.001), shorter LOS (adjusted parameter estimate [aPE] -0.28; 95% CI -0.38-0.17; P < 0.001), less hospital costs (aPE -1510.70; 95% CI -1916.04-1105.37; P < 0.001), and increased nursing home discharges (aOR 1.08; 95% CI 1.05-1.12; P < 0.001) compared to males with T2MI. Females and males with T2MI had similar rates of 30-day all-cause readmission (aOR 1.00; 95% CI 0.97-1.04; P = 0.841).

CONCLUSION

Among T2MI hospitalizations, females have lower in-hospital mortality, hospitalization costs, shorter LOS, and increased rates of nursing home discharge compared to males. Although statistically significant, the clinical significance of these small differences are unknown and require future studies.

Patent foramen ovale closure in the management of cryptogenic stroke: a review of current literature and guideline statements

OBJECTIVE

The management recommendations for patent foramen ovale (PFO) closure in cryptogenic stroke are rapidly evolving. The data has expanded recently with four major trials demonstrating superiority of percutaneous device closure over medical management in preventing cryptogenic stroke recurrence. This paper aims to review the current literature for referring physicians who may encounter patients with patent foramen ovale before referring these patients to stroke specialists and/or interventional cardiologists.

METHOD

For this Narrative review, we conducted a broad literature search with expert selection of relevant data. Our search included a review of the currently available trials, guideline statements, position papers, cost-effectiveness of device closure data, as well as the impact of device closure on quality of life.

RESULTS

Most European societies are now in favor of evaluating all patients aged 60 years or younger with recent cryptogenic stroke in the setting of a PFO after careful consideration of the patient's echocardiographic and clinical risk factors. On the other hand, American societies, except for the American Academy of Neurology, have not yet passed official updated recommendations.

CONCLUSION

PFO closure can be considered for the prevention of recurrent cryptogenic stroke in patients aged ≤60 years after a thorough evaluation and discussion about benefits and potential risks (including but not limited to atrial fibrillation) of the procedure. Accumulating evidence supports prognostic, quality of life, and economic benefit from percutaneous PFO closure with newer generation closure devices in the right subset of patients.

HIGHLIGHTS

Data from 4 major trials (RESPECT, CLOSE, DEFENSE-PFO, REDUCE) demonstrates the superiority of PFO closure over medical management alone in preventing cryptogenic stroke recurrence. Trials investigated mostly patients ≤60 years old, and therefore results may not be generalizable to the entire population. Further randomized trials evaluating the safety and efficacy of PFO closure in patients older than 60 years are warranted.Atrial fibrillation is one of the most common "occult" causes of cryptogenic stroke and should be excluded by ambulatory electrocardiographic monitoring. It is important to also rule out other causes of stroke, including hypercoagulable states, atherosclerotic lesions, other cardioembolic sources, and arterial dissection.Complications of PFO procedure include new-onset AF, development of scar tissue, risk of aortic root dilation and subsequent erosions, and potential thrombi formation on the device.PFO closure with medical therapy is more cost-effective than medical therapy alone.Patients who underwent PFO closure had lower rates of depression, anxiety, and stress compared to those who did undergo closure.Development of the RoPE score has helped clinicians identify patients with cryptogenic stroke and PFO who might be a candidate for PFO closure. A score of 7, 8, and 9-10 corresponds to a causal risk of 72%, 84%, and 88%, respectively, and defines a subset of patients who may benefit from PFO closure.Current guidelines recommend determining the need for PFO closure on a case-by-case basis, depending on risk factors, in patients age 60 or less with recent cryptogenic stroke in the setting of PFO.

Superior vena cava thrombosis and dilated cardiomyopathy as initial presentations of Behcet's disease

Background

Bechet’s disease (BD) is a relatively rare disease that causes recurrent oral and genital ulcers in addition to a variety of systemic manifestations. Concomitant superior-vena-cava (SVC) thrombosis and cardiac involvement with dilated cardiomyopathy (DCM) as initial presentations for BD is considered rare.

Case presentation

A 32-year-old-man presenting with intractable headaches and dyspnea. He was later diagnosed with SVC thrombosis and DCM. A diagnosis of BD was made after detailed history-taking.

Conclusions

Cardiovascular manifisations can be the initial presentation of BD. We aim to highlight the importance of early clinical recognition of BD as a cause of DCM and SVC thrombosis.

A simplified technique for converting antegrade femoral access to retrograde access for catheterization

OBJECTIVES

Femoral access conversion is sometimes required in clinical practice. Various techniques have been reported to convert a retrograde femoral access to antegrade access with a high success rate. However, despite paucity of data, converting an antegrade access to retrograde access is quite challenging with a potentially higher risk of technical failure or loss of access.

METHODS

Here, we report a simple technique of antegrade to retrograde access conversion utilizing a pigtail catheter and an angled Glidewire.

RESULTS

Successful conversion was achieved with no immediate complications with the proposed technique.

CONCLUSIONS

Techniques that describe antegrade to retrograde access conversion are seldomly reported in the medical literature. Our technique was successful in making the conversion utilizing only pigtail catheter and angled Glidewire.

Meta-Analysis of the Efficacy and Safety of P2Y12 Inhibitor Monotherapy After Short Course of Dual-Antiplatelet Therapy in Patients Undergoing Percutaneous Coronary Intervention

BACKGROUND

Guidelines recommend dual antiplatelet therapy (DAPT) following drug-eluting stent (DES) placement for ≥12 months in acute coronary syndrome or 6 months in stable coronary artery disease. However, with the advent of newer-generation stents, the optimal duration of DAPT to balance bleeding and thrombotic risks has been debated.

OBJECTIVES

We aimed to perform a meta-analysis of randomized controlled trials (RCT) comparing P2Y₁₂ monotherapy in short-duration group (SDG) vs. standard treatment group (STG) course of DAPT in patients undergoing PCI.

METHODS

Electronic databases were searched for RCTs of patients undergoing percutaneous coronary intervention (PCI) with DES placement who received short (≤ 3 months) vs. standard DAPT course (≥12 months) and were followed for ≥12-months. Rates of major adverse cardiovascular events (a composite of cardiovascular mortality, non-fatal myocardial infarction, and non-fatal stroke) were the primary outcome. Study-specific odds ratios (OR) and corresponding 95% confidence intervals were calculated using random-effects model.

RESULTS

A total of 20,706 patients (10,344 in the SDG and 10,362 in the STG) were analysed from four studies. There was no significant difference observed for MACE (OR = 0.95, 95% CI: 0.81-1.08, P = .92, I² = 0%) myocardial infarction or stent thrombosis. However, lower rates of major bleeding were noted in the SDG (1.20 vs. 1.80%; OR: 0.61; 95% CI: 0.37-0.99; P = .04; I² = 71%) albeit with increased heterogeneity.

CONCLUSION

A short duration of DAPT followed by P2Y₁₂ inhibitor monotherapy was comparable to 12 months of DAPT with respect to MACE and thrombotic events, with lower rates of major bleeding events in select group of patients undergoing PCI. More data is needed to assess efficacy in patients with complex lesions and high risk ACS population including those with STEMI presentation.