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Background:An increasing number of patients with severe aortic stenosis (AS) have history of prior cardiac surgery which is associated with increased risk of aortic valve replacement. In such cases, the proposed benefit of surgical (SAVR) versus transcatheter aortic valve replacement (TAVR) remains unknown.Objective:To evaluate the impact of prior cardiac surgery on clinical end points in patients undergoing TAVR versus SAVR for severe AS.Methods:Literature search was performed using MEDLINE (via PUBMED), EMBASE, Google Scholar and Scopus databases. The included outcomes were procedural time, acute kidney injury (AKI), bleeding complications, stroke, permanent pacemaker implantation (PPI), duration of hospital stay, 30-day all-cause mortality and 1-2 year all-cause mortality, The main summary estimate was random effects Odds ratio (OR) with 95% confidence intervals (CIs).Results:7 studies (3 randomized trials, 4 cohort) including 8,922 patients with mean age 80 ? 6.6/78 ? 6.3 and 75.5%/75.5% males in the TAVR and SAVR groups, respectively, were included. Our study found that, compared with SAVR, TAVR was associated with lower incidence of stroke (OR = 0.65 (95% CI: 0.44 - 0.97), p = 0.03) and bleeding complications (OR = 0.36 (95% CI: 0.21 - 0.59), p = <0.01). There was no difference in terms of AKI (OR = 0.71 (95% CI: 0.49 - 1.02), p = 0.06), PPI (OR = 1.56 (95% CI: 0.97-12.54), p = 0.06), 30-day all-cause mortality (OR = 0.87 (95% CI: 0.56 - 1.37), p = 0.54) and 1-2 year all-cause mortality (OR = 1.15 (95% CI: 0.71 - 1.86), p = 0.57) between the two groups (Figure 1). The average procedure time and duration of hospital stay were 170 minutes less (95% CI: -249.37, -92.53), p = <0.01) and 3.6 days shorter (95% CI: -5.43, -1.95), p <0.01) in patients with TAVR, respectively.Conclusions:In patients with prior cardiac surgery and severe AS, both TAVR and SAVR are reasonable options. However, TAVR may be associated with lower incidence of outcomes like stroke and perioperative bleeding.

Introduction:Nonagenarians i.e. age > 90 are usually not considered for surgical aortic valve replacement (SAVR) owing to their increased surgical risk. This patient population is also under represented in clinical trials that have evaluated the role of trans-catheter aortic valve replacement (TAVR) for severe aortic stenosis.So the effectiveness of TAVR as compared to SAVR remains unknown.Objective:To compare safety and effectiveness of TAVR versus SAVR in nonagenarians.Methods:Literature search was performed using PubMed, Embase, Web of science, Cochrane library and clinicaltrials.gov. Databases were systematically searched up to 5-21-2019. Primary end point was 30-day mortality. Secondary end points were post-operative incidences of stroke or transient ischemic attacks, vascular access related complications, acute renal failure, transfusion requirement, length of hospital stay, respectively.The main summary estimate was random effects Risk ratio(RR) with 95% confidence intervals (CIs).Results:Four retrospective studies were included (N= 8389). TAVR was performed in 3112 patients while 5277 patients underwent SAVR. Our study found no difference in 30-days mortality between TAVR and SAVR [RR = 0.91 (0.76 - 1.10), p= 0.318]. TAVR was associated with a significantly reduced risk of post-operative ARF [RR = 0.72 (0.62 - 0.83), p<0.001] and a lower transfusion requirement [RR = 0.71 (0.62 - 0.81), p < 0.001], respectively. There was no difference in risk of stroke/TIA between two groups [RR = 1.01 (0.70 - 1.45), p= 0.957] and risk of vascular access complications was significantly higher with TAVR [RR = 3.39 (2.65 - 4.333), p<0.001].On an average, Length of hospital stay was 3 days less in patients undergoing TAVR (p= 0.037).Conclusion:TAVR was not shown to have an increased risk of short term mortality or stroke along with a better post-operative outcomes when weighed against SAVR in nonagenarians.

Introduction:Recent studies have raised concern that fluoroquinolone use is associated with an increased risk of aortopathy, including aortic aneurysm with and without dissection. We performed a meta-analysis with a comprehensive literature review to further investigate this association.Hypothesis:Increased risk aortopathy with use of fluoroquinolone.Methods:This analysis was conducted per PRISMA guidelines. PubMed, Cochrane library, ClinicalTrials.gov, Embase, web of science and Google Scholar were searched for studies including adult (age > 18 years), patients exposed to fluoroquinolones or control antibiotics (amoxicillin/Any other antibiotic) for urinary tract infection or pneumonia with a primary outcome of aortic aneurysm or dissection. Data was extracted in predefined tables and meta-analysis was performed using random effects model. Heterogeneity was calculated using Q statistic and I2. The main summary estimate was Relative Risk with 95% confidence intervals (CI) as shown in figure.Results:Seven studies (2 retrospective, 1 longitudinal cohort, 1 nested case control, 1 nationwide cohort, 1 case time control, and 1 case cross-over study) with 59% males were included. Our analysis showed increased combined risk of development of AA and AD with quinolone exposure when compared with controls (relative risk [RR] (95% confidence interval [CI]) = 2.11 (1.62 - 2.75),I2=83.700). Individual RR for aortic aneurysm (RR of 2.83 (95% confidence interval [CI]) = 2.02 - 3.95,I2=89.150)) and AD (RR of 1.99 (95% confidence interval [CI]) = 1.23-3.06), I2=71.33) were also significantly increased.Conclusion:Compared to other antibiotics, use of fluoroquinolones was associated with significantly higher risk of aortic aneurysm and dissection combined.

Background:The concurrent incidence of aortic stenosis (AS) and coronary artery disease is estimated to be 50 - 60%. Coronary intervention in patients with severe CAD leads to improved outcomes, however impact of completeness of revascularization remains unknown.Objective:The primary objective was to evaluate the prognostic impact of completeness of coronary revascularization on all-cause mortality in patients undergoing TAVR.Methods:Literature search was performed using MEDLINE, EMBASE, Google Scholar and Scopus databases. Three sets of comparisons were performed: 1) Patients with no CAD versus CAD patients with high residual syntax score(rSS) >10, 2) Patients with no CAD versus CAD patients with low rSS ?10, 3) CAD Patients with low rSS versus CAD patients with high rSS. Data on all-cause mortality was extracted digitally form the Kaplan-Meier curves. Hazard ratios were calculated using Palmer method and meta-analysis was performed using random effects model. Heterogeneity was calculated using Q statistic and I2. The main summary estimate was random effects hazard Ratio (HR) with 95% confidence intervals (CIs).Results:Eight studies including 4,237 patients were included to look for prognostic effect of revascularization completeness before TAVR using rSS. Follow up period ranged from 0.7 to 4.8 years. Our results showed that CAD Patients with high rSS (>10) had increased risk of all-cause mortality as compared to patients with no CAD at longest follow up (HR=1.40, 95% CI: 1.10 - 1.78, I2=38.826). Whereas, there was no difference in patients with CAD and low rSS (?10) versus no CAD (HR=1.12, 95% CI: 0.85 - 1.60, I2=57.632). Interestingly, comparison of CAD patients with low rSS and high rSS also revealed no difference in all-cause mortality (HR = 1.05, 95% CI: 0.76 - 1.44,I2=58.88).Conclusions:Completeness of coronary revascularization with PCI or CABG in patients undergoing TAVR for AS did not significantly impact long-term all-cause mortality.