Difference In Procedure-related Complications Research Articles

Intravascular imaging-guided vs. angiography-guided percutaneous coronary intervention: A systematic review and meta-analysis of randomized controlled trials in high-risk patients and complex coronary anatomies

BackgroundDespite a large body of evidence supporting the use of intravascular imaging (IVI) to guide percutaneous coronary intervention (PCI), concerns exist about its universal recommendation. The selective use of IVI to guide PCI of complex lesions and patients is perceived as a rational approach. MethodsWe performed a systematic review and meta-analysis of randomized controlled trials (RCTs). Embase, PubMed, and Cochrane were systematically searched for RCTs that compared IVI-guided PCI with angiography-guided PCI in high-risk patients and complex coronary anatomies. The primary outcome was major adverse cardiac events (MACE). A random-effects model was used to calculate the risk ratios (RRs) with 95 % confidence intervals (CIs). ResultsA total of 15 RCTs with 14,109 patients were included and followed for a weighted mean duration of 15.8 months. IVI-guided PCI was associated with a decrease in the risk of MACE (RR: 0.65; 95 % CI: 0.56–0.77; p < 0.01), target vessel failure (TVF) (RR: 0.66; 95 % CI: 0.52–0.84; p < 0.01), all-cause mortality (RR: 0.71; 95 % CI: 0.55–0.91; p < 0.01), cardiovascular mortality (RR: 0.47; 95 % CI: 0.34–0.65; p < 0.01), stent thrombosis (RR: 0.55; 95 % CI: 0.38–0.79; p < 0.01), myocardial infarction (RR: 0.81; 95 % CI: 0.67–0.98; p = 0.03), and repeated revascularizations (RR: 0.70; 95 % CI: 0.58–0.85; p < 0.01) compared with angiography. There was no significant difference in procedure-related complications (RR: 1.03; 95 % CI: 0.75–1.42; p = 0.84) between groups. ConclusionsCompared with angiographic guidance alone, IVI-guided PCI of complex lesions and high-risk patients significantly reduced all-cause and cardiovascular mortality, MACE, TVF, stent thrombosis, myocardial infarction, and repeat revascularization.

MP-453083-11 SAFETY AND OUTCOMES OF VENTRICULAR TACHYCARDIA ABLATION ACROSS AGE GROUPS

A pharmacotherapy approach to the treatment of ventricular tachycardia (VT) is frequently complicated by poor tolerance, persistent ICD shocks and impartial rhythm control. This can be burdensome in an elderly population who frequently have significant comorbidities complicating medical care. Catheter ablation for ventricular tachycardia has been increasingly employed to treat VT, however a paucity of data on the safety and outcomes of VT ablation in octogenarians exists. To examine the safety and outcomes of ventricular tachycardia ablation therapy in octogenarians. The data used was obtained from the National Inpatient Sample (NIS) database from 2016 to 2019. We identified patients ≥ 21 years old with VT as primary diagnoses and underwent ablation during index hospitalization. Patients were divided into 4 age subgroups 20-39, 40-59, 60-79 and ≥ 80 years old. Primary outcome was all-cause mortality and secondary outcomes were transfer to rehab, hospital length-of-stay and in-hospital complications. Univariate and multivariate logistic regression analyses were used to study the association between catheter ablation and primary and secondary outcomes. A total of 23,900 patients undergoing VT ablation were identified. Most patients were between ages of 50-69 years of age (60.3%), followed by 40-59 (25%), ≥ 80 (9.5%), and 20-39 (5.6%). No significant differences in complications including procedure-related pericardial effusion, pericarditis, tamponade, stroke, hemorrhage, or respiratory failure were seen between all age groups. Similarly, no significant differences in hospital length of stay were appreciated across all ages. However, mortality rates were significantly higher in octogenarians (4.2%), compared to those between 60-79 years old (3.2%), 40-59 years (1.5%) and 20-39 years (2.3%) (p-value 0.023). Rehab transfer was also significantly higher in the elderly (p-value <0.001). In this large, real-world database study, we found no significant differences in procedure related complications or hospital length of stay across all age groups undergoing VT ablation. However, in-hospital mortality rates and transfer to rehab were significantly higher in octogenarians compared to younger subgroups. Despite procedural safety, a decision to pursue VT ablation in octogenarians must be carefully weighed against modest increased risks of mortality in this delicate population.

PO-02-201 OUTCOMES OF RADIOFREQUENCY ABLATION OF ATRIAL FIBRILLATION IN OCTOGENARIANS IN A MULTICENTER REGISTRY (REAL-AF)

Catheter ablation for atrial fibrillation (AF) has significantly increased in prevalence, including in an elderly population. However, some studies suggest that outcomes of AF ablation may be inferior in elderly patients. Real-world, multi-center data is minimal and may provide more insight on this possibility. To compare the outcomes of octogenarians versus non-octogenarians undergoing catheter ablation of AF in high volume centers. Patients undergoing radiofrequency ablation of AF were prospectively enrolled in a multi-center registry (REAL-AF) from January 2018 to May 2021. The cohort was divided into 2 groups, patients ≥ 80 years old (octogenarians) and patients < 80 years old (non-octogenarians). Baseline characteristics and procedural data were collected prospectively on all patients. Routine ambulatory monitoring was performed at 6- and 12-months and additionally as needed based on symptoms. Efficacy was assessed at 12 months. The primary outcome was freedom from symptomatic atrial arrhythmias lasting greater than 30 seconds after a 90-day blanking period. 71 patients were included in the octogenarian group and 1,134 patients in the non-octogenarian group. The proportion of patients with persistent AF was similar between the groups. Octogenarians were more likely to have lower BMI, hypertension, prior bleeding, and left atrial scar as assessed by electro-anatomic mapping system (EAM). Left ventricular ejection fraction and left atrial volume as measured on EAM were also similar among the groups. There was a trend towards increased recurrence of atrial arrhythmias in octogenarians (table 1). At 12 months, octogenarians were more likely to be on anti-arrhythmic drugs as well. However, there was no difference in procedure-related complications between the groups. When controlled for left atrial scar burden, there was no difference in outcomes between the two groups. Octogenarians undergoing ablation of atrial fibrillation are more likely to have recurrent atrial arrhythmias than younger patient; this difference seems to be associated with an increased likelihood of abnormal left atrial voltage in the elderly patients. Although octogenarians are considered a frail population, AF ablation maintained similar safety profiles and arrhythmia related healthcare utilization rates when compared to a younger population.

Fracking compared to conventional balloon angioplasty alone for calcified common femoral artery lesions using intravascular ultrasound analysis: 12-month results

BackgroundFracking is a novel technique to crack calcified lesions by hydraulic pressure. This study aimed to compare the performance of fracking and conventional balloon angioplasty without stenting for calcified common femoral artery (CFA) lesions using intravascular ultrasound (IVUS) analysis.MethodsThis retrospective, single-center, comparative observational study included 59 patients (67 limbs) with calcified CFA lesions treated with either fracking (n = 30) or balloon angioplasty (n = 29) between January 2018 and December 2020. The primary endpoint was 1-year primary patency. The secondary endpoints included procedure success, freedom from target lesion revascularization (TLR), procedure-related complications, and freedom from major adverse limb events (MALE). Predictors of restenosis were identified using multivariate Cox proportional hazards analysis.ResultsThe mean follow-up duration was 403 ± 236 days. The fracking group had significantly higher incidence of 1-year primary patency (89.8% versus 49.2%, P < 0.001), procedure success (96.9% versus 74.3%, P = 0.009), and freedom from TLR (93.5% versus 74.2%, P = 0.038) than the balloon group. The rate of freedom from MALE was significantly higher in the fracking group than in the balloon group (76.9% versus 48.6%, P = 0.033). The groups had no significant difference in procedure-related complications (6.2% versus 5.7%, P = 0.928). A larger postprocedural IVUS-estimated minimum lumen area (MLA) was associated with a lower risk of restenosis (hazard ratio, 0.78; 95% confidence interval, 0.67–0.91; P < 0.001), with a cut-off value of 16.0 mm2 determined using receiver operating characteristics curve analysis. The incidence of 1-year primary patency in patients with a postprocedural MLA ≥16.0 mm2 (n = 37) was significantly higher than that in those with a postprocedural MLA < 16.0 mm2 (n = 30) (87.8% versus 44.6%, P < 0.001).ConclusionThis study demonstrated the superior procedural efficacy of fracking compared to balloon angioplasty in treating calcified CFA lesions. The safety outcomes after fracking were comparable to those after balloon angioplasty. Large postprocedural MLA was an independent positive predictor of patency.

XperCT facilitates sharp recanalization for the treatment of chronic thoracic venous occlusive disease in hemodialysis patients.

Our objective was to evaluate the feasibility of XperCT combined fluoroscopy to guide sharp recanalization for the treatment of chronic thoracic venous occlusive disease in hemodialysis patients. The records of hemodialysis patients with chronic thoracic venous occlusive disease who received endovascular sharp recanalization after conventional techniques failed were retrospectively reviewed. The sharp devices used for recanalization included the stiff end of a guidewire, Chiba biopsy needle, RUPS-100 set, and transseptal needle. The needle was advanced toward a target placed at the opposite end of the occlusion and was guided by fluoroscopy and/or XperCT. While the guidewire crossed the occlusion, endovascular procedures such as percutaneous angioplasty were performed for the treatment of the occlusion. The analysis included 32 sharp thoracic vein recanalization procedures in 29 patients. Two attempts in one patient failed, and in one patient the first attempt failed but the second attempt was successful. In one patient, two separate successful procedures were performed, and the other 26 procedures in 26 patients were successful. The overall technical success rate of sharp recanalization was 90%. The mean number of puncture attempts in the combined group was less than that of the fluoroscopy-guided alone group (2 vs 5, p < 0.05). The success rate of sharp recanalization in the combined group was higher (100% vs 86%), and the recanalization time (28.5 min vs 36 min, p > 0.05) was no different. There was no statistical difference in procedure-related complications between the groups. XperCT can facilitate sharp recanalization for the treatment of chronic thoracic venous occlusive disease in hemodialysis patients.

Abstract 14704: Comparison of Anticoagulation Strategies for Epicardial Access in Ventricular Tachycardia Catheter Ablation

Introduction: Percutaneous epicardial access (EpiAcc) is frequently required for endo-epicardial ablation of ventricular tachycardia (VT), especially in ischemic cardiomyopathy, where it has been demonstrated to increase success rate. For patients who have indications for chronic oral anticoagulation (OAC), this often poses a challenge due to potential risks of procedural complications. We sought to assess the safety and outcomes of epicardial VT ablation on uninterrupted OAC compared to off anticoagulation. Methods: In this multicenter study, we retrospectively analyzed patients with ischemic cardiomyopathy and VT who underwent endo-epicardial ablation with EpiAcc. The study group included patients who underwent ablation either under uninterrupted OAC or off anticoagulation. Procedural data, outcomes, and complication rates were analyzed for comparison of both groups. Results: Overall, we analyzed 135 patients who underwent VT ablation via EpiAcc; 55 under full-dose uninterrupted AC and 80 off AC. There was no difference in procedure-related complications between both groups (1.8% vs 2.5%, p=0.09). There was no major bleeding requiring transfusion in any group. There was no difference in risk of cardiac tamponade between both groups (0% vs 0%, p=1). The rate of groin hematoma was 1.8% vs 1.3%, p=0.087). No thromboembolic events were reported. Conclusion: Epicardial VT ablation on uninterrupted OAC is a safe alternative to off AC, with no additional risk of life-threatening complications, thus preventing the possibility of thromboembolic events in patients who have an indication for chronic AC. 1

Transbronchial needle aspiration combined with cryobiopsy in the diagnosis of mediastinal diseases: a multicentre, open-label, randomised trial

Transbronchial mediastinal cryobiopsy is a novel sampling technique for mediastinal disease. Despite the possibility of lung cancer misdiagnosis, the improved diagnostic yield of this approach for non-lung-cancer lesions compared with standard endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) highlights its diagnostic potential as a complementary technique to conventional biopsy. We aimed to evaluate the safety profile and added value of the combined use of transbronchial mediastinal cryobiopsy and standard EBUS-TBNA for the diagnosis of mediastinal diseases. We conducted an open-label, randomised trial at three hospital sites in Europe and Asia. Eligible patients were aged 15 years or older, with at least one mediastinal lesion of 1 cm or longer in the short axis that required diagnostic bronchoscopy. Participants were randomly assigned (1:1) using a block randomisation scheme generated by a computer (block size of four participants based on a random table from an independent statistician) to the combined use of EBUS-TBNA and transbronchial mediastinal cryobiopsy (combined group) or EBUS-TBNA alone (control group). Because of the nature of the intervention, neither participants nor investigators were masked to group assignment. The coprimary outcomes were differences in procedure-related complications and diagnostic yield (defined as the proportion of participants for whom mediastinal biopsy led to a definitive diagnosis), assessed in the full analysis set, including all the patients who met the eligibility criteria and had a biopsy. A fully paired, intraindividual diagnostic analysis in participants who had both needle aspiration and mediastinal cryobiopsy was conducted, in addition to interindividual comparisons. This trial is now complete and is registered with ClinicalTrials.gov, NCT04572984. Between Oct 12, 2020, and Sept 9, 2021, 297 consecutive patients were assessed for eligibility and 271 were enrolled and randomly assigned to the combined group (n=136) or the control group (n=135). The addition of cryobiopsy to standard sampling significantly increased the overall diagnostic yield for mediastinal lesions, as shown by both interindividual (126 [93%] of 136 participants in the combined group vs 109 [81%] of 135 in the control group; risk ratio [RR] 1·15 [95% CI 1·04-1·26]; p=0·0039) and intraindividual (126 [94%] of 134 vs 110 [82%] of 134; RR 1·15 [95% CI 1·05-1·25]; p=0·0026) analyses. In subgroup analyses in the intraindividual population, diagnostic yields were similar for mediastinal metastasis (68 [99%] of 69 participants in the combined group vs 68 [99%] of 69 in the control group; RR 1·00 [95% CI 0·96-1·04]; p=1·00), whereas the combined approach was more sensitive than standard needle aspiration in benign disorders (45 [94%] of 48 vs 32 [67%] of 48; RR 1·41 [95% CI 1·14-1·74]; p=0·0009). The combined approach also resulted in an improved suitability of tissue samples for molecular and immunological analyses of non-small-cell lung cancer. The incidence of adverse events related to the biopsy procedure did not differ between trial groups, as grade 3-4 airway bleeding occurred in three (2%) patients in the combined group and two (1%) in the control group (RR 0·67 [95% CI 0·11-3·96]; p=1·00). There were no severe complications causing death or disability. The addition of mediastinal cryobiopsy to standard EBUS-TBNA resulted in a significant improvement in diagnostic yield for mediastinal lesions, with a good safety profile. These data suggest that this combined approach is a valid first-line diagnostic tool for mediastinal diseases. National Natural Science Foundation of China.

Endoscopy versus early surgery for the management of chronic pancreatitis: a systematic review and meta-analysis.

Endoscopic stone removal and stenting of pancreatic strictures are the initial treatment for treating chronic pancreatitis-related pain. Surgery is considered when endoscopic interventions fail to improve symptoms. In this meta-analysis, we have compared early surgery versus endoscopic interventions. The study was performed as per the PRISMA statement. The literature search was conducted on online databases to identify studies that compared endoscopy and surgery for the management of chronic pancreatitis symptoms. Primary outcomes of interest were pain relief, complications, and exocrine/endocrine insufficiency. Secondary outcomes were mean length of stay and mean number of procedures. Pooled odds ratio (OR) was calculated using random-effects model with 95% confidence interval (CI). Of a total of 9880 articles that were screened, three randomized controlled trials and two retrospective studies with 602 patients (71.4% males) were found to be eligible. Endoscopic interventions were performed in 317 patients and 285 patients underwent early surgery. Early surgery provided significantly better pain relief compared to endoscopy (OR 0.46; 95%CI 0.27-0.80; p = 0.01; I2 = 17.65%) and required less number of procedures (Mean difference 1.66; 95%CI 0.9-2.43; p = 0.00; I2 = 96.46%). There was no significant difference in procedure-related complication (OR 0.91; 95%CI 0.51-1.61; p = 0.74; I2 = 38.8%), endocrine (OR 1.18; 95%CI 0.63-2.20; p = 0.61; I2 = 28.24%), or exocrine insufficiency (OR 1.78; 95%CI 0.66-4.79; p = 0.25; I2 = 30.97%) or the length of stay (Mean difference 1.21; 95%CI -7.12 to 4.70; p = 0.69). Compared to endoscopy, early surgery appears to be better in controlling chronic pancreatitis-related pain, with no significant difference in procedure-related complications. However, larger randomized controlled trials are needed to ascertain their efficacy.

Outcomes of patients with malignant esophagogastric junction obstruction receiving metallic stents: A single-center experience.

Malignancies-related esophagogastric junction (EGJ) obstruction is usually diagnosed in inoperable status with poor clinical outcomes. Metallic stent placement at EGJ could improve dysphagia for these patients. However, studies regarding the outcomes in these patients receiving metallic stents are still limited. This study aimed to investigate the outcomes of metallic stent placement in malignant EGJ obstruction. Forty-one patients with inoperable malignant EGJ obstruction receiving metallic stent placement were retrospectively enrolled. The clinical outcomes between different stents and deployment techniques were analyzed. The overall technical success rate was 97.6% and clinical success rate was 92.1%. The median overall survival time was 77 (4-893) days, and the patency time was 71 (4-893) days, respectively. Poststent radiotherapy significantly prolonged survival and stent patency. Between patients receiving uncovered or partially covered metal stents, there was no difference in procedure-related complications, survival time, and stent patency time. Moreover, the clinical outcomes in patients receiving duodenal stents for malignant EGJ obstruction are not inferior to those receiving esophageal stents. This study provides crucial information for endoscopists to establish individualized stenting strategies for malignant EGJ obstruction.

A Comparison of Clinical and Radiological Outcomes Between Target 360 Nano and Microplex Hypersoft 3D Used as Finishing Coil.

To compare the clinical outcomes of Target 360 nano (TG) and Microplex hypersoft 3D (MH) used as a finishing coil (FC). From January 2018 to December 2020, we retrospectively reviewed 243 coil embolization procedures performed using TG (n=152) and MH (n=91) coils of 1mm x 2 cm the same size as FC. Further, the clinical and radiographic results were compared by matching the propensity score between the two groups. There were no statistically significant differences in the clinical and angiographic results of the two coils after the propensity score matching. Successful occlusion was 89% and 86.8% and FC insertion failure was 20.9% and 28.6%. There were no differences in procedure-related complications and recurrence between the groups during the eight months follow-up period (3.3% versus 4.4% and 4.4% versus 3.3%, respectively). We also compared two subgroups of failed FC insertion (19 of TG and 26 of MH). The number of angled catheters was significantly higher in the failed TG group than in the failed MH group. There was no statistically significant difference between the clinical and radiological outcomes of TG and MH used as FC. However, in the FC insertion failure subgroups, the number of angled catheters was significantly higher in the TG failed group than in the MH failed. It was experimentally confirmed that the angle change of microcatheter tip with a large angle was large; however, further studies are required.

Same-day discharge after implantation of cardiac implantable electronic devices: A systematic review and meta-analysis.

Due to an increasing need for cardiac implantable electronic device (CIED) placement, the cost of healthcare has been rising including the cost of hospital stay after the procedure. We conducted this systematic review and meta-analysis to assess the safety and feasibility of same-day discharge (SDD) after cardiac device implantations. We searched MEDLINE, and Embase databases from inception to March 2021 to identify studies that compared clinical outcomes between SDD group and hospital overnight stay (HO) group after cardiac device implantations. Outcomes included complications after the procedure, mortality, and re-hospitalization. Data from each study were combined using the random-effects model to calculate pooled odds ratio (OR) with 95% confidence interval (CI). Eight studies (one randomized control trial, three prospective cohort and four retrospective cohort studies) with a total of 61,602 patients (4153 in SDD group and 57,449 in HO group) were included. SDD was not associated with more procedure-related complications. The rates of wound problems (0.94%vs 1.84%, pooled OR=0.86, 95%CI: 0.2-3.68, p=.834), pneumothorax (1.15%vs 0.73%, pooled OR=1.36, 95%CI: 0.26-7.12, p=.718), hematoma (0.59%vs 2.32%, pooled OR=0.35, 95%CI:0.01-9.85, p=.534), lead/device dislodgement (4%vs 2.48%, pooled OR=1.71, 95%CI: 0.64-4.54, p=.281), readmission rate (17.6%vs 17.5%, pooled OR=0.95, 95%CI: 0.74-1.21, p=.667), and mortality rate (1.66%vs 1.44%, pooled OR=0.77, 95%CI: 0.58-1.01, p=.059) were similar between in SDD and HO groups respectively. Our meta-analysis suggested that SDD after cardiac device implantations might be a safe and feasible alternative to HO without differences in procedure-related complications, readmission rates, or mortality rates.

Half‐normal saline versus normal saline for irrigation of open‐irrigated radiofrequency catheters in atrial fibrillation ablation

The creation of effective and permanent lesions is a crucial factor in determining the success rate of atrial fibrillation (AF) ablation. By increasing the efficacy of radiofrequency (RF) energy-mediated lesion formation, half-normal saline (HNS) as an irrigant for open-irrigated ablation catheters has the potential to reduce procedural times and improve acute and long-term outcomes. This is a double-blindrandomized clinical trial of 99 patients undergoing first-time RF catheter ablation for AF. Patients enrolled were randomly assigned in a 1:1 fashion to perform ablation using HNS or normal saline (NS) as an irrigant for the ablation catheter. The use of HNS is associated with shorter RF times (26 vs. 33 min; p = .02) with comparable procedure times (104 vs. 104 min). The rate of acute pulmonary vein reconnections (16% vs. 18%) was comparable, with a median of 1 vein reconnection in the HNS arm versus 2 in the NS arm. There was no difference in procedure-related complications, including the incidence of postprocedural hyponatremia when using HNS. Over the 1-year follow-up, there is no significant difference between the HNS and NS with respect to the recurrence of any atrial arrhythmia (off antiarrhythmic drugs[AAD]: 47% vs. 52%; hazard ratio [HR]: 1.17, 95% confidence interval [CI]: 0.66-2.06; off/on AAD: 66% vs. 66%, HR: 1.06, 95% CI: 0.53-2.12), with a potential benefit of using HNS when considering the paroxysmal AF cohort (on/off AAD 73% vs. 62%, HR: 0.72, 95% CI: 0.19-2.70). In a mixed cohort of patients undergoing first-time AF ablation, irrigation of open-irrigated RF ablation catheters with HNS is associated with shorter RF times, with a comparably low rate of procedure-related complications. In the long term, there is no significant difference with respect to the recurrence of any atrial arrhythmia. Larger studies with a more homogeneous population are necessary to determine whether HNS improves clinical outcomes.

Laparoscopic cholecystectomy: do upper GI and lower GI surgeons have similar outcomes?

Background: Laparoscopic cholecystectomy is operation performed on a regular basis, regardless of surgeon’s primary specialty. Common complications include bile duct injury, bile leaks, bleeding, and bowel injury. In Tier 2 Hospitals, upper GI surgeons will manage patients with non-complex OG and HPB disease including laparoscopic cholecystectomy. The AUGSGBI proposed that laparoscopic cholecystectomy (LC) be performed by surgeons trained in upper GI surgery. NICE guidelines recommend similarly. Concentration of surgical expertise and volumes led to lesser conversions and complications. The aim was to compare the complication rates of consecutive patients undergoing laparoscopic cholecystectomy by upper and lower GI consultants in one hospital. Methods: This was a retrospective observational study. We collected 100 consecutive patients from a list of laparoscopic cholecystectomies performed by upper GI surgeons (UGI) and lower GI (LGI) surgeons. All complications were identified from electronic patient records. Complications were recorded according to the Clavien and Dindo system. Median length of stay (LOS) was recorded and compared between the two groups. Results: There was no difference in between groups with respect to sex, age, length of stay or ASA grade, nor a significant difference in complication rates between surgeons of upper and lower GI surgeons. Conclusions: In this study in a selected group, we did not find any difference in procedure related complications between operations conducted by upper GI and lower GI surgeon groups. However, there appeared to be a higher rate of port closure related complication at the umbilicus in operations performed by the lower GI team.

Left or bilateral internal mammary artery employment in coronary artery bypass grafting: midterm results.

The gold standard for coronary artery bypass grafting to the left anterior descending artery is use of the left internal mammary artery. Better long-term survival has been reported using bilateral internal mammary arteries compared to left internal mammary artery only, but many surgeons are reluctant to employ bilateral internal mammary arteries in coronary artery bypass grafting. This study aimed to evaluate the effectiveness and safety of bilateral internal mammary artery use. From 2014 to 2017, 1703 patients underwent coronary artery bypass grafting in our institute. Of these, 772 met the inclusion criteria and were randomly assigned to receive bilateral (n = 387) or left (n = 385) internal mammary artery grafts. The mean age was 67.1 ± 6.0 years (range 48-85 years) and 474 (61.4%) were male. The mean number of diseased vessels was 3.1 ± 0.9, and mean EuroSCORE II was 3.4% ± 1.1%. Hospital mortality was 1.2% in the left internal mammary artery group vs. 1.8% in the bilateral internal mammary artery group (p = 0.55). There was no difference in procedure-related complications between groups. Mean follow-up was 65.9 months. Survival in the bilateral internal mammary artery group at 1, 3, and 5 years was 98.7%, 98.7%, and 94.8% vs. 98.1%, 98.1%, and 90.9%, respectively, in the left internal mammary artery group (p = 0.63). Application of bilateral internal mammary arteries in coronary artery bypass grafting is safe and effective, with comparable midterm results to those with the left internal mammary artery only.

Safety of leadless pacemaker implantation in the very elderly

The Micra leadless pacemaker (MLP) has proven to be an effective alternative to a traditional transvenous pacemaker (TVP). However, there has been concern about using the MLP in frail elderly patients because of the size of the implant sheath and perceived risk of perforation. The objectives of this study were to report the safety of the MLP and compare MPLs with TVPs in the very elderly. All patients 85 years and older who received an MLP or a single-chamber TVP across 6 hospitals in the Northwell Health system from December 2015 to November 2019 were included. Demographic characteristics, procedural details, and procedure-related complications were reviewed. Over 4 years, 564 patients underwent MLP implantation. During this time, 183 MLPs and 119 TVPs were implanted in patients 85 years and older. The mean age was 89.7 ± 3.4 years, and 47.4% were men. MLP implantation was successful in all but 3 patients (98.4% success rate). There was no difference in procedure-related complications (3.3% vs 5.9%; P = .276). Complications included 5 (2.7%) access site hematomas in the MLP group, 3 (2.5%) in the TVP group, 1 (0.5 vs 0.8%) pericardial effusion in each group, and 3 (2.5%) acute lead dislodgments (<24 hours) in the TVP group. MLP implantation resulted in a significantly shorter mean procedure time (35.7 ± 23.0 minutes vs 62.3 ± 31.5 minutes, P < .001). In a large multicenter study of patients 85 years and older, MLP implantation (1) was successful in 98.4% of patients, (2) was safe with no difference in procedure-related complications compared to the TVP group, and (3) resulted in significantly shorter procedure times.

Metoclopramide Reduces Fluoroscopy and Procedure Time during Gastrojejunostomy Tube Placement: A Placebo-Controlled Trial

PurposeTo determine whether a single 10-mg intravenous dose of the promotility agent metoclopramide reduces the fluoroscopy time, radiation dose, and procedure time required for gastrojejunostomy (GJ) tube placement. MethodsThis prospective, randomized, double-blind, placebo-controlled trial enrolled consecutive patients who underwent primary GJ tube placement at a single institution from April 10, 2018, to October 3, 2019. Exclusion criteria included age less than 18 years, inability to obtain consent, metoclopramide allergy or contraindication, and altered pyloric anatomy. Average fluoroscopy times, radiation doses, and procedure times were compared using t-tests. The full study protocol can be found at www.clinicaltrials.gov (NCT03331965). ResultsOf 110 participants randomized 1:1, 45 received metoclopramide and 51 received placebo and underwent GJ tube placement (38 females and 58 males; mean age, 55 ± 18 years). Demographics of the metoclopramide and placebo groups were similar. The fluoroscopy time required to advance a guide wire through the pylorus averaged 1.6 minutes (range, 0.3–10.1 minutes) in the metoclopramide group versus 4.1 minutes (range, 0.2–27.3 minutes) in the placebo group (P = .002). Total procedure fluoroscopy time averaged 5.8 minutes (range, 1.5–16.2 minutes) for the metoclopramide group versus 8.8 minutes (range, 2.8–29.7 minutes) for the placebo group (P = .002). Air kerma averaged 91 mGy (range, 13–354 mGy) for the metoclopramide group versus 130 mGy (range, 24–525 mGy) for the placebo group (P = .04). Total procedure time averaged 16.4 minutes (range, 8–51 minutes) for the metoclopramide group versus 19.9 minutes (range, 6–53 minutes) for the placebo group (P = .04). There were no drug-related adverse events and no significant differences in procedure-related complications. ConclusionsA single dose of metoclopramide reduced fluoroscopy time by 34%, radiation dose by 30%, and procedure time by 17% during GJ tube placement.

Survival Implications of Increased Utilization of Local Excision for cT1N0 Esophageal Cancer.

We hypothesized that patients with cT1N0 esophageal cancer undergoing local excision would have lower survival compared with esophagectomy due to potential discordant staging. Local excision has become an attractive alternative for management of early esophageal cancer, avoiding the morbidity of esophagectomy. It is uncertain if occult nodal metastasis impacts survival. An observational study was conducted using the National Cancer Database (1998-2012) for patients with clinical T1N0 esophageal cancer who underwent local excision (n = 1625) or esophagectomy (n = 3255). The proportion of patients undergoing local excision increased from 12% in 1998 to 50% in 2012 (P < 0.001). After esophagectomy, 61% of cT1N0 cancers had concordant clinical and pathological staging, with 5.2% having positive nodal disease; 37% were staged concordant after local excision, with excess missing data (60%). Ninety-day mortality was 7.4% after esophagectomy compared with 2.8% after local excision (P < 0.001). While no significant difference was seen in unadjusted survival, adjusted Cox regression analysis indicated worse survival after esophagectomy compared with local excision for all cases [hazard ratio (HR) 1.57, 95% confidence interval (CI) 1.27-1.95] and for patients with concordant staging (HR 1.68, 95% CI 1.23-2.28). Local excision for cT1N0 esophageal cancer has increased over time. Contrary to our hypothesis, despite incomplete nodal staging, patients undergoing local excision have favorable survival, particularly in the adenocarcinoma subgroup. This may reflect early differences in mortality due to differences in procedure-related complications and/or selection bias. As this study has limited power to compare outcomes between T1a and T1b cancers, further analysis is warranted.

Neuropsychological Changes in Patients Undergoing Treatment of Unruptured Intracranial Aneurysms.

Evaluation of differences in neuropsychological outcomes in patients undergoing surgical clipping (SC) vs endovascular coiling (EC) for unruptured cerebral aneurysms is essential in guiding patients seeking treatment of asymptomatic cerebral aneurysms. To perform a prospective longitudinal analysis of neuropsychological outcomes in patients who underwent microsurgery or coiling for unruptured cerebral aneurysms. SC (50 patients), EC (35 patients), and healthy controls (43 individuals) were included. A detailed neuropsychological evaluation was performed at baseline and at 2 wk, 3 mo, 6 mo, and 12 mo. Student's t-test was utilized for comparing neuropsychological outcomes among the 3 groups. A mixed-effects model allowed for evaluation of neuropsychological outcome changes among the groups over time. Both the SC and EC groups had nonsignificant differences in procedure-related complications. SC patients had the greatest initial declines in short-term memory, fine motor control, and executive functioning; however, these patients also recovered to a greater degree in neuropsychological functionality. Over the next year, all groups achieved similar neuropsychological outcomes with no significant differences among groups. Whereas the initial decline in neuropsychological functioning was greater for SC patients, 1 yr after treatment there was no significant difference in neuropsychological outcome among the SC, EC, and healthy control groups.

Abstract TP26: Endovascular Therapy in Patients With Low NIHSS Score on Presentation

Introduction: Approximately 2/3 of all AIS present with NIHSS 0-5. While it has been demonstrated that LVO can be found in ~10-20% of all low NIHSS patients, outcome data in this population remains scarce. Indeed, only 14/1766 patients in the recent endovascular RCTs had baseline (b) NIHSS in the 0-5 range. Yet, the presence of LVO in the setting of low NIHSS is associated with ~10-fold increase in subsequent deterioration. We aim to describe the outcomes in a large cohort of low NIHSS patients undergoing thrombectomy. Methods: Patients derived from a large prospective multicenter international stent-retriever registry (Trevo Registry, n=2,010). Baseline and outcome variables were compared according to bNIHSS 0-8 vs &gt;8 and bNIHSS 0-5 vs &gt;5. The primary and secondary efficacy endpoints were the rates of 90-day mRS 0-2 and mTICI 2b-3, respectively. Safety endpoints included sICH and 90-day mortality. Results: A total of 1,985 patients were included. As compared with patients with higher baseline NIHSS, low baseline NIHSS (0-8, n=342; 0-5, n=160) patients were younger, had less comorbidities and better functional status, more frequently had MCA-M2 or vertebrobasilar occlusions, less frequently received IV tpa, and underwent thrombectomy at later times (Table 1). The reperfusion outcomes were nearly the same. There were no significant differences in procedure-related complications, which were overall low (Table 2). The rates of 90-day mRS 0-2 were significantly higher in the lower NIHSS patients (p&lt;0.001); however, ~20% of those patients were not independent and ~7% were dead at 90 days despite presenting with low clinical severity. Conclusion: Despite safe and efficacious endovascular reperfusion, low-NIHSS LVO patients have a relatively high proportion of bad outcomes. This supports the notion that many of "mildly" presenting patients do not fare well. A randomized clinical trial including immediate endovascular treatment in this patient population is warranted.

Left atrial posterior wall isolation reduces the recurrence of atrial fibrillation: a meta-analysis.

The posterior wall of left atrium plays an important role in atrial fibrillation (AF) recurrence, but the benefit of left atrial posterior wall isolation (PWI) remains still unclear. The objective was to evaluate the benefit of PWI in radiofrequency ablation. PubMed and the Web of Science were searched in September 2015. Studies comparing catheter ablation with PWI [PWI(+)] vs. ablation without PWI [PWI(-)] were included. We performed a meta-analysis to assess atrial arrhythmia recurrence, procedure-related complications, and procedural time. Five studies with 594 AF patients were included. Compared with PWI(-), PWI(+) resulted in a significantly lower atrial arrhythmia recurrence rate (relative risk [RR] 0.81, 95% confidence interval [CI] 0.68-0.97, p = 0.02), which was largely driven by the decreased AF recurrence (RR 0.55, 95% CI 0.35-0.86, p = 0.009). Recurrence rates of atrial tachycardia/flutter (AT/AFL) were comparable between two groups (RR 1.16, 95% CI 0.85-1.58, p = 0.34). There were no significant differences in procedure-related complications (RR 1.07, 95% CI 0.45-2.53, p = 0.89) and procedural times (weight mean difference 0.88, 95% CI -7.29-9.06, p = 0.83). This meta-analysis shows that with comparable procedure-related complications and procedural time, ablation with PWI reduces AF recurrence.