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Thenpandiyan AA, Ling RR, Grignani R, Ling MR, Thenpandiyan AA, Tai BC, Somani J, Ramanathan K, Quek SC. Myopericarditis following COVID-19 vaccination in children: a systematic review and meta-analysis. Singapore Med J 2024:00077293-990000000-00141. [PMID: 39229736 DOI: 10.4103/singaporemedj.smj-2023-081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 12/10/2023] [Indexed: 09/05/2024]
Abstract
INTRODUCTION Myopericarditis is a rare but serious coronavirus disease 2019 (COVID-19) vaccine-related adverse event primarily affecting adolescents. Given recent approvals for childhood vaccination, we performed a meta-analysis investigating myopericarditis following messenger ribonucleic acid COVID-19 vaccination in children aged <19 years, focusing on its overall risk and high-risk subgroups. METHODS We searched MEDLINE via PubMed, Embase and Scopus from inception to 1 August 2022 for observational studies reporting myopericarditis in temporal relation to paediatric COVID-19 vaccination. We conducted random-effects meta-analyses (DerSimonian and Laird) on myopericarditis (primary outcome), myocarditis and pericarditis (secondary outcomes). RESULTS Of 2115 studies, 12 (59,229,160 doses) studies were included in our analysis. There were 19.8 (95% confidence interval [CI]: 10.4-37.6) myopericarditis cases reported per million doses in children, compared to 23.7 (95% CI: 12.2-46.1) cases in adults (eight studies, 376,899,888 doses; P = 0.70). Compared to the second dose (34.4, 95% CI: 15.2-77.8), the number of cases post-first dose was significantly lower (9.1, 95% CI: 4.4-18.8; P = 0.017), while the number of cases post-third dose was not higher than that of post-second dose (28.4, 95% CI: 10.4-61.8; P = 0.57, global P = 0.031). Males were at higher risk of myopericarditis (67.4, 95% CI: 36.5-124.5) than females (6.9, 95% CI: 3.1-15.3; P < 0.0001). Finally, the number of cases was higher (overall P < 0.0001) among children aged ≥12 years (39.9, 95% CI: 24.1-66.0) than among children aged <12 years (3.0, 95% CI: 2.3-3.9). CONCLUSION Our meta-analysis showed 19.8 cases of myopericarditis per million doses among children, not significantly different from that of adults. Higher risk subgroups included adolescents, males, and those receiving their second dose of vaccination.
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Affiliation(s)
| | - Ryan Ruiyang Ling
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Robert Grignani
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Paediatric Cardiology, Department of Paediatrics, Khoo Teck Puat - National University Children's Medical Institute, National University Hospital, Singapore
| | - Megan Ruien Ling
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Bee Choo Tai
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Jyoti Somani
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Infectious Diseases, Department of Medicine, National University Hospital, Singapore
| | - Kollengode Ramanathan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Singapore
| | - Swee Chye Quek
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Paediatric Cardiology, Department of Paediatrics, Khoo Teck Puat - National University Children's Medical Institute, National University Hospital, Singapore
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Hashim SW, Collazo S, Greco A, Mather JF, McKay RG. Half-dose direct oral anticoagulation versus warfarin for atrial fibrillation following cardiac surgery. THE JOURNAL OF CARDIOVASCULAR SURGERY 2024; 65:169-176. [PMID: 38470020 DOI: 10.23736/s0021-9509.24.12815-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/13/2024]
Abstract
BACKGROUND Optimal anticoagulation strategies have not been defined for patients with atrial fibrillation following cardiac surgery. METHODS From a total cohort of 228 patients with pre-existing or new onset atrial fibrillation following coronary artery bypass grafting and/or valve surgery, we compared in-hospital and 30-day outcomes in 119 patients treated with low-dose aspirin and a half-dose direct oral anticoagulant (DOAC) versus 109 treated with low-dose aspirin and warfarin. RESULTS DOAC patients were older (73.1±7.0 vs. 68.7±11.4 years, P<0.001) and had a lower incidence of preoperative atrial fibrillation (37 [31.1%] vs. 69 [63.3%], P<0.001). Otherwise, the two cohorts were well matched for baseline demographics, cardiovascular risk factors, comorbidities, prior cardiac history and STS Risk Score. In comparison to Warfarin patients, DOAC patients had a shorter length of post-surgical stay (6 [5-8] vs. 7 [5-10] days, P=0.037). The two cohorts, however, had a similar incidence of stroke, transient ischemic attack, reoperation for bleeding and postoperative blood bank product usage. Follow-up 30-day outcomes did not differ between the two groups with respect to mortality (0 [0.0%] vs. 0 [0.0%], P=1.000) and hospital readmission (16 [13.4%] vs. 14 [12.8%], P=0.893), although two DOAC patients required drainage of sanguineous pericardial effusions. CONCLUSIONS In comparison to warfarin, half-dose DOAC anticoagulation in patients with atrial fibrillation following cardiac surgery is associated with a shorter postoperative length of stay, without a significant increase in stroke/transient ischemic attack, reoperation for bleeding or postoperative blood product transfusion. Follow-up echocardiography in anticoagulated patients is recommended to rule out significant sanguineous pericardial effusions in the early postoperative period following hospital discharge.
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Affiliation(s)
- Sabet W Hashim
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | - Susan Collazo
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | | | - Jeff F Mather
- Clinical Research Center, Hartford Hospital, Hartford, CT, USA
| | - Raymond G McKay
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA -
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Chatterjee S, Ad N, Badhwar V, Gillinov AM, Alexander JH, Moon MR. Anticoagulation for atrial fibrillation after cardiac surgery: Do guidelines reflect the evidence? J Thorac Cardiovasc Surg 2024; 167:694-700. [PMID: 37037415 DOI: 10.1016/j.jtcvs.2023.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 03/25/2023] [Indexed: 04/12/2023]
Affiliation(s)
- Subhasis Chatterjee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Tex.
| | - Niv Ad
- Division of Cardiac Surgery, White Oak Medical Center, Adventist HealthCare, University of Maryland, Takoma Park, Md
| | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WVa
| | - A Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - John H Alexander
- Division of Cardiology, Duke University School of Medicine & Duke Clinical Research Institute, Durham, NC
| | - Marc R Moon
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Tex
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Chiew JK, Low CJW, Zeng K, Goh ZJ, Ling RR, Chen Y, Ti LK, Ramanathan K. Thoracic Epidural Anesthesia in Cardiac Surgery: A Systematic Review, Meta-Analysis, and Trial Sequential Analysis of Randomized Controlled Trials. Anesth Analg 2023; 137:587-600. [PMID: 37220070 DOI: 10.1213/ane.0000000000006532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
BACKGROUND Research on fast-track recovery protocols postulates that thoracic epidural anesthesia (TEA) in cardiac surgery contributes to improved postoperative outcomes. However, concerns about TEA's safety hinder its widespread usage. We conducted a systematic review and meta-analysis to assess the benefits and risks of TEA in cardiac surgery. METHODS We searched 4 databases for randomized controlled trials (RCTs) assessing the use of TEA against only general anesthesia (GA) in adults undergoing cardiac surgery, up till June 4, 2022. We conducted random-effects meta-analyses, evaluated risk of bias using the Cochrane Risk-of-Bias 2 tool, and rated certainty of evidence via the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach. Primary outcomes were intensive care unit (ICU), hospital length of stay, extubation time (ET), and mortality. Other outcomes included postoperative complications. Trial sequential analysis (TSA) was conducted on all outcomes to elicit statistical and clinical benefit. RESULTS Our meta-analysis included 51 RCTs (2112 TEA patients and 2220 GA patients). TEA significantly reduced ICU length of stay (-6.9 hours; 95% confidence interval [CI], -12.5 to -1.2; P = .018), hospital length of stay (-0.8 days; 95% CI, -1.1 to -0.4; P < .0001), and ET (-2.9 hours; 95% CI, -3.7 to -2.0; P < .0001). However, we found no significant change in mortality. TSA found that the cumulative Z-curve passed the TSA-adjusted boundary for ICU length of stay, hospital length of stay, and ET, suggesting a clinical benefit. TEA also significantly reduced pain scores, pooled pulmonary complications, transfusion requirements, delirium, and arrhythmia, without additional complications such as epidural hematomas, of which the risk was estimated to be <0.14%. CONCLUSIONS TEA reduces ICU and hospital length of stay, and postoperative complications in patients undergoing cardiac surgery with minimal reported complications such as epidural hematomas. These findings favor the use of TEA in cardiac surgery and warrant consideration for use in cardiac surgeries worldwide.
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Affiliation(s)
- John Keong Chiew
- From the Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
| | - Christopher Jer Wei Low
- From the Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
| | - Kieran Zeng
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Zhi Jie Goh
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Ryan Ruiyang Ling
- From the Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
| | - Ying Chen
- From the Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
- Agency of Science, Technology and Research, Singapore
| | - Lian Kah Ti
- From the Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
- Department of Anaesthesia, National University Hospital, National University Health System, Singapore
| | - Kollengode Ramanathan
- From the Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
- Department of Cardiac, Thoracic and Vascular Surgery, Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, National University Health System, Singapore
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Meenashi Sundaram D, Vasavada AM, Ravindra C, Rengan V, Meenashi Sundaram P. The Management of Postoperative Atrial Fibrillation (POAF): A Systematic Review. Cureus 2023; 15:e42880. [PMID: 37664333 PMCID: PMC10474445 DOI: 10.7759/cureus.42880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2023] [Indexed: 09/05/2023] Open
Abstract
Postoperative atrial fibrillation (POAF) refers to new-onset atrial fibrillation (AF) that develops after surgery and is associated with an increased risk of mortality and thromboembolic events. The optimal management and treatment methods for POAF complications are not yet fully established. This systematic review aimed to evaluate the various treatment and management approaches currently available in terms of their suitability, efficacy, and side effects in handling POAF incidence post-surgery. Google Scholar and PubMed electronic databases were searched extensively for relevant articles examining the various management techniques currently used to manage POAF and published between 2018 and 2023. Data were collected on the type of surgery the patients underwent, POAF definition period, intervention, and outcome of interest. Following a systematic assessment guided by the inclusion criteria, 10 of the 579 studies retrieved were included in this study, and 293,417 POAF cases were recorded. Three of these studies used different rhythm control and rate control treatments to manage POAF cases, while seven studies used various anticoagulation therapies to manage POAF incidence. For asymptomatic patients within one to three days of surgery, rate control is sufficient to manage POAF, and routine rhythm control is not needed; rhythm control should be reserved for patients who develop complications such as hemodynamic instability. Anticoagulation was performed in patients whose POAF exceeded four days after surgery. Anticoagulation was associated with an increased risk of mortality, stroke, thromboembolic events, and major bleeding in patients who underwent coronary artery bypass graft (CABG) surgery. In contrast, in a few other studies, anticoagulation treatment led to improved outcomes in patients who developed POAF. A wide range of management methods are available for POAF after different types of surgery. However, there is only limited evidence to guide the clinical practice. The data available are mainly retrospective and insufficient to accurately evaluate the efficacy of the various management methods available for POAF. Future research should make efforts to standardize the treatment for this condition.
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