-
Clinical Microbiology and Infection :... Feb 2019Prediction of embolic events (EEs) in infective endocarditis (IE) could inform clinical decisions, such as surgical timing. We conducted a systematic review to more...
OBJECTIVES
Prediction of embolic events (EEs) in infective endocarditis (IE) could inform clinical decisions, such as surgical timing. We conducted a systematic review to more precisely define associations between risk factors and EEs.
METHODS
We searched two bibliographic databases (1994-2018) for observational studies that reported EEs in IE patients and considered clinical, microbiological or echocardiographic risk factors. Studies that did not use Duke criteria or only investigated a subset of IE patients were excluded. Study quality was assessed using the Newcastle-Ottawa scale. A pooled risk ratio (RR) for each risk factor was estimated using random-effects models; statistical heterogeneity was estimated using I.
RESULTS
Of 3862 unique citations, 47 cohort studies (11 215 IE cases) were included; 54 risk factors were analysed in at least two studies, with nine studies reporting other individual factors. Most studies were of high methodological quality. Major predictors of EEs were intravenous drug use (RR 1.69, 95% CI 1.32-2.17; I = 46%), Staphylococcus aureus infection (RR 1.64, 95% CI 1.45-1.86, I = 32%), mitral valve vegetation (RR 1.24, 95% CI 1.11-1.37, I = 30%), and vegetation size >10 mm (RR 1.87, 95% CI 1.57-2.21, I = 48%). EE risk was also higher with human immunodeficiency virus, chronic liver disease, elevated C-reactive protein, Staphylococcus spp. infection, vegetation presence, and multiple, mobile or prosthetic mechanical valve vegetation, and lower with Streptococcus spp. infection. Most findings were unchanged in sensitivity analyses that removed studies with pulmonary EEs from the outcome.
CONCLUSIONS
Given the serious consequences of embolism, surgical evaluation may be considered in patients with these risk factors.
Topics: Echocardiography; Embolism; Endocarditis, Bacterial; Humans; Risk Factors
PubMed: 30145401
DOI: 10.1016/j.cmi.2018.08.010 -
Journal of the American Heart... Jun 2018Infective endocarditis (IE) after transcatheter pulmonary valve implantation (TPVI) in dysfunctioning right ventricular outflow tract conduits has evoked growing...
BACKGROUND
Infective endocarditis (IE) after transcatheter pulmonary valve implantation (TPVI) in dysfunctioning right ventricular outflow tract conduits has evoked growing concerns. We aimed to investigate the incidence and the natural history of IE after TPVI with the Melody valve through a systematic review of published data.
METHODS AND RESULTS
PubMed, EMBASE, and Web of Science databases were systematically searched for articles published until March 2017, reporting on IE after TPVI with the Melody valve. Nine studies (including 851 patients and 2060 patient-years of follow-up) were included in the analysis of the incidence of IE. The cumulative incidence of IE ranged from 3.2% to 25.0%, whereas the annualized incidence rate ranged from 1.3% to 9.1% per patient-year. The median (interquartile range) time from TPVI to the onset of IE was 18.0 (9.0-30.4) months (range, 1.0-72.0 months). The most common findings were positive blood culture (93%), fever (89%), and new, significant, and/or progressive right ventricular outflow tract obstruction (79%); vegetations were detectable on echocardiography in only 34% of cases. Of 69 patients with IE after TPVI, 6 (8.7%) died and 35 (52%) underwent surgical and/or transcatheter reintervention. Death or reintervention was more common in patients with new/significant right ventricular outflow tract obstruction (69% versus 33%; =0.042) and in patients with non-streptococcal IE (73% versus 30%; =0.001).
CONCLUSIONS
The incidence of IE after implantation of a Melody valve is significant, at least over the first 3 years after TPVI, and varies considerably between the studies. Although surgical/percutaneous reintervention is a common consequence, some patients can be managed medically, especially those with streptococcal infection and no right ventricular outflow tract obstruction.
Topics: Adolescent; Adult; Bioprosthesis; Child; Child, Preschool; Endocarditis; Female; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Incidence; Male; Middle Aged; Prosthesis Design; Prosthesis-Related Infections; Pulmonary Valve; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome; Young Adult
PubMed: 29934419
DOI: 10.1161/JAHA.117.008163 -
Danish Medical Journal Mar 2018Post-operative pulmonary complications are a common cause of morbidity and mortality in patients undergoing heart surgery. The aim of this systematic review was to... (Review)
Review
INTRODUCTION
Post-operative pulmonary complications are a common cause of morbidity and mortality in patients undergoing heart surgery. The aim of this systematic review was to determine if preoperative inspiratory muscle training could prevent the development of pneumonia and atelectasis in patients undergoing coronary artery bypass grafting (CABG) or heart valve surgery.
METHODS
Systematic searches were performed in MEDLINE, Embase and the Cochrane Library. The included studies compared the development of pneumonia and atelectasis in CABG patients or heart valve surgery patients who were prescribed either preoperative inspiratory muscle training or usual care. The quality of the studies was assessed using the Cochrane Risk of Bias Tool.
RESULTS
The search yielded 2,479 records. The inclusion criteria were fulfilled by five studies. All the studies were randomised controlled trials. We found that the development of both pneumonia and atelectasis was significantly reduced among patients who received inspiratory muscle training preoperatively compared with patients treated with usual care.
CONCLUSIONS
Preoperative inspiratory muscle training may reduce the risk of developing pneumonia and atelectasis. However, more trials are needed to support and strengthen the evidence found in this systematic review before routine implementation of this kind of training preoperatively.
Topics: Breathing Exercises; Coronary Artery Bypass; Humans; Length of Stay; Muscle Strength; Pneumonia; Postoperative Complications; Preoperative Care; Pulmonary Atelectasis; Randomized Controlled Trials as Topic; Respiratory Muscles
PubMed: 29510803
DOI: No ID Found -
Respirology (Carlton, Vic.) Nov 2017Continuous positive airway pressure (CPAP) is the standard treatment for moderate-to-severe obstructive sleep apnoea (OSA). However, adherence to CPAP is limited and... (Review)
Review
Continuous positive airway pressure (CPAP) is the standard treatment for moderate-to-severe obstructive sleep apnoea (OSA). However, adherence to CPAP is limited and non-CPAP therapies are frequently explored. Oral appliance (OA) therapy is currently widely used for the treatment of snoring, mild, moderate and severe OSA. The most commonly used and studied OA consists of a maxillary and mandibular splint which hold the lower jaw forward during sleep. The efficacy of OA is inferior to CPAP; however, the effectiveness as measured by sleepiness, quality of life, endothelial function and blood pressure is similar likely due to higher acceptance and subjective adherence. Upper airway stimulation augments neural drive by unilaterally stimulating the hypoglossal nerve. The Stimulation Therapy for Apnea Reduction (STAR) study enrolled 126 patients and demonstrated a 68% reduction in OSA severity. A high upfront cost and variable response are the main limitations. Oropharyngeal exercises consist of a set of isometric and isotonic exercises involving the tongue, soft palate and lateral pharyngeal wall. The collective reported trials (n = 120) showed that oropharyngeal exercises can ameliorate OSA and snoring (~30-40%). Nasal EPAP devices consist of disposable one-way resister valve. A systematic review (n = 345) showed that nasal EPAP reduced OSA severity by 53%. The Winx device consists of a mouthpiece placed inside the oral cavity that is connected by tubing to a console that generates negative pressure. Winx may provide successful therapy for ~30-40% of OSA patients. In conclusion, several non-CPAP therapies to treat OSA are currently available.
Topics: Continuous Positive Airway Pressure; Exercise Therapy; Humans; Sleep Apnea, Obstructive
PubMed: 28901030
DOI: 10.1111/resp.13144 -
Canadian Respiratory Journal 2017Recent studies have reported that obstructive sleep apnea (OSA) patients present alterations in right ventricular (RV) structure and function. However, large randomized... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Recent studies have reported that obstructive sleep apnea (OSA) patients present alterations in right ventricular (RV) structure and function. However, large randomized controlled trials evaluating the impact of OSA on the right ventricle are lacking.
METHODS
A comprehensive electronic database (PubMed, Web of Science, and Google Scholar) and reference search up to October 30, 2016, was performed. A systematic review and meta-analysis were performed to assess RV structure and function in OSA patients based on conventional echocardiography and tissue Doppler imaging.
RESULTS
Twenty-five studies with 1,503 OSA patients and 796 controls were included in this study. OSA patients exhibited an increase in RV internal diameter (weighted mean difference (WMD) (95% confidence intervals (CIs)) 2.49 (1.62 to 3.37); = 0.000) and RV wall thickness (WMD (95% CIs) 0.82 (0.51 to 1.13); = 0.000). Furthermore, OSA patients had a significantly elevated RV myocardial performance index (WMD (95% CI) 0.08 (0.06 to 0.10); = 0.000), decreased RV S' (WMD (95% CI) -0.95 (-1.59 to -0.32); = 0.003), tricuspid annular plane systolic excursion (WMD (95% CI) -1.76 (-2.73 to -0.78); = 0.000), and RV fractional area change (WMD (95% CI) -3.16 (-5.60 to -0.73); = 0.011).
CONCLUSION
OSA patients display RV dilatation, increased wall thickening, and altered RV function.
Topics: Case-Control Studies; Echocardiography; Echocardiography, Doppler; Humans; Sleep Apnea, Obstructive; Tricuspid Valve; Ventricular Dysfunction, Right; Ventricular Remodeling
PubMed: 28814913
DOI: 10.1155/2017/1587865 -
Journal of the American Heart... Aug 2017Transcatheter pulmonary valve implantation is approved for the treatment of dysfunctional right ventricle to pulmonary artery conduits. However, the literature is... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Transcatheter pulmonary valve implantation is approved for the treatment of dysfunctional right ventricle to pulmonary artery conduits. However, the literature is limited because of a small patient population, and it does not reflect changing procedural practice patterns over the last decade.
METHODS AND RESULTS
A comprehensive search of Medline and Scopus databases from inception through August 31, 2016 was conducted using predefined criteria. We included studies reporting transcatheter pulmonary valve implantation in at least 5 patients with a follow-up duration of 6 months or more. In 19 eligible studies, 1044 patients underwent transcatheter pulmonary valve implantation with a pooled follow-up of 2271 person-years. Procedural success rate was 96.2% (95% confidence intervals [CI], 94.6-97.4) with a conduit rupture rate of 4.1% (95% CI, 2.5-6.8) and coronary complication rate of 1.3% (95% CI, 0.7-2.3). Incidence of reintervention was 4.4 per 100 person-years overall (95% CI, 3.0-5.9) with a marked reduction in studies reporting ≥75% prestenting (2.9 per 100 person-years [95% CI, 1.5-4.3] versus 6.5/100 person-years [95% CI, 4.6-8.5]; <0.01). Pooled endocarditis rate was 1.4 per 100 person-years (95% CI, 0.9-2.0).
CONCLUSIONS
Our study provides favorable updated estimates of procedural and follow-up outcomes after transcatheter pulmonary valve implantation. Widespread adoption of prestenting has improved longer-term outcomes in these patients.
Topics: Adolescent; Adult; Cardiac Catheterization; Child; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Observational Studies as Topic; Postoperative Complications; Pulmonary Valve; Risk Factors; Time Factors; Treatment Outcome; Young Adult
PubMed: 28778940
DOI: 10.1161/JAHA.117.006432 -
JACC. Cardiovascular Interventions Jul 2017The aim of this study was to systematically evaluate the incidence of infective endocarditis (IE) in right ventricle-to-pulmonary artery conduits and valves, comparing... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES
The aim of this study was to systematically evaluate the incidence of infective endocarditis (IE) in right ventricle-to-pulmonary artery conduits and valves, comparing bovine jugular vein (BJV) valves with all others.
BACKGROUND
Recent evidence suggests that the incidence of IE is higher in patients with congenital heart disease who have undergone implantation of BJV valves in the pulmonary position compared with other valves.
METHODS
Systematic searches of published research were conducted using electronic databases (MEDLINE, Embase, and CINAHL) and citations cross-referenced current to April 2016. Included studies met the following criteria: patients had undergone right ventricle-to-pulmonary artery conduit or percutaneous pulmonary valve implantation, and investigators reported on the type of conduit or valve implanted, method of intervention (surgery or catheter based), IE incidence, and follow-up time.
RESULTS
Fifty studies (Levels of Evidence: 2 to 4) were identified involving 7,063 patients. The median cumulative incidence of IE was higher for BJV compared with other valves (5.4% vs. 1.2%; p < 0.0001) during a median follow-up period of 24.0 and 35.5 months, respectively (p = 0.03). For patients with BJV valves, the incidence of IE was not different between surgical and catheter-based valve implantation (p = 0.83).
CONCLUSIONS
There was a higher incidence of endocarditis with BJV valves than other types of right ventricle-to-pulmonary artery conduits. There was no difference in the incidence of endocarditis between catheter-based bovine valves and surgically implanted bovine valves, suggesting that the substrate for future infection is related to the tissue rather than the method of implantation.
Topics: Adolescent; Adult; Allografts; Animals; Bioprosthesis; Cattle; Child; Child, Preschool; Endocarditis; Female; Heart Defects, Congenital; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Heterografts; Humans; Incidence; Infant; Jugular Veins; Male; Middle Aged; Odds Ratio; Prosthesis Design; Prosthesis-Related Infections; Pulmonary Valve; Risk Factors; Time Factors; Treatment Outcome; Venous Valves; Young Adult
PubMed: 28728659
DOI: 10.1016/j.jcin.2017.04.025 -
PloS One 2017Frailty is a common condition in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR). The aim of this systematic review... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
Frailty is a common condition in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR). The aim of this systematic review was to assess the impact of frailty status on acute kidney injury (AKI) and mortality after TAVR.
METHODS
A systematic literature search was conducted using MEDLINE, EMBASE, and Cochrane databases from the inception through November 2016. The protocol for this study is registered with PROSPERO (International Prospective Register of Systematic Reviews; no. CRD42016052350). Studies that reported odds ratios, relative risks or hazard ratios comparing the risk of AKI after TAVR in frail vs. non-frail patients were included. Mortality risk was evaluated among the studies that reported AKI-related outcomes. Pooled risk ratios (RR) and 95% confidence interval (CI) were calculated using a random-effect, generic inverse variance method.
RESULTS
Eight cohort studies with a total of 10,498 patients were identified and included in the meta-analysis. The pooled RR of AKI after TAVR among the frail patients was 1.19 (95% CI 0.97-1.46, I2 = 0), compared with non-frail patients. When the meta-analysis was restricted only to studies with standardized AKI diagnosis according to Valve Academic Research Consortium (VARC)-2 criteria, the pooled RRs of AKI in frail patients was 1.16 (95% CI 0.91-1.47, I2 = 0). Within the selected studies, frailty status was significantly associated with increased mortality (RR 2.01; 95% CI 1.44-2.80, I2 = 58).
CONCLUSION
The findings from our study suggest no significant association between frailty status and AKI after TAVR. However, frailty status is associated with mortality after TAVR and may aid appropriate patient selection for TAVR.
Topics: Acute Kidney Injury; Aortic Valve Stenosis; Humans; Transcatheter Aortic Valve Replacement
PubMed: 28545062
DOI: 10.1371/journal.pone.0177157 -
Journal of Clinical and Diagnostic... Mar 2017Nuchal Translucency (NT) is the sonographic form of subcutaneous gathering of liquid behind the foetal neck in the first trimester of pregnancy. There is association of...
INTRODUCTION
Nuchal Translucency (NT) is the sonographic form of subcutaneous gathering of liquid behind the foetal neck in the first trimester of pregnancy. There is association of increased NT with chromosomal and non-chromosomal abnormalities.
AIM
The purpose of this systemic review was to review the pregnancy outcome of abnormal nuchal translucency.
MATERIALS AND METHODS
The present systematic review was conducted by searching English language articles from sources such as International Medical Sciences, Medline, Web of science, Scopus, Google Scholar, PubMed, Index Copernicus, DOAJ, EBSCO-CINAHL. Persian articles were searched from Iranmedex and SID sources. Related key words were "outcome", "pregnancy", "abnormal", and "Nuchal Translucency" (NT). All, randomized, descriptive, analytic-descriptive, case control study conducted during 1997-2015 were included.
RESULTS
Including duplicate articles, 95 related articles were found. After reviewing article titles, 30 unrelated article and abstracts were removed, and 65 articles were evaluated of which 30 articles were duplicate. Finally 22 articles were selected for final analysis. Exclusion criteria were, case studies and reports and quasi experimental designs. This evaluation has optioned negative relationship between nuchal translucency and pregnancy result. Rate of cardiac, chromosomal and other defects are correlated with increased NT≥2.5mm. Cardiac disease which were associated to the increased NT are heart murmur, systolic organic murmur, Atrial Septal Defect (ASD), Ventricular Septal Defect (VSD), tricuspid valve insufficiency and pulmonary valve insufficiency, Inferior Vena Cava (IVC) and Patent Ductus Arteriosus (PDA). The most common problems that related with increased NT were allergic symptoms.
CONCLUSION
According to this systematic review, increased NT is associated with various foetal defects. To verify the presence of malformations, birth defect consultations with a perinatologist and additional tests are required.
PubMed: 28511453
DOI: 10.7860/JCDR/2017/23755.9384 -
The Cochrane Database of Systematic... Apr 2017Aortic valve disease is a common condition that is easily treatable with cardiac surgery. This is conventionally performed by opening the sternum longitudinally down the... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Aortic valve disease is a common condition that is easily treatable with cardiac surgery. This is conventionally performed by opening the sternum longitudinally down the centre ("median sternotomy") and replacing the valve under cardiopulmonary bypass. Median sternotomy is generally well tolerated, but as less invasive options have become available, the efficacy of limited incisions has been called into question. In particular, the effects of reducing the visibility and surgical access has raised safety concerns with regards to the placement of cannulae, venting of the heart, epicardial wire placement, and de-airing of the heart at the end of the procedure. These difficulties may increase operating times, affecting outcome. The benefits of smaller incisions are thought to include decreased pain; improved respiratory mechanics; reductions in wound infections, bleeding, and need for transfusion; shorter intensive care stay; better cosmesis; and a quicker return to normal activity.
OBJECTIVES
To assess the effects of minimally invasive aortic valve replacement via a limited sternotomy versus conventional aortic valve replacement via median sternotomy in people with aortic valve disease requiring surgical replacement.
SEARCH METHODS
We performed searches of CENTRAL, MEDLINE, Embase, clinical trials registries, and manufacturers' websites from inception to July 2016, with no language limitations. We reviewed references of identified papers to identify any further studies of relevance.
SELECTION CRITERIA
Randomised controlled trials comparing aortic valve replacement via a median sternotomy versus aortic valve replacement via a limited sternotomy. We excluded trials that performed other minimally invasive incisions such as mini-thoracotomies, port access, trans-apical, trans-femoral or robotic procedures. Although some well-conducted prospective and retrospective case-control and cohort studies exist, these were not included in this review.
DATA COLLECTION AND ANALYSIS
Two review authors independently assessed trial papers to extract data, assess quality, and identify risk of bias. A third review author provided arbitration where required. The quality of evidence was determined using the GRADE methodology and results of patient-relevant outcomes were summarised in a 'Summary of findings' table.
MAIN RESULTS
The review included seven trials with 511 participants. These included adults from centres in Austria, Spain, Italy, Germany, France, and Egypt. We performed 12 comparisons investigating the effects of minimally invasive limited upper hemi-sternotomy on aortic valve replacement as compared to surgery performed via full median sternotomy.There was no evidence of any effect of upper hemi-sternotomy on mortality versus full median sternotomy (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.36 to 2.82; participants = 511; studies = 7; moderate quality). There was no evidence of an increase in cardiopulmonary bypass time with aortic valve replacement performed via an upper hemi-sternotomy (mean difference (MD) 3.02 minutes, 95% CI -4.10 to 10.14; participants = 311; studies = 5; low quality). There was no evidence of an increase in aortic cross-clamp time (MD 0.95 minutes, 95% CI -3.45 to 5.35; participants = 391; studies = 6; low quality). None of the included studies reported major adverse cardiac and cerebrovascular events as a composite end point.There was no evidence of an effect on length of hospital stay through limited hemi-sternotomy (MD -1.31 days, 95% CI -2.63 to 0.01; participants = 297; studies = 5; I = 89%; very low quality). Postoperative blood loss was lower in the upper hemi-sternotomy group (MD -158.00 mL, 95% CI -303.24 to -12.76; participants = 297; studies = 5; moderate quality). The evidence did not support a reduction in deep sternal wound infections (RR 0.71, 95% CI 0.22 to 2.30; participants = 511; studies = 7; moderate quality) or re-exploration (RR 1.01, 95% CI 0.48 to 2.13; participants = 511; studies = 7; moderate quality). There was no change in pain scores by upper hemi-sternotomy (standardised mean difference (SMD) -0.33, 95% CI -0.85 to 0.20; participants = 197; studies = 3; I = 70%; very low quality), but there was a small increase in postoperative pulmonary function tests with minimally invasive limited sternotomy (MD 1.98 % predicted FEV1, 95% CI 0.62 to 3.33; participants = 257; studies = 4; I = 28%; low quality). There was a small reduction in length of intensive care unit stays as a result of the minimally invasive upper hemi-sternotomy (MD -0.57 days, 95% CI -0.93 to -0.20; participants = 297; studies = 5; low quality). Postoperative atrial fibrillation was not reduced with minimally invasive aortic valve replacement through limited compared to full sternotomy (RR 0.60, 95% CI 0.07 to 4.89; participants = 240; studies = 3; moderate quality), neither were postoperative ventilation times (MD -1.12 hours, 95% CI -3.43 to 1.19; participants = 297; studies = 5; low quality). None of the included studies reported cost analyses.
AUTHORS' CONCLUSIONS
The evidence in this review was assessed as generally low to moderate quality. The study sample sizes were small and underpowered to demonstrate differences in outcomes with low event rates. Clinical heterogeneity both between and within studies is a relatively fixed feature of surgical trials, and this also contributed to the need for caution in interpreting results.Considering these limitations, there was uncertainty of the effect on mortality or extracorporeal support times with upper hemi-sternotomy for aortic valve replacement compared to full median sternotomy. The evidence to support a reduction in total hospital length of stay or intensive care stay was low in quality. There was also uncertainty of any difference in the rates of other, secondary outcome measures or adverse events with minimally invasive limited sternotomy approaches to aortic valve replacement.There appears to be uncertainty between minimally invasive aortic valve replacement via upper hemi-sternotomy and conventional aortic valve replacement via a full median sternotomy. Before widespread adoption of the minimally invasive approach can be recommended, there is a need for a well-designed and adequately powered prospective randomised controlled trial. Such a study would benefit from performing a robust cost analysis. Growing patient preference for minimally invasive techniques merits thorough quality-of-life analyses to be included as end points, as well as quantitative measures of physiological reserve.
Topics: Aged; Aortic Valve; Atrial Fibrillation; Blood Loss, Surgical; Cardiopulmonary Bypass; Heart Valve Diseases; Heart Valve Prosthesis Implantation; Humans; Length of Stay; Middle Aged; Operative Time; Pain Measurement; Postoperative Complications; Randomized Controlled Trials as Topic; Reoperation; Sternotomy; Surgical Wound Infection
PubMed: 28394022
DOI: 10.1002/14651858.CD011793.pub2