Background
Observational studies suggest a survival advantage with bilateral single internal thoracic artery (BITA) versus single internal thoracic artery grafting for coronary surgery, whereas this ...conclusion is not supported by randomized trials. We hypothesized that this inconsistency is attributed to unmeasured confounders intrinsic to observational studies. To test our hypothesis, we performed a meta‐analysis of the observational literature comparing BITA and single internal thoracic artery, deriving incident rate ratio for mortality at end of follow‐up and at 1 year. We postulated that BITA would not affect 1‐year survival based on the natural history of coronary artery bypass occlusion, so that a difference between groups at 1 year could not be attributed to the intervention.
Methods and Results
We searched MEDLINE and Pubmed to identify all observational studies comparing the outcome of BITA versus single internal thoracic artery. One‐year and long‐term mortality for BITA and single internal thoracic artery were compared in the propensity‐score–matched (PSM) series, that is, the form of observational evidence less prone to confounders. Thirty‐eight observational studies (174 205 total patients) were selected for final comparison. In the 12 propensity‐score–matched series (34 019 patients), the mortality reduction for BITA was similar at 1 year and at the end of follow‐up (incident rate ratio, 0.70; 95% confidence interval, 0.60–0.82 versus 0.77; 95% confidence interval, 0.70–0.85; P for subgroup difference=0.43).
Conclusions
Unmeasured confounders, rather than biological superiority, may explain the survival advantage of BITA in observational series.
The timing of hemodynamic support in acute myocardial infarction complicated by cardiogenic shock (AMICS) has yet to be defined. The aim of this meta-analysis was to evaluate the impact of timing of ...Impella initiation on early and midterm mortality.
A systematic literature review and meta-analysis was conducted using PubMed and Cochrane databases. All studies reporting short-term mortality rates and timing of Impella placement in AMICS were included. Meta-regression analysis and sensitivity analysis were performed on the primary endpoint, short-term mortality (≤30 days), and secondary endpoints (midterm mortality, device-related bleeding, and limb ischemia).
Of 1289 studies identified, 13 studies (6810 patients; 2970 patients identified as receiving Impella pre-PCI and 3840 patients receiving Impella during/post-PCI) were included in this analysis. Median age was 63.8 years (IQR 63–65.7); 76% of patients were male, and a high prevalence of cardiovascular risk factors was noted across the entire population. Short-term mortality was significantly reduced in those receiving pre-PCI vs. during/post-PCI Impella support (37.2% vs 53.6%, RR 0.7; CI 0.56–0.88). Midterm mortality was also lower in the pre-PCI Impella group (47.9% vs 73%, RR 0.81; CI 0.68–0.97). The rate of device-related bleeding (RR 1.05; CI 0.47–2.33) and limb ischemia (RR 1.6; CI 0.63–2.15) were similar between the two groups.
This analysis suggests that Impella placement prior to PCI in AMICS may have a positive impact on short- and midterm mortality compared with post-PCI, with similar safety outcomes. Due to the observational nature of the included studies, further studies are needed to confirm this hypothesis (CRD42022300372).
•Impella placement before PCI in ACS complicated by CS is associated with a reduced mortality compared with the post-PCI group.•The meta-regression analysis suggested that male gender and age were associated with the primary outcome.•Complication rate was comparable between the two strategies regarding device-related bleeding and limb ischemia.
Background There remains uncertainty regarding the second-best conduit after the internal thoracic artery in coronary artery bypass grafting. Few studies directly compared the clinical results of the ...radial artery ( RA ), right internal thoracic artery ( RITA ), and saphenous vein ( SV ). No network meta-analysis has compared these 3 strategies. Methods and Results MEDLINE and EMBASE were searched for adjusted observational studies and randomized controlled trials comparing the RA , SV , and/or RITA as the second conduit for coronary artery bypass grafting. The primary end point was all-cause long-term mortality. Secondary end points were operative mortality, perioperative stroke, perioperative myocardial infarction, and deep sternal wound infection ( DSWI ). Pairwise and network meta-analyses were performed. A total of 149 902 patients (4 randomized, 31 observational studies) were included ( RA , 16 201, SV , 112 018, RITA, 21 683). At NMA , the use of SV was associated with higher long-term mortality compared with the RA (incidence rate ratio, 1.23; 95% CI , 1.12-1.34) and RITA (incidence rate ratio, 1.26; 95% CI , 1.17-1.35). The risk of DSWI for SV was similar to RA but lower than RITA (odds ratio, 0.71; 95% CI , 0.55-0.91). There were no differences for any outcome between RITA and RA , although DSWI trended higher with RITA (odds ratio, 1.39; 95% CI , 0.92-2.1). The risk of DSWI in bilateral internal thoracic artery studies was higher when the skeletonization technique was not used. Conclusions The use of the RA or the RITA is associated with a similar and statistically significant long-term clinical benefit compared with the SV . There are no differences in operative risk or complications between the 2 arterial conduits, but DSWI remains a concern with bilateral ITA when skeletonization is not used.
Sodium-glucose transporter 2 inhibitors (SGLT2-I) could modulate atherosclerotic plaque progression, via down-regulation of inflammatory burden, and lead to reduction of major adverse cardiovascular ...events (MACEs) in type 2 diabetes mellitus (T2DM) patients with ischemic heart disease (IHD). T2DM patients with multivessel non-obstructive coronary stenosis (Mv-NOCS) have over-inflammation and over-lipids' plaque accumulation. This could reduce fibrous cap thickness (FCT), favoring plaque rupture and MACEs. Despite this, there is not conclusive data about the effects of SGLT2-I on atherosclerotic plaque phenotype and MACEs in Mv-NOCS patients with T2DM. Thus, in the current study, we evaluated SGLT2-I effects on Mv-NOCS patients with T2DM in terms of FCT increase, reduction of systemic and coronary plaque inflammation, and MACEs at 1 year of follow-up.
In a multi-center study, we evaluated 369 T2DM patients with Mv-NOCS divided in 258 (69.9%) patients that did not receive the SGLT2-I therapy (Non-SGLT2-I users), and 111 (30.1%) patients that were treated with SGLT2-I therapy (SGLT2-I users) after percutaneous coronary intervention (PCI) and optical coherence tomography (OCT) evaluation. As the primary study endpoint, we evaluated the effects of SGLT2-I on FCT changes at 1 year of follow-up. As secondary endpoints, we evaluated at baseline and at 12 months follow-up the inflammatory systemic and plaque burden and rate of MACEs, and predictors of MACE through multivariable analysis.
At 6 and 12 months of follow-up, SGLT2-I users vs. Non-SGLT2-I users showed lower body mass index (BMI), glycemia, glycated hemoglobin, B-type natriuretic peptide, and inflammatory cells/molecules values (p < 0.05). SGLT2-I users vs. Non-SGLT2-I users, as evaluated by OCT, evidenced the highest values of minimum FCT, and lowest values of lipid arc degree and macrophage grade (p < 0.05). At the follow-up end, SGLT2-I users vs. Non-SGLT2-I users had a lower rate of MACEs n 12 (10.8%) vs. n 57 (22.1%); p < 0.05. Finally, Hb1Ac values (1.930, CI 95%: 1.149-2.176), macrophage grade (1.188, CI 95%: 1.073-1.315), and SGLT2-I therapy (0.342, CI 95%: 0.180-0.651) were independent predictors of MACEs at 1 year of follow-up.
SGLT2-I therapy may reduce about 65% the risk to have MACEs at 1 year of follow-up, via ameliorative effects on glucose homeostasis, and by the reduction of systemic inflammatory burden, and local effects on the atherosclerotic plaque inflammation, lipids' deposit, and FCT in Mv-NOCS patients with T2DM.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
The differential impact on ischaemic and bleeding events of the type of drug-eluting stent durable polymer stents DES vs. biodegradable polymer stents vs. bioresorbable scaffolds (BRS) and length of ...dual antiplatelet therapy (DAPT) remains to be defined.
Randomized controlled trials comparing different types of DES and/or DAPT durations were selected. The primary endpoint was Major Adverse Cardiovascular Events (MACE) a composite of death, myocardial infarction (MI), and target vessel revascularization. Definite stent thrombosis (ST) and single components of MACE were secondary endpoints. The arms of interest were: BRS with 12 months of DAPT (12mDAPT), biodegradable polymer stent with 12mDAPT, durable polymer stent everolimus-eluting (EES), zotarolimus-eluting (ZES) with 12mDAPT, EES/ZES with <12 months of DAPT, and EES/ZES with >12 months of DAPT (DAPT > 12 m). Sixty-four studies with 150 arms and 102 735 patients were included. After a median follow-up of 20 months, MACE rates were similar in the different arms of interest. EES/ZES with DAPT > 12 m reported a lower incidence of MI than the other groups, while BRS showed a higher rate of ST when compared to EES/ZES, irrespective of DAPT length. A higher risk of major bleedings was observed for DAPT > 12 m as compared to shorter DAPT.
Durable and biodegradable polymer stents along with BRS report a similar rate of MACE irrespective of DAPT length. Fewer MI are observed with EES/ZES with DAPT > 12 m, while a higher rate of ST is reported for BRS when compared to EES/ZES, independently from DAPT length. Stent type may partially affect the outcome together with DAPT length.
Abstract A non-invasive approach to define grafts patency and stenosis in the follow-up of coronary artery bypass graft (CABG) patients may be an interesting alternative to coronary angiography. ...64-slice-coronary computed tomography is nowadays a diffused non-invasive method that permits an accurate evaluation of coronary stenosis, due to a high temporal and spatial resolution. However, its sensitivity and specificity in CABG evaluation has to be clearly defined, since published studies used different protocols and scanners. We collected all studies investigating patients with stable symptoms and previous CABG and reporting the comparison between diagnostic performances of invasive coronary angiography and 64-slice-coronary computed tomography. As a result, sensitivity and specificity of 64-slice-coronary computed tomography for CABG occlusion were 0.99 (95% CI 0.97–1.00) and 0.99 (95% CI: 0.99–1.00) with an area under the curve (AUC) of 0.99. 64-slice-coronary computed tomography sensitivity and specificity for the presence of any CABG stenosis > 50% were 0.98 (95% CI: 0.97–0.99) and 0.98 (95% CI: 0.96–0.98), while AUC was 0.99. At meta-regression, neither the age nor the time from graft implantation had effect on sensitivity and specificity of 64-slice-coronary computed tomography detection of significant CABG stenosis or occlusion. In conclusion 64-slice-coronary computed tomography confirmed its high sensitivity and specificity in CABG stenosis or occlusion evaluation.
Background
This meta‐analysis was designed to assess whether center experience affects the short‐ and long‐term results and the relative benefits of bilateral internal thoracic artery grafting (BITA) ...for coronary artery bypass grafting.
Methods and Results
MEDLINE and EMBASE were searched to identify all articles reporting the outcome of BITA in patients undergoing coronary artery bypass grafting. The BITA center experience was gauged according to the percentage use of BITA in the institutional overall coronary artery bypass grafting population (%BITA). The primary outcome was long‐term all‐cause mortality. Secondary outcomes were operative mortality, perioperative myocardial infarction, perioperative stroke, deep sternal wound infections (DSWIs), and major postoperative adverse event. The rates of the primary and secondary outcomes were calculated after adjusting for %BITA. Primary and secondary outcomes were also compared between the BITA and the single internal thoracic artery arms in the adjusted studies. Meta‐regression was used to evaluate the effect of %BITA on the primary and secondary outcomes. Thirty‐four studies (27 894 patients undergoing BITA) were included. In the pooled analysis, the incidence rate for long‐term mortality was 2.83% (95% confidence interval, 2.21%–3.61%). %BITA was significantly and inversely associated with long‐term mortality and the rate of DSWI. In the pairwise comparison, %BITA was significantly and inversely associated with the risk of long‐term mortality and DSWI in the group undergoing BITA.
Conclusions
BITA series with higher %BITA report significantly lower long‐term mortality and DSWI rate as well as higher long‐term survival advantage and lower relative risk of DSWI in their BITA cohort. These findings suggest that a specific volume‐outcome relationship exists for BITA grafting.
Aims
The intermediate-term incidence of strut malapposition (SM) and uncovered struts (US), and the degree of neointimal thickness (NIT) according to stent type have not been characterized.
Methods ...and results
All studies of >50 patients in which optical coherence tomography was performed between 6 and 12 months after stent implantation were included. The incidences of SM and US were the co-primary end points, while NIT was the secondary end point. A total of 458 citations were initially appraised at the abstract level, and 11 full-text studies (280 652 analysed struts, 921 patients) were assessed. The 6–12 months incidences of SM and US were 5.0 and 7.8%, respectively, and the mean NIT was 206 μm. Biolimus-eluting stents (BES) and bioresorbable vascular scaffolds (BVS) had the highest SM rates (2.7 and 3.8%, respectively), while everolimus-eluting stents (EES) and fast-release zotarolimus-eluting stents (ZES) had the lowest SM rates (0.9 and 0.1%, respectively). BES and sirolimus-eluting stents (SES) had the highest US rates (7.7 and 8.8%, respectively), while bare metal stents (BMS) and ZES had the lowest US rates (0.3 and 0.3%, respectively). BMS had the greatest NIT (340 μm), while SES, EES, and BES had the least NIT.
Conclusion
Second-generation drug-eluting stents (DES) have better intermediate-term strut apposition and coverage than first-generation DES, BVS, and BMS. EES demonstrate the overall best combination of healing with suppression of neointimal hyperplasia at 6–12 months. Further studies with clinical correlation are warranted to determine the implications of these findings.
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