Risultati per: Infezione da Helicobacter pylori: review

Circulation, Volume 146, Issue Suppl_1, Page A12314-A12314, November 8, 2022. Introduction:Chronic total occlusion (CTO) percutaneous intervention (PCI) is an evolving challenge within interventional cardiology. Anticoagulation during percutaneous intervention remains part of the standard of care for patients undergoing PCI to prevent thrombotic complications peri-procedurally. Unfractionated heparin (UFH) is a commonly used for CTO PCI-related anticoagulation. However, bivalirudin (BV), a synthetic, reversible, direct thrombin inhibitor, has been utilized as an alternative to UFH in CTO patients undergoing PCI. This meta-analysis aims to investigate the efficacy and safety of bivalirudin versus UFH for CTO PCI.Methods:We performed a comprehensive literature search using PubMed, Embase, and Cochrane Library databases through May 2022 for all studies evaluating efficacy and safety of bivalirudin versus UFH in CTO patients undergoing PCI. The primary outcome was mortality. Secondary outcomes were major adverse cardiac events (MACE), major bleeding events, peri-procedure myocardial infarction (MI), in-stent thrombosis, and unplanned revascularization. Pooled risk ratio (RR) and 95% confidence intervals (CIs) were obtained by the Mantel-Haenszel method within a random-effects model. Heterogeneity was assessed by I2 statistic.Results:A total of 5 studies containing 1347 patients with CTO undergoing PCI on anticoagulation (631 BV versus 716 UFH) were included. No significant difference existed between BV and UFH regarding mortality [RR: 0.54 (95% CI: 0.19-1.56); P 0.26 , I2 0%]. Major bleeding events were significantly lower in BV compared with UFH [RR: 0.33 (95% CI: 0.19-0.66); P 0.001, I2 0%]. MACE [RR: 0.75 (95% CI: 0.55-1.00); P 0.05, I2 2%], peri-procedure MI [RR: 0.80 (95% CI: 0.56-1.15); P 0.24, I2 0%], in-stent thrombosis [RR: 0.68 (95% CI: 0.19-2.39); P 0.55, I2 17%] and unplanned revascularization [OR: 0.77 (95% CI: 0.29-2.07); P 0.61, I2 0%] were similar between the two groups.Conclusions:BV seems to be safer than UFH in preventing major bleeding in anticoagulated patients with CTO undergoing PCI; there is no significant difference between groups in terms of mortality, MACE, peri-procedure MI, in-stent thrombosis, or unplanned revascularization. Future randomized controlled trials are needed.

Circulation, Volume 146, Issue Suppl_1, Page A11186-A11186, November 8, 2022. Introduction:The association of the COVID-19 vaccination with myocarditis has been reported in adolescents. However, evidence of myocarditis after COVID-19 vaccination among adolescents is scarce compared to adults. We aimed to investigate the clinical features and outcomes of COVID-19 mRNA vaccination-related myocarditis in adolescents.Methods:PubMed and EMBASE were searched through April 2022 to investigate the characteristics of vaccine-associated myocarditis in adolescent patients (aged 12-20 years) through observational studies, case series, and correspondence according to PRISMA guidelines. Data regarding patient characteristics, the type, and dose of the vaccine, laboratory data, imaging studies, mortality, and treatments were extracted from each article. One-group meta-analysis in a random-effects model was performed.Results:22 observational studies were identified, including 861 cases of vaccine-associated myocarditis. The mean age was 16.0 (95%CI, 15.5-16.5), and the male was predominant at 90.8%. Three-quarters of myocarditis occurred after the second dose (78.2%, 95% CI, 62.4- 94.0). The incident rate was higher after the second dose (12.7 -118.7 per million persons) than the first dose (0.6-10.0 per million persons). Chest pain (85.2%) was the common presenting symptom. Although 16.0% of patients (51/302) had left ventricular (LV) systolic dysfunction (LV ejection fraction [EF] < 55%), most of the cases (40/289) were mildly reduced LVEF as 45-54% (12.0% of total patients). Interestingly, cardiac magnetic resonance imaging revealed late gadolinium enhancement in 80.5% (95% CI, 65.7-95.2) of the cases. Overall, 92.8% of patients required hospitalization, and 14.7% required intensive care unit admission. However, no in-hospital mortality was observed (0/230), and the length of stay at the hospital was less than 5 days.Conclusions:This systematic review and meta-analysis demonstrate a low incident rate and largely favorable outcomes of COVID-19 vaccine-associated myocarditis in adolescents. Our findings would help better understand myocarditis following COVID-19 mRNA vaccination among adolescents and decision-making for parents with vaccine hesitancy.

Circulation, Volume 146, Issue Suppl_1, Page A10535-A10535, November 8, 2022. Introduction:The association of combined low-risk lifestyle behaviors (LRLBs) with cardiovascular disease (CVD) and all-cause mortality has not been systematically quantified.Objective:We undertook a systematic review and dose-response meta-analysis to assess the association of combined LRLBs with CVD and all-cause mortality.Methods:MEDLINE, EMBASE and Cochrane were searched up to December 29, 2021. Prospective cohort studies reporting the association between a minimum of 3 combined LRLBs (including healthy diet) with CVD, coronary heart disease (CHD) and stroke incidence and mortality were included. Independent reviewers extracted data and assessed study quality. Highest vs. lowest LRLB score was pooled using random effects. Heterogeneity was assessed (Cochran Q) and quantified (I2). Global dose response meta-analysis (DRM) for maximum adherence was estimated using one-stage linear mixed model. The certainty of the evidence was assessed using GRADE.Results:116 cohort comparisons (n=9,775,191) involving 382,922 cases were included. Comparing highest with lowest adherence LRLBs were associated with lower risk of CHD incidence (RR, 0.29 [95% CI, 0.21, 0.42]), stroke incidence (0.56 [0.50, 0.62]), CVD incidence (0.47 [0.37, 0.58]), CHD mortality (0.32 [0.25, 0.41]), stroke mortality (0.37 [0.30, 0.46]), CVD mortality (0.41 [0.34, 0.49]) and all-cause mortality (0.46 [0.41 to 0.52]). DRM analysis showed a linear association between LRLBs and all outcomes reaching a global DRM between 59-76% protection. LRLBs were defined with variable ranges as a healthy body weight (body mass index median), regular physical activity (1/week to >30 minutes/day), smoking cessation (never smoked or smoking cessation), light alcohol intake (≤30g/day) and adequate sleep (5.5-9 hours). The certainty of the evidence was graded as moderate to high owing to downgrades for inconsistency and/or upgrades for a large magnitude of effect and significant dose-response gradient.Conclusions:Pooled analyses show that the combination of LRLBs was associated with a substantial lower risk of CVD outcomes and all-cause mortality. The available evidence provides a very good indication of the benefit of combined LRLBs.

Circulation, Volume 146, Issue Suppl_1, Page A10564-A10564, November 8, 2022. Objectives:To investigate the utility of AngioVac-assisted vegetation debulking (AVD) in right sided infective endocarditis (RSIE)Background:AngioVac is a vacuum-based device that was approved in 2014 for the percutaneous removal of undesirable materials from the intravascular system. Although there are multiple reports on the use of the AngioVac device to aspirate right-sided heart chamber thrombi, data on its use to treat RSIE is limited.Methods:We performed a comprehensive literature search for studies that evaluated the utility of AVD. The primary outcomes of our study were the procedural success, defined as the ability of AngioVac to produce residual vegetation size

Circulation, Volume 146, Issue Suppl_1, Page A14258-A14258, November 8, 2022. Introduction:: Cardiac resynchronization therapy (CRT) using a biventricular pacemaker (BVP) reduced mortality and rehospitalizations in patients with symptomatic heart failure (HF) with a left ventricular ejection fraction (LVEF) of less than 35% and concomitant left bundle branch block. However, 10-30% of BVP patients fail to show a clinical or echocardiographic response. Recently left bundle branch pacing (LBBP) has been studied as a more physiological alternative to BVP. The aim of this study is to summarize the available evidence on LBBP.Hypothesis:LBBP is an effective and feasible alternative option for CRT.Methods:Unrestricted searches of the PubMed, EMBASE, and Cochrane databases from inception till June 1, 2022, for studies examining the role of LBBP for CRT in HF patients. Data were analyzed using Revman 5.3 software. Mean Difference (MD), Odds Ratio (OR), and 95% Confidence interval (CI) were calculated using the random-effects model.Results:A total of 8 observational studies (3 single-armed, and 5 comparative studies) examined 756 HF patients who underwent CRT (551 LBBP vs 205 BVP). LBBP was successful in 87% of patients. Compared to baseline, LBBP was associated with a reduction in QRS duration (MD -53.5, 95%CI -69.77, -37.24), an increase in LVEF (MD 17%, 95%CI 13.38, 20.6), and a reduction in NYHA class (MD -1.4, 95%CI -1.56, -1.05). Compared to BVP, LBBP was associated with a significant reduction in QRS duration (MD -22.68, 95%CI -31, -14.35), improvement in LVEF (MD 7.58, 95%CI 5.21, 9.95), and a decrease in NYHA class (MD -0.55, 95% CI -0.73, -0.37) during a mean follow-up of 9.2 months. The super response rate, which is defined as an increase in LVEF of more than 20% or LVEF at or above 50% after CRT, was higher in LBBP compared to BVP (OR 2.98, 95%CI 1.65, 5.32).Conclusions:LBBP is a feasible and effective alternative for CRT. LBBP was associated with better electrical ventricular synchrony than BVP which was also translated into better echocardiographic and clinical outcomes in the short term. Our findings need to be further validated in larger randomized controlled trials with a long-term follow-up.

Circulation, Volume 146, Issue Suppl_1, Page A12263-A12263, November 8, 2022. Introduction:Aortic stenosis (AS) is characterized by highly variable progression rates. Differential rates of AS progression have been proposed to explain apparent disparities in the treatment of severe AS. However, the evidence supporting this claim is uncertain.Methods:We conducted a systematic review of MEDLINE and EMBASE from 1989 to 2022 to identify prospective cohort studies of AS hemodynamic progression. We evaluated the pooled patient demographics, AS severity, baseline and mean annual changes in echocardiographic markers, and prognostic factors.Results:We identified 32 prospective cohort studies. Overall, 11,432 patients were followed for 27 +/- 15 months on average. The average age was 67 +/- 8 years. The average percent female was 36 +/- 14%. Race was reported in only 4 (13%) cohorts; the average proportion of white patients was 93.9 +/- 6.1%. The average baseline hemodynamic severity was consistent with aortic sclerosis, mild AS, moderate AS, and severe AS in 3 (9.4%), 8 (25.0%), 19 (59.3%), and 2 (6.3%) studies, respectively. Overall, average baseline and annual changes in echocardiographic values were: peak aortic jet velocity (Vmax) 3.21 +/- 0.61 m/s (0.20 +/- 0.09 m/s/yr); aortic valve area (AVA) 1.23 +/- 0.31 cm2 (-0.09 +/- 0.05 cm2/yr); and mean aortic valve gradient (MG) 26.2 +/- 7.6 mmHg (3.9 +/- 1.6 mmHg/yr). Age, sex, coronary artery disease, hypertension, diabetes, hyperlipidemia, and smoking were not associated with AS progression in >75% cohorts. Baseline Vmax and MG were associated with greater AS progression in 6 cohorts (75%). Baseline aortic valve calcification (AVC) and AVA were consistently associated with greater AS progression in 9 cohorts (100%). One cohort found that women have a greater ΔMG for a given level of AVC. A univariate analysis of race in one cohort showed that African American ethnicity was associated with lower risk of progression from normal aortic valves to incident AS.Conclusion:There is limited representation of women and ethnic minorities in prospective AS progression cohorts. Active recruitment of diverse populations in these cohorts is needed. The available clinical evidence provides limited support for claims of differential progression as the cause of racial disparities in AS treatment.

Circulation, Volume 146, Issue Suppl_1, Page A11793-A11793, November 8, 2022. Background:The risk of fatal and recurrent cardiovascular complications in Hypertrophic Cardiomyopathy (HCM) warrant data to identify the rate, causes and predictors of readmission on a large scale. We conducted the first-ever meta-analysis to evaluate the pooled rate of short-term and long-term readmissions after index HCM admissions.Methods:PubMed/Medline, EMBASE and SCOPUS databases were systematically reviewed to find studies through May 2022 reporting rates and causes of readmission following index HCM admissions. Random effects models were used to estimate pooled rates and causes of readmissions and I2statistics were used to report inter-study heterogeneity.Results:This meta-analysis included 17860 index HCM admissions (Mean age: 46-67 years, median follow up duration: 321.6 days, Female 53.11%) from 17 studies, which revealed a 14.8% [95% CI 12.2%-17.4%, I2=96%] pooled rate of readmission(Fig. 1). Studies published from China (23.5% vs. 10.5%) had a higher readmission rate than the USA(Fig. 2). The long-term readmission rate was highest within 1-3 years (26.6%) and in patients who underwent alcohol septal ablation procedure (10% vs 7.6%) compared to those who underwent surgical myectomy(Fig. 3). The readmission rate was higher in cohorts with smaller sample sizes (19.2% vs 10.2%) (n1000). Among the readmission events, congestive heart failure, and acute decompensated heart failure were the leading causes of readmission, accounting for up to 66% of the readmission cases [95%CI 32.5%-100.4%, p

Circulation, Volume 146, Issue Suppl_1, Page A14167-A14167, November 8, 2022. Introduction:Recently, there has been a dramatic surge of interest in leadless pacemakers (LP). Although benefits of LP versus transvenous pacemakers (TVP) have been reported in small institutional and some registry-based studies, the systematic comparison and pooling of data remain limited. Therefore, we sought to meta-analyze the safety and benefit of leadless pacemakers over conventional transvenous pacemaker systems.Method:We followed PRISMA guidelines to conduct the study. The study protocol has been registered in the PROSPERO (CRD42022325376). Databases were searched for published literature from inception to April 12, 2022. Comparative studies on TVP with LP reporting device-related, cardiac, vascular, thoracic complications, and infection were included. Studies were analyzed using RevMan 5.4.1 with odds ratios (OR) to assess overall complications, device dislodgement, reintervention, and other complications. The I-squared (I2) test was used to assess the heterogeneity.ResultTotal 879 studies were imported from databases. After the removal of 265 duplicates, 614 papers were screened for eligibility. Among 41 papers screened for full text, 17 meet the inclusion criteria. There were 50% lower odds of overall complications in the LP group (OR 0.50, 95% CI 0.32 to 0.78; n = 20825). Similarly, 73% lower odds of device dislodgment (OR 0.27, 95% CI 0.14 to 0.50; n = 6897), 46% lower odds of re-intervention (OR 0.54, 95% CI 0.45 to 0.64; n= 17009), 87% lower odds of pneumothorax (OR 0.13, 95% CI 0.03 to 0.57; n = 4261), however 2.08 higher odds of pericardial effusion (OR 2.08, 95% CI 1.04 to 4.16; n = 4842) observed in LP group.ConclusionMeta-analysis of observational studies suggests that LP demonstrates a more favorable complication profile than TVP, although with higher rates of pericardial effusion. However, patient selection was not uniform between studies, and inferences remain limited.

Circulation, Volume 146, Issue Suppl_1, Page A323-A323, November 8, 2022. Global prevalence of cardiopulmonary resuscitation and automated external defibrillator training: a systematic review and meta-analysisAim:Sudden cardiac arrest exerts a large disease burden, which may be mitigated by bystander cardiopulmonary resuscitation (CPR) and automated external defibrillation (AED). The global prevalence and distribution of laypersons trained in these skills are poorly understood. We aimed to estimate the global prevalence of CPR and AED training, and identify their determinants.Method:We searched Medline, Embase and Cochrane Library from inception to October 24th, 2021, for cross-sectional studies reporting the prevalence of CPR or AED training from representative samples of laypersons. Prevalences were pooled using random effects models. We examined varying definitions of being identified as CPR-trained, namely CPR-V (valid training within 2-years), CPR-E (ever been trained). Subgroup analysis and meta-regression were used to examine determinants of interest.Results:28 studies were included, representing 53,397 laypersons. Among national studies, the prevalence of CPR-V training was 10.02% (95% CI 6.60 to 14.05), prevalence of CPR-E training was 39.64% (95%CI 29.11 to 50.67), and prevalence of AED training was 15.70% (95% CI 10.17 to 22.18). Subgroup analysis revealed differences in prevalences between continents,with prevalence highest in Oceania and lowest in Asia (p

Circulation, Volume 146, Issue Suppl_1, Page A15477-A15477, November 8, 2022. Introduction:Approximately 8-40% of ST-elevation Myocardial Infarction (STEMI) present later than 12 hours after symptom onset. Current ACC/AHA guidelines recommend primary percutaneous coronary intervention (PCI) for STEMI after 12 hours of symptom onset only in the setting of cardiogenic shock or severe acute heart failure, (Class Ia, LOE B) or persistent ischemic symptoms (Class IIa, LOE B). There are limited data comparing long-term outcomes among patients with a late STEMI presentation managed with PCI versus medical therapy (MT).Objective:To compare long-term outcomes among patients treated with PCI versus MT who have late presentation of STEMIMethods:We followed Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines to extract data from PubMed/Medline, Cochrane, Embase, and Clinicaltrials.gov databases by using the search terms “late” or “delayed” or “ >12 hours” presentation with STEMI from 01/2012 through 12/2022. Included studies reported at least one of the following outcomes: all-cause mortality, reinfarction, heart failure, major adverse cardiac events (MACE), and stroke. Studies reporting delays in PCI due to COVID-19 positive status or COVID-19 enforced protocols were excluded to prevent the impact of pragmatic barriers on treatment. Relative risk (RR) was calculated using random effects model if heterogeneity was >50%, otherwise, fixed effects model was usedResults:Seven studies (n=11,576, delayed PCI n=6,248, and medical therapy n=5,319) were included in our analysis. The median follow-up was 12 months (1-60 months). Overall, among patients with STEMI and PCI >12 hour after presentation had lower incidence of MACE (27% vs. 30%, RR 0.85, 95% CI 0.76-0.69, I2=30%, p=0.007) compared to MT alone, which was driven by a significantly reduced all-cause mortality with PCI (4.4% vs. 17%, RR 0.38, 95% CI 0.17-0.85, I2=95%, p=0.01). No significant differences were observed in the incidence of recurrent MI and heart failure hospitalizations.Conclusion:Our study suggests favorable outcomes of PCI in STEMI with presentation >12 hours compared with medical therapy. Further prospective studies are needed to validate our findings.

Circulation, Volume 146, Issue Suppl_1, Page A14100-A14100, November 8, 2022. Background:Treatment with various sodium-glucose cotransporter 2 inhibitors (SGLT-2Is) has decreased cardiovascular events in patients with heart failure (HF). Therefore, we conducted a network meta-analysis to investigate which SGLT-2Is are more effective in patients with HF.Methods:PubMed, Web of Science, Scopus, and Embase, were systematically searched from inception to February 2022. We included randomized controlled trials (RCTs) that investigated the use of SGLT-2Is vs. placebo in HF patients. The main outcomes were all-cause, cardiovascular mortality, serious adverse events, and hospitalizations due to HF. The random-effects method model and inverse variance statistics were used to calculate the odds ratio (OR) with a 95% confidence interval (CI).Results:Our study included 12 RCTs with a total number of 69,024 patients (37,923 in the SGLT2 inhibitors group and 31,101 in the placebo group). Five RCTs used empagliflozin, 4 used dapagliflozin, 1 used canagliflozin, 1 used ertugliflozin, and 1 used sotagliflozin. Our analysis showed that empagliflozin has a statistically significant lowest odds for both cardiovascular mortality and serious adverse effects (OR: 0.80 with 95% CI [0.67-0.96]) and (OR: 0.84 with 95% CI [0.76-0.93]), respectively compared to other SGLT-2Is. All SGLT-2Is have been associated with the same lower odds without preferences for one over the others regarding all-cause mortality. Furthermore, the hospitalization rate due to HF showed a statistically significant decrease with all the SGLT-2Is except for canagliflozin, which showed insignificant results with (OR: 0.63 with 95% CI [0.39-1.01]).Conclusion:No differences between the SGLT-2Is included in this analysis were observed in terms of all-cause mortality. Empagliflozin had the lowest odds of cardiovascular mortality and serious adverse effects. Canagliflozin was the only SGLT-2Is that showed no significant results in odds of hospitalization for HF.

Circulation, Volume 146, Issue Suppl_1, Page A14901-A14901, November 8, 2022. IntroductionAlthough immune checkpoint inhibitors (ICI) have reshaped the treatment landscape for cancer patients, they carry potential risk for the development of cardiovascular adverse events (CVAEs).ObjectivesWe attempted to identify risk factors for CVAEs in cancer patients receiving ICI.MethodsTwo investigators (C.H.H. and Y.C.) independently reviewed Medline, PubMed, and Embase from inception to May 20, 2022 to identify high quality studies. We included randomized controlled trials, prospective or retrospective cohorts that reported the risks factors for any new onset or worsening CVAEs, including cardiomyopathy, arrhythmia, heart failure, acute coronary syndrome, myocarditis, and pericarditis, in cancer patients receiving ICI. Two investigators (E.A. and M.A.) independently extracted data from included studies. Any discrepancy was resolved through discussion with senior reviewers (K.Y.C and M.N.). We performed random-effects meta-analyses on risk factors for CVAEs after the initiation of ICI. We used I-statistics (I2) to quantify the statistical heterogeneity.Results12 observational studies involving 21,912 patients (CVAEs=2,897) of any cancers were included for final qualitative and quantitative analyses. 11 covariates, including age, gender, body mass index, ever-smoking history, hypertension, type II diabetes, coronary artery disease (CAD), congestive heart failure, chronic kidney disease (CKD), chronic obstructive pulmonary disease, and stroke, were available for the meta-analyses. Our meta-analyses (Table 1) demonstrated that male gender, hypertension, CAD, and CKD were associated with increased odds for the development of CVAEs in patients taking ICI.ConclusionsIn conclusion, male gender, hypertension, CAD, and CKD were identified as significant risk factors for CVAEs in patients taking ICI. Evidence supports a strategy of proper optimization of risk factors before, during, and after the ICI treatment.

Circulation, Volume 146, Issue Suppl_1, Page A15577-A15577, November 8, 2022. Introduction:Despite the increasing rate of hypertensive emergency (elevated blood pressure with acute target organ damage) presentations in the emergency department (ED), subsequent morbidity and mortality data to support clinical decision making remains scarce. We aim to study the prevalence and prognosis of hypertensive emergencies and hypertension mediated organ damage (HMOD) in patients presenting to the ED.Methods:PubMed and Scopus were queried from their inception through the mid of November 2021. Studies were included if they reported the prevalence or prognosis of hypertensive emergencies in patients presenting to the ED. Data from each study was arcsine-transformed and pooled using a random-effects model.Results:Fourteen studies (n = 4370 patients) were included in our analysis. Pooled analysis demonstrates that the prevalence of hypertensive emergencies was 0.5% (95% CI: 0.40 – 0.60) in patients presenting to ED. Ischemic stroke 28.1% (95% CI: 18.7 – 38.6), was the most prevalent HMOD, followed by pulmonary edema/acute heart failure 24.1%, (95% CI: 19.0 – 29.7, hemorrhagic stroke 14.6%, (95% CI: 9.9 – 20.0), acute coronary syndrome 10.8%, (95% CI: 7.3 – 14.8), renal failure 8.0%, (95% CI: 2.9 – 15.5), subarachnoid hemorrhage 6.9%, (95% CI: 3.9 – 10.7), encephalopathy 6.1%, (95% CI: 1.9 – 12.4), and the least prevalent was aortic dissection 1.8%, (95% CI: 1.1 – 2.8) (Figure). Mortality rate among patients admitted to the hospital due to hypertensive emergency was 9.9% (CI: 1.4 – 24.6).Conclusions:Our findings demonstrate substantial morbidity and mortality amongst patients presenting to the ED with hypertensive emergency. Results of studies may help clinicians identify organs at highest risk of damage in patients with hypertensive emergency, aiding the work-up and therefore helping curb the burden of this disease.

Circulation, Volume 146, Issue Suppl_1, Page A11804-A11804, November 8, 2022. Background:Research on fast-track recovery protocols postulate epidural anaesthesia (TEA) in cardiac surgery contribute to improved postoperative outcomes. However, concerns about TEA’s safety and current equivocal evidence, hinder its widespread usage. We conducted a systematic review and meta-analysis to assess the effects of TEA in cardiac surgery.Methods:We searched four databases for randomised controlled trials (RCTs) assessing the use of TEA against only GA in adults undergoing cardiac surgery, up till 4 June 2022. We conducted random effects meta-analyses (DerSimonian and Laird), evaluated risk of bias using the Cochrane Risk-of-Bias 2 tool, and rated certainty of evidence via the GRADE approach. Primary outcomes were ICU and Hospital length of stay, with other outcomes including postoperative complications. Trial sequential analysis (TSA) was conducted on all outcomes to elicit statistical and clinical benefit.Results:Our meta-analysis included 39 RCTs (1941 TEA patients, 2047 GA patients). TEA significantly reduced ICU LOS (Figure 1: -6.8 hours, 95%-CI: -10.8 to -2.8, p=0.0009), hospital LOS (-0.7 days, 95%-CI: -1.2 to -0.2, p=0.0051), and extubation time (-2.8 hours, 95%-CI: -3.8 to -1.8, p=0.0001). However, there was no significant reduction in mortality. TSA found that the cumulative Z-curve passed the TSA-adjusted boundary for ICU LOS (see below), hospital LOS, and ET, suggesting a clinical benefit. TEA also significantly reduced transfusion requirements, pain scores, delirium, arrhythmia, and pooled pulmonary complications, without additional complications such as epidural hematomas.Conclusions:TEA reduces ICU and hospital lengths of stay, and postoperative complications in patients undergoing cardiac surgery with minimal reported complications. These findings favour the use of TEA in cardiac surgery, and warrants consideration for use in cardiac surgeries worldwide.

Circulation, Volume 146, Issue Suppl_1, Page A15314-A15314, November 8, 2022. Introduction:Mycobacterium chimaera is an emerging pathogen, recognized to cause prosthetic valve infective endocarditis (PVIE) and disseminated infection following open-chest cardiac surgery with certain contaminated heater-cooler systems. Diagnosis is challenging and requires a very high index of suspicion. Data regarding the optimal cardiac imaging evaluation of this condition is limited.Methods:Scopus, PubMed, EMBASE, Ovid and Cochrane were searched for published articles through October 2021, using keywords “Mycobacterium chimaera”, “Prosthetic valve” and “Endocarditis”. 169 articles were found and reviewed for study eligibility. Articles were included if they consisted of Mycobacterium chimaera causing IE, with imaging modalities used to establish diagnosisResults:Thirty-three articles were included, yielding twenty-two cases of Mycobacterium chimaera PVIE. The disease manifested on average thirty months after surgery, with an average patient age of 59 years (90% male). Imaging modalities to establish the diagnosis of prosthetic valve infective endocarditis included: transthoracic echocardiogram in 5 cases, transesophageal echocardiogram (TEE) in nine cases, 18F-FDG-PET/CT in seven cases. A combination of imaging modalities with TEE and 18F-FDG-PET/CT was reported once; TTE, TEE and 18F-FDG-PET/CT was also noted in one case. Lastly there was one instance each of combined use of TTE, TEE, and one of the following: CTA, Cardiac MRI, or standard CT. Nine cases did not specify the imaging modality used to achieve diagnosis. Ten patients died.Conclusions:PVIE due to Mycobacterium chimaera infection is a rare and challenging diagnosis, which requires a high index of suspicion. Accurate diagnosis should be aided by multimodality cardiac imaging, with 18F-FDG-PET/CT being a powerful adjunct imaging modality.

Circulation, Volume 146, Issue Suppl_1, Page A12256-A12256, November 8, 2022. Rivaroxaban is a direct oral anticoagulant that works by inhibiting factor Xa. Direct anticoagulants have largely replaced direct vitamin K inhibitors (VKAs) due to the increased risk of major hemorrhages and the need for regular monitoring and dose adjustments. However, there have been multiple reports of elevated international normalized ratio (INR) and incidents of bleeding in patients on rivaroxaban, which brings into question the potential need for monitoring. The purpose of this review is to differentiate the patients that may benefit from regular monitoring and to propose future directions for implementation of monitoring. Here we report a case of an INR of 4.8 in a patient who presented with a gastrointestinal bleed and a drop of five gm/dL in hemoglobin four days after starting rivaroxaban following right femoral popliteal bypass graft stenting. The patient had no liver or kidney abnormalities and was not taking any medication or consuming any foods that could introduce any significant drug interaction. Additionally, we conducted a systematic review of similar reports in the literature with the goal of identifying the factors that could influence rivaroxaban’s levels in the blood or its influence on the INR. We reviewed PubMed using keywords including; “rivaroxaban”, “anti-Xa”, “DOAC”, “elevated”, “INR”, “bleeding”, “hemorrhage”, “pharmacology”, and “pharmacokinetics”. The literature revealed reports of INRs up to 5.2. Reviewing the pharmacokinetics of rivaroxaban indicated possibly higher drug levels in Caucasians, patients with a low body mass index (BMI), and patients with polymorphisms in the genes coding for CYP3A4, CYP2J2, or p-glycoprotein, assuming no renal or liver disease and no significant drug-drug or drug-food interactions. INR can be falsely normal if the thromboplastin reagent used to monitor the INR on warfarin is not sensitive to the changes in INR due to rivaroxaban. We suggest finding a thromboplastin reagent that is sensitive to INR changes with rivaroxaban, which could yield clinically relevant INRs on rivaroxaban allowing for accurate monitoring. We then suggest conducting studies to evaluate the cost effectiveness of regular monitoring in at-risk patients.