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Critical Care Explorations Jun 2023Studies evaluating inhaled prostacyclins for the management of acute respiratory distress syndrome (ARDS) have produced inconsistent results regarding their effect on... (Review)
Review
UNLABELLED
Studies evaluating inhaled prostacyclins for the management of acute respiratory distress syndrome (ARDS) have produced inconsistent results regarding their effect on oxygenation. The purpose of this systematic review and meta-analysis was to evaluate the change in the Pao/Fio ratio after administration of an inhaled prostacyclin in patients with ARDS.
DATA SOURCES
We searched Ovid Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane, Scopus, and Web of Science.
STUDY SELECTION
We included abstracts and trials evaluating administration of inhaled prostacyclins in patients with ARDS.
DATA EXTRACTION
Change in the Pao/Fio ratio, Pao, and mean pulmonary artery pressure (mPAP) were extracted from included studies. Evidence certainty and risk of bias were evaluated using Grading of Recommendations Assessment, Development, and Evaluation and the Cochrane Risk of Bias tool.
DATA SYNTHESIS
We included 23 studies (1,658 patients) from 6,339 abstracts identified by our search strategy. The use of inhaled prostacyclins improved oxygenation by increasing the Pao/Fio ratio from baseline (mean difference [MD], 40.35; 95% CI, 26.14-54.56; < 0.00001; = 95%; very low quality evidence). Of the eight studies to evaluate change in Pao, inhaled prostacyclins also increased Pao from baseline (MD, 12.68; 95% CI, 2.89-22.48 mm Hg; = 0.01; = 96%; very low quality evidence). Only three studies evaluated change in mPAP, but inhaled prostacyclins were found to improve mPAP from baseline (MD, -3.67; 95% CI, -5.04 to -2.31 mm Hg; < 0.00001; = 68%; very low quality evidence).
CONCLUSIONS
In patients with ARDS, use of inhaled prostacyclins improves oxygenation and reduces pulmonary artery pressures. Overall data are limited and there was high risk of bias and heterogeneity among included studies. Future studies evaluating inhaled prostacyclins for ARDS should evaluate their role in ARDS subphenotypes, including cardiopulmonary ARDS.
PubMed: 37303944
DOI: 10.1097/CCE.0000000000000931 -
Journal of Endovascular Therapy : An... Jun 2023Catheter-directed therapy has been increasingly used in acute pulmonary embolism (PE). Whether ultrasound-assisted thrombolysis (USAT) is superior to standard... (Review)
Review
PURPOSE
Catheter-directed therapy has been increasingly used in acute pulmonary embolism (PE). Whether ultrasound-assisted thrombolysis (USAT) is superior to standard catheter-directed thrombolysis (SCDT) remains unclear. This is a systemic review and meta-analysis of comparative trials on USAT and SCDT for PE to determine whether either modality yielded better clinical efficacy and safety.
MATERIALS AND METHOD
Major databases including PubMed, Embase, Cochrane Central, and Web of Science were searched through March 16, 2023. Studies that reported outcomes of SCDT and USAT for acute PE were included. Studies reported data on therapeutic efficacy (a reduction in the right ventricle [RV]/left ventricle [LV] ratio, a reduction in the systolic pulmonary artery pressure [mm Hg], change in Miller index, length of intensive care unit [ICU] and hospital stay) and safety outcomes (in-hospital mortality, overall and major bleeding events).
RESULTS
A total of 9 studies with 2610 patients were included in the meta-analysis. The analysis showed significantly greater improvement in the RV/LV ratio in the SCDT group than in the USAT group (mean difference [MD]: -0.155; 95% confidence interval [CI]: -0.249 to -0.006). No statistically significant differences were found between groups comparing change in systolic pulmonary artery pressure (MD: 0.592 mm Hg; 95% CI: -2.623 to 3.807), change in Miller index (MD: -4.1%; 95% CI: -9.5 to 1.3%), hospital stay (MD: 0.372 days; 95% CI: -0.972 to 1.717), and ICU stay (MD: -0.073.038 days; 95% CI: -1.184 to 1). No significant difference was noted in safety outcomes, including in-hospital mortality (pooled odds ratio: 0.984; 95% CI: 0.597 to 1.622), and major bleeding (pooled odds ratio: 1.162; 95% CI: 0.714 to 1.894).
CONCLUSIONS
In our meta-analysis of observational and randomized studies, USAT is not superior to SCDT in patients with acute PE.INSPLAY registration number: INPLASY202240082.
CLINICAL IMPACT
This study compared SCDT and USAT in patients with acute pulmonary embolism. We found no additional benefit in PA pressure change, thrombus reduction, hospital stay, mortality and major bleeding rate. Additional study using consistent treatment protocol is necessary for further investigation.
PubMed: 37291849
DOI: 10.1177/15266028231181031 -
The Science of the Total Environment Sep 2023Congenital heart diseases (CHDs) are a prevalent form of congenital malformations in newborns. Although previous studies have explored the association between maternal... (Meta-Analysis)
Meta-Analysis Review
Congenital heart diseases (CHDs) are a prevalent form of congenital malformations in newborns. Although previous studies have explored the association between maternal exposure to ambient air pollution and congenital anomalies in offspring, the results still remain ambiguous. To fill the knowledge gap, we performed a systematic review and meta-analysis of existing literature. A comprehensive search of the literature was conducted in PubMed, Embase, and Web of Science until August 12, 2022. We analyzed the relationship between air pollution and multiple CHDs using either a fixed-effect model or a random-effects model. Summary risk estimates of pollution-outcome pairs were calculated based on (i) risk per increment of concentration and (ii) risk at high versus low exposure levels. Additionally, we performed leave-one-out analyses and used funnel plots to assess the potential publication bias. A total of 32 studies were included and four studies utilizing distributed lag nonlinear models (DLNM) models were added to our retrospective review. In the continuous exposure meta-analysis, there were statistically significant negative associations between sulfur dioxide (SO) and transposition of the great arteries (OR = 0.96; 95 % CI: 0.93-0.99), pulmonary artery and valve defect (OR = 0.90; 95 % CI: 0.83-0.97), and ventricular septal defect (OR = 0.95; 95 % CI: 0.91-0.99). High versus low SO exposure was associated with a decreased risk of tetralogy of Fallot [OR = 0.83; 95 % CI: 0.69-0.99]. However, carbon monoxide (CO) increased risk estimates for tetralogy of Fallot in both continuous exposure (OR = 2.25; 95 % CI: 1.42-3.56) and high-low exposure (OR = 1.24; 95 % CI: 1.01-1.54). Particulate matter 10 (PM) statistically significant increased in the risk of overall CHD with odds ratios of 1.03 (95 % CI: 1.01-1.05) and 1.04 (95 % CI: 1.00-1.09) in continuous and categorical exposure analysis, respectively. These findings provide potential evidence for the association between maternal air pollution exposure and CHDs.
Topics: Female; Humans; Child; Infant, Newborn; Maternal Exposure; Air Pollutants; Incidence; Tetralogy of Fallot; Transposition of Great Vessels; Air Pollution; Heart Defects, Congenital; Particulate Matter; Environmental Exposure
PubMed: 37268121
DOI: 10.1016/j.scitotenv.2023.164431 -
Cureus Apr 2023Optimal perioperative fluid management is crucial, with over- or under-replacement associated with complications. There are many strategies for fluid therapy,... (Review)
Review
Optimal perioperative fluid management is crucial, with over- or under-replacement associated with complications. There are many strategies for fluid therapy, including liberal fluid therapy (LFT), restrictive fluid therapy (RFT) and goal-directed fluid therapy (GDT), without a clear consensus as to which is better. We aimed to find out which is the more effective fluid therapy option in adult surgical patients undergoing non-vascular abdominal surgery in the perioperative period. This study is a systematic review and network meta-analysis (NMA) with node-splitting analysis of inconsistency, sensitivity analysis and meta-regression. We conducted a literature search of Pubmed, Cochrane Library, EMBASE, Google Scholar and Web of Science. Only studies comparing restrictive, liberal and goal-directed fluid therapy during the perioperative phase in major non-cardiac surgery in adult patients will be included. Trials on paediatric patients, obstetric patients and cardiac surgery were excluded. Trials that focused on goal-directed therapy monitoring with pulmonary artery catheters and venous oxygen saturation (SvO2), as well as those examining purely biochemical and laboratory end points, were excluded. A total of 102 randomised controlled trials (RCTs) and 78 studies (12,100 patients) were included. NMA concluded that goal-directed fluid therapy utilising FloTrac was the most effective intervention in reducing the length of stay (LOS) (surface under cumulative ranking curve (SUCRA) = 91%, odds ratio (OR) = -2.4, 95% credible intervals (CrI) = -3.9 to -0.85) and wound complications (SUCRA = 86%, OR = 0.41, 95% CrI = 0.24 to 0.69). Goal-directed fluid therapy utilising pulse pressure variation was the most effective in reducing the complication rate (SUCRA = 80%, OR = 0.25, 95% CrI = 0.047 to 1.2), renal complications (SUCRA = 93%, OR = 0.23, 95% CrI = 0.045 to 1.0), respiratory complications (SUCRA = 74%, OR = 0.42, 95% CrI = 0.053 to 3.6) and cardiac complications (SUCRA = 97%, OR = 0.067, 95% CrI = 0.0058 to 0.57). Liberal fluid therapy was the most effective in reducing the mortality rate (SUCRA = 81%, OR = 0.40, 95% CrI = 0.12 to 1.5). Goal-directed therapy utilising oesophageal Doppler was the most effective in reducing anastomotic leak (SUCRA = 79%, OR = 0.45, 95% CrI = 0.12 to 1.5). There was no publication bias, but moderate to substantial heterogeneity was found in all networks. In preventing different complications, except mortality, goal-directed fluid therapy was consistently more highly ranked and effective than standard (SFT), liberal or restricted fluid therapy. The evidence grade was low quality to very low quality for all the results, except those for wound complications and anastomotic leak.
PubMed: 37261162
DOI: 10.7759/cureus.38238 -
Current Problems in Cardiology Oct 2023Twelve CCI patients were studied with confirmed or suspected COVID-19 infection. The majority of these patients were males (83.3%) with a median age of 55 years from... (Review)
Review
Twelve CCI patients were studied with confirmed or suspected COVID-19 infection. The majority of these patients were males (83.3%) with a median age of 55 years from three geographical locations, constituting the Middle East (7), Spain (3), and the USA (1). In 6 patients, IgG/IgM was positive for COVID-19, 4 with high pretest probability and 2 with positive RT-PCR. Type 2 DM, hyperlipidemia, and smoking were the primary risk factors. Right-sided neurological impairments and verbal impairment were the most common symptoms. Our analysis found 8 (66%) synchronous occurrences. In 58.3% of cases, neuroimaging showed left Middle Cerebral Artery (MCA) infarct and 33.3% right. Carotid artery thrombosis (16.6%), tandem occlusion (8.3%), and carotid stenosis (1%) were also reported in imaging. Dual antiplatelet therapy (DAPT) and anticoagulants were conservative therapies (10). Two AMI patients had aspiration thrombectomy, while three AIS patients had intravenous thrombolysis/tissue plasminogen activator (IVT-tPA), 2 had mechanical thrombectomy (MT), and 1 had decompressive craniotomy. Five had COVID-19-positive chest X-rays, whereas 4 were normal. four of 8 STEMI and 3 NSTEMI/UA patients complained chest pain. LV, ICA, and pulmonary embolism were further complications (2). Upon discharge, 7 patients (70%) had residual deficits while 1 patient unfortunately died.
Topics: Female; Humans; Male; Middle Aged; Anticoagulants; COVID-19; Infarction, Middle Cerebral Artery; Stroke; Thrombectomy; Thrombolytic Therapy; Tissue Plasminogen Activator; Treatment Outcome; Case Reports as Topic
PubMed: 37209804
DOI: 10.1016/j.cpcardiol.2023.101814 -
Interdisciplinary Cardiovascular and... May 2023Right heart failure (RHF) is a major complication following left ventricular assist device (LVAD) implantation. Pulmonary artery pulsatility index (PAPi) has been...
OBJECTIVES
Right heart failure (RHF) is a major complication following left ventricular assist device (LVAD) implantation. Pulmonary artery pulsatility index (PAPi) has been evaluated as a haemodynamic marker for RHF, but PAPi is dependent on pulmonary vascular resistance (PVR). We conducted a systematic review to assess the relationship between PAPi and RHF and death in patients undergoing LVAD implantation and examined the relationship between PAPi cut-off and PVR.
METHODS
We searched PubMed, EMBASE, CENTRAL and manually screened retrieved references to identify all clinical studies reporting PAPi in adult patients with a durable LVAD. Eligibility criteria were prespecified and 2 reviewers independently screened and extracted data; the Newcastle-Ottawa Scale was used to assess quality of non-randomized studies. This study was prospectively registered on PROSPERO (CRD42021259009).
RESULTS
From 283 unique records, we identified 16 studies reporting haemodynamic assessment in 20 634 adult patients with an implanted durable LVAD. Only 2 studies reported on mortality and in both, a lower PAPi was significantly associated with death. Fifteen studies reported RHF data and, in 10 studies, a lower PAPi was significantly associated with RHF. Six studies reported on PAPi cut-offs ranging from 0.88 to 3.3; and the cut-offs were directly related to PVR (r = 0.6613, P = 0.019).
CONCLUSIONS
Lower PAPi was associated with RHF and death following LVAD implantation, but a single PAPi cut-off cannot be defined, as it is dependent on PVR.
PubMed: 37171900
DOI: 10.1093/icvts/ivad068 -
EClinicalMedicine May 2023Isolated pulmonary embolism (PE) appears to be associated with a specific clinical profile and sequelae compared to deep vein thrombosis (DVT)-associated PE. The...
BACKGROUND
Isolated pulmonary embolism (PE) appears to be associated with a specific clinical profile and sequelae compared to deep vein thrombosis (DVT)-associated PE. The objective of this study was to identify clinical characteristics that discriminate both phenotypes, and to characterize their differences in clinical outcome.
METHODS
We performed a systematic review and meta-analysis of studies comparing PE phenotypes. A systematic search of the electronic databases PubMed and CENTRAL was conducted, from inception until January 27, 2023. Exclusion criteria were irrelevant content, inability to retrieve the article, language other than English or German, the article comprising a review or case study/series, and inappropriate study design. Data on risk factors, clinical characteristics and clinical endpoints were pooled using random-effects meta-analyses.
FINDINGS
Fifty studies with 435,768 PE patients were included. In low risk of bias studies, 30% [95% CI 19-42%, = 97%] of PE were isolated. The Factor V Leiden [OR: 0.47, 95% CI 0.37-0.58, = 0%] and prothrombin G20210A mutations [OR: 0.55, 95% CI 0.41-0.75, = 0%] were significantly less prevalent among patients with isolated PE. Female sex [OR: 1.30, 95% CI 1.17-1.45, = 79%], recent invasive surgery [OR: 1.31, 95% CI 1.23-1.41, = 65%], a history of myocardial infarction [OR: 2.07, 95% CI 1.85-2.32, = 0%], left-sided heart failure [OR: 1.70, 95% CI 1.37-2.10, = 76%], peripheral artery disease [OR: 1.36, 95% CI 1.31-1.42, = 0%] and diabetes mellitus [OR: 1.23, 95% CI 1.21-1.25, = 0%] were significantly more frequently represented among isolated PE patients. In a synthesis of clinical outcome data, the risk of recurrent VTE in isolated PE was half that of DVT-associated PE [RR: 0.55, 95% CI 0.44-0.69, = 0%], while the risk of arterial thrombosis was nearly 3-fold higher [RR: 2.93, 95% CI 1.43-6.02, = 0%].
INTERPRETATION
Our findings suggest that isolated PE appears to be a specific entity that may signal a long-term risk of arterial thrombosis. Randomised controlled trials are necessary to establish whether alternative treatment regimens are beneficial for this patient subgroup.
FUNDING
None.
PubMed: 37152363
DOI: 10.1016/j.eclinm.2023.101973 -
Archives of Disease in Childhood. Fetal... Nov 2023Prognostication of mortality and decision to offer extracorporeal membrane oxygenation (ECMO) treatment in infants with congenital diaphragmatic hernia (CDH) can inform... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Prognostication of mortality and decision to offer extracorporeal membrane oxygenation (ECMO) treatment in infants with congenital diaphragmatic hernia (CDH) can inform clinical management.
OBJECTIVE
To summarise the prognostic value of echocardiography in infants with CDH.
METHODS
Electronic databases Ovid MEDLINE, Embase, Scopus, CINAHL, the Cochrane Library and conference proceedings up to July 2022 were searched. Studies evaluating the prognostic performance of echocardiographic parameters in newborn infants were included. Risk of bias and applicability were assessed using the Quality Assessment of Prognostic Studies tool. We used a random-effect model for meta-analysis to compute mean differences (MDs) for continuous outcomes and relative risk (RR) for binary outcomes with 95% CIs. Our primary outcome was mortality; secondary outcomes were need for ECMO, duration of ventilation, length of stay, and need for oxygen and/or inhaled nitric oxide.
RESULTS
Twenty-six studies were included that were of acceptable methodological quality. Increased diameters of the right and left pulmonary arteries at birth (mm), MD 0.95 (95% CI 0.45 and 1.46) and MD 0.79 (95% CI 0.58 to 0.99), respectively) were associated with survival. Left ventricular (LV) dysfunction, RR 2.40, (95% CI 1.98 to 2.91), right ventricular (RV) dysfunction, RR 1.83 (95% CI 1.29 to 2.60) and severe pulmonary hypertension (PH), RR 1.69, (95% CI 1.53 to 1.86) were associated with mortality. Left and RV dysfunctions, RR 3.30 (95% CI 2.19 to 4.98) and RR 2.16 (95% CI 1.85 to 2.52), respectively, significantly predicted decision to offer ECMO treatment. Limitations are lack of consensus on what parameter is optimal and standardisation of echo assessments.
CONCLUSIONS
LV and RV dysfunctions, PH and pulmonary artery diameter are useful prognostic factors among patients with CDH.
Topics: Infant, Newborn; Infant; Humans; Hernias, Diaphragmatic, Congenital; Prognosis; Echocardiography; Lung; Hypertension, Pulmonary; Retrospective Studies
PubMed: 37130729
DOI: 10.1136/archdischild-2022-325257 -
Medical Journal of the Islamic Republic... 2023Heart Failure (HF) imposes a relevant burden and a considerable health concern, with high prevalence and mortality rates. This study was conducted to assess the... (Review)
Review
BACKGROUND
Heart Failure (HF) imposes a relevant burden and a considerable health concern, with high prevalence and mortality rates. This study was conducted to assess the cost-effectiveness of remote cardiac monitoring with the CardioMEMS Heart Failure System.
METHODS
In the present systematic review, several scholarly databases were searched and updated from inception up to September 20, 2022. The objective of the present review was formulated according to the patient/population, intervention, comparison and outcomes format. Mortality rate, hospitalization rate, quality-adjusted life year (QALY), total costs, and the incremental cost-effectiveness ratio regarding the use of the CardioMEMS System were the key outcomes of the present study. The quality of included studies was assessed using the Consolidated Health Economic Evaluation Reporting Standards 2022 (CHEERS) checklist.
RESULTS
Finally, 5 articles were retained and analyzed in the present systematic review. All studies employed the Markov and decision tree models. Results show that the CardioMEMS system reduced mortality and hospitalization rate and created a higher QALY. In all selected countries the CardioMEMS method is a more expensive method than the standard of care (SoC), with the highest cost in the United States (US) ($201,437) and the lowest cost in the United Kingdom ($25,963), respectively. the highest willingness to pay in the US and the lowest in Italy ($100,000 and $33,000 per QALY), respectively. Results showed that the most cost per QALY for the CardioMEMS system was in the US and the lowest was in the Netherlands ($46,622 and $26,615 per QALY), respectively.
CONCLUSION
In all selected countries, CardioMEMS is a cost-effective method for monitoring and managing pulmonary artery pressures in HF patients. Strategies such as CardioMEMS, which decrease the rate of hospitalization, are likely to be only more cost-effective in the future.
PubMed: 37123330
DOI: 10.47176/mjiri.37.16 -
Current Problems in Cardiology Sep 2023Pulmonary hypertension (PH) is a progressive disease with a high morbidity and mortality. The treatment is based on the type of PH. Prognosis still remains poor despite... (Meta-Analysis)
Meta-Analysis Review
Pulmonary hypertension (PH) is a progressive disease with a high morbidity and mortality. The treatment is based on the type of PH. Prognosis still remains poor despite the use of different medications. Pulmonary artery denervation (PADN) has been studied as a novel therapeutic option in these patients. PUBMED, EMBASE and COCHRANE databases were searched by 2 investigators until January 2023. Information was analyzed for the following outcomes: 6-minute walk distance (6MWD), mean pulmonary artery pressure, pulmonary vascular resistance and cardiac output. Subgroup analysis comparing pre and post PADN in different PH groups was done. Statistical analysis was performed with the Review Manager version 5.4. This meta- analysis included 6 controlled trials and 6 single-arm prospective studies with a total of 616 patients. Our pooled analysis showed a significant reduction in mean pulmonary artery pressure [WMD -6.51, 95% CI (-9.87, -3.15), p = 0.0001], pulmonary vascular resistance [WMD -3.69, 95% CI (-6.74, -0.64), p = 0.02] and increased cardiac output [WMD -0.37, 95% CI (0.08, 0.65), p = 0.01]. Subgroup analysis pre and post PADN demonstrated a significant improvement in 6MWD in the WHO group 1 [WMD 99.53, 95% CI (19.60, 179.47), p = 0.01], group 2 [WMD: 69.96, 95% CI (36.40, 103.51), p = < 0.0001] and group 4 [WMD: 99.54, 95% CI (21.80, 177.28), p = 0.01]. This meta-analysis supports PADN as a therapeutic option for patients with PH, regardless of group class. Further randomized trials are still needed to evaluate safety and efficacy.
Topics: Humans; Hypertension, Pulmonary; Pulmonary Artery; Prospective Studies; Denervation
PubMed: 37121454
DOI: 10.1016/j.cpcardiol.2023.101776