Robotic Assisted Versus Manual Percutaneous Coronary Intervention: Systematic Review and Meta-Analysis

INTRODUCTION

Robotics in percutaneous coronary intervention (R-PCI) has been one such area of advancement where potential benefits may include reduced operator radiation exposure, improved outcomes, and reduced rate of adverse events. Limited data exist about the benefits of R-PCI versus conventional manual PCI (M-PCI). We appraised the latest evidence in the form of a meta-analysis of observational and retrospective studies.

METHODS

A comprehensive literature search was performed in PubMed, Embase, and Cochrane to identify relevant clinical studies. Summary effects were calculated using a DerSimonian and Laird random-effects model as the pooled odds ratio or mean differences (MDs) with 95% confidence intervals (CIs). All studies adhering to the inclusion criteria of direct comparisons between R-PCI and M-PCI were evaluated.

RESULTS

Seven studies with a total of 2230 patients were identified. There was significant decrease in the chest-level operator radiation exposure (MD = -442.32; 95% CI = -675.88 to -208.76), fluoroscopy time (MD = -1.46; 95% CI = -2.92 to 0.00), and amount of contrast used (MD = -18.28; 95% CI = -24.16 to -12.41) in the robotic group compared to the manual group. PCI time and the procedural success rate was not statistically different between the 2 groups. Clinical outcomes of major adverse cardiac events, all-cause mortality, and myocardial infarction were not different between the 2 groups.

CONCLUSIONS

Robotic PCI is associated with reduced operator radiation exposure, fluoroscopy time, and amount of contrast used. While there is a significant reduction in the procedural characteristics with robotic PCI, the clinical outcomes are not different compared to M-PCI. R-PCI is safe and effective with potential benefits to both the operator and the patient simultaneously.

Clinical outcomes and the impact of valve morphology for transcatheter aortic valve replacement in bicuspid aortic valves: A systematic review and meta-analysis

BACKGROUND

Bicuspid aortic valve (BAV) is present in approximately 0.5%-2% of the general population, causing significant aortic stenosis (AS) in 12%-37% of affected individuals. Transcatheter aortic valve replacement (TAVR) is being considered the treatment of choice in patients with symptomatic AS across all risk spectra.

AIM

Aim Our study aims to compare TAVR outcomes in patients with BAV versus tricuspid aortic valves (TAV).

METHODS

A comprehensive literature search was performed in PubMed, Web of Science, and Cochrane trials. Studies were included if they included BAV and TAV patients undergoing TAVR with quantitative data available for at least one of our predefined outcomes. Meta-analysis was performed by the random-effects model using Stata software.

RESULTS

Fifty studies of 203,288 patients were included. BAV patients had increased 30-day all-cause mortality (odds ratio [OR] = 1.23 [1.00-1.50], p = 0.05), in-hospital stroke (OR = 1.39 [1.01-1.93], p = 0.05), in-hospital and 30-day PPI (OR = 1.13 [1.00-1.27], p = 0.04; OR = 1.16 [1.04-1.13], p = 0.01) and in-hospital, 30-day and 1-year aortic regurgitation (AR) (OR = 1.48 [1.19-1.83], p < 0.01; OR = 1.79 [1.26-2.52], p < 0.01; OR = 1.64 [1.03-2.60], p = 0.04). Subgroup analysis on new-generation valves showed a reduced 1-year all-cause mortality (OR = 0.86 [CI = 0.75-0.98], p = 0.03), despite higher in-hospital and 30-day PPI (OR = 0.1.21 [1.04-1.41], p = 0.01; OR = 1.17 [1.05-1.31], p = 0.01) and in-hospital AR (OR = 1.62 [1.14-2.31], p = 0.01) in the BAV group. The quality of included studies was moderate-to-high, and only three analyses presented high heterogeneity.

CONCLUSION

TAVR is associated with comparable outcomes in patients with BAV and TAV. Careful selection of BAV cases by preprocedural assessment of valve anatomy and burden of calcification, pre- and post-procedural dilation, and implementing newer generations of valves may improve the safety and efficacy of TAVR in BAV patients.

Protease-Activated Receptor Antagonist for Reducing Cardiovascular Events - A Review on Vorapaxar

Acute Coronary Syndrome (ACS) is a term that describes pathologies related to myocardial ischemia, and is comprised of unstable angina, non-ST elevation myocardial infarction, and ST elevation myocardial infarction. Urgent management of ACS is typically necessary to prevent future morbidity and mortality. Current medical recommendations of ACS management involve use of dual antiplatelet therapy, typically with aspirin and clopidogrel. However, newer therapies are being designed and researched to improve outcomes for patients with ACS. Vorapaxar is a novel antiplatelet therapy that inhibits thrombin-mediated platelet aggregation to prevent recurrence of ischemic events. It has been Food and Drug Administration approved for reduction of thrombotic cardiovascular events in patients with a history of MI or peripheral arterial disease with concomitant use of clopidogrel and/or aspirin, based upon the findings of the TRA 2°P-TIMI 50 trial. However, Vorapaxar was also found to have a significantly increased risk of bleeding, which must be considered when administering this drug. Based upon further subgroup analysis of both the TRA 2°P-TIMI 50 trial and TRACER trial, Vorapaxar was found to be potentially beneficial in patients with peripheral artery disease, coronary artery bypass grafting, and ischemic stroke. There are current trials in progress that are further evaluating the use of Vorapaxar in those conditions, and future research and trials are necessary to fully determine the utility of this drug.

Eliminating bradyarrhythmias after orthotopic heart transplantation

BACKGROUND

Bradycardia and sinus node dysfunction are common causes of early postoperative morbidity in orthotopic heart transplant recipients and frequently require the use of chronotropic drugs or permanent pacemakers. Several causes have been postulated, including surgical trauma to the sinus node and its blood supply. We sought to eliminate sinus node dysfunction and postoperative bradyarrhythmias by altering the orthotopic heart transplantation technique.

METHODS AND RESULTS

Seventy orthotopic heart transplant recipients underwent electrophysiological testing of sinus node function a mean of 9 +/- 3 days after surgery. Standard (atrial anastomosis) orthotopic heart transplantation was performed in 33 patients; total (bicaval anastomosis) heart transplantation was performed in 37 patients. Abnormalities of sinus node function were present in 14 of 33 patients (42%) undergoing standard orthotopic heart transplantation compared with 2 of 37 patients arrhythmia (5%) in whom total heart transplantation was performed (P < .005). The resting sinus heart rate of patients with a normal sinus rhythm was also significantly higher in the total heart transplantation group (90 +/- 12 versus 83 +/- 14 bpm, P < .05). Coronary angiography was performed before discharge in 63 patients. Eleven were found to have an abnormal sinoatrial nodal artery, and 7 of these patients also had evidence of sinus node dysfunction (P < .005).

CONCLUSIONS

Surgical trauma to the donor sinus node and/or its blood supply is a significant cause of sinus node dysfunction in the orthotopic heart transplant recipient. By use of a bicaval anastomotic technique, the incidence of and need for treatment of postoperative bradyarrhythmias can be significantly reduced.