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BACKGROUND: Computed tomographic coronary angiography is a noninvasive imaging modality that permits identification and characterization of coronary plaques. Despite consensus statements supporting routine reporting of computed tomographic coronary angiography plaque characteristics, there remains uncertainty whether these data convey prognostic information. We performed a systematic review and meta-analysis assessing the strength of association between computed tomographic coronary angiography-derived plaque characterization and major adverse cardiovascular events (MACE). METHODS AND RESULTS: Electronic databases were searched for studies reporting computed tomographic coronary angiography plaque characterization and MACE. Data were gathered on plaque morphology (noncalcified, partially calcified, and calcified) and high-risk plaque (HRP) features, including low-attenuation plaque, napkin-ring sign, spotty calcification, and positive remodeling. Of 5496 citations, 13 studies met inclusion criteria. Five hundred fifty-two (3.9%) MACE occurred in 13977 patients with mean follow-up ranging between 1.3 and 8.2 years. In terms of plaque morphology, the strongest association was observed for noncalcified plaque (hazard ratio [HR], 1.45; 95% confidence interval [CI], 1.24-1.70; P<0.001), with weaker associations found for partially calcified (HR, 1.37; 95% CI, 1.18-1.60; P<0.001) and calcified plaques (HR, 1.23; 95% CI, 1.16-1.30; P<0.001). All HRP features were strongly associated with MACE, including napkin-ring sign (HR, 5.06; 95% CI, 3.23-7.94; P<0.001), low-attenuation plaque (HR, 2.95; 95% CI, 2.03-4.29; P<0.001), positive remodeling (HR, 2.58; 95% CI, 1.84-3.61; P<0.001), and spotty calcification (HR, 2.25; 95% CI, 1.26-4.04; P=0.006). The presence of >=2 HRP features had highest risk of MACE (HR, 9.17; 95% CI, 4.10-20.50; P<0.001). CONCLUSION(S): These data demonstrate that HRP is most likely an independent predictor of MACE, which supports the inclusion of HRP re

Objectives. To assess whether periprocedural myocardial injury (PPMI) predicts outcomes in patients undergoing transcatheter aortic valve replacement (TAVR). Background. PPMI is a strong predictor of outcomes following coronary intervention, but its impact in the context of TAVR remains unclear. We performed a systematic review and meta-analysis to ascertain the association between PPMI and short or long-term clinical outcomes. Methods. Electronic searches identified studies reporting PPMI following TAVR. Primary endpoint was 30-day all-cause mortality, with secondary endpoints including 1-year all-cause mortality, neurological events, post-TAVR pacemaker implantation and aortic regurgitation (AR). Analyses were performed using random effects modelling and reported as summary odds ratio (OR) with 95% confidence intervals (CI). Results. Nine studies comprising 3,442 patients (mean age 81.0+/-6.6 years, 51.2% female) were included. PPMI occurred in 25.5% of patients following TAVR. The pooled all-cause mortality at 30 days and 1 year was 5.2% and 18.6%, respectively. The occurrence of PPMI following TAVR was associated with significantly increased risk of both 30-day (OR 4.23, CI 1.95-9.19, p<0.001) and 1-year all-cause mortality (OR 1.77, CI 1.05-2.99, p<0.001). Similarly, PPMI was associated with post-TAVR neurological events (OR 2.72, CI 1.69-4.37, p<0.001) and post-TAVR need for permanent pacing (OR 1.43, CI 1.02-2.00, p=0.04), but not with statistically significant increase in AR post-TAVR (OR 1.39, CI 0.93-2.08, PVL (p=0.11). Conclusions. PPMI is common following TAVR and is strongly associated with 30-day and 1-year mortality, with occurrence of post-TAVR neurological events and need for permanent pacemaker implantation. Detection of PPMI has potential to identify TAVR patients at highest risk of subsequent adverse events.

Aim: Targeted therapy (TT) has improved survival for metastatic renal cell carcinoma (mRCC). However, survival is usually limited if brain metastases (BMs) develop. We aimed to evaluate survival outcomes in mRCC patients based on timing of BM diagnosis. Method(s): We conducted a multicenter, retrospective study of mRCC patients with BM who received TT at any point between 2005 and 2014. We determined overall survival (OS) from stage IV diagnosis, TT initiation and BM diagnosis, and prognostic factors. Patients were grouped into three categories: synchronous-BM, metachronous-BM diagnosed while conservatively managed (metachronous-BM before TT) and metachronous-BM diagnosed during TT. Survival was calculated by Kaplan-Meier method and predictors were calculated using Cox hazards regression. Result(s): Incidence of BM was 17% in mRCC patients treated with TT (two centers). Fifty-four mRCC-BM patients were identified from five tertiary centers. Twenty-eight percentage (15/54) had synchronous-BM, 28% (15/54) had metachranous-BM before TT and 44% (24/54) had metachronous-BM during TT. Most had central nervous system (CNS) symptoms at BM diagnosis (78%; 42/54). Median OS from stage IV diagnosis, TT commencement and BM diagnosis was 28 months (95% confidence interval [CI] 16-43), 19 months (95% CI 9-26) and 9 months (95% CI 5-16), respectively. Synchronous-BM group trended toward poorer survival from TT commencement (P = 0.06). Metachronous-BM during TT group had lower survival from BM diagnosis than synchronous-BM and metachronous-BM before TT group (P < 0.001). Eight of 50 deaths (16%) were from neurological complications. The presence of CNS symptoms did not predict worse survival from stage IV diagnosis (P = 0.73). Conclusion(s): In patients with mRCC, the development of BM while on TT portends shorter prognosis compared with synchronous diagnosis of BM at stage IV disease or metachronous BM developed prior to commencing TT. The presence of CNS symptoms does not predict

Background: The appropriate and safe peri-procedural anticoagulation schedule for patients on a direct oral anticoagulant (DOAC) undergoing AF ablation is not known. We aimed to evaluate the safety and efficacy of both continuous and minimally-interrupted novel oral anticoagulant (DOAC) strategies compared with uninterrupted vitamin K antagonist (VKA) for atrial fibrillation (AF) ablation. Method(s): We searched electronic databases for randomized or prospective controlled observational studies comparing DOAC (continuous or interrupted) versus uninterrupted VKA. The primary endpoint was major bleeding. Secondary endpoints were total bleeding (composite of major and minor bleeding) and symptomatic thromboembolism. Data were analyzed by random-effects modeling and sensitivity analyses performed according to study design and peri-procedural DOAC schedule. Result(s): Thirteen studies (4 randomized, 9 observational) with 5463 patients were included in final analysis (45% on DOAC). DOAC was associated with less major bleeding compared with VKA in pooled randomized studies (odds ratio [OR] 0.27, 95% confidence interval [CI] 0.09-0.80, p = 0.03, I2 = 0%), however there was no difference on overall analyses (OR 0.70, 95% CI 0.39-1.24, p = 0.22, I2 = 27%). When stratified by DOAC dose schedule, there was no difference in major bleeding for continuous DOAC (OR 0.48, 95% CI 0.21-1.11, p = 0.09, I2 = 6%) or minimally-interrupted DOAC (OR 0.81, 95% CI 0.37-1.76, p = 0.60, I2 = 43%) compared with VKA. There was no difference between DOAC and VKA for risk of total bleeding (p = 0.20) or symptomatic thromboembolism (p = 0.78). Conclusion(s): Continuous and minimally-interrupted DOAC are both safe and non-inferior peri-procedural anticoagulation strategies compared with uninterrupted VKA for AF ablation. DOAC in general is associated with reduced major bleeding as demonstrated in pooled randomized studies.Copyright © 2018 Elsevier B.V.

Background/purpose: Percutaneous coronary intervention (PCI) is the preferred strategy for treatment of saphenous vein graft (SVG) disease. However, there remains ongoing debate on whether drug-eluting stents (DES) or bare-metal stents (BMS) should be used during SVG-PCI. Methods/materials: We performed a meta-analysis of randomized controlled trials (RCTs) comparing DES and BMS for SVG-PCI. The primary end point was major adverse cardiac events (MACE), defined as composite of all-cause death, myocardial infarction (MI) or repeat revascularization. Secondary end points included individual MACE components, cardiac death and stent thrombosis (ST). Result(s): Six RCTs including 1582 patients (50% receiving DES) met inclusion criteria. MACE occurred in 31% (244/797) patients receiving DES and 36% (281/785) patients receiving BMS (median follow-up, 12-35 months). There was no significant difference in MACE between DES and BMS (Odds Ratio (OR) 0.62, 95%CI 0.36-1.09, p = 0.10, I2 = 77%). However, for individual components of MACE, DES was associated with a significant reduction in repeat revascularization (OR 0.53, 95%CI 0.29-0.97, p = 0.04, I2 = 73%). There was no difference in all-cause death (OR 1.30, 95%CI 0.77-2.20, p = 0.33, I2 = 40%), MI (OR 0.68, 95%CI 0.38-1.25, p = 0.22, I2 = 56%), cardiac death (OR 1.08, 95%CI 0.45-2.64, p = 0.86, I2 = 42%) or ST (OR 0.89, 95%CI 0.37-2.17, p = 0.80, I2 = 35%) between stents. Conclusion(s): Although there was no significant difference in MACE, DES is associated with a reduction in repeat revascularization compared with BMS in pooled randomized trials for SVG-PCI. The high occurrence of MACE in both stent platforms highlights the need for novel therapeutic approaches to improve clinical outcomes following SVG intervention. We performed a meta-analysis of randomized controlled trials comparing DES and BMS for SVG-PCI. There was no significant difference in MACE between DES and BMS. However, for individual components of MACE, DES wa

Background: Polymer-free drug eluting stents (PF-DES) were developed, in part, to overcome risk of late ischemic events observed with permanent polymer-coated DES (PP-DES). However, trial results are inconsistent with longer-term safety and efficacy of PF-DES remaining unknown. We performed a meta-analysis of randomized trials assessing outcomes of patients receiving PF-DES versus PP-DES for treatment of coronary artery disease (CAD). Method(s): Electronic searches were performed for randomized trials comparing outcomes between PF-DES and PP-DES. Trials reporting major adverse cardiovascular events (MACE), myocardial infarction (MI), stent thrombosis (ST), all-cause death, target lesion/vessel revascularization (TLR/TVR), and late lumen loss (LLL) were included. Analyses were performed at longest follow-up and landmarked beyond 1-year. Result(s): Twelve trials (6,943 patients) were included. There was no significant difference in MACE between PF-DES and PP-DES at longest follow-up (Odds Ratio [OR] 0.96, 95%CI 0.85-1.10, P = 0.59) or landmark analysis beyond 1-year (OR 0.96, 95%CI 0.76-1.20, P = 0.70). Although PF-DES were associated with a significant reduction in all-cause death (OR 0.85, 95%CI 0.72-1.00, P < 0.05), this effect was not present on landmark analysis beyond 1-year (OR 0.89, 95%CI 0.73-1.10, P = 0.30). There were no differences observed for MI (OR 1.00, 95%CI 0.77-1.28, P = 0.99) or ST (OR 0.95, 95%CI 0.54-1.68, P = 0.86), with similar efficacy outcomes including TVR (OR 1.07, 95%CI 0.91-1.26, P = 0.42), TLR (OR 1.03, 95%CI 0.88-1.21, P = 0.68) and angiographic LLL (pooled mean difference 0.01 mm, 95%CI -0.08 to 0.11, P = 0.76). Conclusion(s): PF-DES are as safe and efficacious as PP-DES for the treatment of patients with CAD, but do not significantly reduce late ischemic complications.Copyright © 2018 Wiley Periodicals, Inc.

Background: Patients with aggressive lymphoma achieving complete remission (CR) after first-line combination chemotherapy undergo regular surveillance to detect relapse. Current international guidelines recommend routine follow-up blood tests in this context, but evidence supporting this practice is limited. Method(s): We conducted a multi-centre retrospective analysis of all patients diagnosed with aggressive lymphoma treated with curative-intent chemotherapy who achieved CR for at least 3 months between 2000 and 2015. An abnormal blood test was defined as any new and unexplained abnormality for full blood examination, lactate dehydrogenase or erythrocyte sedimentation rate. Result(s): Three hundred and forty-six patients attended a total of 3084 outpatient visits; blood tests were performed at 90% of these appointments. Fifty-six (16%) patients relapsed. Routine laboratory testing detected relapse in only three patients (5% of relapses); in the remaining patients, relapse was suspected clinically (80%) or detected by imaging (15%). The sensitivity of all blood tests was 42% and the positive predictive value was 9%. No significant difference in survival was shown in patients who underwent a routine blood test within 3 months prior to relapse versus those who did not (p = 0.88). Conclusion(s): Routine blood tests demonstrate unacceptably poor performance characteristics, have no impact on survival and thus have limited value in the detection of relapse in routine surveillance.Copyright © 2018, Cancer Research UK.

Optical coherence tomography (OCT) is an increasingly available intracoronary imaging modality that provides high-resolution imaging of coronary arteries. Its fundamental reliance on the emission and reflection of light enables rapid data acquisition without compromise of image resolution. As such, OCT can inform operators planning percutaneous coronary intervention (PCI) by accurately defining luminal geometry and detailing plaque composition. Following PCI, OCT imaging delivers a thorough assessment of the treated arterial segment and can identify specific features not always visible on alternate imaging modalities, including stent edge-related dissection, plaque tissue prolapse, incomplete stent apposition and the presence of intra-coronary thrombus. Clinical trials highlight that procedural strategy is frequently altered based on OCT findings, while concerns over final stent dimensions have been mitigated through use of a sizing protocol based on external elastic lamina dimensions in the reference arterial segment. Randomised trials are now warranted to definitively ascertain whether OCT-guidance improves clinical outcomes when utilised during PCI.Copyright © 2017 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ)

Background Exercise confidence predicts exercise adherence in heart failure (HF) patients. The association between simple tests of functional capacity on exercise confidence are not known. Objectives To evaluate the association between a single 6-min walk test (6MWT) and exercise confidence in HF patients. Methods Observational study enrolling HF outpatients who completed the Cardiac Depression Scale and an Exercise Confidence Survey at baseline and following the 6MWT. Paired t-test was used to compare repeated-measures data, while Repeated Measures Analysis of Covariance was used for multivariate analysis. Results 106 HF patients were enrolled in the study (males, 82%; mean age, 64 +/- 12 years). Baseline Exercise Confidence was inversely associated with age (p < 0.01), NYHA class (p < 0.001), and depression (p < 0.001). The 6MWT was associated with an improvement in Exercise Confidence (F(1,92) = 5.0, p = 0.03) after adjustment for age, gender, HF duration, NYHA class and depression. Conclusions The 6MWT is associated with improved exercise confidence in HF patients.Copyright © 2017 Elsevier Inc.

Introduction: Chronic heart failure (CHF) patients have poor adherence to self-care behaviours, particularly exercise. Patient confidence in their physical abilities is a known predictor of exercise adherence. However, factors influencing confidence are poorly understood and the efficacy of simple interventions to increase such confidence is not known. The aim of this single-site, repeated measures study was to evaluate the effects of a 6-minute walk test (6MWT) on exercise confidence in CHF patients. Method(s): CHF patients attending an out-patient heart failure clinic at a major tertiary hospital were prospectively enrolled to perform a 6MWT under supervised conditions according to American Thoracic Society Guidelines. Consenting participants completed the Cardiac Depression Scale (CDS) at baseline and an Exercise Confidence Survey (range 0-100; higher scores indicate greater confidence) at baseline and following completion of a 6MWT. Baseline demographics, including CHF characteristics, were obtained from hospital medical records. Result(s): Fifty-seven CHF patients were eligible for enrolment to the study (81% males, mean age = 63 +/- 13 years). Most patients (68%) had non-ischemic CHF aetiology and were NYHA class II or III. Over one quarter of patients (28%) were depressed (CDS >= 95). Baseline Total Exercise Confidence (mean 66 +/- 24) was inversely associated with age (p<0.01), NYHA class (p<0.001), and depression (p<0.001). Distance walked on 6MWT (mean = 400 +/- 123 metres) was positively correlated with Baseline Total Exercise Confidence (p<0.001) and with each of the baseline Exercise Confidence sub-scales (ie., Walking, Running, Climbing and Lifting Confidence; p<0.001). Following the 6MWT, a significant improvement in Total Exercise Confidence (F(1, 49) = 7.26, p<0.01) and Running Confidence (F(1, 51) = 4.77, p<0.05) adjusted for age, CDS score and NYHA class, was observed. Conclusion(s): These findings suggest that the 6MWT is a simple and effective i

Chronic heart failure (CHF) is a common, debilitating condition associated with significant health and economic burden. CHF management is multidisciplinary, however, achieving better health relies on a collaborative effort and patient engagement in self-care. Despite the importance of self-care in CHF, many patients have poor adherence to their medical and lifestyle regimens, in particular with regards to engaging in physical exercise. The patient's confidence in their ability, otherwise known as self-efficacy, is an important determinant of CHF health outcomes, most likely due to its effect on the uptake of CHF self-care activities especially exercise initiation and maintenance. Self-efficacy is responsive to experience such as exercise training, however the critical components of exercise interventions to improve self-efficacy have yet to be determined. This narrative review provides an overview of the role of self-efficacy in exercise adherence in CHF.Copyright © 2017 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ)

Background - Current guidelines suggest that coronary artery bypass grafting (CABG) should be the preferred revascularization method for unprotected left main coronary artery stenosis. In light of evidence from recent randomized trials, we assessed whether percutaneous coronary intervention (PCI) using drug-eluting stents is as safe and effective as CABG for the treatment of unprotected left main coronary artery disease. Methods and Results - Digital databases and manual searches were performed for randomized trials comparing PCI and CABG for unprotected left main coronary artery stenosis. Among 3887 potentially relevant studies, 5 met inclusion criteria. The primary safety end point was defined as the composite of all-cause death, myocardial infarction, or stroke. Secondary end points included a clinical effectiveness composite, which was defined as all-cause death, myocardial infarction, stroke, or repeat revascularization. Summary estimates were obtained using random-effects modeling. In total, 4594 patients were included in the analysis. There was no significant difference in the primary safety end point between the revascularization strategies (odds ratio [OR], 0.97; 95% confidence interval [CI], 0.79-1.17; P=0.73). However, when compared with CABG, PCI was less effective (OR, 1.36; 95% CI, 1.18-1.58; P<0.001) because of significantly higher rates of repeat revascularization (OR, 1.85; 95% CI, 1.53-2.23; P<0.001). The incidence of all-cause death (OR, 1.03; 95% CI, 0.78-1.35; P=0.61), myocardial infarction (OR, 1.46; 95% CI, 0.88-2.45; P=0.08), and stroke (OR, 0.88; 95% CI, 0.39-1.97; P=0.53) did not differ between PCI and CABG. Conclusions - PCI using drug-eluting stents and CABG are equally safe methods of revascularization for patients at low surgical risk with significant unprotected left main coronary artery stenosis. However, CABG is associated with significantly lower rates of repeat revascularization.Copyright © 2016 American Heart Association, Inc.