Direct oral anti-coagulants in patients with atrial fibrillation and bioprosthetic valve: a meta-analysis of randomized controlled trials

Background

Patients with atrial fibrillation (AF) and bioprosthetic valve (BPV) are at increased risk for thromboembolic events and require anticoagulation. However, management strategies for these patients have not yet been well addressed by randomized controlled trials (RCTs). For years, warfarin was the only available oral anticoagulant, but this changed with the introduction of the direct oral anticoagulants (DOACs). However, there is no clear consensus about indications for DOACs in these patients due to the lack of prospective trials.

Purpose

The objective of this meta-analysis is to show the efficacy of DOACs in AF patients with BPV in terms of composite cardiovascular outcomes. In addition, the study aims to show the safety of DOACs in terms of major bleeding.

Methods

A comprehensive literature search for randomized controlled trials (RCTs) was performed in MEDLINE, PubMed and Clinicaltrials.gov in human subjects done within 2010 to 2020. Results were pooled using fixed effects. The primary outcome was a composite cardiovascular outcome from all included studies, which include death, major bleeding and major adverse cardiac events (stroke, transient ischemic attack, valve thrombosis, myocardial infarction, systemic embolism, and hospitalization for heart failure). Secondary outcomes include all-cause stroke or systemic embolism, major bleeding, death from cardiovascular cause and all-cause death.

Results

Four RCTs were included in the meta-analysis. DOACs used were Apixaban, Dabigatran, Edoxaban and Rivaroxaban. In patients with AF and BPV, DOACs performed similarly with warfarin in terms of composite cardiovascular outcome (RR 1.01, 95% CI 0.86–1.19, P=0.88, I2=0%). On the other hand, DOACs performed better than warfarin in reduction of all cause stroke and systemic embolism (RR 0.48, 95% CI 0.27–0.87, P=0.01). There is non-statistically significant risk reduction for major bleeding (RR 0.81, 95% CI 0.56–1.17, P=0.26, I2=0%) and other secondary outcomes such as death from cardiovascular causes (RR 0.79, 95% CI 0.39–1.60, P=0.51, I2=0%) and all cause death (RR 0.94, 95% CI 0.55–1.62, P=0.71, I2=0%) showing similar outcomes with NOACs and warfarin.

Conclusion

DOACs compared with warfarin are similar in terms of composite cardiovascular outcome, major bleeding and death. However, DOACs performed better than warfarin in reducing all-cause stroke/systemic embolism and can be an alternative for oral anticoagulation in patients with AF and BPV.

Funding Acknowledgement

Type of funding sources: None. Forest plot for all-cause stroke or systemic embolism

European Society of Endodontology position statement: Use of cone beam computed tomography in Endodontics: European Society of Endodontology (ESE) developed by

This Position Statement represents a consensus of an expert committee convened by the European Society of Endodontology (ESE) on the use of Cone Beam Computed Tomography (CBCT) in Endodontics. This paper is an update of the ESE CBCT position statement which was published in 2014 (European Society of Endodontology 2014, https://doi.org/10.1111/iej.12267). Recent review articles provide more detailed background information and the basis for this position statement. It is intended that this position statement will be updated at least every 4-5 years to keep abreast of relevant research. The aim of this paper is to provide clinicians with evidence-based guidance on the application of CBCT in Endodontics. Since 2014, there has been an increase in the number of clinical studies confirming the positive impact of CBCT on treatment planning, decision-making when reviewing cases and reduced practitioner stress levels.

Cone beam computed tomography in Endodontics - a review of the literature

The use of cone beam computed tomography (CBCT) in the diagnosis and/or management of endodontic problems is increasing and is reflected in the exponential rise in publications on this topic in the last two decades. The aim of this paper is to: (i) Review current literature on the endodontic applications of CBCT; (ii) Based on current evidence make recommendations for the use of CBCT in Endodontics; (iii) Highlight the areas in which more research is required.

European Society of Endodontology position statement: the use of CBCT in endodontics

This Position Statement represents a consensus of an expert committee convened by the European Society of Endodontology (ESE) on the use of Cone Beam Computed Tomography (CBCT). The statement is based on the current scientific evidence, and provides the clinician with evidence-based criteria on when to use CBCT in Endodontics. Given the dynamic and changing nature of research, development of new devices and clinical practice relating to CBCT, this Position Statement will be updated within 3 years, or before that time should new evidence become available.

Comparative accuracy of the Clearing Technique, CBCT and Micro-CT methods in studying the mesial root canal configuration of mandibular first molars

AIMS

To compare the accuracy of the clearing technique and cone beam computed tomography (CBCT) in the assessment of root canal configurations using micro-computed tomography (micro-CT) imaging system as the reference standard.

METHODOLOGY

Thirty-two mesial roots of mandibular first molars, selected on the basis of micro-CT scans (voxel size: 19.6 μm) and presenting several canal configurations, were evaluated using 2 CBCT scanners (voxels sizes: 120 μm and 150 μm) followed by the clearing technique. Two examiners analysed the data from each method and classified the anatomical configuration of the mesial canal according to Vertucci's system. Data were compared using Fisher's exact and chi-square tests. Reliability for each assessment was verified by the kappa test, and significance level was set at 5%.

RESULTS

Kappa value indicated a high level of agreement between the examiners. Detection of type I configurations was significantly lower in cleared teeth (P < 0.05), whilst type II root canals were detected in all specimens by both tests (P > 0.05). In mesial roots with variable anatomical configurations, CBCT and the clearing method were significantly less accurate than the reference standard (P < 0.05).

CONCLUSION

Within the tooth population studied, accuracy of identifying mesial root canal configuration was influenced greatly by the evaluation method and the type of anatomy. Detection of type I configurations in cleared teeth was significantly lower, whilst type II configurations were detected in all specimens by both methods. In mesial roots with variable anatomical configurations, neither CBCT nor clearing methods were accurate for detecting the actual root canal anatomy.

Managing severe curvature of radix entomolaris: three-dimensional analysis with cone beam computed tomography

AIM

To present a case of a mandibular first molar with an additional distolingual root [radix entomolaris (RE)] and to discuss the use of cone beam computed tomography (CBCT) for its identification and management during root canal treatment.

SUMMARY

A 52-year-old Caucasian woman was referred for root canal treatment of the right mandibular first molar (tooth 46). After clinical and radiographic examination, a symptomatic irreversible pulpitis was diagnosed. Three periapical radiographs with different horizontal angulations revealed the presence of an additional distolingual root. This extra root, termed RE, has an incidence of <5% in the Caucasian population. A CBCT examination was also taken, which revealed a severe root canal curvature, especially in the middle third, of this supernumerary root. CBCT provided more accurate information in terms of RE inclination and root canal curvature before commencing root canal treatment. The conventional access opening was modified into a more trapezoidal cavity, and five root canals were found. All canals were instrumented with new nickel-titanium (NiTi) files to reduce the risk of fractured instruments. After preparation, the root canals were filled using thermoplastified techniques. The 1-year follow-up periapical radiographs and CBCT images revealed a continuous periodontal space with no signs of apical periodontitis.

KEY LEARNING POINTS

• Cone beam computed tomography imaging is useful in identifying the root canal system and the surrounding structures. • An accurate detection of supernumerary roots, such as RE, can avoid complications during and after root canal treatment. • The analysis of root canal curvature is important because instrument fracture has been linked to angle and radius of curvature. • The use of new instruments can reduce the incidence of instrument fracture.