Thirty-days versus standard duration of dual antiplatelet treatment after percutaneous coronary interventions: a systematic review and meta-analysis

Background/Introduction

Abbreviation of duration of dual antiplatelet therapy (DAPT) (one or three months) has been recently proposed, especially for high-bleeding risk patients, after percutaneous coronary intervention (PCI) with drug-eluting stent (DES).

Purpose

The purpose of the specific systematic review and meta-analysis was to compare 30-days versus longer duration (≥3 months) of DAPT in patients undergoing PCI with DES, focusing on ischemic and bleeding events.

Methods

Three databases were screened for eligible randomized-control trials. The primary endpoint was the incidence of net adverse clinical events (NACE), as they were defined in each trial. Secondary endpoints consisted of major adverse cardiovascular events (MACE), all-cause and cardiovascular mortality, myocardial infraction, stroke, stent-thrombosis, repeat revascularization and major bleeding.

Results

We included 4 RCTs with a total of 26,576 patients; 13,282 patients were grouped in 30-days DAPT, while the remaining 13,294 were allocated in longer period of DAPT. One-month of DAPT did not significantly reduce NACE (odds ratio [OR]: 0.87, 95% confidence intervals [Cl]: 0.74–1.03); however major bleedings were significantly reduced by 22% (OR: 0.78, 95% Cl: 0.65–0.94). Mortality or ischemic events (stroke, myocardial infraction, revascularization and stent thrombosis) were not affected.

Conclusions

Thirty-days DAPT did not significantly affect NACEs. However, odds of major bleedings were reduced significantly by 22%. Mortality and ischemic events did not differ between the two arms. Thus, 30-days DAPT could be considered as a safe and feasible after PCI with DES in selected patients, especially those in high-bleeding risk. Forthcoming RCTs could shed light on the optimal duration of DAPT.

Funding Acknowledgement

Type of funding sources: None.

Phlegmonous Gastritis and Streptoccocal Toxic Shock Syndrome: An Almost Lethal Combination

We report a case of phlegmonous gastritis in a 70-year-old woman without any predisposing factors, presenting with high fever, epigastric pain, and vomiting complicated by septic shock and multi-organ failure. The ultrasound and the computed tomography scan showed thickening of the stomach wall. Streptococcus pyogenes was isolated in the blood, thereby establishing the diagnosis of streptococcal toxic shock syndrome. An exploratory laparotomy excluded the need for a gastrectomy, and the patient was successfully treated with antibiotics. A short review of phlegmonous gastritis caused by S. pyogenes during the last 12 years is also presented. How to cite this article: Elisabeth P, Cornelia M, Athinna S, Anastasia A, Apostolos A, George D. Phlegmonous Gastritis and Streptoccocal Toxic Shock Syndrome: An Almost Lethal Combination. Indian J Crit Care Med 2021;25(10):1197-1200.

TAVI for low-flow, low-gradient severe aortic stenosis: impact on outcome

Background

Several factors have been identified as predictors of events after transcatheter aortic valve implantation (TAVI) but the impact of transaortic flow (F) and mean transaortic gradient (MG) upon outcomes is controversial. This study aimed to clarify the prognostic role of low FL and low MG after TAVI.

Methods

Patients with severe and symptomatic aortic stenosis [effective orifice area (EOA) ≤1cm2], referred for TAVR at our institution were consecutively enrolled. Given the aim of this analysis, patients were divided according to F and MG into four groups: 1) LF-LG Patients with low flow (SVi <35ml/m2) and low mean gradient (MG <40mmHg), 2) NF-LG Patients with normal flow (SVi ≥35ml/m2) and low mean gradient (MG <40mmHg), 3) LF-HG Patients with low flow (SVi <35ml/m2) and high mean gradient (MG ≥40mmHg) and 4) NF-HG patients with normal flow (SVi ≥35ml/m2) and high mean gradient (MG ≥40mmHg). Prospectively collected demographic, laboratory and echocardiographic data were retrospectively analyzed. One-year outcomes were compared between the 4 groups of patients. Primary clinical endpoint was all-cause mortality at long term follow up, as defined by the criteria proposed by the Valve Academic Research Consortium2.

Results

In total 255 patients undergoing TAVI at our institution were included in our study: 35 (13.7%) patients with LF-LG, 17 (6.7%) with NF-LG, 108 (42.4%) with LF-HG and 95 (37.3%) with NF-HG. There was a statistically significant difference in gender distribution between the groups with most females being represented in the NF-HG group (64.2%) vs the LF-LG (31.4%), the NF-LG (47.1%) or the LF-HG group (50.9%) (p=0.008). Moreover, LF-LG patients were younger than NF-LG, LF-HG or NF-HG patients (ANOVA, p=0.037). There was a greater prevalence of prior myocardial infarction (MI) in the LF-LG group (34.5%) vs 20% in the NF-LG, 16.1% in the LF-HG and 20.2% in the NF-HG group (p=0.005). At 1 year follow up there were no statistically significant differences in major vascular complication, major bleeding complication or permanent pacemaker implantation rates between the groups, (all p>0.05). At a median follow up of 36 months IQR (17, 56) all-cause mortality was significantly higher in the LF-LG group as opposed to the NF-LG, LF-HG and NF-HG groups (77.41% vs 60% vs 55.67% vs 46.15% respectively, p=0.005). These results were confirmed by multivariate logistic regression analysis, as the combination of low flow and low mean gradient emerged as the strongest long term all cause mortality predictor (HR: 5.39, 95% confidence intervals: 1.72–16.83; p=0.004)

Conclusion

Combination of low flow and low mean transaortic gradient portends a worse prognosis after TAVI.

Funding Acknowledgement

Type of funding sources: None.

Impact of significant preprocedural mitral regurgitation on mortality after transcatheter aortic valve implantation

Background

Mitral regurgitation (MR) is commonly encountered in patients with severe aortic stenosis scheduled for transcatheter aortic valve implantation (TAVI). The presence of significant pre-procedural MR, however, has not been accounted in pivotal trials of TAVI and data regarding its independent impact on outcome are contradictory.

Methods

Patients with severe and symptomatic aortic stenosis [effective orifice area (EOA) ≤1cm2] referred for TAVI at our institution were consecutively enrolled. Prospectively collected demographic, laboratory and echocardiographic data were retrospectively analysed. Patients were stratified into two groups according to MR severity: ≤ grade 1 were defined as non-significant and ≥ grade 2 as significant. Change in MR was determined by comparison between baseline and 30-day echocardiogram. Primary clinical endpoint was all-cause mortality, as defined by the criteria proposed by the Valve Academic Research Consortium2.

Results

A total of 331 consecutive patients were enrolled in the study: 247 (74.6%) had non-significant MR and 84 (25.4%) patients had significant MR at baseline. Patients with significant pre-procedural MR had lower baseline ejection fraction (47.7±10.4% versus 51.2±8.4%, p=0.002), higher pulmonary artery systolic pressure (52±14.3mmHg versus 42.5±11.1mmHg, p<0.0001) and higher rates of moderate or severe tricuspid regurgitation (TR) (50% versus 19.4%) compared to patients with non-significant MR. Of all patients, mitral regurgitation improved in 9.5%, remained the same in 83.9%, and worsened in 6.6% 30 days after TAVR. In a multivariable analysis, pre-procedural TR severity was predictor of improved mitral regurgitation [OR 3.003,(95% CI 1.216–7.417, p=0.017)].

The primary clinical end point occurred in 44.7% of all patients during a follow-up period of 36.6.±25.9 months. Patients with significant pre-procedural MR had significantly higher rates of all-cause mortality compared to patients with non-significant (54.7% and 41.3%, respectively; log rank p=0.015). Performing a multivariable analysis demonstrated that preprocedural MR severity could independently predict cumulative mortality [OR 0.480, (95% CI 0.247–0.932, p=0.03)].

Conclusion

Significant pre-procedural MR is common in patients undergoing TAVI and is associated with increased all-cause mortality. TAVI is associated with a significant improvement in MR, especially in severe types. These data provide new insights in the crucial role of mitral regurgitation in the risk assessment of TAVI candidates.

Funding Acknowledgement

Type of funding sources: None.

Effect of concomitant atrioventricular valve regurgitation on the outcome after transcatheter aortic-valve implantation

Background

Many patients undergoing transcatheter aortic valve implantation (TAVI) have concomitant mitral regurgitation (MR) of moderate grade or more. The impact of coexistent tricuspid regurgitation (TR) remains to be determined.

Methods

Patients with severe and symptomatic aortic stenosis [effective orifice area (EOA)≤1cm2] referred for TAVI at our institution were consecutively enrolled. Prospectively collected demographic, laboratory and echocardiographic data were retrospectively analysed. Patients were divided into 4 groups according to MR and TR severity pre-procedurally: no/mild MR and TR, moderate/severe MR, moderate/severe TR, moderate/severe MR and TR. Primary clinical endpoint was all-cause mortality, as defined by the criteria proposed by the Valve Academic Research Consortium2.

Results

A total of 244 consecutive patients were enrolled in the study: 148 (60.7%) patients no/mild MR and TR, 32 (13.1%) moderate/severe MR, 35 (14.3%) moderate/severe TR, 29 (11.9%) moderate/severe MR and TR pre-procedurally. There was significant difference in pre-procedural pulmonary artery systolic pressure (PASP) among groups (no/mild MR and TR: 40.8±10 mmHg, moderate/severe MR: 46.6±11.2 mmHg, moderate/severe TR: 49.9±13mmHg, moderate/severe MR and TR: 59.8±15.2mmHg, p<0.0001). The Kaplan–Meier curves for 2 year mortality showed that the severity of TR was associated with poor survival. Interestingly, patients with moderate/severe MR and TR had the worse survival (no/mild MR and TR (91.2%), moderate/severe MR (78.1%), moderate/severe TR (62.9%), moderate/severe MR and TR (62.1%), p<0.0001).

Conclusion

The presence of concomitant moderate or severe mitral and tricuspid valve regurgitation was associated with the higher mortality. This suggests that a thorough evaluation of the mechanisms underlying concomitant mitral and tricuspid valve regurgitation should be performed to determine the best strategy for avoiding TAVI-related futility.

Funding Acknowledgement

Type of funding sources: None.

Success stories about severe pneumonia caused by Panton-Valentine leucocidin-producing Staphylococcus aureus

We describe three cases of community-acquired necrotizing pneumonia which were caused by Panton-Valentine leucocidin-producing strains of Staphylococcus aureus (one of them methicillin sensitive). All cases were successfully treated without any sequelae for the patients due to the prompt initiation of adequate antimicrobial therapy. High suspicion toward this fatal pathogen was the key to the successful outcome of the patients.