Transcatheter closure of ventricular septal defect in aortic valve prolapse and aortic regurgitation

ObjectiveTo report intermediate follow-up result of transcatheter closure of ventricular septal defect (VSD) in presence of aortic valve prolapse (AVP) with or without aortic regurgitation (AR).MethodThis is a retrospective review of 19 patients with VSD with AVP with AR who underwent transcatheter closure in between September 2011–July 2014. Mean age was 8 years (1–16 years, standard deviation [SD] 4.08 years) and mean weight was 26.03 kg (9–81.5 kg, SD 16.57 kg). Among them 2 had subarterial VSD, 6 had subaortic VSD and 11 had perimembranous VSD. All of them had mild AVP and 13 of them had AR (trivial or mild). Median VSD size was 4.3 mm (4–6 mm). Transcatheter closure was done either by retrograde technique using the Amplatzer Duct Occluder-II in 17 patients or antegrade technique using the Duct Occluder-I in 2 cases. Mean follow-up period was 18 months (12–36 months).ResultImmediate major complications were encountered in 2 (10.5%) cases. Significant aggravation of device related AR was seen in one case & device embolised to right pulmonary artery in another case and both of them were managed surgically.During follow up, 1 child had significant additional VSD requiring device closure. One child developed moderate AR, requiring surgery. None of the other had shown any increase in severity of AR.ConclusionDevice closure of VSD in presence of mild AVP and mild AR appears to be safe. Longer follow-up is necessary to draw final conclusion.     

Diagnostic value of N-terminal pro-brain natriuretic peptide levels in pediatric patients with ventricular septal defect

Background and aimThe plasma concentrations of N-terminal pro-brain natriuretic peptide (NT-proBNP) can reflect the cardiac functions in patients with cardiac diseases. Our aim is to assess the value of NT-proBNP in the diagnosis of heart failure and evaluation of cardiac functions in pediatric patients with ventricular septal defect (VSD).Patients and methodThe study comprised 40 children with VSD (mean age 12 ± 5 months) and 20 healthy children as a control group. Detailed echocardiographic examination was performed and the level of NT-proBNP level was measured.ResultsThe plasma level of NT-proBNP was significantly higher in patients with VSD than in control subjects (P < 0.05). Also, it was significantly increased in VSD patients with congestive heart failure (CHF) than those without heart failure (P < 0.05). Moreover, NT-proBNP level increased with increasing severity of clinical symptoms. There were positive correlations between NT-proBNP level and left ventricular end diastolic diameter, left ventricular end systolic diameter, estimated systolic pulmonary artery pressure and VSD size and negative correlations with ejection fraction (EF) and fractional shortening (FS) in VSD patients with or without heart failure. The plasma levels of NT-proBNP with cutoff value of 101 fmol/ml (854 pg/ml), predicted CHF with a sensitivity of 90.0%, specificity of 80%, and area under ROC curve was 0.980.ConclusionNT-proBNP level is a good marker of disease severity and correlates with echocardiographic measurements and clinical symptoms in pediatric patients with VSD.     

Long-term follow-up after percutaneous closure of patent foramen ovale for secondary prevention of paradoxical embolism in elderly patients (≥ 70 years)

PurposePatent foramen ovale (PFO) has been associated with cryptogenic stroke both in younger and older patients. Although percutaneous PFO closure has been shown safe and effective in patients > 55 years old, the long-term outcome of elderly patients (≥ 70 years) has not specifically been reported.Patients and methodsBetween November 1998 and October 2008, 839 consecutive patients (age 52 ± 13 years; 60% male) underwent percutaneous PFO closure for secondary prevention of paradoxical embolism (94% cerebral, 6% peripheral) using the Amplatzer PFO Occluder under fluoroscopic guidance only. Among them, 58 patients (7%) ≥ 70 years old were included in the present study.ResultsThe implantation procedure was successful in all patients. There were no procedural complications. Transesophageal echocardiography at 6 months, performed in 49 patients (84%), showed complete occlusion in 45 patients (92%), and a residual shunt in four patients (8%). During a mean follow-up of 5.2 ± 2.4 years (median 5.0; total 290 patient-years) three ischaemic strokes (two of them fatal) and five transient ischaemic attacks occurred. Freedom from recurrent ischaemic stroke, transient ischaemic attack, or peripheral embolism was 100% at 1 year, 86% at 5 years, and 82% at 10 years. The risk of recurrent thromboembolic events was significantly higher as compared to the patients < 70 years old (P < 0.001).ConclusionsThis study confirms the safety, feasibility, and clinical efficacy of percutaneous PFO closure guided by fluoroscopy only in elderly patients. Percutaneous PFO closure should be considered a therapeutic option in all patients with suspected paradoxical embolism, including the elderly.     

First Egyptian experience of Transcatheter Aortic Valve Implantation: Immediate results and one year follow up

BackgroundTrans-catheter Aortic Valve Implantation (TAVI) offers a less invasive modality to manage aortic stenosis (AS) especially in high risk patients. It was not available in Egypt until the end of 2011.AimThe aim of this study is to report immediate and one year follow up results of first TAVI implantations in Egyptian patients.Patients and methodsTen patients with severe symptomatic AS underwent TAVI implantation using Edwards SAPIEN™ and SAPIEN XT™ valves.ResultsThe mean age was 78.6 ± 4.6 years and 5 (50%) were males. The mean Logistic EuroSCORE and EuroSCORE II were 21.9 ± 11.5% and 12.6 ± 7.2%, respectively. Procedural success was achieved in all (100%) patients using SAPIEN™ (n = 8) and SAPIEN XT™ (n = 2) valves. Almost all (n = 9) patients underwent a trans-femoral approach and percutaneous closure devices were used in the last 2 patients. Post procedural NYHA grade (1.3 ± 0.3), aortic valve area (2.0 ± 0.1 cm²) and mean pressure gradient (14.1 ± 2.7 mmHg) were nearly maintained all over the one-year-follow-up period.ConclusionTAVI provides a safe and effective alternative to the surgical AVR in high risk patients with severe symptomatic AS. Financial issues, however, limits its application in developing countries.     

Platypnea–orthodeoxia syndrome in the elderly treated by percutaneous patent foramen ovale closure: A case series and literature review

BackgroundPlatypnea–orthodeoxia syndrome (POS) is a rare clinical phenomenon, associating normal oxygen saturation in a supine position and arterial hypoxemia in an upright position. This pathology can be secondary to an intracardiac shunt, a pulmonary vascular shunt or a ventilation–perfusion mismatch. Cardiac POS occurs in the presence of a right-to-left cardiac shunt, most commonly through a patent foramen ovale (PFO).Methods and resultsFrom our single-center prospective database of percutaneous PFO closure we identified five patients (4 females, mean age: 77 ± 11 years) out of 224 (2.2%) patients with a PFO who presented with a POS of cardiac origin. Transthoracic and transoesophageal echocardiographic examinations revealed the underlying mechanisms of POS and the diagnosis was confirmed by right-and-left cardiac catheterization (RLC) and by measuring serial blood oxygen saturation in the pulmonary veins and left atrium in supine and upright positions. PFO was associated with atrial septal aneurysm and a persistent prominent Eustachian valve in 3 patients.All patients underwent a successful percutaneous PFO closure without any immediate or subsequent complications (mean follow-up of 24 ± 18 months). Immediately after the procedure, mean arterial oxygen saturation improved from 83% ± 3 to 93% ± 2 in an upright position and symptoms disappeared.ConclusionPOS is a rare and under-diagnosed pathology that must be actively investigated in the presence of position-dependent hypoxemia. The diagnostic work-up must exclude other causes of hypoxemia and confirm the intracardiac shunt using either contrast echocardiography or RLC. For cardiac POS, percutaneous PFO closure is a safe and effective technique that immediately relieves orthodeoxia and patient symptoms.     

Comparison of determinations of left atrial volume by the biplane area-length and Simpson's methods using 64-slice computed tomography

ObjectivesThere is increasing evidence that left atrial (LA) size is an important predictor of adverse cardiovascular outcomes such as atrial fibrillation, stroke, and congestive heart failure. The aim of this study was to determine whether there is a difference in results of quantification of LA volume by the area-length and Simpson's methods using multislice computed tomography (MSCT).Methods and resultsThe study population consisted of 51 patients with sinus rhythm (sinus group) and 20 patients with atrial fibrillation (af group) clinically indicated for MSCT angiography for evaluation of coronary arteries. Maximum LA volume, obtained at end-systole from the phase immediately preceding mitral valve opening, was measured using the area-length and Simpson's methods. In the sinus group, the mean LA volumes, indexed to body surface area, were 48.4 ± 17.9 ml/m² with the area-length method and 48.3 ± 17.0 ml/m² with the Simpson's method. In the af group, the mean indexed LA volumes with the area-length method and the Simposon's method were 91.5 ± 47.5 ml/m² and 90.3 ± 45.9 ml/m², respectively. LA volumes calculated by the area-length method exhibited a strong linear relationship and agreement with those calculated using Simpson's method in both the groups (sinus group: r = 0.99, P < 0.0001, af group: r = 0.99, P < 0.0001).ConclusionsThe area-length method is a simple and reproducible means of assessment of LA volume. Standardization of LA volume assessment using MSCT is important for serial follow-up and meaningful communication of results of testing among institutions and physicians.     

Traitement chirurgical des anévrismes poplités : résultats à court et à long termes

IntroductionThe popliteal artery aneurysm (PAA) is a rare vascular disease, but represents the most common site of peripheral aneurysms. We report in this paper our experience in the surgical management of PAA.ObjectivesThe aim of this work was to clarify the indications and the results of the surgical management of PAA.MethodsIt was a retrospective study, extended over a period of 12 years, going from 2007 to 2018, covering 26 patients operated on surgically for popliteal aneurysm.ResultsWe have operated 26 patients for PAA. All patients were male. The average age was 59 years [39–80 years]. The aneurysm was symptomatic in 22 cases and asymptomatic in 4 cases. The mean aneurysm diameter was 37 mm [26–70 mm]. Twenty-two patients have received a planned surgery and we did emergency surgery for 4 patients because of a limb ischemia complication. The surgical treatment consisted in a surgical bypass after the aneurysm removing. The restoration of blood continuity was achieved by a vein graft in 23 cases and prosthetic in 3 cases. Three patients needed major amputation within 30 days (11.53%) and no mortality was observed during this period. Mean follow-up was 24 months [12–96 months]. Two-years mortality, complication rate and limb salvage was respectively 7.69%, 15.38% and 84.62%.ConclusionThe PAA represents a serious disease that can affect the vitality of the lower limb. Surgical treatment is currently the gold standard because of its good results.     

A comparative study of ivabradine and atenolol in patients with moderate mitral stenosis in sinus rhythm

BackgroundBeta-blockers are frequently used in patients with mitral stenosis to control the heart rate and alleviate exercise-related symptoms. The objective of our study was to examine whether ivabradine was superior to atenolol for achieving higher exercise capacity in patients with moderate mitral stenosis in sinus rhythm. We also evaluated their effects on left ventricular myocardial performance index (MPI).Methods and resultsEighty-two patients with moderate mitral stenosis in sinus rhythm were randomized to receive ivabradine (n = 42) 5 mg twice daily or atenolol (n = 40) 50 mg daily for 6 weeks. Transthoracic echocardiography and treadmill test were performed at baseline and after completion of 6 weeks of treatment. Mean total exercise duration in seconds markedly improved in both study groups at 6 weeks (298.57 ± 99.05 s vs. 349.12 ± 103.53 s; p = 0.0001 in ivabradine group, 290.90 ± 92.42 s vs. 339.90 ± 99.84 s; p = 0.0001 in atenolol group). On head-to-head comparison, there was no significant change in improvement of exercise time between ivabradine and atenolol group (p = 0.847). Left ventricular MPI did not show any significant change from baseline and at 6 weeks in both drug groups (49.8% ± 8% vs. 48.3% ± 7% in ivabradine group, 52.9% ± 10% vs. 50.9% ± 10% in atenolol groups; p = 0.602).ConclusionIvabradine or atenolol can be used for heart rate control in patients with moderate mitral stenosis in sinus rhythm. Ivabradine is not superior to atenolol for controlling heart rate or exercise capacity. Left ventricular MPI was unaffected by either of the drugs.     

Resultados intrahospitalarios tras tratamiento percutáneo frente a quirúrgico en pacientes con estenosis aórtica y enfermedad arterial coronaria concomitante

Introduction and objectivesConcomitant coronary artery disease (CAD) is prevalent among aortic stenosis patients; however the optimal therapeutic strategy remains debated. We investigated periprocedural outcomes among patients undergoing transcatheter aortic valve implantation with percutaneous coronary intervention (TAVI/PCI) vs surgical aortic valve replacement with coronary artery bypass grafting (SAVR/CABG) for aortic stenosis with CAD.MethodsUsing discharge data from the Spanish National Health System, we identified 6194 patients (5217 SAVR/CABG and 977 TAVI/PCI) between 2016 and 2019. Propensity score matching was adjusted for baseline characteristics. The primary outcome was in-hospital all-cause mortality. Secondary outcomes were in-hospital complications and 30-day cardiovascular readmission.ResultsMatching resulted in 774 pairs. In-hospital all-cause mortality was more common in the SAVR/CABG group (3.4% vs 9.4%, P < .001) as was periprocedural stroke (0.9% vs 2.2%; P = .004), acute kidney injury (4.3% vs 16.0%, P < .001), blood transfusion (9.6% vs 21.1%, P < .001), and hospital-acquired pneumonia (0.1% vs 1.7%, P = .001). Permanent pacemaker implantation was higher for matched TAVI/PCI (12.0% vs 5.7%, P < .001). Lower volume centers (< 130 procedures/y) had higher in-hospital all-cause mortality for both procedures: TAVI/PCI (3.6% vs 2.9%, P < .001) and SAVR/CABG (8.3 vs 6.8%, P < .001). Thirty-day cardiovascular readmission did not differ between groups.ConclusionsIn this large contemporary nationwide study, percutaneous management of aortic stenosis and CAD with TAVI/PCI had lower in-hospital mortality and morbidity than surgical intervention. Higher volume centers had less in-hospital mortality in both groups. Dedicated national high-volume heart centers warrant further investigation.     

Residual SYNTAX score can predict short- and long-term outcomes in patients with STEMI

ObjectivesThe prognostic value of residual SYNTAX score (rSS) has been observed in different patient groups. However, its prognostic value has not been compared in patients with ST segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI).MethodsA total of 208 patients meeting the eligibility criteria were included in the study. Complete revascularisation (CR) was defined as rSS = 0 and incomplete revascularisation (IR) was defined as rSS ≥ 1.ResultsAmong the sample, 78 patients (33.3%) were included in the CR group and 130 patients (67.7%) in the IR group. One patient (1.3%) in the CR group and 8 patients (6.2%) in the IR group died by day 30 (P < 0.01). The incidence of stent thrombosis, recurrent myocardial infarction (MI) and target lesion revascularisation (TLR) was similar between the two groups. During follow-up (mean 28.8 ± 7.1 months), 2 patients (2.6%) from the CR group and 10 (7.7%) patients from the IR group died (P > 0.05). The incidence of recurrent MI (18.5% vs. 7.7%; P < 0.01) and major adverse cardiovascular events (MACE) (24.6% vs. 7.7%; P < 0.01) were significantly higher in the IR group.ConclusionrSS, which is an indirect marker of incomplete revascularisation, was independently correlated with recurrent MI and MACE after STEMI.     

Fine needle sclerotherapy as a new effective therapeutic approach for nonparasitic splenic cysts: A case series

BackgroundNonparasitic splenic cysts are rare. Until now, surgical intervention has been the standard therapy of symptomatic splenic cysts.AimsWe herein present a retrospective analysis of an approach using percutaneous ultrasound-guided fine needle aspiration and sclerotherapy.MethodsOut of 88,151 ultrasound reports, we identified 138 patients who presented with splenic cysts. A single splenic cyst was found in 88% (mean size 28.9 mm). Twelve patients underwent percutaneous therapy of symptomatic splenic cysts. They were younger, had larger splenic cysts and more often cyst internal echoes than the 126 untreated patients (all p < 0.0001).ResultsInitial sclerotherapy was performed with polidocanol 1% in 9 patients and with NaCl 10% in 2 patients. One hemorrhagic cyst was only purged. Serious adverse events were not noted. Eight patients had to undergo 1–11 further percutaneous cyst therapies. 15 of these 30 reinterventions were cyst aspiration therapies, only, and 11 of them were sclerotherapies with NaCl 10%. Four patients were readmitted to hospital for cyst retreatment. After 57 ± 43 months of follow-up, cyst size significantly decreased (p < 0.0001). Only two patients had a complicated course of cyst therapy.ConclusionsPercutaneous ultrasound-guided sclerotherapy is a new approach for symptomatic splenic cysts. In most patients, cyst size and symptoms can be significantly reduced during one hospital stay.     

Percutaneous closure of ruptured sinus of Valsalva aneursym with Amplatzer ductal occluder

Rupture of a sinus of Valsalva aneurysm (SVA) is clinically characterized by widening of an existing sinus of Valsalva aneurysm in time and its opening to other cardiac cavities, primarily to the right atrium and right ventricle. Increased biventricular filling appearing due to rupture causes symptoms of heart failure. Although classical treatment of ruptured SVA is surgical, various percutaneous closure devices are being used successfully for treatment of lesions in recent years. With this paper, we described a case about rupture of a sinus of Valsalva aneurysm causing a haemodynamically important left-to-right shunt and heart failure due to this, and we explained how we successfully repaired it with an Amplatzer ductal occluder device. Our clinical experience and early term results of similar cases in the literature suggest that percutaneous closure methods can be an alternative to surgical treatment to treat ruptured sinus ofValsalva aneurysms.     

Contemporary outcomes of percutaneous closure of patent ductus arteriosus in adolescents and adults

BackgroundCatheter based treatment has gained wide acceptance for management of patent ductus arteriosus (PDA) ever since its introduction. Percutaneous closure in adults can be challenging because of anatomical factors including large sizes, associated pulmonary arterial hypertension (PAH) and co-morbidities. This study aimed to provide comprehensive contemporary data on the safety and efficacy of percutaneous device closure of PDA in adult and adolescent population at a large referral center.MethodsThis single-center retrospective analysis included 70 patients (33 adolescents and 37 adults) who underwent successful percutaneous device closure of PDA between January 2011 and February 2017.Baseline patient demographics, clinical characteristics, procedural and device related variables, and immediate outcomes during hospital stay were recorded. Patients were followed up for residual shunt and complications.ResultsOf 70 PDA device closure cases, 71.4% were females; the mean age was 23 years (range:10-58years). Devices used were 4-Cook’s detachable coils, 64-occluders (ADO-I and II, Lifetech, Cardi-O-Fix), 1-vascular plug and 1-ventricular septal occluder device. Device success was achieved in all including those with very large PDAs. At 24-h post-procedure, the success rate of transcatheter intervention was 95.7%. At 6-months follow up, complete closure was observed in all (mean follow up duration-531 days). In patients with severe PAH, significant immediate and sustained reduction of the mean pulmonary pressure was observed(77 mmHg to 33 mmHg;P = 0.014). No procedure-related complications including death, device embolization and stenosis of aorta or pulmonary artery occurred.ConclusionsIn contemporary practice, percutaneous device closure is an effective and safe treatment option for adolescent and adult PDA patients.     

Thoracoscopic radiofrequency ablation for lone atrial fibrillation: Box-lesion technique

BackgroundWe report the feasibility and outcomes of box-lesion ablation technique to treat stand-alone atrial fibrillation (AF).MethodsThere were 31 patients with a mean age of 63.3 ± 8.4 years who underwent bilateral totally thoracoscopic ablation of symptomatic paroxysmal AF (n = 8; 25.8%) and long-standing persistent AF (n = 23; 75.2%). The box-lesion procedure included bilateral pulmonary vein and left atrial posterior wall ablation using irrigated bipolar radiofrequency with documentation of conduction block.ResultsThere were no intra- or perioperative ablation-related complications. There was no operative mortality, no myocardial infarction, and no stroke. Skin-to-skin procedure time was 152.1 ± 36.7 min and the postoperative average length of stay was 6.26 ± 1.24 days. At discharge, 29 patients (93.5%) were in sinus rhythm. Median follow-up time was 20.4 ± 8.3 months. At three months postsurgery, 20 patients of 30 (66.6%) were free from AF without the need of antiarrhythmic drugs. Six patients (20%) underwent catheter reablation. Twenty-three patients (76.6%) were in sinus rhythm at one year after the last performed ablation (surgical ablation or catheter reablation).ConclusionThe thoracoscopic box-lesion ablation procedure is a safe, effective, and minimally invasive method for the treatment of isolated (lone) AF. This procedure provided excellent short-term freedom from AF.     

Elective Percutaneous Paravalvular Leak Closure Under Conscious Sedation: Procedural Techniques and Clinical Outcomes

BackgroundParavalvular leaks (PVLs) are a well-recognized complication of prosthetic valves that are detected up to 18% of all implanted surgical valves. Perioperative morbidity is thought to be lower in percutaneous compared to surgical PVL repair. However, a direct comparison of PVL closure techniques has never been performed. Our study is the first to demonstrate that elective PVL closure with monitored anesthesia care can be achieved with high success and low complications rates resulting in short hospital stays.MethodsThis is a retrospective cohort of patients admitted electively for catheter-based treatment of symptomatic prosthetic paravalvular regurgitation from Jan 2013 to April 2018. Both mitral and aortic PVLs were included. Patients' demographics, risk factors, procedural outcomes, In-hospital and thirty-day mortality were all reported. We followed the Valve Academic Research Consortium (VARC) criteria to define device and procedural technical success. In-hospital and 30- day outcomes were assessed by retrospective chart review.ResultsA total of 54 PVLs in thirty-seven patients were repaired (65% aortic & 35% mitral). The mean-age in the mitral cohort was lower than the aortic cohort (61 vs 72 years, P < 0.0001) but the two groups shared similar clinical risk factors (P > 0.05). Average hospital stay was 1–2 days (<1.5 days overall cohort) which was significantly lower in the aortic compared to the mitral cohort (P = 0.009). All procedures were guided by TEE under conscious sedation with monitored anesthesia care. Procedural technical success defined as any significant residual shunt was 81% in the overall cohort and 88% in the aortic group. No procedural deaths were reported. Short-term mortality during the first 30 days was 5.4% (two patients).ConclusionElective catheter-based repair of symptomatic prosthetic paravalvular regurgitation appears to be safe and effective. The use of conscious sedation with monitored anesthesia care resulted in short hospital stay.     

Prediction of atrial fibrillation after ischemic stroke using P-wave signal averaged electrocardiography

BackgroundAtrial fibrillation (AF) is highly prevalent in patients with ischemic stroke, but the diagnosis is often difficult.MethodsThis study consisted of 68 stroke patients in sinus rhythm without history of AF. All patients underwent P-wave signal-averaged electrocardiography (P-SAECG), echocardiography, 24-h Holter monitoring, and measurement of plasma B-type natriuretic peptide (BNP) concentrations at admission.ResultsAn abnormal P-SAECG was found in 34 of 68 stroke patients. In the follow-up period of 11 ± 4 months, AF developed in 17 patients (AF group). The remaining 51 patients were classified as the non-AF group. The prevalence of atrial late potentials (ALP) on P-SAECG, and the number of premature atrial contractions (PACs) were significantly higher in the AF group than those in the non-AF group (88.2% vs 37.3%; p < 0.001, 149 ± 120 vs 79 ± 69; p = 0.030, respectively). However, there were no significant differences in age, left atrial dimension, or BNP concentrations between both groups. Cox proportional hazards analysis revealed that the presence of ALP (risk ratio 11.15; p = 0.002) and frequent PACs (more than 100/24 h) (risk ratio 4.53; p = 0.007) had significant correlation to the occurrence of AF.ConclusionsALP may be a novel predictor of AF in stroke patients. P-SAECG should be considered in stroke of undetermined etiology.     

Relation entre pression artérielle,fréquence cardiaque et dysfonction autonome cardiaque chez les obèses non diabétiques

RationaleSome studies suggest that a high heart rate (HR) would be predictive of the incidence of an elevated blood pressure (BP). Cardiac autonomic dysfunction (CAD) affects a high proportion of obese patients. CAD could be involved in BP increase. Our aim was to examine the relationship between CAD, HR and BP in obese patients without known diabetes.Patients and methodsWe included 428 overweight or obese patients. CAD was assessed by analyzing HR variations during three standard tests (Valsalva, deep breathing, lying-to-standing), which are mostly dependent on vagal control. An oral load in glucose was performed and the Matsuda index was calculated.ResultsThe population was separated in 4 groups according to the grade of CAD (no or only one abnormal test, 2 or 3 abnormal tests) and HR (< or ≥ 75 bpm). Age was similar in the four groups. Systolic (P = 0.05), diastolic (P < 0.005) and mean BP (P < 0.001) differed significantly between the 4 groups, and was the highest in the group of patients who had 2 or 3 abnormal tests and HR ≥ 75 bpm. Matsuda index differed across the groups (P = 0.018) and was the lowest in this group.ConclusionThese data indicate that among overweight or obese patients with a defect in cardiac vagal activity BP is elevated only in those with a high heart rate, which is indicative of a more marked insulin resistance and probably an excess in sympathetic activity.     

Safety and efficacy of device closure for patent foramen ovale for secondary prevention of neurological events: Comprehensive systematic review and meta-analysis of randomized controlled trials

BackgroundControversy persists regarding the management of patients with cryptogenic stroke and patent foramen ovale (PFO). We performed a meta-analysis of randomized controlled trials comparing PFO closure with medical therapy.Methods and ResultsA prospective protocol was developed and registered using the following data sources: PubMed, Cochrane Register of Controlled Trials, conference proceedings, and Internet-based resources of clinical trials. Primary analyses were performed using the intention-to-treat method. Three randomized trials comparing percutaneous PFO closure vs. medical therapy for secondary prevention of embolic neurological events formed the data set. Baseline characteristics were similar. During long-term follow-up, the pooled incidence of the primary endpoint (composite of stroke, death, or fatal stroke) was 3.4% in the PFO closure arm and 4.8% in the medical therapy group [risk-reduction (RR) 0.7 (0.48–1.06); p = 0.09]. The incidence of recurrent neurological events (secondary endpoint) was 1.7% for PFO closure and 2.7% for medical therapy [RR 0.66 (0.35–1.24), p = 0.19]. There was no difference in terms of death or adverse events between the two groups.ConclusionsWhile this meta-analysis of randomized clinical trials demonstrated no statistical significance in comparison to medical therapy, there was a trend towards overall improvement in outcomes in the PFO closure group.