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ABSTRACTBackgroundThe safety and efficacy of percutaneous transaxillary transcatheter aortic valve replacement (TAVR) require evaluation. Transfemoral (TF) approach is the standard vascular access for TAVR, but some patients require alternative access due to iliofemoral artery disease. Transaxillary access has been shown to be as safe as TF access. There are limited reports of percutaneous transaxillary TAVR with a minimalist approach.MethodsConsecutive patients undergoing percutaneous transaxillary TAVR were enrolled. Clinical and procedural characteristics and clinical outcomes were reviewed and compared to TF TAVR performed during the same period.ResultsAmong 221 patients who underwent TAVR, 25 patients (11%) had TAVR with a percutaneous transaxillary approach based on computed tomography findings. Median age was 80 years; median STS score was 7%. STS score was higher (7% vs 4%, P= 0.008) and peripheral artery disease was more prevalent (64% vs 13%, P= 0.0001) among patients requiring transaxillary access. Twenty-four (96%) patients underwent the procedure with monitored anesthesia care with pectoral-1 nerve block. Hemostasis was achieved with preapplied ProglideTMclosure devices, with an additional closure device in 5 patients (20%). Median length of stay was 3 days, longer than in the TF group (2 days). There was no death, stroke, or major vascular complication. One minor vascular complication required surgical repair. Fluoroscopy time was longer in the transaxillary group than in the TF group (20 vs 16 min, P= 0.0004).ConclusionsPercutaneous transaxillary TAVR is a safe and effective alternative approach and can be performed with a minimalist approach with outcomes comparable to TF TAVR.

Rebound hyperthermia (RH) is frequently seen after completion of targeted temperature management (TTM) in comatose survivors of cardiac arrest. However, its clinical significance is not well understood. Previous studies analyzing the association of RH with clinical outcome have reported conflicting results. The purpose of this meta-analysis is to examine the impact of RH after completion of TTM in patients postcardiac arrest. We reviewed six studies that evaluated the incidence of RH (T > 38°C) with documentation of outcome based on the presence of hyperthermia. We reviewed all six articles and extracted the data for mortality and neurological outcome. A total of 729 patients were analyzed for neurological outcome and 950 patients were analyzed for mortality. RH was found to be associated with a significantly worse neurological outcome (odds ratio [OR] 1.55; 95% confidence interval [CI] 1.13–2.14). RH was not significantly associated with a higher mortality (OR 1.31; 95% CI 1.00–1.72). We also analyzed three studies totaling 206 patients for neurological outcomes and mortality that included patients with severe RH (T > 38.5°C). Severe RH was found to be associated with significantly worse neurological outcome (OR 1.92, 95% CI 1.28–1.90) and significantly worse mortality (OR 2.22, 95% CI 1.50–3.29). RH is common after completion of TTM in comatose patients because of cardiac arrest and is associated with poor neurological outcomes. The clinical impact of RH is likely proportional to the magnitude of RH.

Introduction:Amputation has been known to be a rare adverse event of sodium glucose co-transporter 2 (SGLT2) inhibitors. It remains unclear whether the SGLT2 inhibitor as a class and specific categories of the SGLT2 inhibitors are linked with an increased risk of amputation.Hypothesis:The objective of this meta-analysis was to investigate the association between the amputation risk and the use of SGLT2 inhibitors. The main outcome measure was the risk of amputation.Methods:Multiple databases were searched up to April 2019. Inclusion criteria included randomized controlled trials (RCTs) which reported risk of amputation with SGLT2 inhibitors over non-SGLT2 inhibitors or placebo.Results:A total of five RCTs were included in the meta-analysis. The five included studies evaluated a total of 39,067 patients with diabetes mellitus, including 21,395 patients on SGLT2 inhibitors. The incidence rate for amputation ranged from 0.36 to 3.18% in SGLT2 inhibitors and from 0% to 2.87% in control. Follow up duration ranged from 24 weeks to 4.2 years. The meta-analyses showed that the use of SGLT2 inhibitors was not significantly associated with increased risk of amputation as compared with comparators (OR: 1.31, 95% CI: 0.92-1.87, I2= 75%). Subgroup meta-analyses showed that neither canagliflozin (OR 1.60, 95% CI: 0.79-3.26, I2= 89%), empagliflozin (OR 1.03, 95% CI: 0.72-1.49, I2= 0%), nor dapagliflozin (OR 1.09, 95% CI: 0.84-1.41) was associated with increased risk of amputation. No significant differences were observed among these groups (P=0.32).Conclusions:In conclusion, our meta-analysis showed that neither canagliflozin nor the other SGLT2 inhibitors showed an increased risk of amputation.