30-day Stroke Rate Research Articles

Radial and ulnar approach for carotid artery stenting with Roadsaver™ double layer micromesh stent:Early and long-term follow-up.

We aimed to evaluate the feasibility and safety of carotid artery stenting (CAS) with a newly designed double-layer micromesh stent using wrist approach in patients with significant carotid disease. Between January 2016 and December 2021, 105 patients undergoing CASwith Roadsaver™ stent were enrolled in a single center prospective study. Follow-up assessments included neurological exams, duplex ultrasound (DUS), and 12-lead ECG. The primary endpoint was the 30-day composite rate of stroke, death, and myocardial infarction. Secondary endpoints included procedure success, access site complications, device success, target lesion revascularization, and in-stent restenosis evaluated with DUS. Long-term outcomes up to 72 months of follow-up were assessed in all eligible patients. The study population was predominantly male (69.5%) with a median age of 68 ± 8 years. Patients were symptomatic in 80% of the cases, and 35% fulfilled the high-risk criteria for surgical endarterectomy. The right internal carotid artery was the target artery in 56 (53.4%), and the left in 49 (46.6%) of the cases. All procedures were successfully completed from the right wrist, with right radial access in 94 (89.5%) cases and ulnar artery access with previous radial artery occlusion in 11 (10.5%) cases. All patients were treated successfully with the study device. The primary endpoint was met with a 30-day major adverse eventrate of 0.9% (1/105). Up to 72 months of follow-up (median 30 ± 20 months) there were no strokes, neurological deaths, or target lesion revascularization of the treated lesion. Doppler ultrasound examination revealed nonsignificant in-stent restenosis in two asymptomatic patients. There was no hand ischemia detected in any patient. Results from this study demonstrate the radial and ulnar access for CASwith double layer micromesh Roadsaver™ stent is safe and feasible and associated with favorable early and long-term follow-up.

Enhanced recovery after minimally invasive heart valve surgery: Early and midterm outcomes

BackgroundAlthough the use of protocols for “enhanced recovery after surgery” (ERAS) have been associated with improved results in different surgical specialties, only a few data are available for ERAS in cardiac surgery. This study aimed to compare 30-day outcomes of patients undergoing ultra-fast-track minimally invasive valve surgery (UFT-MIVS) versus conventional MIVS (c-MIVS). MethodsThe key features of UFT-MIVS approach involves: 1) less invasive valve surgery techniques, 2) normothermic cardiopulmonary bypass management, 3) UFT-anesthesia with table extubation, 4) immediate rehabilitation therapy and patient-family contact. Five-hundred and seventy-six consecutive patients who underwent aortic or mitral MIVS were analyzed (2016–2020). Treatment selection bias (UFT-MIVS vs. c-MIVS) was addressed by the use of propensity score (PS) matching. After PS-matching 2 well-balanced groups of 152 patients each were created. ResultsIn the matched cohort, the overall 30-day mortality and stroke rates were 0.3% and 0.7%, respectively, with no difference between groups. UFT-MIVS resulted in lower rates of respiratory insufficiency and agitation/delirium compared with c-MIVS. Patients receiving UFT-MIVS were associated with significantly shorter intensive care unit length of stay and hospital stay. ConclusionsOur study confirms that MIVS is associated with excellent results in terms of early mortality and major postoperative complications rates. The implementation of UFT-MIVS protocol showed to be safe and was associated with improved clinical outcomes in regard to respiratory insufficiency, delirium and lengths of stay.

Abstract 15248: Clinical Outcomes of Transcatheter Aortic Valve Replacement With and Without Percutaneous Coronary Intervention - An Updated Meta-Analysis and Systematic Review

Hypothesis: Transcatheter aortic valve replacement (TAVR) serves as a less-invasive treatment option for high-risk patients with severe aortic stenosis. Given the coexistence of obstructive coronary artery disease in patients with high-grade aortic stenosis (estimated to be 40-75%), there is inconsistent clinical data regarding potential mortality benefits of paired percutaneous coronary intervention (PCI) with TAVR procedures. Methods: We performed a literature search using PubMed, Embase, and Cochrane Library from inception through April 2022 to assess the mortality impact of preceding/concomitant PCI in patients undergoing transcatheter aortic valve replacement. The primary outcomes were 30-day all-cause mortality, 30-day cardiovascular mortality, and 6 months-1 year all-cause mortality. Secondary outcomes included 30-day myocardial infarction, stroke, major bleeding/vascular complications, and acute kidney injury. Results: 11 studies (10 retrospective cohort studies, 1 randomized control trial) involving 2791 patients were included in the meta-analysis. Compared to patients undergoing TAVR alone, the TAVR+PCI group showed no significant difference in 30-day all-cause mortality (RR 0.90, CI 0.66, 1.22, p =0.49), 30-day cardiovascular mortality (RR 0.71 CI 0.44, 1.14, p =0.16), or 6 months-1 year all-cause mortality (RR 0.94, CI 0.75, 1.18, p =0.57). Regarding secondary outcomes, 30-day myocardial infarction was higher in the TAVR+PCI group compared to the TAVR group (RR 3.09, CI 1.26, 7.57, p =0.01), while no significant differences were found in rates of 30-day stroke (RR 1.14, CI 0.56, 2.33, p =0.72), major bleeding/vascular complications (RR 1.11, CI 0.79, 1.56, p =0.55), and acute kidney injury (RR 1.07, CI 0.75, 1.54, p =0.71). Conclusion: Concomitant/preceding percutaneous coronary intervention does not confer any additional mortality benefit, and may increase the risk of 30-day myocardial infarction, in patients with high-grade aortic stenosis undergoing transcatheter aortic valve replacement. Further trials with large sample sizes are needed to confirm our findings.

Bivalirudin plus a high-dose infusion versus heparin monotherapy in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention: a randomised trial

Previous randomised trials of bivalirudin versus heparin in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) have reported conflicting results, in part because of treatment with different pharmacological regimens. We designed a large-scale trial examining bivalirudin with a post-PCI high-dose infusion compared with heparin alone, the regimens that previous studies have shown to have the best balance of safety and efficacy. BRIGHT-4 was an investigator-initiated, open-label, randomised controlled trial conducted at 87 clinical centres in 63 cities in China. Patients with STEMI undergoing primary PCI with radial artery access within 48 h of symptom onset who had not received previous fibrinolytic therapy, anticoagulants, or glycoprotein IIb/IIIa inhibitors were randomly assigned (1:1) to receive bivalirudin with a post-PCI high-dose infusion for 2-4 h or unfractionated heparin monotherapy. There was no masking. Glycoprotein IIb/IIIa inhibitor use was reserved for procedural thrombotic complications in both groups. The primary endpoint was a composite of all-cause mortality or Bleeding Academic Research Consortium (BARC) types 3-5 bleeding at 30 days. This trial is registered with ClinicalTrials.gov (NCT03822975), and is ongoing. Between Feb 14, 2019, and April 7, 2022, a total of 6016 patients with STEMI undergoing primary PCI were randomly assigned to receive either bivalirudin plus a high-dose infusion after PCI (n=3009) or unfractionated heparin monotherapy (n=3007). Radial artery access was used in 5593 (93·1%) of 6008 patients. Compared with heparin monotherapy, bivalirudin reduced the 30-day rate of the primary endpoint (132 events [4·39%] in the heparin group vs 92 events [3·06%] in the bivalirudin group; difference, 1·33%, 95% CI 0·38-2·29%; hazard ratio [HR] 0·69, 95% CI 0·53-0·91; p=0·0070). All-cause mortality within 30 days occurred in 118 (3·92%) heparin-assigned patients and in 89 (2·96%) bivalirudin-assigned patients (HR 0·75; 95% CI 0·57-0·99; p=0·0420), and BARC types 3-5 bleeding occurred in 24 (0·80%) heparin-assigned patients and five (0·17%) bivalirudin-assigned patients (HR 0·21; 95% CI 0·08-0·54; p=0·0014). There were no significant differences in the 30-day rates of reinfarction, stroke, or ischaemia-driven target vessel revascularisation between the groups. Within 30 days, stent thrombosis occurred in 11 (0·37%) of bivalirudin-assigned patients and 33 (1·10%) of heparin-assigned patients (p=0·0015). In patients with STEMI undergoing primary PCI predominantly with radial artery access, anticoagulation with bivalirudin plus a post-PCI high-dose infusion for 2-4 h significantly reduced the 30-day composite rate of all-cause mortality or BARC types 3-5 major bleeding compared with heparin monotherapy. Chinese Society of Cardiology Foundation (CSCF2019A01), and a research grant from Jiangsu Hengrui Pharmaceuticals.

Carotid Endarterectomy for Carotid Stenosis: Predictive Factors for 30-Day Stroke and Mortality Rates

Carotid Endarterectomy for Carotid Stenosis: Predictive Factors for 30-Day Stroke and Mortality Rates

PERFORMANCE 1 study: Novel carotid stent system with integrated post-dilation balloon and embolic protection device.

The PERFORMANCE I study was designed to evaluate the safety and feasibility of the Neuroguard IEP® System, a novel carotid stent system with an integrated embolic filter and post-dilatation balloon, to treat clinically significant carotid artery stenosis. The risk of major adverse events during carotid artery stenting is comparable to carotid endarterectomy, however, the risk of minor stroke remains higher with stenting. In total, 67 patients undergoing carotid artery stenting were enrolled at nine centers in Europe. Follow-up assessments included neurological exams, duplex ultrasound, 12-lead electrocardiogram, and cardiac enzyme analysis. The primary endpoint was the 30-day composite rate of stroke, death, and myocardial infarctions versus a prespecified performance goal. Secondary endpoints included procedure success, device success, and target lesion revascularization. The study population was predominantly male (74.6%) with a mean age of 69.3 ± 8.9 years and 67% of subjects met at least one criterion placing them at an elevated risk for adverse events following carotid endarterectomy. All patients were treated successfully with the study device. There were no deaths or strokes within 30 days of the index procedure. One subject (1.5%) experienced a non-ST elevation myocardial infarction at day 17. The primary endpoint was met with a 30-day major adverse events rate of 1.5% (1/67). Through 12-month follow-up, there were no strokes, neurological deaths, target lesion revascularizations, or instances of in-stent-restenosis. Results from this study demonstrate the Neuroguard IEP system is safe and feasible with a stroke/death rate of 0% at 30 days. A large pivotal study is currently underway.

Impact of frailty on 30-day death, stroke, or myocardial infarction in severe carotid stenosis: Endarterectomy versus stenting

ObjectiveCarotid endarterectomy (CEA) and carotid artery stenting (CAS) are used for stroke prevention in patients with carotid stenosis. It remains unclear which surgical approach produces the best outcomes for elderly and frail patients. We investigated the impact of age and frailty on 30-day combined outcomes of death, stroke, and myocardial infarction (MI) in patients who received CEA or CAS for severe symptomatic carotid stenosis. MethodsA retrospective analysis of the NSQIP database identified patients with severe carotid stenosis who received either CEA or CAS between 2015 and 2020 for study inclusion. Frailty was measured by the Modified Frailty Index 5-item (mFI-5), which stratified patients as non-frail (score=0), pre-frail (=1), frail (=2), or severely frail (=3). Age was subdivided into 65 years or younger, 66–84 years, and 85 years or older. The primary outcome was 30-day combined rates of death, stroke, and MI, as analyzed by multivariate logistic regression analyses, adjusted for sex, body mass index, smoking status, anesthetic type, and contralateral carotid stenosis. ResultsA total of 18,074 patients were included in analyses, of which 14,428 received CEA (80 %) and 3646 received CAS (20 %). Mean age was 70.8 and 70.5 years for CEA and CAS, respectively. The rate of combined outcome of death, stroke or MI at 30 days was significantly higher in CEA (3.3 %) than CAS (1.3 %) (χ2 =41.90, p < 0.001). Increasing frailty was associated with higher rates of the primary outcome in CEA patients (χ2 =30.26, p < 0.001) but not CAS (χ2 =6.95, p = 0.07). A 6-component risk score was constructed for the combined outcomes in CEA, which predicted adverse events with 80.7 % accuracy. ConclusionsAge and frailty have a significant impact on the risk of death, stroke, and MI at 30 days in patients with severe, symptomatic carotid stenosis who receive CEA, but not CAS. Non-standard Abbreviations and AcronymsBody mass index (BMI), carotid artery stenting (CAS), carotid endarterectomy (CEA), current procedural technology (CPT), myocardial infarction (MI), modified Frailty Index 5-item (mFI-5), American College of Surgeons National Surgical Quality Improvement Program (NSQIP).

Primary arterial closure after carotid endarterectomy is a safe and expeditious technique in appropriately selected patients

BackgroundCarotid endarterectomy (CEA) remains a safe and durable operation for both symptomatic and asymptomatic carotid stenosis, however conflicting evidence exists on the benefit of patch angioplasty and its effects on post-operative outcomes. MethodsA retrospective review of all patients undergoing CEA from 2011 to 2018 was performed. ResultsOf 851 patients, primary closure was performed in 277 (33%). Patients with primary closure were older (74 vs 72, p = 0.001), symptomatic (39% vs 34%, p = 0.024), and male (69% vs 31% p < 0.001), with a higher incidence of diabetes mellitus (47% vs 39%, p = 0.046) and ESRD (4% vs 2%, p = 0.015). Restenosis rates were similar (7% vs 8%, p = 0.67). Operative time was shorter for primary closure (87 ± 28 vs 102 ± 26 min, p < 0.001). There were no differences in 30-day ipsilateral stroke rates (1% vs 1%, p = 0.51) or stroke-free survival. ConclusionsPrimary arterial closure is safe and expeditious in appropriately selected high-risk patients.

Intraoperative Flow Measurement as a Quality Control during Carotid Endarterectomy in a Teaching Hospital Setting

Background: To evaluate the technical results of an arterial repair, a variety of intraoperative imaging and assessment techniques can be used during carotid endarterectomy (CEA). The aim of the study was to evaluate the usefulness of intraoperative ultrasound flow measurement as a quality control after primary CEA in a teaching hospital setting. Methods: Over 36 months, 107 consecutive CEAs were performed at our institution. Retrospectively acquired demographics, intraoperative flow measurements, duplex results, revisions, and surgical outcomes were reviewed. Postoperative 30-day transient ischemic attack (TIA), stroke, and death rates were analyzed. Results were compared with ultrasound flow measurement and duplex ultrasonography. Results: From March 2012 to March 2015, 107 primary consecutive CEAs were performed in 107 patients (71% male, 29% female), whose age ranged from 51 to 81 years with a mean age of 68 ± 4 years. Associated risk factors included diabetes for 89 (83%), smoking for 92 (86%), hypertension for 94 (87.8%), chronic renal insufficiency for 71 (66%), and coronary artery disease for 57 (53%) of the patients. Early postoperative duplex scans in all 107 patients showed no significant changes from intraoperative findings. The ipsilateral stroke and death rate in this study was 0 (0/107) and the 30-day death and stroke rate was also 0 (0/107), with no significant difference between trainees and senior surgeons. Three patients (2.8%) had flow &lt; 100 mL/Min and two of them were revised after completion of contrast angiography. Conclusions: The findings of this study indicate that the intraoperative flow measurement is an alternative method for detecting technical errors and a tool for quality-control imaging. Especially for trainees, it makes sense to ensure effectiveness of the procedure upon its completion and to assess the technical adequacy of CEA.

Thoracic Endovascular Aortic Repair with Supra-Aortic Trunk Revascularization is Associated with Increased Risk of Periprocedural Ischemic Stroke

Ischemic stroke is a devastating complication of thoracic endovascular aortic repair (TEVAR). This risk may be higher in more proximal aneurysms that require arch manipulation. The purpose of this study is to (1) describe 30-day stroke and death rates in patients undergoing TEVAR, (2) compare stroke rates in patients undergoing TEVAR for arch versus descending aneurysm pathology, and (3) identify predictive factors associated with stroke after TEVAR. The Vascular Quality Initiative registry was queried (2015-2021) for TEVAR procedures performed for degenerative aneurysms. Our primary outcomes were any stroke or death at 30 days. Patient-, procedure-, and hospital-level predictors of stroke were assessed using multivariable Poisson regression. Among 3,072 patients with degenerative aneurysms (197 [6.4%] arch versus 2,875 [93.6%] descending) treated with elective TEVAR, the median age was 73 years (interquartile range 67-79) and 54.8% were male. Within the arch aneurysm group, there were 27.4% zone 0, 22.8% zone 1, and 49.8% zone 2 interventions. Overall 30-day stroke and death rates were 3.2% and 3.8%. The distribution of stroke events was bilateral (52.9%), left carotid (20.7%), left vertebrobasilar (11.5%), right carotid (9.2%), and right vertebrobasilar (5.7%). Although mortality was similar between groups, the rate of ischemic stroke was higher for patients undergoing TEVAR for arch aneurysm versus descending aneurysms (7.1% arch versus 2.9% descending, P=0.001). Factors that were associated with ischemic stroke after TEVAR included age (>79years, relative risk [RR] 1.79, 95% confidence interval [CI] 1.08-2.98 vs. <79years), dependent functional status (RR 1.73, 95% CI 1.07-2.78), procedural time (RR 1.25, 95% CI 1.15-1.36), and endovascular intervention for supra-aortic trunk revascularization (RR 2.66, 95% CI 1.06-6.70 versus no intervention). Ischemic stroke risk after TEVAR was increased for arch aneurysms compared to descending aneurysms. More proximal zone coverage and endovascular interventions on the supra-aortic trunks were associated with increasing risk for stroke. Adequate preparation for stroke prevention is necessary prior to TEVAR with supra-aortic trunk revascularization.

A single-center experience of 30-day perioperative and one year clinical outcomes of transcarotid artery revascularization in 100 consecutive patients.

Transcarotid Artery Revascularization (TCAR) using the ENROUTE system (Silk Road) has been proposed as a safe and effective alternative to both carotid endarterectomy (CEA) and transfemoral carotid artery stenting (TF-CAS). Two large registries (ROADSTER 1 and ROADSTER 2) have shown that TCAR has acceptable/low rates of perioperative stroke/death. This study will analyze the 30-day perioperative and 1-year clinical outcomes from a single-center. This is a retrospective analysis of prospectively collected data from SVS/VQI TCAR surveillance project (TSP) of 100 consecutive patients (102 TCAR procedures) done in our institution. These procedures were done for high-risk patients for CEA, which included anatomical (previous CEA, high cervical lesion, neck radiation, stoma, arch type, etc.), physiological (CHF, severe coronary artery disease, COPD on O2 therapy, etc.) and combined anatomical/physiological reasons. These procedures were done by vascular surgeons after receiving the appropriate training. The perioperative stroke, death, and MI rates were analyzed. Kaplan Meyer analysis was used to estimate rate of freedom from stroke/death and the incidence of ≥50% and ≥80% in-stent restenosis at 1year. 100 consecutive high-risk patients for CEA included: 38% anatomical, 44% physiological, and 18% combined anatomical and physiological reasons. The mean age was 72.5years (range 52-90years). Indications for TCAR were 34% for symptomatic lesions (TIA/stroke) and 66% for asymptomatic lesions. Mean ipsilateral treated stenosis was 80.4%. Contralateral ≥50% stenosis/occlusion was present in 31% of patients. Technical success rate was 100%. 92% had pre-stenting PTA and 26% had post-stenting PTA. The mean flow reversal time was 8.5min (range 3-26min). The 30-day perioperative stroke rate was 2.9% (1/67, 1.5% for asymptomatic patients), the stroke/death rate was 2.9%, and stroke/death and MI rate was 3.9% (4/102). Other perioperative complications included cranial nerve injury 3/102 (2.9%), carotid artery dissection (2%), and major hematoma (necessitated operation evacuation) (5.9%). Freedom from stroke rates and stroke/death rates at 1year were: 90% and 89%. Freedom from ≥50% and ≥80% in-stent restenosis rates at 1year were 82% and 90%, respectively. None of these restenosis were symptomatic except two (2/13). Freedom from reintervention rate at 1 year was 98%. Although the perioperative events were somewhat higher than what has been reported in previous registries, TCAR for patients who are high-risk for CEA has a low perioperative stroke and stroke/death rates with satisfactory outcome at 1year. Further long-term data is probably needed to verify long-term outcome.

Spatial distribution of stroke readmission within 30 days and the influencing factors in Hunan Province.

Stroke readmission increases financial burden on the family and the consumption of medical resources, and 30-day readmission rate is an important indicator for quality evaluation on health services. The influential factors for readmission mainly include patient-related factors, hospital factors, and society-related factors, with regional differences. This study aims to explore the spatial distribution and its main relevant factors for 30-day readmission of stroke patients in Hunan Province, and to provide the useful information for the improvement of regional prevention and control of stroke readmission. Stroke patients in Hunan Province who were hospitalized in 2018 and readmitted within 30 days were included in the study. The vector map of the county boundary in Hunan Province was used as the basic map since county was the spatial analysis unit. SPSS 26.0 and ArcGIS 10.8 were used for statistical analysis that contains descriptive analysis of the general situation and the distribution map of readmission rate within 30 days of stroke patients. Spatial autocorrelation analysis and spatial regression analysis were further used to find the spatial clusters of the 30-day readmission rate of stroke and the local relationship between the readmission rate and main influential factors. In 2018, a total of 172 800 stroke patients were hospitalized in Hunan Province, of which 6 953 patients were re-hospitalized within 30 days after discharging due to stroke. The 30-day readmission rate was 4.09% in Hunan Province. The clusters of stroke readmission rates were mainly concentrated in the northeast and western regions in Hunan Province. The geographically weighted regression revealed that proportion of patients with complications, number of hospitals per 10 000 population and number of primary medical and health care institution per 10 000 population were the main relevant factors for stroke readmission, and there were differences both in the direction and degree of the effect on readmission in different regions. The 30-day readmission rate for stroke patients in Hunan province and its main influential factors had spatial heterogeneity. The key prevention and control areas were mainly concentrated in the northeast and western regions. It is recommended that the prevention and treatment of stroke complications and the construction of medical institutions need to be strengthened to improve the quality of medical services, particularly in the western region. The importance to the treatment of stroke complications should be attached in the northern region, and the primary health care should be reinforced in the northeast region. All counties should take prevention and control measures according to local conditions, so as to effectively control the readmission rate of stroke within 30 days.

Early outcomes of the suprasternal transcatheter aortic valve replacement technique.

Transcatheter aortic valve replacement (TAVR) is now an established treatment option for patients with severe aortic stenosis. The most utilized approach remains transfemoral. In patients with difficult femoral access a variety of alternate approaches have been used. Recently, suprasternal access has emerged as a viable alternate approach in patients with very complex vascular access. We describe our 30-day outcomes of patients who underwent suprasternal transcatheter aortic valve replacement (suprasternal [SS]-TAVR), which constitutes the largest single-center cohort to date. From May 2016 to September 2021, 658 patients underwent TAVR at our institution. Of which 29underwent SS-TAVR. We performed a retrospective analysis to evaluate early (30 days) outcomes of this procedure. Main outcomes evaluated included 30-day mortality, stroke and pacemaker rates, length of stay, readmission, and valvular function. All patients were alive 30 days after the procedure. The median hospital length-of-stay was 2 days. Two patients (6.9%) had a stroke on the contra-lateral side of access. Two patients (6.90%) had significant cardiac arrhythmias requiring pacemaker placement. In 30 days, one patient was readmitted (3.45%). Our data confirmthe SS-TAVR as a feasible and safe alternative with comparable results to established approaches in patients who are unsuitable for femoral artery access and offers clinicians another access site in patients with very complex anatomy.

The Impact of Sex on Outcomes Following Carotid Endarterectomy

Previous studies have demonstrated significant sex differences in vascular surgery outcomes. We assessed the 30-day and 1-year stroke or death rates following carotid endarterectomy (CEA) in women vs men.

Drug-Coated Balloon Treatment for Delayed Recanalization of Symptomatic Intracranial Artery Occlusion

Patients with medically refractory non-acute intracranial artery occlusion (ICAO) are difficult to treat. The optimal intervention for these patients is not known. We evaluated the feasibility and safety of drug-coated balloon (DCB) treatment for non-acute ICAO. Consecutive patients with symptomatic medically refractory atherosclerotic non-acute ICAO from January 2015 to July 2021 who underwent DCB treatment were retrospectively analyzed. The rates of stroke, transient ischemic attack, and death within 30 days and the follow-up results were evaluated. A total of 148 patients were enrolled in this study. The 30-day rate of stroke, transient ischemic attack, and death was 8.8%. During the 25.8 ± 15.8-month clinical follow-up period, the rate of outcome beyond 30 days was 4.7%. In the 66 patients with vessel imaging follow-up, 13.6% (9/66) had restenosis. The present study suggests that DCB dilatation is a feasible and effective alternative in carefully selected patients with symptomatic non-acute ICAO.

Late Outcomes of Carotid Artery Stenting for Radiation Therapy-Induced Carotid Stenosis

A retrospective review of 11 French academic institutions (University Association for Research in Vascular Surgery—AURC) from 2005 to 2017. One hundred and twenty-one transfemoral carotid artery stent (TF-CAS) procedures were performed in 112 patients (31% symptomatic). The mean interval between irradiation and TF-CAS was 15 years. Duplex ultrasound examination was performed at 1, 6, and 12 months, and annually thereafter. The combined 30-day perioperative stroke and mortality rate was 6.5%. After 5 years, the neurologic event-free survival rate was 88% and in-stent restenosis rate was 39%. Diabetes mellitus and single postoperative antiplatelet therapy were significant predictors of in-stent restenosis. TF-CAS is an effective option for radiation-induced stenosis. CAS was associated with low rates of neurological events and reinterventions at a mean follow-up of 3.5 years.

Medium-term outcomes from mitral valve surgery for rheumatic heart disease in young adults in Aotearoa New Zealand: a cohort study.

Rheumatic heart disease (RHD) remains an important cause of morbidity and mortality in New Zealand. Factors associated with the choice of surgical treatment for advanced RHD in young adults are poorly understood. We sought to review our local experience with the surgical management of young adults with rheumatic mitral valvular disease. From 2003 to 2016, all patients aged 15-24 years undergoing mitral valve surgery for rheumatic disease at Auckland City Hospital, New Zealand were retrospectively reviewed. During the 13-year study period, 73 young adults underwent mitral surgery; 85% were Maori or Pacific Islanders. Mitral repair was performed in 32 patients and replacement in 41 patients. Isolated mitral valve surgery was performed in 36%, double valve procedures in 47%, and triple valve procedures in 17% of patients. The 30-day mortality rate and stroke rate were 1.4% and 2.7% respectively. The medium-term mortality rate was 11.9% across a mean follow-up of 6 years (6.9% in the repair group, 15.8% in the replacement group, p=0.25). There were increased bleeding complications (p=0.04) in patients with mechanical mitral valve replacement. For patients on warfarin, across medium-term follow-up, the INR was in the therapeutic range only 23% of the time. Most young adults in New Zealand with severe RHD requiring surgery are of indigenous Maori or Pacific Island ethnicity. There is a trend towards improved survival with mitral repair. There is a significant tendency towards increased bleeding complications in patients on warfarin for mechanical mitral replacement. Warfarin compliance is poor.

Aortic valve versus root surgery after failed transcatheter aortic valve replacement

ObjectiveWe sought to determine outcomes of aortic valve replacement (AVR) versus root replacement after transcatheter AVR (TAVR) explantation because they remain unknown. MethodsFrom November 2009 to September 2020, data from the EXPLANT-TAVR International Registry of patients who underwent TAVR explant were retrospectively reviewed, divided by AVR versus root replacement. After excluding explants performed during the same admission as the initial TAVR and concomitant procedures involving the other valves, 168 AVR cases were compared with 28 root replacements, and outcomes were reported at 30 days and 1 year. ResultsAmong 196 patients (mean age, 73.5 ± 9.9 years) who had primary aortic valve intervention at TAVR explant, the median time from TAVR to surgical explant was 11.2 months (interquartile range, 4.4-32.9 months). Indications for explant were similar between the 2 groups. Compared with AVR, patients requiring root replacement had fewer comorbidities but more unfavorable anatomy for redo TAVR (52.6% vs 26.4%; P = .032), fewer urgent/emergency cases (32.1% vs 58.3%; P = .013), longer median interval from index TAVR to TAVR explant (17.6 vs 9.9 months; P = .047), and more concomitant ascending aortic replacement (58.8% vs 14.0%; P < .001). Median follow-up was 6.9 months (interquartile range, 1.4-21.6 months) after TAVR explant and 97.4% complete. Overall survival at follow-up was 81.2% with no differences between groups (log rank P = .54). In-hospital, 30-day, and 1-year mortality rates and stroke rates were not different between the 2 groups. ConclusionsIn the EXPLANT-TAVR Registry, AVR and root replacement groups had different clinical characteristics, but no differences in short-term mortality and morbidities. Further investigations are necessary to identify patients at risk of root replacement in TAVR explant.

Trends and Outcomes of Oral Anticoagulation With Direct Current Cardioversion for Atrial Fibrillation/Flutter at an Academic Medical Center.

BackgroundIncreasing reports suggest the safe use of direct oral anticoagulants (DOACs) in electrical cardioversion. The aim of this study was to assess the trends and 30-day outcomes associated with anticoagulation for cardioversion.MethodsPatients who underwent electrical cardioversion from January 2015 to October 2020 with a 30-day follow-up were included; and outcomes including stroke, transient ischemic attack, intracranial hemorrhage (ICH), and major gastrointestinal bleeding were recorded.ResultsOf the 515 patients, 351 (68%) were men and 164 (32%) were women, with a mean CHA2DS2VASc score of 2.6 ± 1.6. Outpatient apixaban use increased from 10% in 2015 to 46% in 2020 (P < 0.001) with a decline in the use of warfarin from 24% in 2015 to 10% in 2020 (P = 0.023). Apixaban use peri-procedurally for cardioversion increased from 32% in 2015 to 35% in 2020 (P = 0.317), while warfarin use decreased from 23% in 2015 to 14% in 2020 (P = 0.164). At discharge, apixaban prescriptions increased from 21% in 2015 to 61% in 2020 (P < 0.001), while warfarin prescriptions declined from 30% in 2015 to 13% in 2020 (P = 0.009). No ICH was recorded in the 30 days after cardioversion. Ischemic stroke occurred in four (0.7%) patients with one (0.29%) of the 338 patients on a DOAC, one (0.8%) of the 124 patients on warfarin and two (5.5%) of the 36 patients not receiving anticoagulation post cardioversion. There were seven (1%) major gastrointestinal bleeding events in patients on oral anticoagulation, of which four (3%) were on warfarin and three (0.8%) were on DOACs.ConclusionsOur study shows the increasing and safe use of DOACs for the purpose of cardioversion. The rates of 30-day ischemic stroke post cardioversion were low and only occurred in patients admitted in the intensive care unit.

Surgical Aortic Valve Replacement Versus Conservative Treatment in Asymptomatic Severe Aortic Stenosis: An Updated Systematic Review and Meta-Analysis

BackgroundWhile aortic valve replacement (AVR) is indicated for symptomatic severe aortic stenosis (AS), the appropriate management of asymptomatic severe AS remains unclear. We conducted an updated meta-analysis to compare the outcomes of surgical AVR (SAVR) versus conservative treatment in patients with asymptomatic severe AS. MethodsWe searched PubMed, EMBASE, Cochrane, clinicaltrials.gov, and Google Scholar for studies comparing outcomes of SAVR versus conservative treatment in asymptomatic severe AS. Risk ratios (RRs) and 95% confidence intervals (CIs) were calculated for each individual study. Outcomes included all-cause mortality, cardiovascular and non-cardiovascular mortality, 30-day operative mortality, sudden cardiac death (SCD), heart failure hospitalization (HFH), myocardial infarction (MI), and stroke. ResultsA total of 8 studies with 2685 patients were included. The mean age was above 60 years, and the median follow-up duration was 4 years. Compared to conservative treatment, SAVR was associated with significantly lower all-cause mortality (RR 0.39; 95% CI 0.23–0.64) and HFH rates (RR 0.18; 95% CI 0.05–0.71). There were no significant differences in cardiovascular mortality (RR 0.24; 95% CI 0.03–1.67), non-cardiovascular mortality (RR 0.49; 95% CI 0.23–1.03), 30-day operative mortality (RR 0.48; 95% CI 0.10–2.32), SCD (RR 0.37; 95% CI 0.05–2.89), MI (RR 0.48; 95% CI 0.04–5.52), and stroke rates (RR 1.20; 95% CI 0.35–4.11) between the two strategies. ConclusionsIn patients with asymptomatic severe AS, SAVR is associated with significantly lower all-cause mortality and HFH compared to conservative treatment. While SAVR is a promising option for asymptomatic severe AS, most studies were observational and nonrandomized; randomized trials are needed to establish a clear benefit.