The objective was to compare the efficacy of treatment options for right heart thrombi (RHT) in transit. All published reports between 1992 and 2013 were identified and pooled. We analyzed 328 patients with RHT and pulmonary embolism (PE). The treatments administered were none in 11 patients (3.4%), anticoagulation (AC) with heparin in 70 patients (21.3%), thrombolytics in 122 patients (37.2%), catheter-related treatments in five patients (1.5%) and surgical embolectomy in 120 patients (36.6%). The overall short-term mortality for the entire cohort was 23.2%. The mortality rate associated with no therapy was highest at 90.9%. The mortality associated with AC alone was significantly higher than surgical embolectomy or thrombolysis (37.1% vs 18.3% vs 13.7%, respectively). In univariate analysis, any therapy was better than no therapy with a favorable odds of 16.92 (95% CI 2.05-139.87) for AC, 61.76 (95% CI 7.42-513.81) for thrombolysis and 44.54 (95% CI 5.42-366.32) for surgical embolectomy. In multivariate analysis with age and hemodynamic status entered as covariates, thrombolytic therapy was better than AC with favorable odds of 4.83 (95% CI 1.52-15.36). Similarly, there was a trend in favor of surgical embolectomy with an odds of 2.61 (95% CI 0.90-7.58). The estimated probability of survival in hemodynamically unstable patients with AC, surgical embolectomy and thrombolysis was 47.7%, 70.45% and 81.5%, respectively. There was no significantly increased risk of complications with thrombolytic therapy. In conclusion, left untreated, patients with RHT and PE have very high mortality. Aggressive management with thrombolysis or surgical thrombectomy may be more effective than AC alone in the management of these patients.

Background and Purpose-Studies have suggested that the early excess risk of stroke in coronary artery bypass grafting (CABG) may be compensated for by a slow but progressive catch-up phenomenon in patients undergoing percutaneous coronary intervention (PCI). We therefore undertook this analysis to compare the temporal stroke risk between PCI and CABG in patients with unprotected left main stenosis and multivessel coronary artery disease. Methods-Studies of PCI versus CABG for unprotected left main stenosis and multivessel disease published between January 1994 (stent era) and July 2013 were identified using an electronic search and reviewed using meta-analytic techniques. Results-We selected 57 reports for the meta-analysis by applying the inclusion and exclusion criteria. The primary search terms used were CABG and PCI. For the Cochrane database the search terms were limited by the term clinical trial. Limiting the search parameters to the English language was applied subsequently. Citations were screened at the title and abstract level and retrieved as full reports if they were clinical studies, compared PCI with CABG, and provided information on the outcome of stroke. The full texts of all potential articles were reviewed in detail. The bibliography of retained studies was used to seek additional relevant studies. Inclusion CriteriaStudies were included if the following criteria applied: (1) comparative trials of CABG versus PCI with stent placement, (2) unprotected left main stenosis of >50% narrowing or multivessel disease, (3) a minimum of 30 patients, and (4) a minimum follow-up of 1 year. When 2 similar studies were reported from the same institution or author, the most recent publication was included in the analysis. Exclusion CriteriaStudies were excluded if any of the following criteria applied: (1) outcome of interest was not clearly reported or was impossible to extract or calculate from the published results, (2) <1-year follow-up, (3) included patients with ST-segment-elevation myocardial infarction, and (4) included patients with percutaneous transluminal coronary angioplasty without stents. Data ExtractionInformation collected included first author, year and journal of publication, study design, inclusion/exclusion criteria, definition of primary and secondary end points, number of subjects included, subjects undergoing PCI and CABG, percentage of drug-eluting stent used, study population demographics, number of diseased vessels, stenting technique, type of CABG (on pump versus off pump), left internal mammary artery graft used (single versus double), follow-up time period, rates of angiographic follow-up, antiplatelet regimen used, and primary and secondary outcomes. There was no disagreement between the 2 reviewers (G.A. and P.C.).

Sickle cell disease (SCD) is an inherited disorder in which microvascular occlusion causes complications across multiple organ systems. The precise incidence of myocardial ischemia and infarction (MI), potentially under-recognized microvascular disease-related complications, remains unknown. The absence of typical atherosclerotic lesions seen in other patients with MI suggests a microvascular mechanism of myocardial injury. Cardiac magnetic resonance (CMR) can demonstrate microvascular disease, making it an appealing modality to assess symptomatic SCD patients. We demonstrate in several dramatic instances how CMR uniquely able to depict cardiac microvascular obstruction in patients with SCD and chest pain, without which the possibility of myocardial injury would almost certainly be otherwise neglected. Much remains unknown regarding ischemic heart disease in patients with SCD including prevalence, detection and management. Further work to define evaluation and management algorithms for chest pain in SCD and to develop risk assessment tools may reduce sudden cardiac death in this population.

Introduction Endocardial catheter ablation (ECA) for atrial fibrillation (AF) has limited efficacy. Hybrid convergent procedure (HCP) with both epicardial and endocardial ablation is a novel strategy for AF treatment. In this meta‐analysis, we aimed to evaluate the efficacy and safety of HCP in AF ablation. Method We performed a comprehensive literature search for studies that evaluated the efficacy and safety of HCP compared with ECA for AF. The primary outcome was freedom of atrial arrhythmia (AA). The secondary outcome was the periprocedural complication rate. Pooled relative risk (RR) and corresponding 95% confidence intervals (CIs) were calculated using the random effects model. Results A total of eight studies, including 797 AF patients (mean age: 60.7 ± 9.8 years, 366 patients with HCP vs. 431 patients with ECA alone), were included. HCP showed a higher rate of freedom of AA compared with ECA (RR: 1.48, 95% CI: 1.13–1.94, p = .004). However, HCP was associated with higher rates of periprocedural complications (RR: 3.64, 95% CI: 2.06–6.43; p = .00001). Moreover, the HCP had a longer procedure time and postprocedural hospital stay. Conclusions Although hybrid ablation was associated with a higher success rate, this should be judged for increased periprocedural adverse events and extended hospital stay. Prospective large‐scale randomized trials are needed to validate these results.

No abstract

Introduction Catheter placement and stability are well‐known challenges in atrial fibrillation (AF) ablation. As a result, steerable sheaths (SS) were developed to improve catheter stabilization and maintain proper catheter–tissue contact. The purpose of this systematic review and meta‐analysis is to see if employing a SS influences procedure outcome. Method We performed a comprehensive literature search for studies that evaluated the efficacy and safety of SS compared to nonsteerable sheaths (NSS) in AF ablation. The primary outcome was the rate of atrial arrhythmia (AA) freedom by the time of the last follow‐up. The secondary outcomes were the procedure‐related complications and procedural characteristics. Risk ratio (RR) or the mean difference (MD) and corresponding 95% confidence intervals (CIs) were calculated using the random‐effects model. Results A total of 10 studies, including 967 AF patients (mean age: 59.2 ± 11.1 years, 516 patients managed with SS vs. 454 with NSS), were included. SS group showed a higher rate of freedom of AA compared to NSS (RR: 1.19; 95% CI 1.09–1.29; p < .001). Both techniques had similar rate for procedural‐related complication (RR: 1.09, 95% CI 0.50–2.39; p = .83). The SS strategy had a shorter procedure time (MD −10.6 [min], 95% CI −20.97, −0.20; p = .05) but comparable fluoroscopic and radiofrequency application times to the NSS group. Conclusions The SS for AF catheter ablation not only reduced the total procedure time but also significantly increased the rate of successful ablation while maintaining a similar safety profile when compared to the traditional NSS.

Background Low voltage areas (LVAs) on left atrial (LA) bipolar voltage mapping correlate with areas of fibrosis. LVAs guided substrate modification was hypothesized to improve the success rate of atrial fibrillation (AF) ablation particularly in nonparoxysmal AF population. However, randomized controlled trials (RCTs) and observational studies yielded mixed results. Methods The databases of Pubmed, EMBASE and Cochrane Central databases were searched from inception to August 2022. Relevant studies comparing LVA guided substrate modification (LVA ablation) versus conventional AF ablation (non LVA ablation) in patients with nonparoxysmal AF were identified and a meta‐analysis was performed (Graphical Abstract image). The efficacy endpoints of interest were recurrence of AF and the need for repeat ablation at 1‐year. The safety endpoint of interest was adverse events for both groups. Procedure related endpoints included total procedure time and fluoroscopy time. Results A total of 11 studies with 1597 patients were included. A significant reduction in AF recurrence at 1‐year was observed in LVA ablation versus non LVA ablation group (risk ratio [RR] 0.63 (27% vs. 36%),95% confidence interval [CI] 0.48–0.62, p < .001]. Also, redo ablation was significantly lower in LVA ablation group (RR 0.52[18% vs. 26.7%], 95% CI 0.38–0.69, p < .00133). No difference was found in the overall adverse event (RR 0.7 [4.3% vs. 5.4%], 95% CI 0.36–1.35, p = .29). Conclusion LVA guided substrate modification provides significant reduction in recurrence of all atrial arrhythmias at 1‐year compared with non LVA approaches in persistent and longstanding persistent AF population without increase in adverse events.

No abstract