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Background Coronary artery calcification is associated with poor outcomes in patients undergoing percutaneous coronary intervention (PCI). Atheroablative techniques such as orbital atherectomy (OA) and rotational atherectomy (RA) are routinely utilized to treat these calcified lesions in order to optimize lesion preparation and facilitate stent delivery. Objectives The purpose of this systematic review and meta-analysis is to compare the performance of OA versus RA in patients with calcified coronary artery disease (CAD) undergoing PCI. Methods We conducted an electronic database search of all published data for studies that compared OA versus RA in patients with calcified coronary artery disease undergoing PCI and reported on outcomes of interest. Event rates were compared using a forest plot of odds ratios using a random-effects model assuming interstudy heterogeneity. Results A total of five observational studies (total number of patients = 1872; OA = 535, RA = 1337) were included in the final analysis. On pooled analysis, OA compared to RA was associated with a significant reduction in fluoroscopy times (OR = −6.33; 95% CI = −9.90 to −2.76; p Conclusion Except for lower fluoroscopy time with OA, there are no significant differences between OA and RA in relation to procedural, periprocedural, and thirty day outcomes among patients with calcified CAD undergoing PCI.

Introduction The purpose of this meta-analysis is to compare the efficacy of MitraClip plus medical therapy versus medical therapy alone in patients with functional mitral regurgitation (FMR). FMR caused by left ventricular dysfunction is associated with poor prognosis. Whether MitraClip improves clinical outcomes in this patient population remains controversial. Methods We conducted an electronic database search of PubMed, CINAHL, Cochrane Central, Scopus, Google Scholar, and Web of Science databases for randomized control trials (RCTs) and observational studies with propensity score matching (PSM) that compared MitraClip plus medical therapy with medical therapy alone for patients with FMR and reported on subsequent mortality, heart failure re-hospitalization, and other outcomes of interest. Event rates were compared using a random-effects model with odds ratio as the effect size. Results Five studies (n = 1513; MitraClip = 796, medical therapy = 717) were included in the final analysis. MitraClip plus medical therapy compared to medical therapy alone was associated with a significant reduction in overall mortality (OR = 0.66, 95% CI = 0.44–0.99, P = 0.04) and heart failure (HF) re-hospitalization rates (OR = 0.57, 95% CI = 0.36–0.91, P = 0.02). There was reduced need for heart transplantation or mechanical support requirement (OR = 0.48, 95% CI = 0.25–0.91, P = 0.02) and unplanned mitral valve surgery (OR = 0.21, 95% CI = 0.07–0.61, P = 0.004) in the MitraClip group. No effect was observed on cardiac mortality (P = 0.42) between the two groups. Conclusions MitraClip plus medical therapy improves overall mortality and reduces HF re-hospitalization rates compared to medical therapy alone in patients with FMR. Electronic supplementary material The online version of this article (10.1007/s40119-019-00157-3) contains supplementary material, which is available to authorized users.

Objectives: The objective of this study was to compare safety and efficacy of patent foramen ovale (PFO) closure compared with medical therapy in patients with cryptogenic stroke (CS). Background: The role of PFO closure in preventing recurrent stroke in patients with prior CS has been controversial. Methods: We searched PubMed, EMBASE, the Cochrane Central Register of Controlled trials, and the clinical trial registry maintained at clinicaltrials.gov for randomized control trials that compared device closure with medical management and reported on subsequent stroke and adverse events. Event rates were compared using a forest plot of relative risk using a random-effects model assuming interstudy heterogeneity. Results: A total of 6 studies (n = 3747) were included in the final analysis. Mean follow-up ranged from 2 to 5.9 years. Pooled analysis revealed that device closure compared to medical management was associated with a significant reduction in stroke (risk ratio [RR] = 0.41, 95% CI = 0.20–0.83, I2 = 51%, P = 0.01). There was, however, a significant increase in atrial fibrillation with device therapy (RR = 5.29, 95% CI = 2.32–12.06, I2 = 38%, P

OBJECTIVE The purpose of this meta-analysis is to compare the safety and efficacy of transcatheter aortic-valve replacement (TAVR) to surgical aortic valve replacement (SAVR) in low-surgical-risk patients. BACKGROUND TAVR is proven to be safe and effective in patients with high- and intermediate-risk aortic stenosis. However, there is limited data on the safety and efficacy of TAVR in patients with low surgical risk. METHODS We conducted an electronic database search of all published data for studies that compared TAVR to SAVR in low-surgical-risk patients (mean society for thoracic surgery [STS] score

Objective This meta-analysis sought to evaluate the outcomes of absorb bioresorbable vascular scaffolds (BVS) compared with second-generation drug-eluting stents (DES) after 3 years, the approximate time of complete polymer bioresorption. Background BVS were found to be inferior to second-generation DES in early and mid-term outcomes with a higher rate of target vessel myocardial infarction (TV-MI) and device thrombosis (DT). Improper implantation techniques and incomplete bioresorption of the poly-l-lactide (PLLA) polymer were sighted as possible reasons. Methods We conducted an electronic database search for all randomized control trials that compared absorb BVS to second-generation DES and reported outcomes of interest after 3 years of absorb BVS implantation. Assuming interstudy heterogeneity, a random-effects analysis was conducted with odds ratio as the effect size of choice to compare the event rates between the two groups. Results A total of four studies (n = 3,245, BVS = 2075, DES = 1,170) were included in the final analysis. Pooled analysis revealed that there was no difference between absorb BVS and second-generation DES with respect to target lesion failure (TLF) (OR = 1.23, 95% CI = 0.73-2.07, p = 0.44), TV-MI (OR = 1.03, 95% CI = 0.42-2.53, p = 0.95), target lesion revascularization (TLR) (OR = 1.61, 95% CI = 0.77-3.33, p = 0.20) and definite/probable DT (OR = 0.71, 95% CI = 0.10-5.07, p = 0.74). Also, there was no difference in cardiac mortality (OR = 0.66, 95% CI = 0.22-1.94, p = 0.45). Conclusions Between 3 and 4 years of follow-up, patients receiving absorb BVS did not have significantly different outcomes, in terms of TLF, TV-MI, TLR, DT, and cardiac mortality, compared to DES.

BACKGROUND Debate still occurs of the benefits of transradial access (TRA) versus transfemoral access (TFA), especially for complex percutaneous coronary interventions. Recent data has shown equivalent efficacy and improved safety outcomes with TRA. OBJECTIVES To systematically review and perform a meta-analysis comparing procedural characteristics and clinical outcomes of TRA versus TFA in patients who underwent percutaneous coronary intervention (PCI) for left main (LM) disease. METHODS We conducted an electronic database search of all published data for studies that compared TRA with TFA in patients undergoing PCI of LM disease. Event rates were compared using the odds ratio (OR) as a measure of effect size. Random-effects models were used to account for interstudy heterogeneity. RESULTS A total of 12 observational studies including 17,258 patients (TRA n = 7,971; TFA n = 9,287) were included. Compared to TFA, TRA was associated with a significant reduction in access site bleeding (OR = 0.11; 95% confidence interval [CI] = 0.04-0.26; I2 = 0%; p

Background Current quality-monitoring initiatives do not accurately evaluate surgical site infections based on type of surgical procedure. Objective This study aimed to characterize the effect of the anatomical site resected (right, left, rectal) on wound complications, including superficial, deep, and organ space surgical site infections, in patients who have cancer. Settings Data were retrieved from the American College of Surgeons National Surgical Quality Improvement Program database. Design This study was designed to determine the independent risk associated with the anatomical location of cancer resection for all subtypes of surgical site infection. Statistical methods included the Fisher exact test, the χ test, and univariable and multivariable analyses for each outcome of interest. Patients All colon and rectal resections for colorectal cancer between 2006 and 2012 were selected. Included were 45,956 patients: 17,993 (39.2%) underwent right colectomy, 11,538 (25.1%) underwent left colectomy, and 16,425 (35.7%) underwent rectal resections. Results The overall surgical site infection rate was 12.3%: 3.7% organ space, 1.4% deep, and 7.2% superficial. On multivariable analysis, rectal resection was associated with the greatest odds of overall surgical site infections in comparison with left- or right-sided resections (rectal OR, 1.51; 95% CI, 1.35-1.69 vs left OR, 1.09; 95% CI, 0.97-1.23 vs right OR, 1). Rectal resections were also associated with greater odds of developing a deep surgical site infection than either right (rectal OR, 1.45; 95% CI, 1.06-1.99) or left (OR, 0.89; 95% CI, 0.62-1.27). The likelihood of organ space surgical site infection followed a similar pattern (rectal OR, 1.83; 95% CI 1.49-2.25; left colon, OR, 0.95; 95% CI, 0.75-1.19). Rectal and left resections had increased odds of superficial surgical site infections compared with right resections (rectal OR, 1.31; 95% CI, 1.14-1.51; left OR, 1.19; 95% CI, 1.03-1.37). Limitations This is a retrospective observational study. Conclusions Rectal resections for cancer are independently associated with an increased likelihood of superficial, deep, and organ space infections. The policy on surgical site infections as a quality measure currently in place requires modification to adjust for the location of pathology and, hence, the anatomical segment resected when assessing the risk for type of surgical site infection.

INTRODUCTION: COVID-19 poses a special challenge for patients with inflammatory bowel disease (IBD) on biologics due to concern of higher risk for infection In an effort to limit patient exposure, our center underwent an expedited process to consider transitioning IBD patients from hospital-based infusions to home infusions In this study, we present data on barriers and delays to home infusion (HI) transitions in the setting of the COVID-19 METHODS: We performed a retrospective chart review of adult IBD patients receiving IV biologics at our hospital-based infusion center between 1/1/2020 and 5/15/2020 Patients were excluded if receiving biologics for a non-IBD indication, if receiving infusion at a different center, or if already receiving HI The primary objective was to assess barriers to HI transition The secondary objectives were to identify delays in receiving HI and factors contributing to delayed HI A HI was considered delayed if there was a delay of greater than 3 days from the planned infusion due date RESULTS: 149/400 patients met the inclusion criteria Patients were categorized into 3 groups 1) 70 (47 3%) patients who completed transition to HI 2) 29 patients (19 6%) who had the HI transition in process at the time of this review but were not considered delayed 3) 49 patients (33 1%) who did not undergo HI transition Those who completed HI transition, 68/70 (97 1%) were aged 65 or less 16/70 (22 9%) patients experienced a delay in receiving HI Median HI delay time was 7 days (range: 5 5-12 0) COVID-19 contributed to HI delay in 3/16 (18 75%), either due to confirmed testing or contact with a positive case 11/16 patients (68 75%) had no clearly documented or identifiable reason for the HI delay In 40/49 patients (81 6%) who did not complete transition to HI, Medicare insurance was identified as the barrier to HI Patient preference against HI was identified in 5/49 (10 2%) as a barrier CONCLUSION: The main barrier to HI transition was Medicare A successful HI transition was accomplished in the majority of the patients without any delay About one-fourth of the patients experienced HI delay, with a small proportion attributed to COVID-19 A small subset of those who did not transition had a personal preference against HI transition The expedited process of tran-sitioning to HI was considered successful, though it requires further assessment for cost-effectiveness and long-term safety outcomes in the setting of COVID-19

While laparoscopic colorectal resection may be underused in technically challenging circumstances, the minimally invasive approach may in fact maximally benefit patients at the greatest risk of complications. Obesity and proctectomy pose particular technical challenges during laparoscopic resection and are also associated with the greatest risks of complications, especially surgical site infections (SSIs). We evaluated the role of laparoscopy in minimizing SSI in such patients. From the American College of Surgeons-National Surgical Quality Improvement Program database, outcomes for obese [body mass index (BMI) ≥ 30 kg/m2] and non-obese (BMI

Acute myocardial infarction (AMI) is the most common cause of cardiogenic shock (CS). Sepsis can predispose to the development of AMI and is also a known cause of CS. The incidence and outcomes of CS with the clinical phenotype of sepsis-AMI are not well studied. We analyzed the United States

Introduction Clarification as to whether conversion to open surgery during laparoscopic colectomy leads to adverse clinical outcomes when compared to laparoscopic surgery that is completed will help establish if the minimally invasive approach should routinely be attempted in most instances with open surgery reserved for only when this were to fail. Method The National Surgery Quality Improvement Program 2012 database was used for analysis of patients who underwent laparoscopic colectomy. Patients were categorised into those who completed laparoscopic procedures, who had laparoscopic procedures with conversion to open, and who had open procedures. Analysis was carried out using chi-squared test, fisher exact test, and logistic regression. Results Of the 16,648 patients included, 7409 (44.50%) underwent open surgery. Of the 9239 who underwent laparoscopic colectomy, 1147 (12.41%) had conversion to open procedure. Strongest association with conversion was found with emergency procedures, preoperative sepsis and septic shock. The other associated factors were male sex, history of CHF, COPD, hypertension, steroid use and disseminated cancer. Post-operatively, compared to the patients who had laparoscopic procedure those who had conversion to open procedure had a higher risk of surgical and medical complications (see Table 1). However, when compared to patients who completed open surgery straightaway, patients who had conversion to open surgery had a higher risk for superficial SSI. While other complications were comparable to open surgery, converted patients had a lower risk of post-operative pneumonia, re-intubation, need for ventilation > 48 h, bleeding that required transfusion, sepsis, septic shock and return to the operating room. Conclusion While patients who have open conversion have worse outcomes than those who complete laparoscopic colectomy, outcomes for converted patients are not significantly worse than for comparable patients who undergo open surgery straightaway. Considering the benefits of the minimally invasive approach, laparoscopic colectomy may reasonably be attempted in any patient, even when completion may not be assured, with conversion reserved for when this is not feasible. Disclosure of interest None Declared.

Introduction Controversy pertaining to whether or not preoperative chemo and radiotherapy worsen immediate postoperative outcomes after colorectal surgery continues to persist. Data for a large number of patients from a standardised national dataset may allow an adequate evaluation of their influence on postoperative outcomes after colorectal surgery. Method Patients who underwent colorectal surgery for cancer from 2012–2013 were identified from the NSQIP database. Patients who underwent preoperative chemotherapy ( Results Of the 2,936 CRC patients selected, 2,431 (82.8%) underwent colorectal resection alone, 127 (4.3%) received chemotherapy, 45 (1.5%) radiotherapy and 333 (11.3%) chemoradiotherapy. When comparing patients who underwent preoperative chemoradiotherapy to those who had surgery alone, the chemoradiotherapy group had a lower mean age (59 vs. 66 years, p Conclusion Patients who undergo preoperative chemotherapy and radiotherapy prior to surgery for colorectal cancer are at greater risk for postoperative thromboembolic complications and surgical site infection. Since both these complications are potentially preventable, an awareness of the increased risks in these patients along with greater scrutiny and adoption of preventive strategies will likely reduce these complications. Disclosure of interest None Declared.

Introduction: Peritoneal carcinomatosis denotes extensive tumour involvement of the peritoneum, and is often regarded as terminal. There has been a paradigm shift in treatment, with the application of cytoreductive surgery combined with intra-peritoneal chemotherapy. The extensive nature of the surgery and malignancy-associated hypercoagulable state should increase the risk of PE, which can further increase morbidity and/or mortality. Incidence and risk factors for pulmonary embolism (PE) in this population have not been investigated in detail. Aims: To establish the incidence and specific operative risk factors for developing PE in patients with peritoneal carcinomatosis post peritonectomy and peri-operative intraperitoneal chemotherapy. Methods: A cohort of 596 patients that underwent cytoreductive surgery (peritonectomy) over a 12-year period was identified using the prospective database from St George Hospital Peritonectomy Unit. A case-control study was undertaken whereby cases were defined by the development of PE within 60 days of peritonectomy. A diagnosis of PE was based on computed tomography pulmonary angiography confirmation. The prospective database was reviewed to obtain the following clinical information for both cases (with PE) and controls (without PE): length of surgery, use of hyperthermic intraperitoneal chemotherapy (HIPEC) and early postoperative intraperitoneal chemotherapy (EPIC), peritoneal carcinomatosis index (PCI) and number of intraoperative blood transfusions. Results: The mean age of the cohort was 52.7 ± 13.1 years, with no significant difference in the ages of cases or controls; 43.3% were male and 56.7% were female. Primary malignancies in these patients were pseudomyxoma peritonei, appendiceal, ovarian or colorectal cancer, and mesothelioma. Out of the 596 patient cohort, 34 were identified as having PE post cytoreductive surgery (5.7%). When compared to controls, the PE group had longer mean operative time of 10.4 ± 2.8 hours vs 8.9 ± 3.1 hours (p=0.01) and higher mean PCI values at 23 ± 12 vs 18 ± 11 (p=0.02). An operative time of more >9 hours increased the risk of developing PE (OR 3.3, 95% CI 1.41-7.72, p=0.006) as did having a PCI of >20 (OR 2.4, 95% CI 1.18-4.9, p=0.02). There was no difference in mean transfusion requirements (6.6 vs 6.0; p=0.67). No significant association was found between HIPEC and development of PE (x2=2.87, 1 df, P=0.9) or EPIC and subsequent PE (x2=0.001, 1 df, P=1). Conclusions: There is a relatively high incidence of pulmonary embolism in patients following cytoreductive surgery for peritoneal carcinomatosis. Patients at highest risk of developing PE postoperatively are those with PCI of more than 20 and those who have operations lasting more than 9 hours. Peri-operative chemotherapy and blood transfusions are not risk factors for PE.