Prognostic benefit of catheter ablation of atrial fibrillation in heart failure: An updated meta‐analysis of randomized controlled trials

Abstract Background The prognostic role of catheter ablation of atrial fibrillation (AF) in patients with heart failure (HF) remains uncertain, with guideline recommendations largely based on a single trial. We conducted a meta‐analysis of randomized controlled trials (RCTs) assessing the prognostic impact of AF ablation in patients with HF. Methods Electronic databases were searched for RCTs comparing ‘AF ablation’ versus ‘other care’ (medical therapy and/or atrioventricular node ablation with pacing) in patients with HF. Primary endpoints were ≥1‐year mortality, HF hospitalization and change in left ventricular ejection fraction (LVEF). Meta‐analyses were performed using random‐effects modelling. Results Nine RCTs (n = 1462) met inclusion criteria. Compared to ‘other care’, AF ablation significantly reduced ≥1‐year mortality (relative risk [RR] 0.65; 95% confidence intervals [CI], 0.49–0.87) and HF hospitalization (RR 0.64; 95% CI, 0.51–0.81). AF ablation demonstrated significantly greater improvement in LVEF (mean difference [MD] 5.4; 95% CI, 4.4–6.4), 6‐min walk test distance (MD 21.5 meters; 95% CI, 4.6–38.4) and quality of life as measured by Minnesota Living with Heart Failure Questionnaire score (MD 7.2; 95% CI, 2.8–11.7). Meta‐regression analyses showed the beneficial impact of AF ablation on LVEF was significantly blunted by higher prevalence of ischaemic cardiomyopathy. Conclusions Our meta‐analysis demonstrates AF ablation is superior to ‘other care’ in improving mortality, HF hospitalization, LVEF and quality of life in patients with HF. However, the highly selected study populations in included RCTs and effect modification mediated by etiology of HF suggests these benefits do not uniformly apply across the HF population

Percutaneous pulmonary valve implantation : a systematic review of clinical outcomes [letter to the editor]

3 page(s

A Meta-analysis of mitral valve repair versus replacement for ischemic mitral regurgitation

Background: The development of ischemic mitral regurgitation (IMR) portends a poor prognosis and is associated with adverse long-term outcomes. Although both mitral valve repair (MVr) and mitral valve replacement (MVR) have been performed in the surgical management of IMR, there remains uncertainty regarding the optimal approach. The aim of the present study was to meta-analyze these two procedures, with mortality as the primary endpoint. Methods: Seven databases were systematically searched for studies reporting peri-operative or late mortality following MVr and MVR for IMR. Data were independently extracted by two reviewers and meta-analyzed according to pre-defined study selection criteria and clinical endpoints. Results: Overall, 22 observational studies (n=3,815 patients) and one randomized controlled trial (n=251) were included. Meta-analysis demonstrated significantly reduced peri-operative mortality [relative risk (RR) 0.61; 95% confidence intervals (CI), 0.47-0.77; I²=0%; P<0.001] and late mortality (RR, 0.78; 95% CI, 0.67-0.92; I²=0%; P=0.002) following MVr. This finding was more pronounced in studies with longer follow-up beyond 3 years. At latest follow-up, recurrence of at least moderate mitral regurgitation (MR) was higher following MVr (RR, 5.21; 95% CI, 2.66-10.22; I²=46%; P<0.001) but the incidence of mitral valve re-operations were similar. Conclusions: In the present meta-analysis, MVr was associated with reduced peri-operative and late mortality compared to MVR, despite an increased recurrence of at least moderate MR at follow-up. However, these findings must be considered within the context of the differing patient characteristics that may affect allocation to MVr or MVR. Larger prospective studies are warranted to further compare long-term survival and freedom from re-intervention.11 page(s

Letter to the editor : Systematic review of percutaneous coronary intervention and transcatheter aortic valve implantation for concomitant aortic stenosis and coronary artery disease

3 page(s

Insulin Pump Therapy Is Associated with Lower Rates of Retinopathy and Peripheral Nerve Abnormality.

OBJECTIVE:To compare rates of microvascular complications in adolescents with type 1 diabetes treated with continuous subcutaneous insulin infusion (CSII) versus multiple daily injections (MDI). RESEARCH DESIGN AND METHODS:Prospective cohort of 989 patients (aged 12-20 years; diabetes duration >5 years) treated with CSII or MDI for >12 months. Microvascular complications were assessed from 2000-14: early retinopathy (seven-field fundal photography), peripheral nerve function (thermal and vibration threshold testing), autonomic nerve abnormality (heart rate variability analysis of electrocardiogram recordings) and albuminuria (albumin creatinine ratio/timed overnight albumin excretion). Generalized estimating equations (GEE) were used to examine the relationship between treatment and complications rates, adjusting for socio-economic status (SES) and known risk factors including HbA1c and diabetes duration. RESULTS:Comparing CSII with MDI: HbA1C was 8.6% [70mmol/mol] vs. 8.7% [72 mmol/mol]) (p = 0.7), retinopathy 17% vs. 22% (p = 0.06); microalbuminuria 1% vs. 4% (p = 0.07), peripheral nerve abnormality 27% vs. 33% (p = 0.108) and autonomic nerve abnormality 24% vs. 28% (p = 0.401). In multivariable GEE, CSII use was associated with lower rates of retinopathy (OR 0.66, 95% CI 0.45-0.95, p = 0.029) and peripheral nerve abnormality (OR 0.63, 95% CI 0.42-0.95, p = 0.026), but not albuminuria (OR 0.46, 95% CI 0.10-2.17, p = 0.33). SES was not associated with any of the complication outcomes. CONCLUSIONS:In adolescents, CSII use is associated with lower rates of retinopathy and peripheral nerve abnormality, suggesting an apparent benefit of CSII over MDI independent of glycemic control or SES

Characteristics and complication rates in adolescents with type 1 diabetes according to treatment.

<p>Characteristics and complication rates in adolescents with type 1 diabetes according to treatment.</p

Rate of microvascular complications according to insulin delivery: CSII vs MDI.

<p>Rate of microvascular complications according to insulin delivery: CSII vs MDI.</p

Effect of pump therapy compared to multiple daily injections for microvascular complications.

<p>Multivariable analysis (GEE), after inclusion of HbA1c and other confounders: significant reduction for retinopathy after allowing for HbA1c, age and duration; and significant reduction for peripheral nerve abnormalities after allowing for HbA1c, male gender and height SDS.</p