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<1>
Accession Number
20160396029
Author
Rao C.; Du J.; Li X.; Li J.; Zhang H.; Zhao Y.; Hu S.; Jiang L.; Zheng Z.
Institution
(Rao, Du, Li, Li, Zhang, Zhao, Hu, Jiang, Zheng) National Clinical
Research Center of Cardiovascular Diseases, State Key Laboratory of
Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular
Diseases, Chinese Academy of Medical Sciences, Peking Union Medical
College, Beijing, China
(Li, Zhang, Hu, Zheng) Department of Cardiovascular Surgery, Fuwai
Hospital, National Center for Cardiovascular Diseases, Chinese Academy of
Medical Sciences, Peking Union Medical College, Beijing, China
Title
Rationale and design of a randomized cluster trial to improve
guideline-adherence of secondary preventive drugs prescription after
coronary artery bypass grafting in China: Measurement and Improvement
Studies of Surgical Coronary Revascularization: Secondary Prevention
(MISSION-1) Study.
Source
American Heart Journal. 178 (pp 9-18), 2016. Date of Publication: 01 Aug
2016.
Publisher
Mosby Inc.
Abstract
Objectives The benefits of secondary preventive drugs after coronary
artery bypass grafting have been thoroughly established. However, the
prescription rates of these drugs are low at discharge in China. We sought
to evaluate the effectiveness of continuous quality improvement with
mobile-based interventions for clinicians on improving the
guideline-adherence of secondary preventive drugs prescription. Methods
and Results The quality MISSION-1 study is a cluster-randomized controlled
trial. We enrolled 60 hospitals with a bypass surgery volume of more than
30 a year and randomly assigned them into the intervention group or the
control group in a 1:1 ratio using minimized random grouping. The
intervention group undertakes a series of mobile-based interventions,
while the control group maintains a routine practice pattern. All sites
consecutively register patients who underwent isolated coronary artery
bypass grafting and submit in-hospital data. We require supporting
documents regarding prescription information at discharge to adjudicate
the outcome measures. The estimated sample size of enrolled patients is
9,600. The primary outcome measure is the prescription rate of statins for
eligible patients at discharge. The secondary outcome measures are
beta-blockers, angiotensin-converting enzyme inhibitors or angiotensin
receptor blockers, and optimal medical therapy. MISSION-1 study is now
recruiting patients. Conclusions The MISSION-1 study has the potential to
identify the effectiveness of interventions on improving secondary
prevention adherence at discharge after bypass surgery in China and
further disseminate findings to other settings to improve the quality of
care. (Am Heart J 2016;0:1-10.).

<2>
Accession Number
20160404770
Author
Yusuf S.; Bosch J.; Dagenais G.; Zhu J.; Xavier D.; Liu L.; Pais P.;
Lopez-Jaramillo P.; Leiter L.A.; Dans A.; Avezum A.; Piegas L.S.;
Parkhomenko A.; Keltai K.; Keltai M.; Sliwa K.; Peters R.J.G.; Held C.;
Chazova I.; Yusoff K.; Lewis B.S.; Jansky P.; Khunti K.; Toff W.D.; Reid
C.M.; Varigos J.; Sanchez-Vallejo G.; McKelvie R.; Pogue J.; Jung H.; Gao
P.; Diaz R.; Lonn E.
Institution
(Yusuf, Bosch, McKelvie, Pogue, Jung, Gao, Lonn) Population Health
Research Institute, Hamilton Health Sciences, McMaster University, 237
Barton St. E., Hamilton, ON L8L 2X2, Canada
(Yusuf, McKelvie, Lonn) Department of Medicine, McMaster University,
Hamilton, ON, New Zealand
(Pogue) Department of Clinical Epidemiology and Biostatistics, McMaster
University, Hamilton, ON, New Zealand
(Bosch) School of Rehabilitation Science, McMaster University, Hamilton,
ON, New Zealand
(Dagenais) Institut Universitaire de Cardiologie et Pneumologie de Quebec,
Universite Laval, Quebec, QC, Canada
(Leiter) Li Ka Shing Knowledge Institute, Keenan Research Centre for
Biomedical Science, St. Michael's Hospital, University of Toronto,
Toronto, Canada
(Zhu, Liu) Fu Wai Hospital, Chinese Academy of Medical Sciences, Peking
Union Medical College, Beijing, China
(Xavier) St. John's Medical College, Bangalore, India
(Xavier, Pais) St. John's Research Institute, Bangalore, India
(Lopez-Jaramillo) Fundacion Oftalmologica de Santander, Instituto Masira,
Medical School, Universidad de Santander, Bucaramanga, Colombia
(Sanchez-Vallejo) University of Quindio, Armenia
(Dans) College of Medicine, University of the Philippines, Manila,
Philippines
(Avezum) Dante Pazzanese Institute of Cardiology, Sao Paulo, Brazil
(Piegas) HCor-Heart Hospital, Sao Paulo, Brazil
(Parkhomenko) Institute of Cardiology, Kiev, Ukraine
(Keltai, Keltai) Hungarian Institute of Cardiology, Semmelweis University,
Budapest, Hungary
(Sliwa) Hatter Institute for Cardiovascular Research in Africa, Department
of Medicine, University of Cape Town, Soweto Cardiovascular Research
Group, Cape Town, South Africa
(Peters) Department of Cardiology, Academic Medical Center, Amsterdam,
Netherlands
(Held) Department of Medical Sciences, Cardiology, Clinical Research
Center, Uppsala University, Uppsala, Sweden
(Chazova) Institute of Clinical Cardiology, Russian Cardiology Research
Complex, Moscow, Russian Federation
(Yusoff) Universiti Teknologi Majlis Amansh Rakyat, Selayang, Malaysia
(Yusoff) University College Sedaya International University, Kuala Lumpur,
Malaysia
(Lewis) Lady Davis Carmel Medical Center, Ruth and Bruce Rappaport School
of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
(Jansky) University Hospital Motol, Prague, Czech Republic
(Khunti) Diabetes Research Centre, Leicester, United Kingdom
(Toff) Department of Cardiovascular Sciences, Leicester, United Kingdom
(Toff) University of Leicester, National Institute for Health Research,
Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital,
Leicester, United Kingdom
(Reid) School of Public Health, Curtin University, Perth, WA, Australia
(Reid) Primary Care Diabetes and Vascular Medicine, Monash Centre of
Cardiovascular Research and Education in Therapeutics, Australia
(Varigos) Department of Epidemiology and Preventive Medicine, Australia
(Varigos) Monash University, Melbourne, VIC, Australia
(Diaz) Instituto Cardiovascular de Rosario, Rosario, Argentina
Title
Cholesterol lowering in intermediate-risk persons without cardiovascular
disease.
Source
New England Journal of Medicine. 374 (21) (pp 2021-2031), 2016. Date of
Publication: 26 May 2016.
Publisher
Massachussetts Medical Society
Abstract
BACKGROUND Previous trials have shown that the use of statins to lower
cholesterol reduces the risk of cardiovascular events among persons
without cardiovascular disease. Those trials have involved persons with
elevated lipid levels or inflammatory markers and involved mainly white
persons. It is unclear whether the benefits of statins can be extended to
an intermediate-risk, ethnically diverse population without cardiovascular
disease. METHODS In one comparison from a 2-by-2 factorial trial, we
randomly assigned 12,705 participants in 21 countries who did not have
cardiovascular disease and were at intermediate risk to receive
rosuvastatin at a dose of 10 mg per day or placebo. The first coprimary
outcome was the composite of death from cardiovascular causes, nonfatal
myocardial infarction, or nonfatal stroke, and the second coprimary
outcome additionally included revascularization, heart failure, and
resuscitated cardiac arrest. The median follow-up was 5.6 years. RESULTS
The overall mean low-density lipoprotein cholesterol level was 26.5% lower
in the rosuvastatin group than in the placebo group. The first coprimary
outcome occurred in 235 participants (3.7%) in the rosuvastatin group and
in 304 participants (4.8%) in the placebo group (hazard ratio, 0.76; 95%
confidence interval [CI], 0.64 to 0.91; P = 0.002). The results for the
second coprimary outcome were consistent with the results for the first
(occurring in 277 participants [4.4%] in the rosuvastatin group and in 363
participants [5.7%] in the placebo group; hazard ratio, 0.75; 95% CI, 0.64
to 0.88; P<0.001). The results were also consistent in subgroups defined
according to cardiovascular risk at baseline, lipid level, C-reactive
protein level, blood pressure, and race or ethnic group. In the
rosuvastatin group, there was no excess of diabetes or cancers, but there
was an excess of cataract surgery (in 3.8% of the participants, vs. 3.1%
in the placebo group; P = 0.02) and muscle symptoms (in 5.8% of the
participants, vs. 4.7% in the placebo group; P = 0.005). CONCLUSIONS
Treatment with rosuvastatin at a dose of 10 mg per day resulted in a
significantly lower risk of cardiovascular events than placebo in an
intermediate-risk, ethnically diverse population without cardiovascular
disease.

<3>
Accession Number
20160405476
Author
Bauters C.; Lemesle G.
Institution
(Bauters, Lemesle) Centre Hospitalier Regional et Universitaire de Lille,
Lille, France
(Bauters) Inserm U1167, Institut Pasteur de Lille, Universite Lille Nord
de France, Lille, France
(Bauters, Lemesle) Faculte de Medecine de Lille, Lille, France
(Bauters, Lemesle) Hopital Cardiologique, CHRU de Lille, Boul. Prof.
Leclercq, Lille Cedex 59037, France
Title
Screening for asymptomatic coronary artery disease in patients with
diabetes mellitus: A systematic review and meta-analysis of randomized
trials.
Source
BMC Cardiovascular Disorders. 16 (1) (no pagination), 2016. Article
Number: 90. Date of Publication: 10 May 2016.
Publisher
BioMed Central Ltd.
Abstract
Background: Screening diabetic patients for the presence of asymptomatic
coronary artery disease (CAD) may potentially impact therapeutic
management and outcome. We performed a systematic review and meta-analysis
of randomized trials addressing this question. Methods: We searched the
PubMed database for studies reporting a randomized comparison of
systematic screening for CAD in diabetic patients versus no systematic
screening. The screening protocols were variable with the use of exercise
electrocardiogram test, or stress echocardiography, or nuclear test, or
coronary computed tomography angiography. Results: The final analysis
included 5 randomized studies and 3,314 patients altogether. The screening
strategy had no detectable impact on outcome with odds ratios (OR) [95 %
confidence interval (CI)] of 1.00 [0.67-1.50], 0.72 [0.33-1.57], 0.71
[0.40-1.27], and 0.60 [0.23-1.52] for all-cause death, cardiovascular
death, non-fatal myocardial infarction, and the composite cardiovascular
death or non-fatal myocardial infarction, respectively. Protocol-related
coronary procedures were relatively infrequent in screened patients:
coronary angiography was performed in 8 % of the cases, percutaneous
coronary intervention in 2.5 %, and coronary artery bypass surgery in 1.5
%. There was no evidence for an effect of screening on the use of statins
(OR = 1.19 [0.94-1.51]), aspirin (OR = 1.02 [0.83-1.25]), or
angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (OR
= 0.97 [0.79-1.19]). Conclusion: The present analysis shows no evidence
for a benefit of screening diabetic patients for the presence of
asymptomatic CAD. The proportion of patients who undergo myocardial
revascularization as a consequence of screening was low.

<4>
Accession Number
20160402185
Author
Heidari A.; Dezfouli F.G.; Tabatabi K.; Mali S.; Ahang R.; Latifi S.M.;
Sheikhi M.A.
Institution
(Heidari) Department of Cardiac surgery, Atherosclerosis Research Center
and Imam Hospital, University of Medical Sciences, Ahvaz Jundishapur,
Ahvaz, Iran, Islamic Republic of
(Dezfouli, Tabatabi, Mali, Ahang, Latifi) Ahvaz Jundishapur University of
Medical Sciences, Ahvaz, Iran, Islamic Republic of
(Sheikhi) Department of Cardiac surgery, Atherosclerosis Research Center
Golestan Hospital, Ahvaz Jundishapur University of Medical Sciences,
Ahvaz, Iran, Islamic Republic of
Title
Combined clopidogrel and aspirin treatment up to surgery dosen't increase
the risk of postoperative blood loss and reoperation for bleeding in
patients undergoing coronary artery bypass grafting.
Source
International Journal of Pharmaceutical Research and Allied Sciences. 5
(3) (pp 164-167), 2016. Date of Publication: 2016.
Publisher
International Journal of Pharmaceutical Research and Allied Sciences
Abstract
Dual antiplatelet therapy is widely used in patients with coronary artery
disease and the optimal management of aspirin and clopidogrel before
surgery in patients with acute coronary syndrome is uncertain. The study
was a prospective and randomized trial .Patients undergoing urgent
coronary artery bypass graft surgery (CABG) were randomly assigned to one
of two groups . Group A of patients operated by an experienced surgeon .
Group B of patients that treated precautionary by blood products operated
by two recently graduate surgeons . Simultaneously one group of elective
patients operated after 5 days of antiplatelet cessation by mentioned
experienced surgeon (Group C). Randomly assigned patients were 150 adults
whom 50 in each group .The total units of given packed red cell ; fresh
frozen plasma and platelets in groups of A , B and C were (0.78+/-1.14 ;
3.60 +/-2.20 ; 3.14 +/- 1.90 ; P < 0.0001 - 0 +/- 0 ; 5.20 +/- 3.40 ; 2.34
+/- 2.36 ; P < 0.0001 and 0 +/- 0 ; 2.10 +/- 4.90 ; 0.06 +/- 0.42 ; p <
0.005 respectively ) . The amount of bleeding in that order was (987 +/-
443 ml ; I2I0 +/- 830.30 ml ; 973 +/- 537.50 ml ; p< 0.204 ) No
re-exploration was found in groups A and C while 4 case of group B
returned to operating room for control of bleeding and tamponade (8%).
Precise CABG with good hemostasis by experienced surgeons can reduce
requirement of blood products and bleeding in patients undergoing primary
urgent CABG without clopidogrel and aspirin cessation.

<5>
Accession Number
20160392412
Author
Gupta P.; Rettiganti M.; Jeffries H.E.; Scanlon M.C.; Ghanayem N.S.;
Daufeldt J.; Rice T.B.; Wetzel R.C.
Institution
(Gupta) Division of Pediatric Cardiology, Department of Pediatrics,
University of Arkansas for Medical Sciences, Little Rock, AR, United
States
(Rettiganti) Section of Biostatistics, Department of Pediatrics,
University of Arkansas for Medical Sciences, Little Rock, AR, United
States
(Jeffries) Department of Pediatrics, Seattle Children's Hospital,
University of Washington School of Medicine, Seattle, WA, United States
(Jeffries, Scanlon, Daufeldt, Rice, Wetzel) Virtual PICU Systems, LLC, Los
Angeles, CA, United States
(Scanlon, Ghanayem, Rice) Division of Critical Care, Department of
Pediatrics, Medical College of Wisconsin, Milwaukee, WI, United States
(Wetzel) Division of Critical Care Medicine, Department of Pediatrics and
Anesthesiology, Children's Hospital Los Angeles, USC Keck School of
Medicine, Los Angeles, CA, United States
Title
Risk factors and outcomes of in-hospital cardiac arrest following
pediatric heart operations of varying complexity.
Source
Resuscitation. 105 (pp 1-7), 2016. Date of Publication: 01 Aug 2016.
Publisher
Elsevier Ireland Ltd
Abstract
Background: Multi center data regarding cardiac arrest in children
undergoing heart operations of varying complexity are limited. Methods:
Children <18 years undergoing heart surgery (with or without
cardiopulmonary bypass) in the Virtual Pediatric Systems (VPS, LLC)
Database (2009-2014) were included. Multivariable mixed logistic
regression models were adjusted for patient's characteristics, surgical
risk category (STS-EACTS Categories 1, 2, and 3 classified as "low"
complexity and Categories 4 and 5 classified as "high" complexity), and
hospital characteristics. Results: Overall, 26,909 patients (62 centers)
were included. Of these, 2.7% had cardiac arrest after cardiac surgery
with an associated mortality of 31%. The prevalence of cardiac arrest was
lower among patients undergoing low complexity operations (low complexity
vs. high complexity: 1.7% vs. 5.9%). Unadjusted outcomes after cardiac
arrest were significantly better among patients undergoing low complexity
operations (mortality: 21.6% vs. 39.1%, good neurological outcomes: 78.7%
vs. 71.6%). In adjusted models, odds of cardiac arrest were significantly
lower among patients undergoing low complexity operations (OR: 0.55, 95%
CI: 0.46-0.66). Adjusted models, however, showed no difference in
mortality or neurological outcomes after cardiac arrest regardless of
surgical complexity. Further, our results suggest that incidence of
cardiac arrest and mortality after cardiac arrest are a function of
patient characteristics, surgical risk category, and hospital
characteristics. Presence of around the clock in-house attending level
pediatric intensivist coverage was associated with lower incidence of
post-operative cardiac arrest, and presence of a dedicated cardiac ICU was
associated with lower mortality after cardiac arrest. Conclusions: This
study suggests that the patients undergoing high complexity operations are
a higher risk group with increased prevalence of post-operative cardiac
arrest. These data further suggest that patients undergoing high
complexity operations can be rescued after cardiac arrest with a high
survival rate.

<6>
Accession Number
20160411365
Author
Kotidis K.; Marinceu D.; Loubani M.
Institution
(Kotidis, Marinceu, Loubani) Department of Cardiothoracic Surgery, Castle
Hill Hospital, Cottingham HU16 5JQ, United Kingdom
Title
Gender difference in Syntax Score: Implications for risk scoring and
outcomes.
Source
Chirurgia (Turin). 29 (2) (pp 31-33), 2016. Date of Publication: 2016.
Publisher
Edizioni Minerva Medica
Abstract
BACKGROUND: Female gender represents a negative prognostic factor
following coronary artery bypass surgery (CABG) specifically and cardiac
surgery in general compared with male patients. This fact is well
documented in the current risk stratification systems. Through this study
we explore gender difference in the complexity of coronary anatomy between
male and female patients. METHODS: One hundred male and one hundred female
consecutive patients who underwent elective coronary artery bypass surgery
over a 2-year period in our department were included in the study. A
blinded observer calculated the anatomical syntax score data for all the
patients. RESULTS: The two groups of patients were similar in age
(66.8+/-9.0 vs. 68.1+/-8.7; P=0.31) and Logistic Euroscore (3.3+/-2.7 vs.
4.0+/-2.9; P=0.06). The female patients had a significantly higher
anatomical Syntax score (39.6+/-13.7 vs. 32.8+/-9.8; P=0.0002), mean
number of lesions (4.3+/-1.5 vs. 3.6+/-1.2; P=0.0019), mean number of
bifurcated lesions (0.5+/-0.6 vs. 0.2+/-0.3; P=0.0002) and mean number of
trifurcated lesions (0 versus 0.03+/-0.17; P=0.04). CONCLUSIONS: There is
higher complexity of coronary anatomy in females compared to males. This
may explain the difference in predicted mortality following cardiac
surgery. We propose that the anatomical Syntax score could potentially be
included in the risk stratification scoring systems, for patients
undergoing CABG.

<7>
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Accession Number
20160393802
Author
Kim H.Y.; Choi J.M.; Lee Y.-H.; Lee S.; Yoo H.; Gwak M.
Institution
(Kim) Department of Anesthesiology and Pain Medicine, Hangang Sacred Heart
Hospital, Hallym University College of Medicine, South Korea
(Choi, Lee, Lee, Yoo, Gwak) Department of Anesthesiology and Pain
Medicine, Asan Medical Center, University of Ulsan College of Medicine,
Seoul, South Korea
Title
Effects of the trendelenburg position and positive end-expiratory pressure
on the internal jugular vein cross-sectional area in children with simple
congenital heart defects.
Source
Medicine (United States). 95 (18) (pp e3525), 2016. Date of Publication:
2016.
Publisher
Lippincott Williams and Wilkins
Abstract
Catheterization of the internal jugular vein (IJV) remains difficult in
pediatric populations. Increasing the cross-sectional area (CSA) of the
IJV facilitates cannulation and decreases complications. We aimed to
evaluate the Trendelenburg position and the levels of positive
end-expiratory pressure (PEEP) at which the maximum increase of CSA of the
IJV occurred in children undergoing cardiac surgery. In this prospective
study, the CSA of the right IJV was assessed using ultrasound in 47
anesthetized pediatric patients with simple congenital heart defects. The
baseline CSA was obtained in response to a supine position with no PEEP
and compared with 5 different randomly ordered maneuvers, that is, a PEEP
of 5 and 10 cm H2O in a supine position and of 0, 5, and 10 cm H2O in a
108 Trendelenburg position. Hemodynamic variables, incluDing blood
pressure and heart rate, maximum and minimum diameters, and CSA, were
measured. All maneuvers increased the CSA of the right IJV with respect to
the control condition. In the supine position, the CSA was increased by
9.4% with a PEEP of 5 and by 19.5% with a PEEP of 10 cm H2O. The
Trendelenburg tilt alone increased the CSA by 19.0%, and combining the 108
Trendelenburg with a 10 cm H2O PEEP resulted in the largest IJV CSA
increase (33.3%) compared with the supine position with no PEEP.
Meanwhile, vital signs remained relatively steady during the experiment.
The application of the Trendelenburg position and a 10 cm H2O PEEP thus
significantly increases the CSA of the right IJV, perhaps improving the
chances of successful cannulation in pediatric patients with simple
congenital heart defects.

<8>
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Accession Number
20160392487
Author
Basciani R.M.; Rindlisbacher A.; Begert E.; Brander L.; Jakob S.M.; Etter
R.; Carrel T.; Eberle B.
Institution
(Basciani, Eberle) Department of Anesthesiology and Pain Medicine,
University Hospital, University of Bern, Bern, Switzerland
(Rindlisbacher, Begert, Brander, Jakob, Etter) Department of Intensive
Care Medicine, University Hospital, University of Bern, Inselspital,
Freiburgstrasse, Bern CH-3010, Switzerland
(Carrel) Department of Cardiovascular Surgery, University Hospital,
University of Bern, Bern, Switzerland
(Brander) Department of Anesthesia, Cantonal Hospital, Lucerne,
Switzerland
Title
Anaesthetic induction with etomidate in cardiac surgery.
Source
European Journal of Anaesthesiology. 33 (6) (pp 417-424), 2016. Date of
Publication: 01 Jun 2016.
Publisher
Lippincott Williams and Wilkins
Abstract
BACKGROUND Etomidate is perceived as preserving haemodynamic stability
during induction of anaesthesia. It is also associated with adrenocortical
dysfunction. The risk/benefit relationship is controversial. OBJECTIVES We
tested the hypotheses that single-dose etomidate increases cumulative
vasopressor requirement, time to extubation and length of stay in the ICU.
DESIGN Double-blind randomised controlled trial. SETTING Bern University
Hospital, Switzerland, from November 2006 to December 2009. PATIENTS There
were 90 patients undergoing coronary artery bypass grafts (CABG) and 40
patients undergoing mitral valve surgery (MVS). Reasons for noninclusion
were known adrenocortical insufficiency, use of etomidate or propofol
within 1 week preoperatively, use of glucocorticoids within 6 months
preoperatively, severe renal or liver dysfunction, or carotid stenosis.
INTERVENTIONS CABG patients were allocated randomly to receive either
etomidate 0.15mgkg -1 with placebo, propofol 1.5mgkg -1 with placebo or
etomidate 0.15mgkg -1 with hydrocortisone (n=30 in each arm). Risk
stratification (low vs. high) was achieved by block randomisation. MVS
patients received either etomidate 0.15mgkg -1 or propofol 1.5mgkg -1
(n=20 in each arm). MAIN OUTCOME MEASURES Cumulative vasopressor
requirements, incidence of adrenocortical insufficiency, length of time to
extubation and length of stay in ICU. RESULTS Cumulative vasopressor
requirements 24h after induction did not differ between treatments in
patients who underwent CABG, whereas more noradrenaline was used in MVS
patients following propofol induction (absolute mean difference 5.86mugkg
-1 over 24h P=0.047). The incidence of relative adrenocortical
insufficiency was higher after etomidate alone than propofol (CABG 83 vs.
37%, P<0.001; MVS: 95 vs. 35%, P<0.001). The time to extubation, length of
stay in ICU and 30-day mortality did not differ among treatments. Within
low and high-risk subgroups, no differences in vasopressor use or outcomes
were found. CONCLUSION In elective cardiac surgery, laboratory indicators
of etomidate-induced adrenal insufficiency do not translate into increased
vasopressor requirement or inferior early outcomes. TRIAL REGISTRATION
ClinicalTrials.gov Identifier: NCT 00415701.

<9>
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Accession Number
20160392486
Author
Haas E.; Fischer F.; Levy F.; Degirmenci S.-E.; Grunebaum L.; Kindo M.;
Collange O.; Mertes P.-M.; Steib A.
Institution
(Haas, Fischer, Levy, Degirmenci, Collange, Mertes, Steib) Department of
Anaesthesiology, Strasbourg University Hospital, France
(Grunebaum) Department of Haematology, United Kingdom
(Kindo) Department of Cardiovascular Surgery, Strasbourg University
Hospital, France
Title
Identifying optimal heparin management during cardiopulmonary bypass in
obese patients.
Source
European Journal of Anaesthesiology. 33 (6) (pp 408-416), 2016. Date of
Publication: 01 Jun 2016.
Publisher
Lippincott Williams and Wilkins
Abstract
BACKGROUND The heparin regimen providing anticoagulation during
cardiopulmonary bypass (CPB) is usually adapted to total body weight
(TBW), but may be inaccurate in obese patients in whom TBW exceeds their
ideal body weight. OBJECTIVES The objective is to compare the effects of
heparin injection based on TBW on haemostatic parameters between obese and
nonobese patients during cardiac surgery and to calculate the optimal
heparin regimen. DESIGN Prospective comparative study. SETTING University
hospital. PATIENTS Two groups of 50 patients (BMI> or <30kgm -2) were
included in the study over a 9-month period in 2013. The study started on
27 February 2013. INTERVENTIONS An unfractionated heparin (UFH) bolus of
300IUkg -1 TBW was injected before initiation of CPB followed by
additional doses (50 to 100IUkg -1) to maintain a target activated
coagulation time (ACT) of at least 400s. MAIN OUTCOME MEASURES ACT and
plasma heparin concentration were measured at different time points after
initiation of, and weaning from CPB. RESULTS Obese patients received
higher initial and total doses of heparin (P<0.0001). Plasma heparin
concentrations were significantly higher in obese patients at each time
point (P<0.001) and reached very high values after the initial bolus (5.90
vs. 4.48IUml -1, P<0.0001). The relationship between plasma heparin
concentration and ACT after the initial bolus was not linear and followed
an asymptotic regression curve. Haemoglobin concentration decreased
intraoperatively to a greater extent in the obese group (P<0.001). No
significant differences in postoperative bleeding or global transfusion
requirements were observed. CONCLUSION The standard heparin regimen based
on TBW in obese patients during CPB results in excessive plasma heparin
concentrations and a significant intraoperative decrease in haemoglobin
concentration. ACT monitoring was not accurate in identifying this excess
dosage. An initial bolus of 340IUkg -1 ideal body weight would achieve a
heparin concentration of 4.5IUml -1, similar to that observed in nonobese
patients. Further investigations are warranted to confirm this heparin
regimen.

<10>
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Accession Number
20160392483
Author
Straarup T.S.; Hausenloy D.J.; Rolighed Larsen J.K.
Institution
(Straarup) Department of Anaesthesia, Aarhus University Hospital, Viborg,
Denmark
(Hausenloy) Hatter Cardiovascular Institute, University College London,
London, United Kingdom
(Rolighed Larsen) Institute of Clinical Medicine, Aarhus University
Hospital, Department of Anaesthesia, Viborg and Silkeborg, Denmark
Title
Cardiac troponins and volatile anaesthetics in coronary artery bypass
graft surgery.
Source
European Journal of Anaesthesiology. 33 (6) (pp 396-407), 2016. Date of
Publication: 01 Jun 2016.
Publisher
Lippincott Williams and Wilkins
Abstract
BACKGROUND Reports from animal studies indicate that volatile anaesthetics
protect the myocardium against the effects of acute ischaemia-reperfusion
injury by reducing infarct size. This cardioprotective effect in the
clinical setting of coronary artery bypass graft (CABG) surgery, where the
heart is subjected to global ischaemia-reperfusion injury, remains
controversial. OBJECTIVE The objective was to demonstrate that clinical
studies investigating the cardioprotective effect of volatile anaesthetics
on cardiac troponins in CABG are no longer warranted. We also investigated
the effect of volatile anaesthetics on cardiac enzymes in off-pump cardiac
surgery. DESIGN Systematic review of randomised clinical trials,
meta-analyses and trial sequential analysis (TSA). DATA SOURCES Trials
between January 1985 and March 2015 were obtained from electronic
databases (Medline, Excerpta Medica Database (EMBASE), Cochrane Controlled
Trial Register, abstracts from major anaesthesiology and cardiology
journals and reference lists of relevant randomised trials and review
articles. ELIGIBILITY CRITERIA Relevant randomised clinical trials were
included. We investigated the effect of volatile anaesthetics in both
off-pump and on-pump CABG surgery with respect to troponin release [peak
postoperative cardiac troponin I (cTnI) and cardiac troponin T (cTnT),
cTnI/cTnT] and performed two separate meta-analyses. TSA was used to
overcome the weakness of a type-1 error associated with repeated
meta-analyses. RESULTS From 30 studies, 2578 patients were pooled for the
meta-analysis. The outcome significantly favours the use of peroperative
volatile over non-volatile anaesthetics during on-pump CABG surgery with
regard to peak postoperative cTnI (0.995mgl -1; standard mean difference,
95% confidence interval, -1.316 to -0.673; P<0.001). Meta-analysis of 11
off-pump studies showed no difference in peak postoperative cTnI (0.385mgl
-1; standard mean difference, 95% confidence interval, -0.857 to 0.087;
P=0.11). TSA indicated that the required information size for on-pump
surgery was 1072 patients, and for off-pump surgery it was 1442; this
latter figure has not yet been reached. CONCLUSION Studies investigating
the cardioprotective effect of volatile anaesthetics on cardiac troponins
in on-pump CABG surgery are no longer warranted. This is not yet the case
for off-pump surgery.

<11>
[Use Link to view the full text]
Accession Number
20160392479
Author
De Hert S.
Institution
(De Hert) Department of Anaesthesiology, Ghent University, Hospital Ghent
University, De Pintelaan 185, Ghent B-9000, Belgium
Title
Cardiac troponins and volatile anaesthetics in on-pump coronary surgery:
How much longer do we need to state the obvious?.
Source
European Journal of Anaesthesiology. 33 (6) (pp 393-395), 2016. Date of
Publication: 01 Jun 2016.
Publisher
Lippincott Williams and Wilkins

<12>
Accession Number
20160403008
Author
Shaw C.; Nitsch D.; Lee J.; Fogarty D.; Sharpe C.C.
Institution
(Shaw) UK Renal Registry, Southmead Hospital, Bristol, London, United
Kingdom
(Shaw, Sharpe) Department of Renal Medicine, Kings College London, London,
United Kingdom
(Nitsch) London School of Hygiene and Tropical Medicine, London, United
Kingdom
(Lee) Department of Renal Medicine, Guy's and St Thomas' NHS Foundation
Trust, London, United Kingdom
(Fogarty) Department of Renal Medicine, Belfast Health and Social Care
Trust, Belfast, United Kingdom
Title
Impact of an early invasive strategy versus conservative strategy for
unstable angina and non-ST elevation acute coronary syndrome in patients
with chronic kidney disease: A systematic review.
Source
PLoS ONE. 11 (5) (no pagination), 2016. Article Number: e0153478. Date of
Publication: 01 May 2016.
Publisher
Public Library of Science
Abstract
Background: Clinical practice guidelines support an early invasive
approach after NSTE-ACS in patients with chronic kidney disease (CKD).
There is no direct randomised controlled trial evidence in the CKD
population, and whether the benefit of an early invasive approach is
maintained across the spectrum of severity of CKD remains controversial.
Methods: We conducted a systematic review to evaluate the association
between an early invasive approach and all-cause mortality in patients
with CKD. We searched MEDLINE and EMBASE (1990-May 2015) and article
reference lists. Data describing study design, participants, invasive
management strategies, renal function, all-cause mortality and risk of
bias were extracted. Results: 3,861 potentially relevant studies were
identified. Ten studies, representing data on 147,908 individuals with
NSTE-ACS met the inclusion criteria. Qualitative heterogeneity in the
definitions of early invasive approach, comparison groups and renal
dysfunction existed. Meta-analysis of the RCT derived and observational
data were generally supportive of an early invasive approach in CKD
(RR0.76 (95% CI 0.49-1.17) and RR0.50 (95%CI 0.42-0.59) respectively).
Meta-analysis of the observational studies demonstrated a large degree of
heterogeneity (I² 79%) driven in part by study size and
heterogeneity across various kidney function levels. Conclusions: The
observational data support that an early invasive approach after NSTE-ACS
confers a survival benefit in those with early-moderate CKD. Local
opportunities for quality improvement should be sought. Those with severe
CKD and the dialysis population are high risk and under-studied. Novel and
inclusive approaches for CKD and dialysis patients in cardiovascular
clinical trials are needed.

<13>
Accession Number
20160385644
Author
Deppe A.-C.; Weber C.; Zimmermann J.; Kuhn E.W.; Slottosch I.; Liakopoulos
O.J.; Choi Y.-H.; Wahlers T.
Institution
(Deppe, Weber, Zimmermann, Kuhn, Slottosch, Liakopoulos, Choi, Wahlers)
Department of Cardiothoracic Surgery, Heart Center of the University of
Cologne, Kerpener Strasse 62, Cologne 50924, Germany
(Choi) Center of Molecular Medicine Cologne, University of Cologne,
Cologne, Germany
Title
Point-of-care thromboelastography/thromboelastometry-based coagulation
management in cardiac surgery: A meta-analysis of 8332 patients.
Source
Journal of Surgical Research. 203 (2) (pp 424-433), 2016. Date of
Publication: 15 Jun 2016.
Publisher
Academic Press Inc.
Abstract
Objectives Severe bleeding related to cardiac surgery is associated with
increased morbidity and mortality. Thromboelastography (TEG) and
thromboelastometry (ROTEM) are point-of-care tests (POCT). Bedside
ROTEM/TEG can rapidly detect changes in blood coagulation and therefore
provide a goal-directed, individualized coagulation therapy. In this
meta-analysis, we aimed to determine the current evidence for or against
POCT-guided algorithm in patients with severe bleeding after cardiac
surgery. Methods We performed a meta-analysis of randomized controlled
trials and observational trials retrieved from a literature search in
PubMed, EMBASE, and Cochrane Library. Only trials comparing transfusion
strategy guided by TEG/ROTEM with a standard of care control group
undergoing cardiac surgery were included. In addition, at least one
clinical outcome had to be mentioned: mortality, surgical re-exploration
rate, sternal wound infection, and acute kidney injury (AKI). Also,
surrogate parameters such as transfusion requirements and amount of blood
loss were analyzed. The pooled treatment effects (odds ratio [OR] and 95%
confidence intervals [CI]) were assessed using a fixed or random-effects
model. Results The literature search retrieved a total of 17 trials (nine
randomized controlled trial and eight observational trials) involving 8332
cardiac surgery patients. POCT-guided transfusion management significantly
decreased the odds for patients to receive allogeneic blood products (OR
0.63, 95% CI 0.56-0.71; P < 0.00001) and the re-exploration rate due to
postoperative bleeding (OR 0.56, 95% CI 0.45-0.71; P < 0.00001).
Furthermore, the incidence of postoperative AKI (OR 0.77, 95% CI
0.61-0.98; P = 0.0278) and thromboembolic events (OR 0.44, 95% CI
0.28-0.70; P = 0.0006) was significantly decreased in the TEG/ROTEM group.
No statistical differences were found with regard to inhospital mortality,
cerebrovascular accident, or length of intensive care unit and hospital
stay. Conclusions TEG/ROTEM-based coagulation management decreases the
risk of allogeneic blood product exposure after cardiac surgery.
Furthermore, it results in significantly lower re-exploration rate,
decreased incidence of postoperative AKI, and thromboembolic events in
cardiac surgery patients. Results of this meta-analysis indicate that
POCT-guided transfusion therapy is superior to the current standard of
care.

<14>
Accession Number
20160399605
Author
Chertow G.M.; Winkelmayer W.C.
Institution
(Chertow) Department of Medicine, Division of Nephrology, Stanford
University, School of Medicine, 1070 Arastradero Rd, Palo Alto, CA 94034,
United States
(Winkelmayer) Selzman Institute for Kidney Health, Section of Nephrology,
Department of Medicine, Baylor College of Medicine, Houston, TX, United
States
Title
Early to Dialyze healthy and wise?.
Source
JAMA - Journal of the American Medical Association. 315 (20) (pp
2171-2172), 2016. Date of Publication: 24 May 2016.
Publisher
American Medical Association

<15>
Accession Number
20160386686
Author
McElroy I.; Sareh S.; Zhu A.; Miranda G.; Wu H.; Nguyen M.; Shemin R.;
Benharash P.
Institution
(McElroy, Sareh, Zhu, Miranda, Wu, Nguyen, Shemin, Benharash) Division of
Cardiac Surgery, Department of Surgery, David Geffen School of Medicine at
UCLA, Los Angeles, CA, United States
(Benharash) Division of Cardiac Surgery, UCLA Center for Health Sciences,
10833 Le Conte Avenue, Los Angeles, CA 90095, United States
Title
Use of digital health kits to reduce readmission after cardiac surgery.
Source
Journal of Surgical Research. 204 (1) (pp 1-7), 2016. Date of Publication:
01 Jul 2016.
Publisher
Academic Press Inc.
Abstract
Background Unintended rehospitalizations after surgical procedures
represent a large percentage of readmissions and have been associated with
increased morbidity and cost of care. Beginning in 2017, Medicare will
expand diagnostic categories subject to financial penalties for excess
postoperative readmissions to include coronary revascularization
procedures. Arrhythmias and pulmonary complications comprise the largest
categories for readmission after cardiac surgery. Technologic advances in
remote monitoring have led to the use of web-based digital health kits
(DHK) aimed at reducing readmissions and improving postoperative outcomes.
The present study was performed to determine the added benefit of
incorporating DHK's into a formal readmissions reduction program (RRP) in
preventing 30-d readmissions and to evaluate patient and provider
satisfaction with the use of these devices. Materials and methods This was
a prospective study of all adult patients who underwent cardiac surgery at
our institution from March 2014 to June 2015. During the study period, 443
adult patients (mean age, 65 +/- 14, 33% female) were identified and
participated in the formal RRP, 27 of whom also received a DHK after
discharge (416 control group). In addition to providing a live video link
to a provider specializing in cardiac surgery, the DHK also allowed for
automatic daily transmission of weight, oxygen saturation, heart rate, and
blood pressure. Patients also completed a daily health survey targeting
symptoms concerning for heart failure, poor wound healing, poor
ambulation, and nonadherence to medications. Abnormal vitals or survey
responses triggered automatic notifications to the healthcare team.
Satisfaction surveys were administered to participants and members of the
healthcare team. Pearson chi² test and the Welch's t-test were
used to assess statistical differences in baseline characteristics and
outcome variables. Results During the study period, the readmission rate
for the DHK and control groups were similar (7.4% versus 9.9%, P = 0.65).
The use of DHKs led to 1649 alerts and 144 interventions, with the highest
number of alerts occurring during d 5-9. The majority of alerts (64%) were
prompted by abnormal biometric measurements, and a significant correlation
was noted between abnormal biometrics and required intervention (r = 0.62,
P < 0.001). No correlation was seen between alerts because of health
survey responses (r = 0.07, P = 0.71) or missed check-ins (r = 0.06, P =
0.76) and required interventions. Poststudy satisfaction surveys showed an
overall satisfaction rating of 4.9 +/- 0.5 for DHK patients and 4.9 +/-
0.2 for members of the care team (scale 1-5, 5 = agree). Conclusions In
our study, adding DHKs to a formal RRP was not associated with a
significant decrease in 30-d readmission rates. We also found that
notifications because of abnormal biometric measures were significantly
correlated with required interventions. In contrast, notifications due to
abnormal health survey responses were not associated with increased
interventions. Both patients and members of the healthcare team were
highly satisfied with this technology. DHKs appear to extend care beyond
the inpatient period and provide a portal for telemonitoring of surgical
patients. However, this modality is highly resource intensive and may not
significantly reduce readmissions. Further studies are warranted to
evaluate the efficacy of such kits in reducing readmissions and costs of
care.

<16>
Accession Number
20160230065
Author
Morgan C.T.; Manlhiot C.; McCrindle B.W.; Dipchand A.I.
Institution
(Morgan, Manlhiot, McCrindle, Dipchand) Labatt Family Heart Centre,
Department of Pediatrics, Hospital for Sick Children, University of
Toronto, 555 University Avenue, Toronto, ON M5G 1X8, Canada
Title
Outcome, incidence and risk factors for stroke after pediatric heart
transplantation: An analysis of the International Society for Heart and
Lung Transplantation Registry.
Source
Journal of Heart and Lung Transplantation. 35 (5) (pp 597-602), 2016. Date
of Publication: 01 May 2016.
Publisher
Elsevier USA
Abstract
Background In the registry of the International Society for Heart and Lung
Transplantation (ISHLT), cerebrovascular accidents are the fifth most
common cause for mortality after pediatric heart transplantation (PHTx),
but details are lacking in the literature. The purpose of this analysis of
the ISHLT registry was to determine the prevalence, risk factors and
outcomes of stroke after PHTx. Methods Data from the ISHLT registry (1998
to 2010) were used to identify all patients whose primary transplantation
was performed at <18 years of age. Of the 10,441 transplants reviewed,
9,837 primary transplants and 604 retransplants were analyzed. Results
Three hundred thirty-three (3%) patients had a stroke after PHTx; 54% were
male, median age at PHTx was 6 years (0 to 17 years), and 44% had a
diagnosis of congenital heart disease (CHD). Freedom from stroke was 99%
at 1 month, 97% at 5 years, 95% at 10 years and 91% at 20 years post-PHTx.
After a stroke, survival at 1 month, 1 year and 5 years was 83%, 69% and
55%, respectively. Multivariable independent risk factors for stroke
included a primary diagnosis of congenital heart disease [hazard ratio
(HR) 1.4 (1.1 to 1.7), p = 0.01], previous stroke [HR 4.5 (3.2 to 6.2), p
< 0.001], history of aborted sudden death [HR 1.5 (1.1 to 2), p = 0.01],
ventricular assist device [HR 1.5 (1.1 to 2.2), p = 0.03] or
extracorporeal membrane oxygenation [HR 1.7 (1.2 to 2.2), p = 0.01],
post-operative dialysis [HR 3.3 (2.3 to 4.7), p < 0.001], infection
requiring antibiotics before discharge [HR 1.9 (1.4 to 2.5), p < 0.001],
pacemaker implantation [HR 1.6 (1 to 2.5), p = 0.04] or drug-treated
hypertension [HR 1.4 (1.1 to 1.8), p = 0.003] during follow-up.
Conclusions Stroke after pediatric heart transplantation is associated
with increased mortality. Congenital heart disease and mechanical support
both portend greater risk, in addition to markers of increased pre- and
post-transplant medical acuity.

<17>
Accession Number
20160149626
Author
Cuenca S.; Ruiz-Cano M.J.; Gimeno-Blanes J.R.; Jurado A.; Salas C.;
Gomez-Diaz I.; Padron-Barthe L.; Grillo J.J.; Vilches C.; Segovia J.;
Pascual-Figal D.; Lara-Pezzi E.; Monserrat L.; Alonso-Pulpon L.;
Garcia-Pavia P.
Institution
(Cuenca, Segovia, Alonso-Pulpon, Garcia-Pavia) Heart Failure and Inherited
Cardiac Diseases Unit, Department of Cardiology, Hospital Universitario
Puerta de Hierro, Manuel de Falla 2, Majadahonda, Madrid 28222, Spain
(Ruiz-Cano, Jurado) Heart Failure and Heart Transplantation Unit,
Department of Cardiology, Hospital Universitario 12 de Octubre, Madrid,
Spain
(Gimeno-Blanes, Pascual-Figal) Department of Cardiology, Hospital
Universitario Virgen de la Arrixaca, Murcia, Spain
(Salas) Department of Pathology, Hospital Universitario Puerta de Hierro,
Madrid, Spain
(Gomez-Diaz, Monserrat) Health in Code, A Coruna, Spain
(Padron-Barthe, Lara-Pezzi, Garcia-Pavia) Myocardial Biology Programme,
Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain
(Grillo) Department of Cardiology, Hospital Universitario Nuestra Senora
de Candelaria, Tenerife, Spain
(Vilches) Department of Immunology, Hospital Universitario Puerta de
Hierro, Madrid, Spain
Title
Genetic basis of familial dilated cardiomyopathy patients undergoing heart
transplantation.
Source
Journal of Heart and Lung Transplantation. 35 (5) (pp 625-635), 2016. Date
of Publication: 01 May 2016.
Publisher
Elsevier USA
Abstract
Background Dilated cardiomyopathy (DCM) is the most frequent cause of
heart transplantation (HTx). The genetic basis of DCM among patients
undergoing HTx has been poorly characterized. We sought to determine the
genetic basis of familial DCM HTx and to establish the yield of modern
next generation sequencing (NGS) technologies in this setting. Methods
Fifty-two heart-transplanted patients due to familial DCM underwent NGS
genetic evaluation with a panel of 126 genes related to cardiac conditions
(59 associated with DCM). Genetic variants were initially classified as
pathogenic mutations or as variants of uncertain significance (VUS). Final
pathogenicity status was determined by familial cosegregation studies.
Results Initially, 24 pathogenic mutations were found in 21 patients
(40%); 25 patients (48%) carried 19 VUS and 6 (12%) did not show any
genetic variant. Familial evaluation of 220 relatives from 36 of the 46
families with genetic variants confirmed pathogenicity in 14 patients and
allowed reclassification of VUS as pathogenic in 17 patients, and as
non-pathogenic in 3 cases. At the end of the study, the DCM-causing
mutation was identified in 38 patients (73%) and 5 patients (10%) harbored
only VUS. No genetic variants were identified in 9 cases (17%).
Conclusions The genetic spectrum of familial DCM patients undergoing HTx
is heterogeneous and involves multiple genes. NGS technology plus detailed
familial studies allow identification of causative mutations in the vast
majority of familial DCM cases. Detailed familial studies remain critical
to determine the pathogenicity of underlying genetic defects in a
substantial number of cases.

<18>
Accession Number
20160397075
Author
Field J.K.; Duffy S.W.; Baldwin D.R.; Brain K.E.; Devaraj A.; Eisen T.;
Green B.A.; Holemans J.A.; Kavanagh T.; Kerr K.M.; Ledson M.; Lifford
K.J.; McRonald F.E.; Nair A.; Page R.D.; Parmar M.K.B.; Rintoul R.C.;
Screaton N.; Wald N.J.; Weller D.; Whynes D.K.; Williamson P.R.;
Yadegarfar G.; Hansell D.M.
Institution
(Field, Green, McRonald, Yadegarfar) Department of Molecular and Clinical
Cancer Medicine, Institute of Translational Medicine, University of
Liverpool, Liverpool, United Kingdom
(Duffy) Centre for Cancer Prevention, Wolfson Institute of Preventive
Medicine, Queen Mary University of London, London, United Kingdom
(Baldwin) Respiratory Medicine Unit, David Evans Research Centre,
Department of Respiratory Medicine, Nottingham University Hospitals,
Nottingham, United Kingdom
(Brain, Lifford) Division of Population Medicine, College of Biomedical
and Life Sciences, Cardiff University, Cardiff, United Kingdom
(Devaraj, Hansell) Department of Radiology, Royal Brompton and Harefield
NHS Foundation Trust, London, United Kingdom
(Eisen) Department of Oncology, University of Cambridge, Cambridge, United
Kingdom
(Holemans) Department of Radiology, Liverpool Heart and Chest Hospital,
Liverpool, United Kingdom
(Kavanagh) Lung Cancer Patient Advocate, Liverpool, United Kingdom
(Kerr) Department of Pathology, Aberdeen Royal Infirmary, Aberdeen, United
Kingdom
(Ledson) Department of Respiratory Medicine, Liverpool Heart and Chest
Hospital, Liverpool, United Kingdom
(Nair) Department of Radiology, Guy's and St Thomas' NHS Foundation Trust,
London, United Kingdom
(Page) Department of Thoracic Surgery, Liverpool Heart and Chest Hospital,
Liverpool, United Kingdom
(Parmar) MRC Clinical Trials Unit, University College London, London,
United Kingdom
(Rintoul) Department of Thoracic Oncology, Papworth Hospital NHS
Foundation Trust, Cambridge, United Kingdom
(Screaton) Department of Radiology, Papworth Hospital NHS Foundation
Trust, Cambridge, United Kingdom
(Wald) Centre for Environmental and Preventive Medicine, Wolfson Institute
of Preventive Medicine, Queen Mary University of London, London, United
Kingdom
(Weller) School of Clinical Sciences and Community Health, University of
Edinburgh, Edinburgh, United Kingdom
(Whynes) School of Economics, University of Nottingham, Nottingham, United
Kingdom
(Williamson) Department of Biostatistics, Institute of Translational
Medicine, University of Liverpool, Liverpool, United Kingdom
Title
The UK lung cancer screening trial: A pilot randomised controlled trial of
low-dose computed tomography screening for the early detection of lung
cancer.
Source
Health Technology Assessment. 20 (40) (no pagination), 2016. Date of
Publication: May 2016.
Publisher
NIHR Journals Library
Abstract
Background: Lung cancer kills more people than any other cancer in the UK
(5-year survival < 13%). Early diagnosis can save lives. The USA-based
National Lung Cancer Screening Trial reported a 20% relative reduction in
lung cancer mortality and 6.7% all-cause mortality in low-dose computed
tomography (LDCT)-screened subjects. Objectives: To (1) analyse LDCT lung
cancer screening in a high-risk UK population, determine optimum
recruitment, screening, reading and care pathway strategies; and (2)
assess the psychological consequences and the health-economic implications
of screening. Design: A pilot randomised controlled trial comparing
intervention with usual care. A population-based risk questionnaire
identified individuals who were at high risk of developing lung cancer
(>5% over 5 years). Setting: Thoracic centres with expertise in lung
cancer imaging, respiratory medicine, pathology and surgery: Liverpool
Heart & Chest Hospital, Merseyside, and Papworth Hospital, Cambridgeshire.
Participants: Individuals aged 50-75 years, at high risk of lung cancer,
in the primary care trusts adjacent to the centres. Interventions: A
thoracic LDCT scan. Follow-up computed tomography (CT) scans as per
protocol. Referral to multidisciplinary team clinics was determined by
nodule size criteria. Main outcome measures: Population-based recruitment
based on risk stratification; management of the trial through web-based
database; optimal characteristics of CT scan readers (radiologists vs.
radiographers); characterisation of CT-detected nodules utilising
volumetric analysis; prevalence of lung cancer at baseline;
sociodemographic factors affecting participation; psychosocial measures
(cancer distress, anxiety, depression, decision satisfaction); and
cost-effectiveness modelling. Results: A total of 247,354 individuals were
approached to take part in the trial; 30.7% responded positively to the
screening invitation. Recruitment of participants resulted in 2028 in the
CT arm and 2027 in the control arm. A total of 1994 participants underwent
CT scanning: 42 participants (2.1%) were diagnosed with lung cancer; 36
out of 42 (85.7%) of the screen-detected cancers were identified as stage
1 or 2, and 35 (83.3%) underwent surgical resection as their primary
treatment. Lung cancer was more common in the lowest socioeconomic group.
Short-term adverse psychosocial consequences were observed in participants
who were randomised to the intervention arm and in those who had a major
lung abnormality detected, but these differences were modest and
temporary. Rollout of screening as a service or design of a full trial
would need to address issues of outreach. The health-economic analysis
suggests that the intervention could be cost-effective but this needs to
be confirmed using data on actual lung cancer mortality. Conclusions: The
UK Lung Cancer Screening (UKLS) pilot was successfully undertaken with
4055 randomised individuals. The data from the UKLS provide evidence that
adds to existing data to suggest that lung cancer screening in the UK
could potentially be implemented in the 60-75 years age group, selected
via the Liverpool Lung Project risk model version 2 and using CT
volumetry-based management protocols.

<19>
[Use Link to view the full text]
Accession Number
20160301675
Author
Uhlig C.; Bluth T.; Schwarz K.; Deckert S.; Heinrich L.; De Hert S.;
Landoni G.; Neto A.S.; Schultz M.J.; Pelosi P.; Schmitt J.; De Abreu M.G.
Institution
(Uhlig, Bluth, De Abreu) Department of Anesthesiology and Intensive Care
Medicine, Pulmonary Engineering Group, Technische Universitat Dresden,
Fetscherstr. 74, Dresden 01307, Germany
(Uhlig) Division of Health Care Sciences, Center for Clinical Research and
Management Education, Dresden International University, Dresden, Germany
(Schwarz, Deckert, Heinrich, Schmitt) Center for Evidence-Based
Healthcare, University Hospital Dresden, Technische Universitat Dresden,
Dresden, Germany
(De Hert) Department of Anesthesiology, Faculty of Medicine and Health
Sciences, Ghent University, Ghent, Belgium
(Landoni) Department of Anesthesia and Intensive Care, IRCCS San Raffaele
Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
(Neto) Department of Critical Care Medicine, Hospital Israelita Albert
Einstein, Program of Post-Graduation,Research and Innovation, Sao Paulo,
Brazil
(Schultz) Department of Intensive Care, Academic Medical Center,
Amsterdam, Netherlands
(Pelosi) Department of Surgical Sciences and Integrated Diagnostics, IRCCS
San Martino IST, University of Genoa, Genoa, Italy
Title
Effects of volatile anesthetics on mortality and postoperative pulmonary
and other complications in patients undergoing surgery: A systematic
review and meta-analysis.
Source
Anesthesiology. 124 (6) (pp 1230-1245), 2016. Date of Publication: 01 Jun
2016.
Publisher
Lippincott Williams and Wilkins
Abstract
Background: It is not known whether modern volatile anesthetics are
associated with less mortality and postoperative pulmonary or other
complications in patients undergoing general anesthesia for surgery.
Methods: A systematic literature review was conducted for randomized
controlled trials fulfilling following criteria: (1) population: adult
patients undergoing general anesthesia for surgery; (2) intervention:
patients receiving sevoflurane, desflurane, or isoflurane; (3) comparison:
volatile anesthetics versus total IV anesthesia or volatile anesthetics;
(4) reporting on: (a) mortality (primary outcome) and (b) postoperative
pulmonary or other complications; (5) study design: randomized controlled
trials. The authors pooled treatment effects following Peto odds ratio
(OR) meta-analysis and network meta-analysis methods. Results: Sixty-eight
randomized controlled trials with 7,104 patients were retained for
analysis. In cardiac surgery, volatile anesthetics were associated with
reduced mortality (OR = 0.55; 95% CI, 0.35 to 0.85; P = 0.007), less
pulmonary (OR = 0.71; 95% CI, 0.52 to 0.98; P = 0.038), and other
complications (OR = 0.74; 95% CI, 0.58 to 0.95; P = 0.020). In noncardiac
surgery, volatile anesthetics were not associated with reduced mortality
(OR = 1.31; 95% CI, 0.83 to 2.05, P = 0.242) or lower incidences of
pulmonary (OR = 0.67; 95% CI, 0.42 to 1.05; P = 0.081) and other
complications (OR = 0.70; 95% CI, 0.46 to 1.05; P = 0.092). Conclusions:
In cardiac, but not in noncardiac, surgery, when compared to total IV
anesthesia, general anesthesia with volatile anesthetics was associated
with major benefits in outcome, including reduced mortality, as well as
lower incidence of pulmonary and other complications. Further studies are
warranted to address the impact of volatile anesthetics on outcome in
noncardiac surgery.

<20>
Accession Number
20160225945
Author
Lakomkin N.; Sathiyakumar V.; Dodd A.C.; Jahangir A.A.; Whiting P.S.;
Obremskey W.T.; Sethi M.K.
Institution
(Lakomkin, Sathiyakumar, Dodd, Jahangir, Obremskey, Sethi) Vanderbilt
Orthopaedic Institute Center for Health Policy, Medical Center East, 1215
21st Avenue South, South Tower, Nashville, TN 37232, United States
(Whiting) University of Wisconsin Hospital and Clinics, 1685 Highland Ave,
Madison, WI 53704, United States
Title
Pre-operative labs: Wasted dollars or predictors of post-operative cardiac
and septic events in orthopaedic trauma patients?.
Source
Injury. 47 (6) (pp 1217-1221), 2016. Date of Publication: 01 Jun 2016.
Publisher
Elsevier Ltd
Abstract
Purpose As US healthcare expenditures continue to rise, there is
significant pressure to reduce the cost of inpatient medical services.
Studies have estimated that over 70% of routine labs may not yield
clinical benefits while adding over $300 in costs per day for every
inpatient. Although orthopaedic trauma patients tend to have longer
inpatient stays and hip fractures have been associated with significant
morbidity, there is a dearth of data examining pre-operative labs in
predicting post-operative adverse events in these populations. The purpose
of this study was to assess whether pre-operative labs significantly
predict post-operative cardiac and septic complications in orthopaedic
trauma and hip fracture patients. Methods Between 2006 and 2013, 56,336
(15.6%) orthopaedic trauma patients were identified and 27,441 patients
(7.6%) were diagnosed with hip fractures. Pre-operative labs included
sodium, BUN, creatinine, albumin, bilirubin, SGOT, alkaline phosphatase,
white count, hematocrit, platelet count, prothrombin time, INR, and
partial thromboplastin time. For each of these labs, patients were deemed
to have normal or abnormal values. Patients were noted to have developed
cardiac or septic complications if they sustained (1) myocardial
infarction (MI), (2) cardiac arrest, or (3) septic shock within 30 days
after surgery. Separate regressions incorporating over 40 patient
characteristics including age, gender, pre-operative comorbidities, and
labs were performed for orthopaedic trauma patients in order to determine
whether pre-operative labs predicted adverse cardiac or septic outcomes.
Results 749 (1.3%) orthopaedic trauma patients developed cardiac
complications and 311 (0.6%) developed septic shock. Multivariate
regression demonstrated that abnormal pre-operative platelet values were
significantly predictive of post-operative cardiac arrest (OR: 11.107, p =
0.036), and abnormal bilirubin levels were predictive (OR: 8.487, p =
0.008) of the development of septic shock in trauma patients. In the hip
fracture cohort, abnormal partial thromboplastin time was significantly
associated with post-operative myocardial infarction (OR: 15.083, p =
0.046), and abnormal bilirubin (OR: 58.674, p = 0.002) significantly
predicted the onset of septic shock. Conclusions This is the first study
to demonstrate the utility of pre-operative labs in predicting
perioperative cardiac and septic adverse events in orthopaedic trauma and
hip fracture patients. Particular attention should be paid to
haematologic/coagulation labs (platelets, PTT) and bilirubin values. Level
of evidence Prognostic Level II.

<21>
Accession Number
20160126693
Author
Zhou D.; Fan Y.; Wan Z.; Wen W.; Wang X.; Zhou J.; Chen T.; Yuan Z.
Institution
(Zhou, Fan, Wan, Wen, Wang, Zhou, Chen, Yuan) Department of Cardiovascular
Medicine, First Affiliated Hospital of xi'An Jiaotong University, 277
Yanta West Road, Xi'an, Shaanxi 710061, China
(Yuan) Key Laboratory of Environment and Genes Related to Diseases,
Ministry of Education, Xi'an, China
(Yuan) Key Laboratory of Molecular Cardiology, Xi'an, China
(Zhou) Department of Cardiovascular Medicine, Hanzhong Central Hospital,
Hanzhong, China
Title
Platelet-to-Lymphocyte Ratio Improves the Predictive Power of GRACE Risk
Score for Long-Term Cardiovascular Events in Patients with Acute Coronary
Syndrome.
Source
Cardiology (Switzerland). 134 (1) (pp 39-46), 2016. Date of Publication:
01 Apr 2016.
Publisher
S. Karger AG
Abstract
Objectives: This study aims to evaluate the relationship between
platelet-to-lymphocyte ratio (PLR) and GRACE risk score and to examine
whether PLR on admission can improve the predictive value of GRACE risk
score for cardiovascular disease (CVD) events in patients with acute
coronary syndrome (ACS). Methods: PLR was calculated from the platelet and
lymphocyte counts from the complete blood count of 2,230 ACS patients upon
admission. The GRACE risk score was also calculated. Results: Spearman's
rank correlation demonstrated that GRACE risk score was positively
correlated with PLR (r = 0.190, p < 0.001). After a median follow-up
period of 58 months, multivariate Cox analysis showed that both GRACE risk
score [hazard ratio (HR) 1.092, 95% confidence interval (CI) 1.067-1.117,
p < 0.001] and PLR (HR 1.100, 95% CI 1.088-1.112, p < 0.001) could
independently predict CVD events. Receiver-operating characteristic curve
(ROC) analysis proved that using PLR together with GRACE risk score
improved the score from 0.70 (95% CI 0.67-0.73, p < 0.001) when used alone
to 0.81 (95% CI 0.79-0.83, p < 0.001) for CVD events and from 0.73 (95% CI
0.70-0.77, p < 0.001) when used alone to 0.80 (95% CI 0.77-0.83, p <
0.001) for all-cause mortality. Conclusions: This study proves, for the
first time, a positive association between GRACE risk score and PLR, and
that a combination of PLR and GRACE risk score is more effective in
predicting CVD events in ACS patients.

<22>
[Use Link to view the full text]
Accession Number
20160381974
Author
Young M.N.; Elmariah S.
Institution
(Young, Elmariah) Department of Medicine, Massachusetts General Hospital,
Harvard Medical School, Boston, MA, United States
Title
Transcatheter aortic valve replacement in low-risk patients within the
observational study of effectiveness of SAVR-TAVI procedures for severe
aortic stenosis treatment study.
Source
Circulation: Cardiovascular Interventions. 9 (5) (no pagination), 2016.
Article Number: e003830. Date of Publication: 01 May 2016.
Publisher
Lippincott Williams and Wilkins

<23>
Accession Number
20160381967
Author
Regueiro A.; Altisent O.A.-J.; Del Trigo M.; Campelo-Parada F.; Puri R.;
Urena M.; Philippon F.; Rodes-Cabau J.
Institution
(Regueiro, Altisent, Del Trigo, Campelo-Parada, Puri, Philippon,
Rodes-Cabau) Quebec Heart and Lung Institute, Laval University, 2725
Chemin Ste-Foy, Quebec City, QC G1V 4GS, Canada
(Urena) Cardiology Department, Bichat-Claude Bernard Hospital, Paris,
France
Title
Impact of new-onset left bundle branch block and periprocedural permanent
pacemaker implantation on clinical outcomes in patients undergoing
transcatheter aortic valve replacement.
Source
Circulation: Cardiovascular Interventions. 9 (5) (no pagination), 2016.
Article Number: e003635. Date of Publication: 01 May 2016.
Publisher
Lippincott Williams and Wilkins
Abstract
Background - Available data on the clinical impact of new-onset left
bundle branch block (LBBB) and permanent pacemaker implantation (PPI)
after transcatheter aortic valve replacement (TAVR) remains controversial.
We aimed to evaluate the impact of (1) periprocedural new-onset LBBB or
PPI post-TAVR on cardiac mortality and all-cause 1-year mortality and (2)
new-onset LBBB on the need for PPI at 1-year follow-up. Methods and
Results - We performed a systematic search from PubMed and EMBASE
databases for studies reporting raw data on new-onset LBBB post-TAVR and
the need for PPI or mortality at 1-year follow-up, or on 1-year mortality
according to the need for periprocedural PPI post-TAVR. Data from 17
studies, including 4756 patients (8 studies) and 7032 patients (11
studies) for the evaluation of the impact of new-onset LBBB and
periprocedural PPI post-TAVR were sourced, respectively (with 2 studies
used for both outcomes). New-onset LBBB post-TAVR was associated with a
higher risk of PPI (risk ratio [RR], 2.18; 95% confidence interval [CI],
1.28-3.70) and cardiac death (RR, 1.39; 95% CI, 1.04-1.86) during
follow-up, as well with a tendency toward an increase in all-cause
mortality (RR, 1.21; 95% CI, 0.98-1.50). Periprocedural PPI post-TAVR was
not associated with any increased risk of all-cause mortality at 1 year
(RR, 1.03; 95% CI, 0.9-1.18), yet a tendency toward a protective effect on
cardiac death was observed (RR, 0.78; 95% CI, 0.60-1.03). Conclusions -
New-onset LBBB post-TAVR is a marker of an increased risk of cardiac death
and need for PPI at 1-year follow-up. The need for PPI early post-TAVR did
not increase the risk of death.

<24>
[Use Link to view the full text]
Accession Number
20160381960
Author
Popma C.J.; Sheng S.; Korjian S.; Daaboul Y.; Chi G.; Tricoci P.; Huang
Z.; Moliterno D.J.; White H.D.; Van De Werf F.; Harrington R.A.; Wallentin
L.; Held C.; Armstrong P.W.; Aylward P.E.; Strony J.; Mahaffey K.W.;
Gibson C.M.
Institution
(Popma, Korjian, Daaboul, Chi, Gibson) Division of Cardiology, Department
of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United
States
(Sheng) Department of Vascular Surgery, Tongji Medical College, Huazhong
University of Science and Technology, Wuhan, China
(Tricoci, Huang) Duke Clinical Research Institute, Durham, NC, United
States
(Moliterno) Department of Medicine, Gill Heart Institute, University of
Kentucky, Lexington, KY, United States
(White) Department of Cardiology, Green Lane Cardiovascular Service,
Auckland City Hospital, Auckland, New Zealand
(Van De Werf) Department of Cardiology, University of Leuven, Leuven,
Belgium
(Harrington, Mahaffey) Department of Medicine, Stanford University,
Stanford, CA, United States
(Wallentin, Held) Department of Medical Sciences, Cardiology, Uppsala
Clinical Research Center, Uppsala University, Uppsala, Sweden
(Armstrong) Division of Cardiology, Department of Medicine, University of
Alberta, Edmonton, Canada
(Aylward) Department of Medicine, South Australian Health and Medical
Research Institute, Flinders University and Medical Centre, Adelaide,
Australia
(Strony) Merck Clinical Research, Merck and Co, Whitehouse Station, NJ,
United States
Title
Lack of concordance between local investigators, angiographic core
laboratory, and clinical event committee in the assessment of stent
thrombosis.
Source
Circulation: Cardiovascular Interventions. 9 (5) (no pagination), 2016.
Article Number: e003114. Date of Publication: 01 May 2016.
Publisher
Lippincott Williams and Wilkins
Abstract
Background - Stent thrombosis (ST) is an important end point in
cardiovascular clinical trials. Adjudication is traditionally based on
clinical event committee (CEC) review of case report forms and source
documentation rather than angiograms. However, the degree to which this
method of adjudication is concordant with the review of independent
angiographic core laboratories (ACLs) has not been studied. This report
represents the first assessment of variability between local investigators
(LIs), a CEC, and an ACL. Methods and Results - Serial angiograms of 329
patients with acute coronary syndrome without ST-segment-elevation who
underwent percutaneous coronary intervention at entry in the Trial to
Assess the Effects of Vorapaxar in Preventing Heart Attack and Stroke in
Particpants With Acute Coronary Syndrome (TRACER) and who met criteria for
possible ST subsequent to the index event were reviewed by an ACL. The ACL
was blinded to the assessment by both LIs and the CEC regarding the
presence or absence of ST. CEC adjudication was based on Academic Research
Consortium definitions of ST, using case report form data and source
documents, including catheterization laboratory reports. The ACL, CEC, and
LIs agreed on the presence or absence of ST in 52.9% events (kappa=0.32;
95% confidence interval, 0.26-0.39). The ACL and CEC agreed on 82.7% of
events (kappa=0.57; 95% confidence interval, 0.47-0.67); the ACL and LIs
agreed on 61.1% of events (kappa=0.25; 95% confidence interval,
0.16-0.34); and the CEC and LIs agreed on 62% of events (kappa=0.28; 95%
confidence interval, 0.21-0.36). Conclusions - ST reporting by an ACL, a
CEC, and LIs is discordant. The assessment of ST is more often detected by
direct review of angiograms by an ACL.

<25>
Accession Number
20160385852
Author
Vedel A.G.; Holmgaard F.; Rasmussen L.S.; Paulson O.B.; Thomsen C.;
Danielsen E.R.; Langkilde A.; Goetze J.P.; Lange T.; Ravn H.B.; Nilsson
J.C.
Institution
(Vedel, Holmgaard, Ravn, Nilsson) University of Copenhagen, Department of
Cardiothoracic Anaesthesiology, Heart Centre, Rigshospitalet, Blegdamsvej
9, Copenhagen DK-2100, Denmark
(Rasmussen) University of Copenhagen, Department of Anaesthesia, Centre of
Head and Orthopaedics, Rigshospitalet, Blegdamsvej 9, Copenhagen DK-2100,
Denmark
(Paulson) University of Copenhagen, Neurobiology Research Unit,
Neuroscience Centre, Rigshospitalet, Blegdamsvej 9, Copenhagen DK-2100,
Denmark
(Thomsen, Danielsen, Langkilde) University of Copenhagen, Department of
Radiology, Diagnostic Centre, Rigshospitalet, Blegdamsvej 9, Copenhagen
DK-2100, Denmark
(Goetze) University of Copenhagen, Department of Clinical Biochemistry,
Diagnostic Centre, Rigshospitalet, Blegdamsvej 9, Copenhagen DK-2100,
Denmark
(Lange) University of Copenhagen, Department of Biostatistics, Oster
Farimagsgade 5, Copenhagen DK-2100, Denmark
Title
Perfusion Pressure Cerebral Infarct (PPCI) trial - the importance of mean
arterial pressure during cardiopulmonary bypass to prevent cerebral
complications after cardiac surgery: Study protocol for a randomised
controlled trial.
Source
Trials. 17 (1) (no pagination), 2016. Article Number: 247. Date of
Publication: 17 May 2016.
Publisher
BioMed Central Ltd.
Abstract
Background: Debilitating brain injury occurs in 1.6-5 % of patients
undergoing cardiac surgery with cardiopulmonary bypass. Diffusion-weighted
magnetic resonance imaging studies have reported stroke-like lesions in up
to 51 % of patients after cardiac surgery. The majority of the lesions
seem to be caused by emboli, but inadequate blood flow caused by other
mechanisms may increase ischaemia in the penumbra or cause watershed
infarcts. During cardiopulmonary bypass, blood pressure can be below the
lower limit of cerebral autoregulation. Although much debated, the
constant blood flow provided by the cardiopulmonary bypass system is still
considered by many as appropriate to avoid cerebral ischaemia despite the
low blood pressure. Methods/design: The Perfusion Pressure Cerebral
Infarct trial is a single-centre superiority trial with a blinded outcome
assessment. The trial is randomising 210 patients with coronary vessel
and/or valve disease and who are undergoing cardiac surgery with the use
of cardiopulmonary bypass. Patients are stratified by age and surgical
procedure and are randomised 1:1 to either an increased mean arterial
pressure (70-80 mmHg) or 'usual practice' (40-50 mmHg) during
cardiopulmonary bypass. The cardiopulmonary bypass pump flow is fixed and
set at 2.4 L/minute/m² body surface area plus 10-20 % in both
groups. The primary outcome measure is the volume of the new ischaemic
cerebral lesions (in mL), expressed as the difference between a baseline,
diffusion-weighted, magnetic resonance imaging scan and an equal scan
conducted 3-6 days postoperatively. Secondary endpoints are the total
number of new ischaemic cerebral lesions, postoperative cognitive
dysfunction at discharge and 3 months postoperatively, diffuse cerebral
injury evaluated by magnetic resonance spectroscopy and selected
biochemical markers of cerebral injury. The sample size will enable us to
detect a 50 % reduction in the primary outcome measure in the intervention
compared to the control group at a significance level of 0.05 and with a
power of 0.80. Discussion: This is the first clinical randomised study to
evaluate whether the mean arterial pressure level during cardiopulmonary
bypass influences the development of brain injuries that are detected by
diffusion-weighted magnetic resonance imaging. Trial registration:
ClinicalTrials.gov, NCT02185885. Registered on 7 July 2014.

<26>
Accession Number
20160392328
Author
Zhao S.-J.; Zhong Z.-S.; Qi G.-X.; Shi L.-Y.; Chen L.; Tian W.
Institution
(Zhao, Qi, Shi, Chen, Tian) Department of Geriatric Cardiology, First
Affiliated Hospital, China Medical University, Shenyang, China
(Zhong) Department of Respiratory, Central Hospital, Shenyang Medical
College, Shenyang, China
Title
Effect of pioglitazone in preventing in-stent restenosis after
percutaneous coronary intervention in patients with type 2 diabetes: A
meta-analysis.
Source
PLoS ONE. 11 (5) (no pagination), 2016. Article Number: e0155273. Date of
Publication: 01 May 2016.
Publisher
Public Library of Science
Abstract
Background: The benefits of pioglitazone in patients with type 2 diabetes
mellitus (T2DM) after percutaneous coronary intervention (PCI) is unclear.
Objectives: To evaluate the effect of pioglitazone on prevention of
in-stent restenosis (ISR) in patients with T2DM after PCI. Methods: All
full-text published relevant studies compared the effect of pioglitazone
with control group (placebo or no pioglitazone treatment) on ISR in
patients with T2DM after PCI were identified by searching the databases
including PubMed, EMBASE, Cochrane Library and ISI Web of Science through
October 2015. The endpoints were defined as the rate of ISR, late lumen
loss, in-stent neointimal volume, target lesion revascularization (TLR)
and major adverse cardiac events (MACE). Results: Six studies (5 RCTs and
1 retrospective study), comprising 503 patients, were included into this
meta-analysis. In the pioglitazone group, as compared with the control
group, the risk ratio for ISR was 0.48 (I² = 14.5%, P = 0.322;
95%CI 0.35 to 0.68, P<0.001), the risk ratio for TLR was 0.58
(I² = 6.0%, P = 0.363; 95%CI 0.38 to 0.87, P = 0.009). The
result showed there was no association between the use of pioglitazone and
the events of MACE (I² = 36.7%, P = 0.209; RR 0.56, 95%CI 0.30
to 1.05, P = 0.071). For the considerable heterogeneity, further analysis
was not suitable for the endpoints of late lumen loss (I² =
81.9%, P<0.001) and neointimal volume (I² = 75.9%, P = 0.016).
Conclusions: The treatment of pioglitazone was associated with a reduction
in ISR and TLR in T2DM patients suffering from PCI, except the incidence
of MACE.

<27>
Accession Number
20160394930
Author
Li Q.; He Y.; Chen L.; Chen M.
Institution
(Li, He, Chen) Sichuan University, Department of Cardiology, West China
Hospital, Chengdu, China
(Li) Sichuan Provincial People's Hospital and Sichuan Academy of Medical
Science, Department of Cardiology, Chengdu, China
(Chen) Sichuan University, Department of Physiology, West China School of
Preclinical and Forensic Medicine, Chengdu, China
Title
Intensive plaque modification with rotational atherectomy and cutting
balloon before drug-eluting stent implantation for patients with severely
calcified coronary lesions: A pilot clinical study.
Source
BMC Cardiovascular Disorders. 16 (1) (no pagination), 2016. Article
Number: 112. Date of Publication: 26 May 2016.
Publisher
BioMed Central Ltd.
Abstract
Background: This study investigated whether, for patients with severely
calcified coronary lesions, use of a cutting balloon (CB) during
rotational atherectomy (RA) before placing a drug-eluting stent will
improve periprocedural outcomes, compared to RA with a conventional plain
balloon. Methods: In a randomized controlled trial, patients with severely
calcified lesions of calcium arc >180degree were apportioned to receive
intensive plaque modification with RA and CB (RA + CB; n = 35) or RA with
conventional plain balloon (RA; n = 36). Intravascular ultrasound was
applied for quantitative or qualitative analyses of percutaneous coronary
intervention outcomes. The primary outcome was acute lumen gain after
drug-eluting stent. Results: The RA + CB and RA groups were similar in
baseline mean arcs of superficial calcium, and minimum lumen
cross-sectional areas (CSAs). The mean minimum stent CSA after
percutaneous coronary intervention (PCI) of the RA + CB group (5.9 +/- 1.7
mm²) was significantly larger than that of the RA group (5.0
+/- 1.4 mm²; P = 0.021). Patients in the RA + CB group achieved
significantly larger acute CSA gain after PCI (4.5 +/- 1.5 mm²)
relative to the RA group (3.8 +/- 1.5 mm²; P = 0.035). The
groups were similar in rates of periprocedural complications, but at the
1-year follow-up the RA + CB had a lower rate of revascularization for
restenosis of the target vessel and MACE (5.7 %) than did the RA group
(22.2 %, P = 0.046). Conclusion: Aggressive plaque preparation with RA and
CB seems to be safe and effective for patients with severely calcified
coronary lesions. Trial registration: Current Controlled Trials
ChiCTR-INR-16008274. Retrospectively registered 12 April 2016.

<28>
Accession Number
20160388734
Author
Kim J.H.; Chae S.-C.; Oh D.J.; Kim H.-S.; Kim Y.J.; Ahn Y.; Cho M.C.; Kim
C.J.; Yoon J.-H.; Park H.-Y.; Jeong M.H.
Institution
(Kim, Ahn, Jeong) Heart Center of Chonnam National University Hospital,
Gwangju, South Korea
(Chae) Department of Internal Medicine, Kyungpook National University
Hospital, Daegu, South Korea
(Oh) Cardiovascular Center University Guro Hospital, Seoul, South Korea
(Kim) Department of Internal Medicine, Seoul National University Hospital,
Seoul, South Korea
(Kim) Department of Cardiology, Yeungnam University Medical Center, Daegu,
South Korea
(Cho) Cardiology Division, Department of Internal Medicine, Chungbuk
National University Hospital, Cheongju, South Korea
(Kim) Department of Internal Medicine, Kyunghee University College of
Medicine, Seoul, South Korea
(Yoon) Department of Internal Medicine, Yonsei University Wonju College of
Medicine, Wonju, South Korea
(Park) Division of Cardiovascular and Rare Diseases, Center for Biomedical
Sciences, National Institute of Health, Osong, South Korea
Title
Multicenter cohort study of acute myocardial infarction in Korea - Interim
analysis of the Korea acute myocardial infarction registry-national
institutes of health registry.
Source
Circulation Journal. 80 (6) (pp 1427-1436), 2016. Date of Publication:
2016.
Publisher
Japanese Circulation Society
Abstract
Background:The Korea Acute Myocardial Infarction Registry (KAMIR)-National
Institutes of Health (NIH) registry has the aim of evaluating the clinical
characteristics, management, and long-term outcomes of patients with acute
myocardial infarction (AMI) in Korea.Methods and Results:Patients
hospitalized for AMI in 20 tertiary university hospitals in Korea have
been enrolled since November 2011. The study is expected to complete the
scheduled enrollment of approximately 13,000 patients in October 2015, and
follow-up duration is up to 5 years for each patient. As of October 2015,
an interim analysis of 13,623 subjects was performed to understand the
baseline clinical profiles of the study population. The mean age was 64.1
years, 73.5% were male, and 48.2% were diagnosed with ST-segment elevation
AMI. Hypertension is a leading cause of AMI in Korea (51.2%), followed by
smoking (38.5%) and diabetes mellitus (28.6%). Percutaneous coronary
intervention was performed in 87.4% and its success rate was very high
(99.4%). In-hospital, 1-year, and 2-year mortality rates were 3.9%, 4.3%,
and 8.6%, respectively. The rates of major adverse cardiac events at 1 and
2 years were 9.6% and 18.8%, respectively.Conclusions:This analysis
demonstrated the clinical characteristics of Korean AMI patients in
comparison with those of other countries. It is necessary to develop
guidelines for Asian populations to further improve their prognosis.

<29>
Accession Number
72296880
Author
Najjar S.; Pearlman D.M.; MacKenzie T.A.; Hernandez Jr. F.; Brown J.R.
Institution
(Najjar, Pearlman, MacKenzie, Hernandez Jr., Brown) Department of
Neurology, Hofstra North Shore-LIJ School of Medicine, New York, NY,
United States
Title
Role of glial activation and BBB disruption in the pathophysiology of
depression.
Source
Neurology Psychiatry and Brain Research. Conference: 13th Psychoimmunology
Expert Meeting Guenzburg Germany. Conference Start: 20160303 Conference
End: 20160306. Conference Publication: (var.pagings). 22 (1) (pp 17-18),
2016. Date of Publication: March 2016.
Publisher
Elsevier GmbH
Abstract
Background: Adding to the established role of inflammation and glial
injury/activation in depression, recent evidence has implicated
neurovascular dysfunction with blood-brain barrier hyperpermeability.
However, to date, no studies have assessed the directionality between
these mechanisms in humans. We investigated these mechanisms in the
context of a systemic inflammatory challenge paradigm of cardiac surgery
known to be associated with depression. Methods: In this prospective
cohort of patients undergoing coronary artery bypass grafting (N = 50), we
measured the change in depressive symptom severity measured as Beck
Depression Inventory-II (DELTABDI-II) scores from preoperative baseline to
postoperative discharge. For each participant, we then compared these
values with changes in S-100 calcium-binding protein B (DELTAS- 100B),
high-sensitivity C-reactive protein (DELTAhs-CRP), and interleukin- 6
(DELTAIL-6) levels in serum or plasma from preoperative baseline to 2 days
postoperative. Results: DELTABDI-II exhibited a strong correlation with
DELTAS-100B (Spearman r = 0.64, P = 0.0004; R² = 0.23, P =
0.0105) but not DELTAhs- CRP or DIL-6 levels. This correlation remained
statistically significant at alpha = 0.001 after separate adjustments for
each clinicodemographic characteristic that had a significant univariate
association with DELTABDI-II orDELTAS-100B (age, weight, BMI,beta-blocker-
except for baseline BDI-II scores). Conclusions: In this small but
unselected cohort, perioperative incremental changes in S100B, a potential
biomarker of blood-brain barrier disruption and glial activation and
injury, showed a specific, strong, and robust association with acute
worsening of depressive symptoms after inflammatory challenge. These
findings are consistent with the hypothesis that depression can be
mechanistically linked to glial activation and injury as well as
blood-brain barrier disruption in the context of systemic inflammation
challenge paradigms. Further, a follow-up single-blind, randomized,
controlled trial [off-pump (n = 102), conventional (n = 99)] showed that
off-pump, relative to conventional, coronary artery bypass grafting was
associated with greater within-subject DELTABDI-II scores between baseline
and postoperative discharge. The proportion of participants who did not
have depression at baseline but did have depression at 3 months was
similar among both groups (results will be shown in the meeting).

<30>
Accession Number
72296786
Author
Azzouz M.S.; Haddad T.M.; Akinapelli A.; Smer A.; Woodruff M.; Del Core
M.; White M.
Institution
(Azzouz, Haddad, Akinapelli, Smer, Woodruff, Del Core, White) Creighton
University, Omaha, NE, United States
Title
Trans-femoral versus trans-apical access in transcatheter aortic valve
implantation; a meta-analysis.
Source
JACC: Cardiovascular Interventions. Conference: Cardiovascular Research
Technologies, CRT 2016 Washington, DC United States. Conference Start:
20160220 Conference End: 20160223. Conference Publication: (var.pagings).
9 (4 SUPPL. 1) (pp S45-S46), 2016. Date of Publication: 22 Feb 2016.
Publisher
Elsevier Inc.
Abstract
BACKGROUND Transcatheter aortic valve implantation (TAVI) is a
breakthrough treatment option for inoperable or high surgical risk
patients with symptomatic, severe aortic valve disease. Traditionally
Trans-Femoral (TF) access has been the most common route. Trans- Apical
(TA) access has been used since 2004 as an alternative in patients with
unfavorable anatomy. We conducted a meta-analysis to compare between these
two approaches. METHODS We searched PubMed, Cochrane Library and Web of
Science databases for randomized studies comparing TF versus TA access in
TAVI patients between 2002-2015 using the search terms: Transcatheter
aortic valve replacement, TAVR, TAVI, trans-femoral, and trans-apical. The
primary outcome assessed was 30-day mortality. We also evaluated the risks
of the following postoperative conditions: stroke, heart block, bleeding
and renal failure. We conducted our meta-analysis using RevMan 5.3
software with random effects model. Visual inspection of the funnel plot
showed no publication bias. P value less than 0.05 was considered
statistically significant. RESULTS A total of 24 randomized studies with a
total of 8581 patients (TF:5693; TA: 2888) were included in the final
analysis. TF patients had less 30-day mortality (OR: 0.57[0.38-0.87])
compared to TA patients. Bleeding (OR: 0.6 [0.49-0.73]) and renal failure
(OR: 0.33 [0.24-0.46]) were less in the TF arm as well. There was no
statistically significant difference in the rate of stroke or heart block
between both groups. A sensitivity analysis was performed and confirmed
the above mentioned results. CONCLUSION TF approach has less 30-day
mortality, bleeding complications, and renal failure as compared with the
TA approach. One should be mindful though that the TA approach is usually
saved for patient with extensive comorbidities which may be contribute to
these differences. (Table Presented).

<31>
Accession Number
72295923
Author
Jeffery N.; Mcaulay L.; Gilbourd D.; Ranasinghe A.; Mancuso P.; Haghighi
K.; Gassner P.; Lalak N.; Wong E.; Hayden L.
Institution
(Jeffery, Haghighi, Lalak, Hayden) Campbelltown Hospital, Sydney,
Australia
(Mcaulay, Gilbourd, Ranasinghe, Mancuso, Gassner, Wong) Liverpool
Hospital, Sydney, Australia
Title
Music during flexible cystoscopy under local anaesthesia to reduce pain
and anxiety.
Source
BJU International. Conference: 69th Annual Scientific Meeting of the
Urological Society of Australia and New Zealand Gold Coast, QLD Australia.
Conference Start: 20160416 Conference End: 20160419. Conference
Publication: (var.pagings). 117 (pp 9), 2016. Date of Publication: April
2016.
Publisher
Blackwell Publishing Ltd
Abstract
Introduction and Objectives: To investigate whether playing music during
flexible cystoscopy under local anaesthesia improves patient pain and
anxiety scores. Method: Our prospective multicentre randomised controlled
trial is still in process, and data will be updated prior to presentation.
Patients are being randomised to undergo flexible cystoscopy with or
without music at Liverpool and Campbelltown hospitals. An investigator
blinded to patient allocation administers a visual analogue pain scale
(VAS) post-procedure and a State Anxiety Inventory (STAI-S) pre- and
post-procedure. Heart rate and blood pressure will be recorded pre- and
post-procedure as physiological surrogates of pain and anxiety. Results:
We are aiming to recruit a total of 72 participants (n = 36 in each
group), so that our study will be powered to detect an improvement by 1
point out of 10 on the VAS, and an improvement by 5 points on the STAI-S
(p < 0.05, power 0.80). We will compare the two groups with an independent
sample t-test, with p < 0.05 considered significant. Thus far, we have
recruited 37 participants (n = 18 in "no music" group, n = 19 in "music"
group). Thus far, there is no statistically significant difference between
the two groups in mean VAS pain score (1.49 in "no music" versus 1.8 in
"music", t<inf>35</inf> = 0.64, p = 0.52) or mean delta STAI-S score (6.78
in "no music" versus 8.84 in "music", t35 = 0.57, p = 0.57). Conclusions:
Our conclusion is pending recruitment of an adequate number of patients to
enable meaningful statistical analysis. We anticipate recruiting adequate
numbers prior to presentation.

<32>
Accession Number
72294219
Author
Zhang C.; Anderson L.; Stephens R.
Institution
(Zhang) Faculty of Medicine, Imperial College London, United Kingdom
(Anderson) University of Rochester, New York, United States
(Stephens) Centre for Anaesthesia, University College Hospital, London,
United Kingdom
Title
An audit and literature review of oesophageal Doppler monitoring for
intraoperative fluid management.
Source
Anaesthesia. Conference: AAGBI GAT Annual Scientific 2015 Manchester
United Kingdom. Conference Start: 20150617 Conference End: 20150619.
Conference Publication: (var.pagings). 70 (pp 18), 2015. Date of
Publication: June 2015.
Publisher
Blackwell Publishing Ltd
Abstract
Oesophageal Doppler monitoring (ODM) is a minimally invasive method for
delivering goal-directed fluid therapy (GDFT). ODM measures stroke volume,
enabling anaesthetists to titrate intravenous fluid replacement to meet an
individual's specific demands. Guidance from NICE issued in March 2011
recommended considering ODM in major or high-risk surgery and for
operations where invasive cardiovascular monitoring is considered. Are we
using ODM in these situations and what is the evidence base for using ODM?
Methods For a 2-week period in July 2014, we prospectively assessed all
patients undergoing elective major abdominal surgery in a large London
hospital for any clinical indications for Doppler use. These were
predefined based on review of the existing literature. We documented the
duration and type of surgery, ASA grade, use of an arterial line or
central venous catheter and use of ODM. Recent metaanalyses evaluating
GDFT have included studies utilising pulmonary artery catheters in pooled
analysis [1, 2]. The focus has been on GDFT as a whole opposed to the
method of delivering GDFT. With current guidelines in mind, we searched
the MEDLINE literature for clinical studies specific to ODM. Results A
total of 44 patients were identified, of which 18 (41%) had a clinical
indication for ODM. Of these, only three (17%) had documented ODM.
However, six (33%) had an arterial line and four (22%) had central venous
catheterisation, which could have been avoided given the associated risks
and availability of a less invasive alternative. Interestingly, nine (50%)
patients had spectral entropy monitoring despite a weaker evidence base.
Additionally, ODM was used in 5 of the 26 (19%) patients who lacked any
clinical indication. The literature on ODM reveals a modest reduction in
post-operative complications and hospital length of stay. Discussion Use
of ODM has been patchy despite clinical research suggesting a benefit in
major surgery. Trusts are also given a financial incentive to use ODM,
which reduces the average length of hospital stay. There needs to be
greater consideration of Doppler use, particularly in hospitals that
already have this technology. Our audit demonstrates that ODM is rarely
used when clinically indicated and often deployed inappropriately. We have
presented the results of this audit and accompanying literature review
within the department, clarifying the indications for ODM and recommending
an extra line of thinking in major surgery. A survey is planned to
investigate and tackle the reasons behind the low uptake of ODM. A
re-audit will be carried out when this is completed.

<33>
Accession Number
72290048
Author
Internullo E.
Institution
(Internullo) Thoracic Surgery Unit, Bristol Royal Infirmary, University
Hospitals Bristol, Bristol, United Kingdom
Title
Pulmonary metastasectomy for colorectal cancer: Are we doing the right
thing?.
Source
Anticancer Research. Conference: 4th China-United Kingdom Cancer
Conference, CUKC 2015 Cardiff United Kingdom. Conference Start: 20150717
Conference End: 20150718. Conference Publication: (var.pagings). 35 (7)
(pp 4308-4309), 2015. Date of Publication: July 2015.
Publisher
International Institute of Anticancer Research
Abstract
Surgical resection is widely employed as a conventional treatment option
for patients with lung metastases originating from a wide range of primary
tumours. Of these, colorectal cancer is the most common. However, lung
metastasectomy relies on no higher level of evidence than case series and
metastasectomy registries. Not only the lack of evidence leaves space for
a large variability in practice but, under a deeper analysis, the whole
rationale for the surgical resection of lung metastases vacillates. In
fact, after a critical examination, much of the apparent benefit may be
due to selection of patients rather than the resection itself. This issue
was raised for the first time in 1980 by Aberg who argued whether the
survival rates of about 30% at 5 years were actually due to the surgery or
to the involuntary careful selection of patients affected with cancers
with more favourable biologic behaviour. The commonly accepted selection
criteria for lung metastasectomy are: (i) control of primary tumour, (ii)
disease limited to lung (+/-liver), (iii) ability to resect all metastatic
disease, (iv) sufficient cardiopulmonary reserve. The majority of thoracic
surgeons would probably agree on adding to the previous list a limited
number of metastases (the lesser the better, but no cutoff has been
defined). The abovementioned selection criteria happen to be prognostic or
predictive factors, hence affecting cancer survival by themselves,
regardless of the treatment the patient receives. This leads to the bias
of selecting the longterm survivors ahead of the treatment and, then, to
the mistake of attributing that survival to the treatment. In order to
define the actual role of lung metastasectomy in the treatment of
colorectal cancer, a randomized controlled trial (RCT) is necessary. For
years the idea of a RCT to solve the question was considered utopian and
impractical. In 2007, Professor Tom Treasure reopened the debate on the
lack of evidence for lung metastasectomy. In 2010, the PulMiCC trial was
launched. PulMiCC is a randomised trial that will compare active
monitoring with active monitoring and pulmonary metastasectomy in patients
with colorectal cancer. It has been designed as a "real life" feasibility
study. In stage 1 of the trial, patients with treated primary colorectal
cancer metastatic to the lungs are invited to consent for protocol-based
evaluation of their suitability for metastasectomy. The evaluation is as
in current practice and includes positron emission tomography/ computed
tomography (PET/CT). A decision for or against metastasectomy may be based
on the opinion of the clinicians and the preference of the patient. If
there is uncertainty, the patient is invited to consent to have the
treatment arm assigned by randomization in stage 2 of PulMiCC. More than
300 patients have entered stage 1 and more than 70 are in stage 2. PulMiCC
trial is going to be amended from feasibility study to phase III study and
is still recruiting throughout UK.

<34>
Accession Number
72289378
Author
Jhaveri V.
Institution
(Jhaveri) Massachusetts General Hospital, Cambridge, MA, United States
Title
The coronary CT: Where one diagnosis turned into three.
Source
Journal of General Internal Medicine. Conference: 39th Annual Meeting of
the Society of General Internal Medicine, SGIM 2016 Hollywood, FL United
States. Conference Start: 20160511 Conference End: 20160514. Conference
Publication: (var.pagings). 31 (2 SUPPL. 1) (pp S746-S747), 2016. Date of
Publication: May 2016.
Publisher
Springer New York LLC
Abstract
LEARNING OBJECTIVE #1: Identify the indications for coronary CT scans and
its potential use in undifferentiated chest pain. LEARNING OBJECTIVE #2:
Describe the pathophysiology of penetrating aortic ulcers. CASE: A
74-year-old man with chronic obstructive pulmonary disease, hypertension,
hyperlipidemia, cerebrovascular accident and a 60 pack-year smoking
history, presented with chest pain. Four days prior, he developed
squeezing chest pain with walking in the central chest with radiation to
both shoulders and jaw, diaphoresis and dyspnea, but no nausea or
vomiting; 1 day prior, he had 3 episodes of chest pain (two with walking,
one at rest) for which he took nitroglycerin with minimal relief. He then
came to the emergency department (ED). On presentation, he was afebrile,
with pulse 64, blood pressure 159/86, and oxygen saturation of 100 %. His
chest pain had resolved. He was in no acute distress, heart had regular
rate and rhythm without murmurs, rubs or gallops, lungs were clear, and
with trace lower-extremity edema bilaterally. His distal pulses were 2+
bilaterally; he had no bruits. Initial evaluation revealed first degree
heart block with no ischemic changes on EKG; two sets of negative
troponins; and chest x-ray showing normal lung parenchyma, a calcified
aortic arch, and a right hilar opacity. A chest CT was recommended. He was
diagnosed with unstable angina, started on full-dose aspirin and heparin
drip, and admitted for further evaluation. Instead of an early
catheterization or stress test, a coronary CT (cCTA) was chosen to further
evaluate for coronary artery disease (CAD) and the hilar opacity. The cCTA
revealed: a calcium score of 627 (severe >400) predominantly affecting his
left circumflex artery, a 10 mm spiculated nodule in the left upper lobe
of the lung and multiple penetrating aortic ulcers (PAU) in the descending
thoracic aorta. The right hilum contained enlarged lymph nodes within the
upper limit of normal. With this one test, three new diagnoses were
discovered: a potential malignancy, potentially serious aortic syndrome,
and severe CAD. Following the cCTA, oncology and thoracic surgery were
consulted. Oncology recommended a PET scan for nodule staging. Thoracic
surgery recommended deferring coronary catheterization (and associated
dual anti-platelet therapy) pending further oncology evaluation. The
patient was medically optimized during his hospitalization with aspirin,
high dose statin, and improved blood pressure control and smoking
cessation. A few weeks later, the lung nodule was found to be PET-avid,
suggestive of malignancy, and a resection is planned. His penetrating
aortic ulcers will be monitored with periodic aortic CT. DISCUSSION: Since
1999, the quality of CT has allowed for visualization of coronary
calcifications. In 2010, the AHA released the Coronary Artery
Calcification Score as a screening tool for coronary disease. CCTA is
useful in ruling out CAD, as a zero calcium score has a very high negative
predictive value (NPV) for major cardiac events within 30 days. The
incidence of >50 % coronary obstruction is <1 % with a zero calcium score.
Furthermore, the NPV of cCTA for major adverse cardiac events is 99.3%[1].
As a result, cCTA is most useful in patients with low-to-moderate pre-test
probability for CAD because negative results lead to decreased use of
invasive coronary angiography, length of stay, and cumulative radiation
dose. The cCTA was not the ideal test for evaluating this patient's
coronary ischemia given his high pre-test probability, but proved
invaluable in its' other findings. The incidence of significant incidental
clinical findings is suggested to be 13%[2]. A CT with timed angiography
has been proposed for use as a "triple rule out" for pulmonary embolism,
CAD, and aortic dissection, but ED studies have not shown improved
mortality, cost effectiveness, or time to discharge [3]. However,
excluding aortic pathology in patients with acute chest pain syndromes is
crucial, since stress testing may increase wall stress on a diseased
aorta. Penetrating aortic ulcers are sequelae of severe atherosclerotic
disease. The atherosclerotic plaque disrupts the vessel intima,
penetrating into the media of the aorta. From there, it can remain stable,
progress to a focal dissection or aneurysm, or evolve to aortic rupture.
Data on the natural course of PAU is lacking; the incidence of progression
to dissection or aneurysm varies between studies. However, the finding of
PAU portends a more aggressive lesion that should be monitored and managed
with a high-intensity statin and tight blood pressure and heart rate
control to decrease plaque progression and aortic wall stress [4]. CCTA is
likely to become more prevalent in the future as it has a high negative
predictive value for coronary ischemia, but it also can have a role when
multiple thoracic pathologies are suspected. [1] Takakuwa KM, et al. A
meta-analysis of 64-section coronary CT angiography findings forpredicting
30-day major adverse cardiac events in patients presenting with symptoms
suggestive of acute coronary syndrome.

<35>
Accession Number
72288974
Author
Cruz Rodriguez J.B.; Cler L.
Institution
(Cruz Rodriguez, Cler) Methodist Dallas Medical Center, Dallas, TX, United
States
Title
Acute severe thrombocytopenia induced by eptifibatide.
Source
Journal of General Internal Medicine. Conference: 39th Annual Meeting of
the Society of General Internal Medicine, SGIM 2016 Hollywood, FL United
States. Conference Start: 20160511 Conference End: 20160514. Conference
Publication: (var.pagings). 31 (2 SUPPL. 1) (pp S542), 2016. Date of
Publication: May 2016.
Publisher
Springer New York LLC
Abstract
LEARNING OBJECTIVE #1: Describe a case of acute severe thrombocytopenia
induced by eptifibatide. LEARNING OBJECTIVE #2: Compare and contrast
thrombocytopenia induced by eptifibatide versus other etiologies of
thrombocytopenia. CASE: CASE PRESENTATION Our patient was a 59-year-old
female with history of gastroesophageal reflux, type II diabetes mellitus,
hypertension, chronic left bundle branch block and coronary artery disease
(CAD) status post coronary artery bypass graft in 2003 (left internal
mammary to left anterior descending and saphenous vein to first obtuse
marginal [OM] artery), stenting in 2004 (native mid-circumflex artery) and
2010 (ostial 70% left main). She presented with several days of burning
and crushing sensation in her left chest that was not responsive to her
usual treatment with esomeprazole. Sublingual nitroglycerin provided some
relief and walking made the pain worse. Home medications were aspirin,
carvedilol, clopidogrel, hydrochlorothiazide, insulin levemir,
esomeprazole, simvastatin and valsartan. She was allergic to ACEI and
losartan. The physical exam was within normal limits. EKG showed normal
sinus rhythm with left bundle branch block and left axis deviation,
unchanged from previous ones. Serial troponins were negative. Initial labs
showed hemoglobin of 12 mg/dL, platelets 181,000/microL, no leukocytosis,
normal coagulation profile, kidney and liver function. She was admitted
for evaluation of unstable angina. Her cardiologist was consulted and
decision was made to take her to coronary angiogram 2 days after
admission. A focal high-grade stenosis was found in the first OM, just
distal to the previous stent, which was treated with a new drug-eluting
stent. During the procedure, the patient was placed on heparin drip per
protocol, bivalirudin 500 mg, and eptifibatide 80,000 mcg. She was also
loaded with 300 mg of clopidogrel. She had received heparin 7500 units for
DVT prophylaxis. Her cardiac symptoms resolved completely after the
procedure. The next morning, while still asymptomatic, her platelet count
dropped to 21,000/microL, which was confirmed by repeating the blood count
and by peripheral smear. There was no platelet clumping in the smear.
TREATMENT Her 4 T's score was 4 (14 % pre-test probability of
heparin-induced thrombocytopenia [HIT]), so HIT-ELISA antibody was sent,
prophylactic heparin was stopped and she was started on argatroban. She
never developed any bleeding nor thrombotic events. After 24 h, the
HIT-ELISA came back negative, and argatroban was stopped. Medications were
reviewed and it was felt that the best explanation for the severe acute
drop in platelets was related to eptifibitide. The platelet count improved
daily without further therapy. OUTCOME AND FOLLOW UP At the time of
discharge, her platelet count was 85,000/microL. She was discharged with
optimal therapy for her CAD and other comorbidities. Follow up in clinic 3
weeks after showed a platelet count of 198,000, with no change in the
other hematologic lines. DISCUSSION: Epitifibatide and the other
glycoprotein IIb/IIIa inhibitors (GPI), commonly used in patients with
CAD, can be associated with thrombocytopenia (TCP), often within minutes
to hours of the initial administration. Although heparin is often
coadministered with these agents, case reports and clinical trial data
suggest that GPI are most commonly the etiology of TCP when both agents
are used. Furthermore, heparin rarely causes severe TCP (platelet count
<20,000). Randomized controlled studies have shown significantly increased
rates of TCP for patients treated with eptifibatide. The TCP caused by GP
IIb/IIIa inhibitors is clinically distinct from HIT. TCP caused by GP
IIb/IIIa inhibitors is sudden and severe, while TCP in HIToften occurs
more gradually and platelet counts are rarely less than 30,000/microL.
Thrombosis is a common occurrence in HIT. On the contrary, paradoxical
thrombosis is very rare with GP IIb/IIIa inhibitors although it has been
reported. In addition to acute TCP, GP IIb/IIIa inhibitors can also cause
pseudothrombocytopenia, a laboratory artifact when EDTA anticoagulant
present in blood collection tubes causes platelet clumping. This
possibility was ruled out in our patient by peripheral smear. A unique
feature of GP IIb/IIIa inhibitor-induced TCP is its severity and acuity,
typically occurring within 24 h and occasionally within 30 min to several
hours of initial administration. This is distinct from other drugs that
cause TCP mediated by drugdependent anti-platelet antibodies, which can
take up to 14-21 days. It has been hypothesized that the rapid occurrence
of TCP following new exposure to GP IIb/IIIa inhibitors is because of
natural preformed antibodies against platelet neoepitopes, exposed during
normal platelet aggregation, possibly during the process of aging. If TCP
due to a GP IIb/IIIa inhibitor is suspected, the drug should be
discontinued as well as heparin products. Pseudothrombocytopenia needs to
be excluded with a blood smear and the 4 T score calculated to evaluate
for HIT. In contrast to HIT, there is no need to anticoagulate. The use of
IV gamma globulin has not been proven to be beneficial. Platelet
transfusion is only recommended if the platelet count is <20,000, if there
is overt bleeding or if an emergency invasive procedure is required.
Readministration of the drug that caused TCP is not encouraged because of
the risk for more severe TCP if rechallenged; furthermore, there is a 15 %
cross-reactivity with the other GP IIb/IIIa inhibitors.

<36>
Accession Number
72287211
Author
Punjasawadwong Y.; Punjasawadwong S.
Institution
(Punjasawadwong, Punjasawadwong) Chiang Mai University, Chiang Mai,
Thailand
Title
Bispectral index for prevention of postoperative delirium in elderly
patients undergoing general anesthesia for non-cardiac surgery: A result
from a meta-analysis.
Source
Journal of Neurosurgical Anesthesiology. Conference: 43rd Annual Meeting
of the Society for Neuroscience in Anesthesiology and Critical Care San
Diego, CA United States. Conference Start: 20151023 Conference End:
20151023. Conference Publication: (var.pagings). 27 (4) (pp 446), 2015.
Date of Publication: October 2015.
Publisher
Lippincott Williams and Wilkins
Abstract
Background: Elderly surgical patients are prone to develop postoperative
delirium. Despite controversies regarding the use of bispectral index
(BIS) in a routine practice,1 it has been postulated that optimizing depth
of anesthesia as guided by a processed EEG monitoring may reduce risk of
postoperative delirium. We are conducting a systematic review to address
whether the use of processed EEG indices including Bispectral index as
guides to anaesthetic delivery can reduce the risk of post operarive
cognitive decline (POCD) and postoperative delirium (POD) in non-cardiac
surgical patients undergoing general anesthesia compared with standard
practice where only clinical signs are used.2 Here is a part of our
systematic review focusing on the impact of BIS on reduced risk of
postoperative delirium in the elderly surgical patients. Materials and
methods: We conducted a systematic review based on our published protocol
in a Cochrane library.2 Both identified published and unpublished
randomized controlled trials using BIS as a guide to deliver anesthesia
were selected. Only data concerning postoperative delirium were extracted
for the meta-analysis by using a fixed effect model. Results: We
identified three randomized controlled trials. Two of them are published
articles.3,4 The other one is an unpublished one from a small study.5 The
result indicates a significant effect of the BIS-guided anesthesia on
reducing the risk of postoperative delirium in elderly surgical patients
(2197 participants; OR 0.66, 95% CI 0.53 to 0.82). Conclusion: The result
from our preliminary meta-analysis indicates BIS guide anesthesia can
reduce the risk of postoperative delirium in elderly surgical patients
undergoing general anesthesia for non-cardiac surgeries. Further
meta-analysis is still ongoing to determine the impact of BIS on
post-operative cognitive dysfunction.

<37>
Accession Number
72284259
Author
Azarbaijani Y.; O'Callaghan K.; Sanders W.; Wu C.; Laschinger J.; Dabic
D.M.; Ronk C.; Strauss D.; Canos D.; Zusterzeel R.
Institution
(Azarbaijani, O'Callaghan, Sanders, Wu, Laschinger, Dabic, Ronk, Strauss,
Canos, Zusterzeel) FDA, Silver Spring, MD, United States
Title
Sex-differences in outcomes after transcatheter aortic valve replacement:
A systematic literature review.
Source
Journal of Women's Health. Conference: 24th Annual Women's Health
Congress: Women's Health 2016 Washington, DC United States. Conference
Start: 20160414 Conference End: 20160417. Conference Publication:
(var.pagings). 25 (4) (pp A5), 2016. Date of Publication: 2016.
Publisher
Mary Ann Liebert Inc.
Abstract
Background: Aortic stenosis is a common valvular disease, especially in
the aging population of Western countries. While surgical aortic valve
replacement is the predominant treatment for patients with symptomatic
severe aortic stenosis, 30% to 40% of patients are not eligible for
surgery due to advanced age, severe left ventricular dysfunction, or other
comorbidities. Transcatheter aortic valve replacement (TAVR) has been
shown to be an alternative therapeutic approach for these patients showing
better or equal results compared to surgical valve replacement. However,
the effects of sex on outcomes after TAVR remain to be elucidated.
Objective(s): We gathered and compared all previously reported
sex-specific data on effectiveness and safety outcomes after TAVR.
Material/Methods: We conducted a search in PUBMED and EMBASE using the
following key words: 'transcatheter aortic valve replacement',
'transcatheter aortic valve implantation', 'sex differences', 'gender',
'sex characteristics'. Selected publications consisted of original reports
that included sex-specific data on outcomes after TAVR and were written in
English. From the publications we collected information on sex-specific
baseline features, procedural characteristics and post procedural outcomes
after TAVR. We used mortality, valve complications, cerebrovascular
complications, vascular complications and other outcomes as our main
endpoints. Results: After in- and exclusion criteria were applied, our
search resulted in 25 publications. At baseline, men had more
comorbidities than women, especially in terms of pre-procedural
cardiovascular disease and cardiac interventions. Women were older, had
higher aortic valve gradients and a higher ejection fraction. While there
were no significant sex-differences in mortality rates at 30 days, most
studies reported better survival in women at mid- and long-term follow up
with hazard ratios (for women compared to men) ranging from 0.27 (95% CI:
0.09-0.84) to 0.91 (95% CI: 0.75-1.10). Other outcomes included aortic
regurgitation, which was the most common valve complication. At 30 days of
follow up, aortic regurgitation was more prevalent among men (12%-24%and
7-19% in women and men, respectively). Stroke rates were similar at 30
days (women: 1%-7% and men: 1%-5%). Women also had higher rates of
vascular complications at 30 days, ranging from 6%-20% compared to 2%-14%
in men and higher bleeding rates ranging from 10%-44% compared to 8%-25%
in men. Myocardial infarction was similar between the sexes as well as
tamponade, kidney injury/ failure and sepsis. Permanent pacemaker
implantation was more frequent among men with rates from 10%-25% in women
and 15%-31% in men. Conclusions: In this systematic literature review we
found a better survival in women compared to men after TAVR at midand
long-term follow up. However, in general women had more vascular
complications and bleeding, but less aortic regurgitation and pacemaker
implantations; stroke rates were similar between women and men. These
findings may partly be explained by better baseline characteristics and
less valve mismatch in women compared to men. Results should be
interpreted with caution as most measures only include raw percentages.
Future studies including a larger sample of patients, preferably based on
individual-patient data meta-analysis, are required to confirm and
thoroughly evaluate these preliminary findings.

<38>
Accession Number
72283797
Author
Anouti K.; Qureshi W.T.; Refaat M.
Institution
(Anouti, Qureshi, Refaat) Lankenau Medical Center, Wynnewood, PA, Wake
Forest Baptist Medical Center, Winston-Salem, NC, American University of
Beirut Faculty of Medicine and Medical Center, Beirut, Lebanon
Title
Risk assessment of postoperative atrial fibrillation and stroke after left
atrial appendage closure during routine cardiac surgery: A systematic
review of literature.
Source
Heart Rhythm. Conference: 37th Annual Scientific Sessions of the Heart
Rhythm Society, Heart Rhythm 2016 San Francisco, CA United States.
Conference Start: 20160504 Conference End: 20160507. Conference
Publication: (var.pagings). 13 (5 SUPPL. 1) (pp S423-S424), 2016. Date of
Publication: May 2016.
Publisher
Elsevier
Abstract
Introduction: The left atrial appendage (LAA) is a significant source of
cardiac emboli leading to stroke. Open heart surgery is an opportune time
to exclude the LAA without significant morbidity. It is not known if LAA
closure during routine cardiac surgery leads to lower risk of stroke and
postoperative atrial fibrillation. Methods: We systematically reviewed
studies evaluating LAA closure during routine cardiac surgery and the risk
of post procedure stroke or transient ischemic attack (TIA) and atrial
fibrillation (AF). We searched MEDLINE, CINAHL, Web of Science, meeting
abstracts, presentations and Cochrane databases from inception through
November 2015. Data were extracted by 2 independent authors. Results: A
total of 11 studies including 16403 patients (mean age was 64, 66% males)
were analyzed. 3237 (20%) patients that underwent LAA closure and 13166
(80%) patients did not undergo LAA closure. Over a mean follow up of 21.6
months, 65 (2.0%) stroke/TIA and 685 (21.9%) incident AF occurred in LAA
exclusion group, while 596 (4.5%) stroke/TIA and 2978 (31.9%) incident AF
occurred in non LAA closure group. In a random effects model, there was a
trend towards lower risk of stroke/ TIA in individuals with LAA exclusion
[pooled HR (95% CI); 0.78 (0.60-1.01) p-value= 0.06] but no significant
association of LAA closure with incident AF (p-value= 0.71). Conclusions:
In this meta-analysis of studies, LAA closure during routine cardiac
surgery showed a trend towards lower risk of post procedure stroke/TIA but
did not show an association with reduced risk of AF. It remains uncertain
whether prophylactic LAA closure is necessary for stroke protection during
non-AF related cardiac surgery. (Figure Presented).

<39>
Accession Number
72279083
Author
Langlois P.; Manzanares W.
Institution
(Langlois) Universite De Sherbrooke, Sherbrooke, Canada
(Manzanares) University Hospital, Montevideo, Uruguay
Title
Omega-3 fatty acids in patients undergoing cardiac surgery: A systematic
review and meta-analysis.
Source
Critical Care. Conference: 36th International Symposium on Intensive Care
and Emergency Medicine Brussels Belgium. Conference Start: 20160315
Conference End: 20160318. Conference Publication: (var.pagings). 20 (no
pagination), 2016. Date of Publication: 2016.
Publisher
BioMed Central Ltd.
Abstract
Introduction Over the last few years, supplementation with omega-3
polyunsaturated fatty acids (n-3 PUFA) has emerged as a therapeutic option
for patients undergoing cardiac surgery due to their immunomodulatory
properties and anti-arrhythmic action. Nonetheless, there is a paucity of
data supporting the effectiveness of n-3 PUFA in the treatment of cardiac
surgery patients. So far, several randomized controlled trials (RCTs) have
assessed the effect of perioperative n-3 PUFA preventing postoperative
atrial fibrillation (POAF), although their efficacy still remains
controversial. Therefore, we conducted an updated systematic review and
meta-analysis evaluating the effects of perioperative oral/ enteral n-3
PUFA and intravenous (IV) fish oil lipid emulsions on relevant clinical
outcomes for cardiac surgery patients. Methods We included RCTs enrolling
adult patients undergoing cardiac surgery, which evaluated oral/enteral
and parenteral n-3 PUFA compared to a placebo and reported clinically
important outcomes. According to eligibility criteria, original studies
were abstracted in duplicate. Intensive care unit (ICU) length of stay
(LOS) was the primary outcome; secondary outcomes were incidence of POAF,
duration of mechanical ventilation (MV) and hospital LOS.
Hypothesis-generating subgroup analysis was performed to identify
potentially more beneficial treatment strategies. Results A total of 11
RCTs (n = 2846 patients) met inclusion criteria. When the data from 4
trials were aggregated, n-3 PUFA had no effect on ICU LOS (WMD -4.43, 95 %
CI -13.43, 4.48, P = 0.34, heterogeneity I2 = 43 %). However, n-3 PUFA
were associated with a trend in the reduction of POAF (RR 0.89, 95 % CI
0.76, 1.05, P = 0.17; I2 = 34 %, P = 0.13). In addition, in those
oral/enteral based trials, n-3 PUFA showed a tendency towards a reduction
in POAF (RR 0.87, 95 % CI 0.74, 1.03, P = 0.11; I2 = 47 %, P = 0.07; Fig.
75). The test for subgroup differences on overall POAF showed a trend (P =
0.16). There was no effect of n-3 PUFA on MV days and hospital LOS.
Conclusions In patients undergoing cardiac surgery, supplementation with
omega-3 fatty acids does not improve any clinical outcome in the
postoperative period. (Figure Presented).

<40>
Accession Number
72278930
Author
Ferreira G.; Caldas J.; Fukushima J.; Osawa E.A.; Arita E.; Camara L.;
Zeferino S.; Jardim J.; Gaioto F.; Dallan L.; Jatene F.B.; Kalil Filho R.;
Galas F.; Hajjar L.A.
Institution
(Ferreira, Caldas, Fukushima, Osawa, Arita, Camara, Zeferino, Jardim,
Gaioto, Dallan, Jatene, Kalil Filho, Galas, Hajjar) University of Sao
Paulo, Sao Paulo, Brazil
Title
Intra-aortic balloon counterpulsation in patients undergoing cardiac
surgery (IABCS): Preliminary results.
Source
Critical Care. Conference: 36th International Symposium on Intensive Care
and Emergency Medicine Brussels Belgium. Conference Start: 20160315
Conference End: 20160318. Conference Publication: (var.pagings). 20 (no
pagination), 2016. Date of Publication: 2016.
Publisher
BioMed Central Ltd.
Abstract
Introductions: The intra-aortic balloon pump (IABP) is used in a variety
of clinical settings in which myocardial function is reduced. In cardiac
surgery, its role on clinical outcomes is debated due to conflicting
results of retrospective analysis and limitations of a recent prospective
study. The IABCS study aims to evaluate the effectiveness of prophylactic
IABP in high-risk patients undergoing cardiac surgery. Methods: The IABCS
study is a prospective, single-center, randomized controlled trial in
high-risk patients scheduled to elective cardiac surgery at the Heart
Institute/University of Sao Paulo. Inclusion criteria were additive
EuroSCORE > = 6 or left ventricular ejection fraction (LVEF) < = 40 %.
Eligible patients were randomly assigned, in a 1:1 ratio, to IABP group or
control group. Removal of IABP catheter was accomplished after 24 hours of
the procedure under the following circumstances: cardiac index > = 2.2
L/min/m² and dobutamine infusion dose < = 5 mug/kg/min. The
catheter was immediately removed if a severe adverse event related to the
procedure was detected. The primary outcome was the composite endpoint of
mortality and major morbidity in 30 days after cardiac surgery, according
to the modified Society of Thoracic Surgeons definition, which included:
prolonged mechanical ventilation (>24 hours), stroke, mediastinitis, need
for reoperation, cardiogenic shock, and acute renal failure. Results: A
total of 116 patients were enrolled from April 2014 to September 2015.
Fifty-two patients were assigned to IABP group and 64 patients to control
group. The mean age was 64 +/- 8 years in the IABP group and 67 +/- 9
years in the control group (P = 0.06). The median LVEF was 40 % (31-45) in
the IABP group and 40 % (35-55) in the control group (P = 0.873) and the
median EuroSCORE was 6 (4-7) vs. 6 (4-7), P = 0.873, respectively. The
primary outcome was observed in 40.4 % in the IABP group and 37.5 % in the
control group (P = 0.751). Mortality rate was similar in both groups (15.4
% in the IABP group vs. 10.9 % in the control group, P = 0.478). Patients
from the IABP group had a greater duration of inotrope use (3215 minutes
[2003-5670] vs. 2110 minutes [1521-3355], P = 0.006) and longer ICU length
of stay (5 [4-9] vs. 4 [3-6], P = 0.008). Conclusions: Preliminary data
demonstrated a similar occurrence of the primary outcome in both groups,
with greater use of inotropes and longer ICU stay in the IABP group. Our
results suggest that a tailored approach for IABP placement should be
incorporated in future cardiac surgery studies.

<41>
Accession Number
72278926
Author
Docherty A.; O'Donnell R.; Brunskill S.; Trivella M.; Doree C.; Holst L.;
Parker M.; Gregersen M.; Almeida J.; Walsh T.; Stanworth S.
Institution
(Docherty, O'Donnell, Walsh) University of Edinburgh, Edinburgh, United
Kingdom
(Brunskill, Trivella, Doree, Stanworth) John Radcliffe Hospital, Oxford,
United Kingdom
(Holst) Copenhagen University Hospital, Copenhagen, Denmark
(Parker) Peterborough NHS Trust, Peterborough, United Kingdom
(Gregersen) Aarhus University, Aarhus, Denmark
(Almeida) Hospital De Sao Paulo, Sao Paulo, Brazil
Title
The impact of transfusion thresholds on mortality and cardiovascular
events in patients with cardiovascular disease (non-cardiac surgery): A
systematic review and meta-analysis.
Source
Critical Care. Conference: 36th International Symposium on Intensive Care
and Emergency Medicine Brussels Belgium. Conference Start: 20160315
Conference End: 20160318. Conference Publication: (var.pagings). 20 (no
pagination), 2016. Date of Publication: 2016.
Publisher
BioMed Central Ltd.
Abstract
Introductions: Restrictive red cell transfusion policies are recommended
as safe for the majority of hospital patients with anaemia. Uncertainty
exists for patients with cardiovascular disease, in whom the heart may be
more susceptible to limited coronary oxygen supply. Methods: We performed
a systematic review with meta-analyses of in-hospital randomised
controlled trials that evaluated a restrictive vs liberal transfusion
threshold and that included patients with cardiovascular disease. A
comprehensive search of databases (including CENTRAL, MEDLINE and Embase)
was performed on 02/11/2015. Data extraction was completed in duplicate.
Risk of bias was assessed using Cochrane methodology. Mantel-Haenzel
random effects models were used with relative risk ratios (95 % CI).
Outcome measures were thirty-day mortality, and cardiovascular events.
Results: We identified 41 trials of which 11 trials enrolling
cardiovascular patients (n = 3033) were included for meta-analysis
(restrictive n = 1514 patients; liberal n = 1519). There was no
association between transfusion thresholds and 30 day mortality RR 1.10
(95 % CI 0.88-1.50, P = 0.30, I2 = 14 %). There was an increased risk of
acute coronary syndrome (ACS) in patients in the restrictive transfusion
threshold (9 trials; RR 1.71, 95 % CI 1.11-2.65, P = 0.01, I2 = 0 %) (Fig.
27). Conclusions: Restrictive transfusion practice is associated with
higher rates of ACS in patients with cardiovascular disease. This supports
the uncertainty highlighted in current guidelines, and indicates the need
for further research into best practice for this group. (Table Presented).

<42>
Accession Number
72278920
Author
Siemens K.; Sangaran D.; Hunt B.J.; Durward A.; Nyman A.; Murdoch I.A.;
Tibby S.M.
Institution
(Siemens, Sangaran, Durward, Nyman, Murdoch, Tibby) Evelina London
Children's Hospital, London, United Kingdom
(Hunt) St Thomas Hospital, London, United Kingdom
Title
A scoping review of strategies for prevention and management of bleeding
following paediatric cardiopulmonary bypass surgery.
Source
Critical Care. Conference: 36th International Symposium on Intensive Care
and Emergency Medicine Brussels Belgium. Conference Start: 20160315
Conference End: 20160318. Conference Publication: (var.pagings). 20 (no
pagination), 2016. Date of Publication: 2016.
Publisher
BioMed Central Ltd.
Abstract
Introductions: To systematically review literature reporting strategies
for prevention and management of mediastinal bleeding post paediatric
cardiopulmonary bypass (CPB) surgery. Methods: Scoping review of
publications (1980-2015) reporting the effect of any intervention on
outcomes for postoperative bleeding (mediastinal drain loss, transfusion
requirement, coagulation parameter). Inclusions: <18 years, cardiac
surgery on CPB. Exclusions: haematological disorders. Databases included
MEDLINE and EMBASE. Results: 548/2794 screened articles were included: 466
(85.0 %) original research, predominantly retrospective 175 (37.6 %) and
prospective 119 (25.5 %) observational studies, a smaller proportion of
randomised controlled trials (RCTs) of 85 (18.2 %) and non-randomised
controlled trials 24 (5.2 %) (Fig. 24). Study sizes ranged 5 - 22,258
(median 62). Most frequently evaluated interventions: blood products (17.3
%), CPB circuit modification (13.6 %), antifibrinolytics (13.2 %) (Fig.
24). Publication numbers increased at a mean rate of 6 per year from 14
(1980-85) to 229 (2010-15). Within this group the raise of increase of
RCTs was 0 (1980-85) to 35 (2010-15). Conclusions: A variety of
interventions for bleeding prevention/treatment are available. Trial sizes
are often small, quality of evidence low. There is a trend towards studies
of higher quality (RCTs) in recent years. (Figure Presented).

<43>
Accession Number
72282150
Author
Mittal M.K.; Omran J.; Firwana B.; Velagapudi P.; Gupta V.; Kumar A.;
Aggarwal K.
Institution
(Mittal, Omran, Velagapudi, Kumar, Aggarwal) University of Missouri
Columbia, United States
(Firwana) University of Arkansas for Medical Sciences, United States
(Gupta) Borgess Heart Institute, Borgess Medical Center, United States
Title
Neurological outcomes and mortality associated with transcatheter versus
surgical aortic valve replacement: A meta-analysis of studies.
Source
Catheterization and Cardiovascular Interventions. Conference: 39th Annual
Scientific Sessions of the Society for Cardiovascular Angiography and
Intervention, SCAI 2016 Orlando, FL United States. Conference Start:
20160504 Conference End: 20160507. Conference Publication: (var.pagings).
87 (pp S149-S150), 2016. Date of Publication: April 2016.
Publisher
John Wiley and Sons Inc.
Abstract
Background: Transcatether aortic valve replacement (TAVR) has emerged as a
promising alternative to Surgical AVR (SAVR). Nowadays, candidacy for TAVR
is considered in patients who have a highrisk surgical profile.
Nevertheless, neurological complications associated with TAVR may be
hampering the momentum, and their true incidence compared to SAVR remains
unknown. Methods: MEDLINE, EMBASE and the Cochrane Central Register of
Controlled Trials were queried till December 2015. Only studies comparing
TAVR to SAVR were included. Two viewers selected, appraised studies and
extracted data using a pre-specified work sheet. Random effect
meta-analysis methods was used to pool outcomes across studies.
Heterogeneity of treatment effect among studies was assessed using I2
statistics. Publication bias was assessed using inspection of funnel
plots. Primary endpoints were major stroke at 1 and 12 month. Secondary
endpoints were transient ischemic attacks (TIA), any stroke (major and
minor) and mortality at 1 and 12 months. Results: A total of 4167 patients
were included from five studies (3 RCTs, 1 cohort and 1 observational
study) meeting the inclusion criteria and comparing TAVR to SAVR in
patients undergoing AVR. No evidence of publication bias was detected.
Compared to SAVR, TAVR had similar outcomes in terms of major stroke
incidence at 1month (RR 1.30; 95% CI 0.74 to 2.29) and 12 months (RR 1.10;
95% CI 0.56 to 2.16). Outcomes were similar when compared in terms of TIA,
any stroke and mortality at 12 months. 1 month mortality was lower in
patients underwent TAVR (RR 0.7; 95% CI 0.5 to 0.98). Conclusion: In
patients undergoing AVR, both TAVR and SAVR had similar neurological
outcomes at 1 and 12 months. One month mortality was lower in TAVR
patients.

<44>
Accession Number
72282131
Author
Bajaj A.; Sethi A.; Rathor P.; Pancholy S.
Institution
(Bajaj, Pancholy) Wright Center for Graduate Medical Education, United
States
(Sethi) St.Lukes Cardiology Associates, United States
(Rathor) Zhengzhou Unversity, United States
Title
Staged versus concomitant PCI for cad in patient undergoing tavr: A
meta-analysis.
Source
Catheterization and Cardiovascular Interventions. Conference: 39th Annual
Scientific Sessions of the Society for Cardiovascular Angiography and
Intervention, SCAI 2016 Orlando, FL United States. Conference Start:
20160504 Conference End: 20160507. Conference Publication: (var.pagings).
87 (pp S140), 2016. Date of Publication: April 2016.
Publisher
John Wiley and Sons Inc.
Abstract
Background: Significant coronary artery disease (CAD) is present in 40 to
75% of the patients undergoing Transcatheter aortic valve replacement
(TAVR). Percutaneous coronary intervention (PCI) before TAVR has the
potential to reduce the procedural risk of TAVR as well as the need for
revascularization after TAVR; however, optimal timing of revascularization
is uncertain in patients undergoing TAVR. We performed a meta-analysis to
compare the outcomes of staged versus concomitant PCI in patients
undergoing TAVR. Methods: A systemic search of database, including,
Medline, EMBASE and Cochrane was done by two independent reviewers to
identify relevant studies. Studies were included comparing staged with
concomitant PCI for significant CAD in patients undergoing TAVR for severe
aortic stenosis. The primary end point was 30 day mortality and secondary
end points were risk of acute kidney injury, life threatening bleeding
events, fluoroscopy time and contrast volume. Results: Four studies,
including 209 patients were included in the analysis. Overall, 12% of the
patient died at 30 days in staged PCI group and 13.2% died in the
concomitant PCI group. There was no significant difference in mortality
between the two groups (odds ratio [OR], 0.79; 95% CI 0.25 to 2.55,
I2=23%). There was no difference in fluoroscopy time ([OR], -2.09; 95% CI
-8.89 to 4.71, I2=80%) and risk of bleeding ([OR], 2.08; 95% CI 0.11 to
39.29, I2=76%) between the two groups. The risk of acute kidney injury
([OR], 0.14; 95% CI 0.02 to 0.93, I2=25%) and contrast agent volume ([OR],
-83.80; 95% CI -117.11 to -50.48, I2=0%) were significantly higher in the
concomitant PCI group as compared to staged PCI group. Conclusion: There
was no difference in short term mortality among staged versus concomitant
PCI group in patients undergoing TAVR. Staged PCI may be a preferable
option as compared to concomitant PCI group in patients with chronic
kidney disease because of increased risk for acute kidney injury in the
later group.

<45>
Accession Number
72282130
Author
Bajaj A.; Pancholy S.; Rathor P.; Sethi A.; Sehgal V.; Suppogu N.
Institution
(Bajaj) Wright Center of Graduate Medical Education, United States
(Pancholy, Suppogu) Wright Center for Graduate Medical Education, United
States
(Rathor) Zhengzhou University, China
(Sethi) St.Lukes and Hrave; Cardiology associates, United States
(Sehgal) University of Tennessee, United States
Title
The impact of pre-existing and new onset atrial fibrillation in patients
undergoing transcatheter aortic valve replacement: A meta-analysis.
Source
Catheterization and Cardiovascular Interventions. Conference: 39th Annual
Scientific Sessions of the Society for Cardiovascular Angiography and
Intervention, SCAI 2016 Orlando, FL United States. Conference Start:
20160504 Conference End: 20160507. Conference Publication: (var.pagings).
87 (pp S139-S140), 2016. Date of Publication: April 2016.
Publisher
John Wiley and Sons Inc.
Abstract
Background: Atrial fibrillation (AF) frequently coexists in patients with
aortic stenosis undergoing transcatheter aortic valve replacement (TAVR).
The prognostic implications of pre-existing AF, and new onset AF (NOAF) in
patients undergoing TAVR is unclear. We performed a meta-analysis to
compare the clinical outcomes in patients undergoing TAVR with preexisting
and new onset AF. Methods: A systematic search of database, including,
Medline, EMBASE and Cochrane was done by two independent reviewers to
identify relevant studies. Studies were included which compared clinical
outcomes in patients undergoing TAVR with and without pre-existing AF and
NOAF. The primary outcomes were short term (in-hospital or 30 days) and
long term (one year) mortality. The secondary outcomes were short term and
long term cardiovascular events (CVE). Results: We found twenty two
studies, including 26,865 patients, which reported clinical outcomes
relevant to our study. The prevalence of preexisting AF and NOAF was 33.5%
and 10.3%. The 30 day mortality was 9% in patients with preexisting AF and
7.2% in patients with sinus rhythm (SR). There was a slightly higher
mortality in patients with preexisting AF compared to SR (odds ratio [OR],
1.25; 95% CI 1.05 to 1. 48, I2=0). The one year mortality was also
significantly higher in patients with preexisting AF ([OR], 1.25; 95% CI
1.05 to 1. 48, I2=72%). The short term and long term CVEs (stroke and
TIAs) were similar in patients with preexisting AF and SR. The short term
([OR], 3.58; 95% CI 1.62 to 7.94, I2=73%) and long term mortality ([OR],
1.5; 95% CI 1.40to 2.73, I2=33%) were also significantly higher in
patients with NOAF compared to SR group. Similarly, the short term ([OR],
1.98; 95% CI 1.33 to 2.95, I2=0%) and long term CVEs ([OR], 1.; 95% CI
1.04 2.34, I2=0%) were higher in NOAF group compared to SR. Conclusion:
Both Preexistent AF and NOAF are predictors of adverse events in patients
undergoing TAVR. Preexisting AF should be a part of the risk
stratification model in patients undergoing TAVR. Efforts should be made
to prevent AF after the procedure to decrease adverse events.

<46>
Accession Number
72282128
Author
Ando T.; Holmes A.; Taub C.; Slovut D.; De Rose J.
Institution
(Ando) Mount Sinai Beth Israel, United States
(Holmes, Taub, Slovut, De Rose) Albert Einstein College of Medicine,
Montefiore Medical Center, United States
Title
Iatrogenic ventricular septal defect following transcatheter aortic valve
replacement: A systematic review.
Source
Catheterization and Cardiovascular Interventions. Conference: 39th Annual
Scientific Sessions of the Society for Cardiovascular Angiography and
Intervention, SCAI 2016 Orlando, FL United States. Conference Start:
20160504 Conference End: 20160507. Conference Publication: (var.pagings).
87 (pp S138-S139), 2016. Date of Publication: April 2016.
Publisher
John Wiley and Sons Inc.
Abstract
Background: Ventricular septal defects (VSD) are rarely reported as a
complication following transcatheter aortic valve replacement (TAVR). We
sought to characterize the patients, clinical management, and outcomes, as
well as the current state of knowledge regarding this rare phenomenon.
Methods: Relevant articles were identified by a systematic search of
MEDLINE and EMBASE databases from January, 2002 to September, 2015.
Additionally, the reference lists of each article were manually reviewed.
Original articles and case reports were included if they reported the
baseline characteristics or patient outcomes. Abtracts presented at
conferences were not included. Results: A total of 18 studies, including
20 patients, were identified. The median age was 83 years and 6 were male.
Median Logistic Euro- SCORE was 19.8 (range 11.7-33.8). Twelve were
performed by transfemoral approach. Pre-dilation was performed in 12
patients and postdilation in four. Balloon expandable valves were used in
majority (84%) of cases. The clinical presentation varied from
asymptomatic to progressive heart failure. The timing of the diagnosis
also varied significantly from immediately post valve implantation to one
year afterwards. There were two cases of Gerbode-type defect while the
rest were interventricular defect. The location was mostly membranous or
perimenbranous (79%) and adjacent to the valve landing zone. A total of 7
interventions (1 open surgery and 6 percutaneous closure) were performed.
Four patients died during the same hospital admission. 16 survived past
discharge (range 12 days to 2 years). Conclusion: VSD post-TAVR was seen
more with balloon expandable valves and with pre-dilation or
post-dilation. Percutaneous treatment of the VSD was preferred over open
cardiac surgery given the high surgical risk in this patient population.
Some, but not all, patients survived VSD post TAVR and had a good
prognosis for both patients group who had with or without VSD closure.

<47>
Accession Number
72282127
Author
Ando T.; Afonso L.
Institution
(Ando) Mount Sinai Beth Israel, United States
(Afonso) Wayne State University, Detroit Medical Center, United States
Title
A systematicreview of percutaneous closure of paravalvular regurgitation
after transcatheter aortic valve replacement.
Source
Catheterization and Cardiovascular Interventions. Conference: 39th Annual
Scientific Sessions of the Society for Cardiovascular Angiography and
Intervention, SCAI 2016 Orlando, FL United States. Conference Start:
20160504 Conference End: 20160507. Conference Publication: (var.pagings).
87 (pp S138), 2016. Date of Publication: April 2016.
Publisher
John Wiley and Sons Inc.
Abstract
Background: Paravalvular regurgitation (PVR) remains to be one of the
drawbacks of transcatheter aortic valve replacement (TAVR). Common
treatment strategy includes post-dilation and second valve implantation.
However, some patients develop worse PVR and become symptomatic and thus
require percutaneous PVR closure, which detail remain obscured. The
purpose of this systematic review was to explore PVR closure timing,
success rate and outcomes both in balloon- expandable (BE) and
self-expandable (SE) valves. Methods: Relevant articles were identified by
a systematic search of MEDLINE and EMBASE databases from January, 2002 to
September, 2015. Additionally, the reference lists of each article were
manually reviewed. Abstracts presented at conferences were not included.
Also, reports including same institutions were excluded. Results: Sixteen
studies including 58 patients were included in the study. Majority of the
studies were either case report or case series (15 studies) and two
studies were cohort studies. There were 43 (74%) male. BE was used
frequently than SE (71% versus 29%, respectively). Initial success rate
was 88% (SE versus BE, 100% and 83%, respectively, p=0.093). The main
reason for procedural failure was unable to pass through the sheath into
the leakage area. Median number of closure devices used were 1 (range 1-4)
and did not differ between SE and BE (p=0.81). Mean days for index
procedure to PVR closure were 337+/-379 days and there were no difference
between SE and BE (401+/-354 vs 303+/-392 days, p=0.59). Five PVR closure
devices were implanted during the index procedure. There were 9 patients
who had history of valve-in-valve and at least 7 patients had procedural
success. For the patients whose out-patient follow up data were available
(83%), 14 (29%) patients died during the follow up period. Conclusion:
Percutaneous PVR closures had high success rate in selected patients in
both BE and SE valves. The initial success rate, timing and number of
closure devices were similar between BE and SE valves. The procedure was
also feasible in patients with prior valve-in-valve procedure. However,
prognosis remains fairly poor and preventative measure for PVR is expected
in the next generation valves.

<48>
Accession Number
72282011
Author
Sardar P.; Kundu A.; Chatterjee S.; Pasala T.; Owan T.; Mukherjee D.
Institution
(Sardar, Pasala) University of Utah Hospitals and Clinics, United States
(Kundu) University of Massachusetts, United States
(Chatterjee) St Luke's Roosvelt Medical Center, Mount Sinai, United States
(Owan) University of Utah Medical Center, United States
(Mukherjee) Texas Tech University, UMC Hospital, EL Paso, TX, United
States
Title
Hybrid coronary revascularization vs. coronary artery bypass grafting in
patients with multivessel coronary artery disease: Evidence from a
meta-analysis.
Source
Catheterization and Cardiovascular Interventions. Conference: 39th Annual
Scientific Sessions of the Society for Cardiovascular Angiography and
Intervention, SCAI 2016 Orlando, FL United States. Conference Start:
20160504 Conference End: 20160507. Conference Publication: (var.pagings).
87 (pp S76-S77), 2016. Date of Publication: April 2016.
Publisher
John Wiley and Sons Inc.
Abstract
Background: Coronary Artery Bypass Grafting (CABG) is the treatment of
choice for patients with multivessel coronary artery disease (CAD).
However, CABG has certain limitations including risks of conventional
surgery and unsatisfactory long-term patency of saphenous grafts . Hybrid
Coronary Revascularization (HCR) involves a combination of surgical and
percutaneous techniques, and may be used as an alternative to CABG in
select group of patients. We performed a metaanalysis to evaluate the
efficacy of HCR compared to CABG for treatment of multivessel CAD.
Methods: We searched PubMed, Cochrane Library, EMBASE, EBSCO, Web of
Science, and CINAHL databases till November 15th, 2015 for studies that
compared HCR with CABG for treatment of multivessel CAD. We calculated
summary odds ratios (ORs) and 95% CIs with the random-effects model. The
primary outcome of interest was the occurrence of major adverse cardiac
events (MACE) defined as a composite of all cause mortality, myocardial
infarction and stroke. Results: 11 studies (1 randomized controlled trial
and 10 observational studies) involving 3430 patients were included in the
final analysis. The primary outcome with HCR and CABG was 3.2% and 4.6%
respectively [Odds ratio (OR) 0.60; 95% Confidence Interval (CI) 0.33-
1.10]. Compared to CABG, patients undergoing HCR had similar rates of all
cause mortality [OR 0.89; 95% CI 0.47-1.67], myocardial infarction [OR
0.75; 95% CI 0.39-1.43], stroke [OR 0.53; 95% CI 0.26-1.09], and repeat
revascularization [OR 1.41; 95% CI 0.62-3.21]. The need for postoperative
blood transfusion was significantly lower in the HCR group [OR 0.39; 95%
CI 0.26-0.60]. Conclusion: Our analysis showed that HCR was as effective
as conventional CABG with respect to outcomes of all cause mortality,
myocardial infarction, stroke and repeat revascularization. HCR may be a
suitable alternative to conventional CABG in select patients with
multivessel CAD.

<49>
Accession Number
72282007
Author
Alam M.; Khan M.; Kayani W.; Ahmad W.; Virani S.; Hamzeh I.; Jneid H.;
Lakkis N.
Institution
(Alam, Kayani, Hamzeh, Lakkis) Baylor College of Medicine, United States
(Khan) King Edward Medical University, United States
(Ahmad) Nishtar Medical College, United States
(Virani, Jneid) Baylor College of Medicine, Michael E. DeBakey Veterans
Affair Medical Center, United States
Title
Five year outcomes of percutaneous coronary intervention vs. coronary
artery bypass grafting in 5,349 patients with unprotected left main
coronary artery disease in the era of drug eluting stents.
Source
Catheterization and Cardiovascular Interventions. Conference: 39th Annual
Scientific Sessions of the Society for Cardiovascular Angiography and
Intervention, SCAI 2016 Orlando, FL United States. Conference Start:
20160504 Conference End: 20160507. Conference Publication: (var.pagings).
87 (pp S73-S74), 2016. Date of Publication: April 2016.
Publisher
John Wiley and Sons Inc.
Abstract
Background: Patients with unprotected left main coronary artery (LMCA)
disease are increasingly treated with percutaneous coronary intervention
(PCI) using drug-eluting stents (DES), but long term outcomes comparing
PCI with coronary artery bypass grafting (CABG) remain scarce. Methods: We
performed aggregate data meta-analyses of clinical outcomes [all cause
death; non-fatal myocardial infarction (MI); stroke; repeat
revascularization; cardiac death and major adverse cardiac and
cerebrovascular events (MACCE)] in studies comparing 5 year outcomes of
PCI with DES vs. CABG in patients with LMCA disease. A comprehensive
literature search (01/01/2003 to 10/01/2015) identified 7 studies (5,349
patients). Effect size for individual clinical outcomes were estimated
using odds ratio (OR) with 95% Confidence Intervals using a random-effects
model. Results: At 5 years, PCI with DES was associated with equivalent
cardiac (OR 0.91, 95% CI 0.54 - 1.53) and all cause mortality (OR 1.00,
95% CI 0.69-1.45), lower rates of stroke (OR 0.50, 95% CI 0.26-0.95) and
higher rates of repeat revascularization (OR 3.95, 95% CI 1.96-5.06),
MACCE showed a trend favoring CABG but did not reach statistical
significance (OR 1.20, 95% CI 0.99- 1.46). (Table 1). Conclusion: At 5
years follow-up, PCI with DES is comparable to CABG in terms of all-cause
and cardiac mortality. a higher risk of repeat revascularization and lower
stroke risk after PCI when compared to CABG. (Table Presented).

<50>
Accession Number
72282006
Author
Alam M.; Khan M.; Kayani W.; Ahmad W.; Iham H.; Thamwiwat A.; Hamzeh I.;
Virani S.; Jneid H.; Lakkis N.
Institution
(Alam, Kayani, Iham, Thamwiwat, Hamzeh, Lakkis) Baylor College of
Medicine, United States
(Khan) King Edward Medical University, Pakistan
(Ahmad) Nishtar Medical College, Pakistan
(Virani, Jneid) Baylor College of Medicine, Michael E. DeBakey Veterans
Affair Medical Center, United States
Title
Comparison of percutaneous coronary intervention with drug eluting stents
and coronary artery bypass grafting in octogenarians-a meta analysis.
Source
Catheterization and Cardiovascular Interventions. Conference: 39th Annual
Scientific Sessions of the Society for Cardiovascular Angiography and
Intervention, SCAI 2016 Orlando, FL United States. Conference Start:
20160504 Conference End: 20160507. Conference Publication: (var.pagings).
87 (pp S73), 2016. Date of Publication: April 2016.
Publisher
John Wiley and Sons Inc.
Abstract
Background: Data comparing outcomes of Percutaneous Coronary Intervention
(PCI) with Drug Eluting Stents (DES) and Coronary Artery Bypass Grafting
(CABG) for unprotected left main coronary artery (LMCA) disease in the
elderly (>80 years) is scarce. This subset of population has not been
studied in randomized clinical trials that form the basis for therapeutic
guidelines/recommendations by major cardiovascular societies. Methods: We
performed aggregate data meta-analyses of short and long term clinical
outcomes (all-cause mortality, nonfatal myocardial infarction, repeat
revascularization, and major adverse cardiac and cerebrovascular events
[MACCE]) in studies comparing PCI and CABG in octogenarians with
unprotected LMCA disease. A comprehensive, timeunlimited literature search
to October 1, 2015 identified 5 studies with a total of 1,099 patients.
One study was excluded as it reported <50 patients in each arm. Final
analysis included 4 studies (1,023 patients, CABG 498, PCI 525). Summary
odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using
the random-effects model. Results: There was no major difference in the
baseline characteristics of the patients who underwent PCI or CABG. Mean
age of the patients in CABG and PCI arms was 80.3 and 82.8 years
respectively. At 30- days and intermediate term (12-36 months) follow-up,
PCI with DES and CABG showed no difference in all cause mortality. PCI was
associated with higher needs for repeat revascularizaton at intermediate
term follow-up (odds ratio 6.41, 95% CI 3.39 - 12.13). There was no
significant difference in the rates of MACCE, Stroke, Cardiac death and
Nonfatal MI between the two groups. (Table 1) Conclusion: In octogenerians
with unprotected LMCA disease, coronary revascularization with PCI using
drug eluting stents and CABG are comparable in terms of all-cause and
cardiovascular mortality as well as safety endpoints (non-fatal MI,
stroke, MACCE). PCI however is associated with increased rates of repeat
revascularization at intermediate term follow-up.

<51>
Accession Number
72281175
Author
Nowak R.M.; Frisoli T.; Michaels A.; Jain T.; Muller C.C.; McCord J.
Institution
(Nowak, Frisoli, Michaels, Jain, Muller, McCord) Henry Ford Health System,
Detroit, MI, United States
Title
A cost analysis of the use of modified heart score to determine early
discharge for possible ACS patients presenting to the emergency
department.
Source
Academic Emergency Medicine. Conference: 2016 Annual Meeting of the
Society for Academic Emergency Medicine, SAEM 2016 New Orleans, LA United
States. Conference Start: 20160510 Conference End: 20160513. Conference
Publication: (var.pagings). 23 (pp S202), 2016. Date of Publication: May
2016.
Publisher
Blackwell Publishing Inc.
Abstract
Background: The evaluations of the 8 to10 million patients who annually
present with possible acute coronary syndrome (ACS) to the Emergency
Department (ED) in the United States is time-consuming and costly. The
Modified HEART Score (MHS) stratifies suspicion for ACS based on the
History, ECG and the Age and Risk facTors in patients with serial negative
cardiac troponin (cTn) values. A MHS < 3 identifies low risk possible ACS
patients who may be safe for early discharge from the ED without further
observation/cardiac testing. Objectives: To determine the effect on
hospital length of stay and total and stress testing costs at 30 days for
patients with a MHS < 3 randomized to observation/cardiac stress testing
or early ED discharge. Methods: This was a prospective, randomized
controlled trial enrolling adult patients who presented to the ED with
symptoms of possible ACS, had 2 cTn values < 0.04 ng/ml, and the ED
physician decided required further observation/cardiac stress testing.
Informed consent was obtained and patients were randomized to receive
observation/stress testing or early discharge. Results: There were 105
patients enrolled. The mean hospital length of stay, total costs and the
cost of stress testing were significantly decreased in patients with a MHS
< 3 who received early ED discharge without further cardiac evaluations as
compared to those receiving observation/stress testing (Figure). There
were no deaths, non-fatal MIs, hospitalizations, or coronary
revascularizations in the 103 of 105 patients who had 30-day follow-up.
Three patients randomized to early discharge had stress testing within 30
days but none led to coronary revascularization. Conclusion: Early
discharge without observation/stress testing for ED patients with possible
ACS classified as low risk by a MHS < 3 and with normal serial cTn values
can substantially reduce the length of stay and costs of care for these
patients. Such a decision aid, if further validated for safety and
implemented nationally, could save billions of dollars annually. (Figure
Presented).

<52>
Accession Number
72280954
Author
Mahler S.A.; Riley R.F.; Hiestand B.C.; Hoekstra J.W.; Lefebvre C.W.;
Nicks B.A.; Cline D.M.; Askew K.L.; Elliott S.B.; Miller C.D.
Institution
(Mahler, Hiestand, Hoekstra, Lefebvre, Nicks, Cline, Askew, Elliott,
Miller) Wake Forest University, School of Medicine, Winston-Salem, NC,
United States
(Riley) University of Washington, Seattle, WA, United States
Title
The heart pathway randomized controlled trial: One-year safety outcomes.
Source
Academic Emergency Medicine. Conference: 2016 Annual Meeting of the
Society for Academic Emergency Medicine, SAEM 2016 New Orleans, LA United
States. Conference Start: 20160510 Conference End: 20160513. Conference
Publication: (var.pagings). 23 (pp S116-S117), 2016. Date of Publication:
May 2016.
Publisher
Blackwell Publishing Inc.
Abstract
Background: The HEART Pathway is a decision aid designed to identify
emergency department (ED) patients with acute chest pain for early
discharge. Prior HEART Pathway studies demonstrate >99% negative
predictive value (NPV) for adverse events at 30 days. However, ability of
the HEART Pathway to predict adverse events at 1 year has not been
studied. Objectives: To determine the rate of 1 year major adverse cardiac
events (MACE) for the HEART Pathway and usual care among ED patients with
acute chest pain and to test whether the HEART Pathway can predict 1 year
MACE. Methods: Adult ED patients with symptoms concerning for acute
coronary syndrome without ST-elevation on electrocardiogram (N=282) were
randomized to the HEART Pathway or usual care. In the HEART Pathway arm,
ED providers used the HEART score and troponin measures at 0 and 3 hours
to identify patients for early discharge. Usual care was based on ACC/AHA
guidelines. MACE was defined as death, myocardial infarction (MI), or
coronary revascularization and was assessed at 1 year by phone interview,
record review, and Social Security Death Index. The NPV and positive
predictive value (PPV) of the HEART Pathway for MACE at 1 year were
calculated. Fisher's exact tests were used to compare MACE rates among
randomization arms. Results: During the study period 282 patients were
enrolled, of which 141 were randomized to the HEART Pathway and usual care
arms. Participants had a mean age of 53 years and 21% (45/282) had known
coronary disease (MI or revascularization prior to enrollment). MACE
within 1 year of randomization occurred in 10% (29/282). Among patients
randomized to the HEART Pathway 8.5% (12/141) had MACE (0 deaths, 10 MIs,
2 revascularizations without MI) at 1 year compared to usual care in which
12% (17/141) had MACE (4 deaths, 13 MIs); p=0.43. The HEART Pathway
identified 47% (66/141) of patients as low-risk, of which 0% (0/ 66) had 1
year MACE. In the usual care arm 18% (26/141) received early discharge,
with 4% (1/26) having 1 year MACE (1 death); p for comparison = 0.28. The
NPV of the HEART Pathway for 1 year MACE was 100% (95%CI: 93-100%), with a
PPV of 16% (95%CI: 9-26%). Conclusion: The HEART Pathway has a high NPV
for MACE at 1 year. MACE rates at 1 year were similar among the HEART
Pathway and usual care arms.