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BACKGROUND: The objective of the present study is to clarify safety and efficacy of thoracic endovascular aortic repair (TEVAR), excluding the primary entry in the descending aorta, for type-B0,D acute aortic dissection (TB0,DAAD) (so-called retrograde type-A acute aortic dissection). METHODS: Forty-six patients with hyperacute-phase (within 2 days after the onset) type-A acute aortic dissection (TAAAD) and TB0,DAAD underwent urgent (on the admission or next day) intervention (TEVAR or conventional surgical aortic repair [CSAR]) for 2 years. Results of TEVAR for TB0,DAAD were compared with those of CSAR for TAAAD. Outcomes included 30-day mortality, aortic reintervention, and major complications (stroke and paraplegia/paraparesis). Details of TEVAR were also analyzed. RESULTS: Seven patients with TB0,DAAD and 39 patients with TAAAD underwent respectively urgent TEVAR and CSAR. Aortic reintervention was significantly more frequent in the TEVAR than CSAR group (28.6% vs. 0%, P < 0.01). There was no difference in incidence of death and stroke between the TEVAR and CSAR group. All the 7 patients survived and 5 of the 7 (71.4%) patients were relieved of aortic reintervention for 30 days following TEVAR. One patient, however, underwent aortic arch replacement on postoperative day (POD) 1 owing to the patent and nonshrinking ascending false lumen (FL). The entry existed in the aortic arch. Another patient underwent ascending and transverse aortic replacement with frozen elephant trunk on POD13 due to proximal stent graft-induced new entry irrespective of the thrombosed and shrinking ascending FL. Because of the patent and nonshrinking ascending FL, 1 patient underwent additional TEVAR for the residual entry in the distal descending thoracic aorta on POD33 and subsequently ascending aortic replacement 4 months later. No entry was detected in the ascending or transverse aorta. The ascending FL in the other 4 patients was thrombosed early, shrinking gradually, and disappeared at last following TEVAR. CONCLUSIONS: Urgent TEVAR for TB0,DAAD may be alternative to CSAR in selected cases. Accurate diagnosis of the primary entry location on preinterventional computed tomography scans for exclusion of the entry and cautious selection and delivery of a stent graft to prevent stent graft-induced new entry or endoleak are requisite for success of the procedure, remodeling of the FL, and satisfactory prognosis.

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INTRODUCTION: To determine whether renin-angiotensin system inhibitor (RASI) prescription is associated with better survival after transcatheter aortic valve implantation (TAVI), we performed the first meta-analysis of currently available studies. EVIDENCE ACQUISITION: To identify all studies reporting impact of RASI prescription on survival after TAVI, we searched PubMed, Web of Science, Google Scholar, etc. through October 2019. We extracted adjusted (if unavailable, unadjusted) hazard ratios (HRs) with their confidence intervals (CIs) of midterm (up to ≥6-month) all-cause mortality for RASI prescription from each study and combined study-specific estimates using inverse variance-weighted averages of logarithmic HRs in the random-effects model. EVIDENCE SYNTHESIS: We identified 13 eligible studies with a total of 26,132 TAVI patients and included them in the present meta-analysis. None was a randomized controlled trial, 5 were observational studies comparing patients with versus without RASI prescription (including 3 propensity score matched studies), and 8 were observational studies investigating RASI prescription as one of covariates. The primary meta-analysis of all studies demonstrated that RASI prescription was associated with significantly lower midterm mortality (HR=0.83; 95% CI: 0.76 to 0.92; P=0.0002). Although we identified significant funnel plot asymmetry (P=0.036 by the rank correlation test) suggesting publication bias, correcting for it using the trim-and-fill method did not substantially alter the result favoring RASI prescription (corrected HR=0.85; 95% CI: 0.76 to 0.95; P=0.004). CONCLUSIONS: RASI prescription may be associated with better midterm survival after TAVI.

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Although a number of studies compared mortality after transcatheter aortic valve implantation (TAVI) with that after surgical aortic replacement (SAVR) in patients with chronic obstructive pulmonary disease (COPD), no meta-analysis of them has been conducted to date. To determine whether TAVI or SAVR is associated with better postprocedural survival in patients with COPD, a meta-analysis of all studies currently available was performed. Design. To identify all comparative studies of TAVI with SAVR in patients with COPD, PubMed and Web of Science were searched through January 2020. Studies meeting the following criteria were included in the present meta-analysis: the design was an observational comparative study or a randomized controlled trial; the study population was patients with COPD; patients were assigned to TAVI versus SAVR; and outcomes included all-cause mortality. Adjusted (if unavailable, unadjusted) odds or hazard ratios with their confidence intervals (CIs) of mortality for TAVI versus SAVR were extracted from each study. Study-specific estimates were combined in the random-effects model. Results. Six eligible studies with a total of 4771 patients with COPD were identified and included in the present meta-analysis. The meta-analysis indicated significantly lower early (in-hospital or 30-day) mortality after TAVI than after SAVR (odds ratio, 0.69; 95% CI, 0.53-0.90; p = .006) but no significant difference in midterm (1-year to 5-year) mortality between TAVI and SAVR (hazard ratio, 1.07; 95% CI, 0.79-1.44; p = .68). Conclusions. In patients with COPD, TAVI was associated with reduced early mortality, while midterm mortality appeared similar, as compared with SAVR.

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OBJECTIVES: To determine whether baseline C-reactive protein (CRP) levels can predict mortality after transcatheter aortic valve implantation (TAVI), we performed a meta-analysis of currently available studies. METHODS: All studies investigating the prognostic impact of baseline (preprocedural) CRP levels on all-cause mortality after TAVI were identified by means of searching PubMed and Google Scholar through May 2019. For each study, (preferentially, adjusted rather than unadjusted) odds/hazard ratios (ORs/HRs) with corresponding 95% confidence intervals of mortality per standard-deviation (SD) (or unit) increase in CRP levels or those for high vs low CRP levels. RESULTS: Our search identified 14 eligible studies including a total of 3449 patients undergoing TAVI and reporting early (in-hospital to 3-month) and midterm (1-year to 3-year) all-cause mortality after TAVI. Pooled analyses demonstrated associations of high-baseline CRP levels with a marginal, but statistically nonsignificant increase in early mortality (pooled OR/HR per SD increase in CRP levels, 2.72; P = .09 and pooled OR/HR for high vs low CRP levels, 3.32; P = .07) and a statistically significant increase in midterm mortality after TAVI (pooled OR/HR per SD increase in CRP levels, 1.45; P < .0001 and pooled OR/HR for high vs low CRP levels, 1.78; P < .00001). Excluding HRs for high-sensitivity CRP, combining ORs/HRs of 1-year mortality, pooling HRs of ≥2-year mortality, and combining adjusted HRs did not alter the primary results. CONCLUSION: High-baseline CRP levels may predict increased midterm, but not early, mortality after TAVI.

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BACKGROUND: To determine whether baseline gait speed predicts mortality after transcatheter aortic valve implantation (TAVI), a meta-analysis of currently available studies was performed. METHODS: To identify all studies researching the impact of preprocedural gait speed on mortality after TAVI, PubMed and Web of Science were searched through May 2019. Adjusted (if unavailable, unadjusted) hazard/odds ratios (ORs/HRs) with their confidence interval of mortality for slow (if available, the slowest) versus fast (if available, the fastest) gait speed (with cut-off values defined in each study) and those for unable to walk versus walker (if available, with the fastest gait speed) were extracted from each study, and then separately pooled by means of inverse variance-weighted averages of logarithmic ORs/HRs in the random-effects model. RESULTS: Twelve eligible studies (7 and 5 based on the distance-limited and time-limited walk test, respectively) were identified and integrated in the present meta-analysis. The pooled analysis of all ORs/HRs demonstrated that slow walkers (primary meta-analysis; OR/HR, 2.38; p < 0.00001) and unable to walk (OR/HR, 1.75; p = 0.01) were significantly associated with increased mortality. The subgroup analysis for the primary meta-analysis indicated no significant subgroup difference between studies utilizing the 4-m/5-m/15-foot walk test and those applying the 6-min walk test (p = 0.45). Combining studies with 1-year follow-up did not alter the primary result (p < 0.0001). Pooling studies with adjusted ORs/HRs did not change the principal result (p = 0.0002). No funnel plot asymmetry for the primary meta-analysis was identified. CONCLUSIONS: Slow baseline gait speed (and unable to walk) is associated with increased mortality after TAVI.

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AIMS: We performed a meta-analysis of currently available studies investigating the impact of postprocedural thrombocytopenia on mortality after transcatheter aortic valve implantation (TAVI). METHODS: All studies researching the impact of postprocedural thrombocytopenia on mortality after TAVI were identified after searching PubMed and Web of Science through July 2019. The outcome of interest was early (in-hospital or 30-day) and overall (1- to 2-year) all-cause mortality after TAVI. From each study, the number of deaths in both patients with major (moderate/severe or higher postprocedural drop platelet counts defined in each study) and nonmajor (no/minor or lower drop platelet counts defined in each study) postprocedural thrombocytopenia was extracted. Then, odds ratios (ORs) of mortality for major vs. no/minor thrombocytopenia and their confidence intervals were generated. Alternatively, ORs and hazard ratios of mortality for major vs. no/minor thrombocytopenia (if available, adjusted) were directly extracted. Study-specific estimates were pooled in both the fixed-effect and random-effects models. RESULTS: The principal pooled analysis demonstrated that postprocedural thrombocytopenia was associated with statistically significant increases in early (OR, 3.79; P for effect <0.00001; P for heterogeneity = 0.89) and overall mortality (OR/hazard ratio, 1.22; P for effect = 0.009; P for heterogeneity = 0.17) in the fixed-effect model. All sensitivity analyses did not substantively alter the results of the principal analysis. No funnel plot asymmetry of the principal analysis was detected (P for early mortality = 0.88; P for overall mortality = 0.14), which suggested probably no publication bias. CONCLUSION: Postprocedural thrombocytopenia is associated with increased early and overall mortality after TAVI.

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To identify prospective cohort studies enrolling adults and investigating an association of egg consumption with incidence and mortality of coronary artery disease (CAD), PubMed and Web of Science were searched through June 2019. Adjusted hazard ratios (HRs) of CAD incidence/mortality for more versus the least frequent egg consumption were extracted from each study. Study-specific estimates were pooled in the random-effects model. Sixteen eligible studies with a total of 1 285 505 participants were identified and included in the present meta-analysis. The primary meta-analysis pooling all HRs for the most versus least frequent egg consumption demonstrated that egg consumption was associated with significantly low CAD incidence/mortality (pooled HR: 0.93; 95% confidence interval: 0.89-0.98; I2 = 9%). In the secondary meta-analyses (separately combining HRs for the third vs first tertile, the fourth vs first quartile, the third vs first quartile, the fifth vs first quintile, the fourth vs first quintile, and the third vs first quintile egg consumption), the fifth (vs first) quintile egg consumption was only associated with significantly low CAD incidence/mortality. In conclusion, egg consumption is independently associated with low incidence/mortality of CAD, which may be derived from the comparisons of the fifth versus first quintile egg consumption.

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INTRODUCTION: It remains unclear whether long-term survival is superior following transcatheter aortic valve implantation (TAVI) than following surgical aortic valve replacement (SAVR). We performed a meta-analysis of mortality with ≥5-year follow-up in randomized controlled trials (RCTs) and propensity-score matched (PSM) studies of TAVI versus SAVR. EVIDENCE ACQUISITION: MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched through March 2019. Eligible studies were RCTs or PSM studies of TAVI versus SAVR enrolling patients with severe aortic stenosis and reporting all-cause mortality with ≥5-year follow-up as an outcome. A hazard ratio of mortality for TAVI versus SAVR was extracted from each individual study. EVIDENCE SYNTHESIS: Our search identified 3 RCTs and 7 PSM studies enrolling 5498 patients. A pooled analysis of all 10 studies demonstrated a statistically significant 38% increase in mortality with TAVI relative to SAVR. A subgroup meta-analysis showed no statistically significant difference between TAVI and AVR in RCTs and a statistically significant 68% increase with TAVI relative to SAVR in PSM studies. CONCLUSIONS: On the basis of a meta-analysis of 7 PSM studies, TAVI is associated with greater all-cause mortality with ≥5-year follow-up than SAVR. However, another meta-analysis of 3 RCTs suggests no difference in mortality between TAVI and SAVR.

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INTRODUCTION: To determine whether troponin (Tn) can predict mortality after transcatheter aortic valve implantation (TAVI), we performed a meta-analysis of currently available studies investigating impact of baseline and postprocedural Tn. EVIDENCE ACQUISITION: MEDLINE and EMBASE were searched through April 2019 using PubMed and OVID. Studies considered for inclusion met the following criteria: the study investigating impact of baseline and postprocedural Tn on mortality; the study population was patients undergoing TAVI for aortic stenosis (AS); outcomes included early (30-day or in-hospital)/late (including early) mortality. For each study, data regarding early/late mortality in both high and low (defined in each study) level of baseline/postprocedural Tn groups were used to generate odds ratios (ORs) and 95% confidence intervals (CIs), or reported ORs and hazard ratios (HRs) with 95% CIs were directly extracted. Study-specific estimates were combined using inverse variance-weighted averages of logarithmic ORs/HRs in the random-effects model. EVIDENCE SYNTHESIS: We identified 19 eligible studies including a total of 7555 patients undergoing TAVI. Pooled analyses demonstrated associations of high levels of baseline Tn with statistically significant increases in both 30-day (P=0.002) and midterm mortality (P<0.00001), no correlation of high postprocedural Tn with 30-day mortality (P=0.13), and an association of high postprocedural Tn with a statistically significant increase in midterm mortality (P=0.002). High levels of baseline/postprocedural TnT predicted statistically significant increases in both 30-day (P=0.002/<0.0001) and midterm mortality (P<0.00001/0.0003). CONCLUSIONS: Both baseline and postprocedural Tn, especially TnT, may predict mortality after TAVI for AS.

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OBJECTIVES: To summarize the present evidence for the association of matrix metalloproteinases (MMPs) with acute aortic dissection (AAD), we performed the first meta-analysis of all currently available case-control studies comparing circulating MMP levels between AAD patients and control subjects. METHODS: To identify all studies investigating the levels of circulating MMPs in AAD patients, PubMed and Web of Science were searched up to July 2019. The levels of MMPs in AAD patients and control subjects were extracted from each study, and the standardized mean differences (SMDs) in MMP levels were generated. The study-specific estimates were combined in the random-effects model. RESULTS: Twelve studies enrolling a total of 458 AAD patients and 711 control subjects were identified and included. Pooled analyses demonstrated no significant differences in MMP-1 (4 studies; P = 0.21), MMP-2 (5 studies; P = 0.62) and MMP-3 levels (2 studies; P = 0.94) between AAD patients and control subjects; and significantly higher MMP-8 (2 studies; SMD 2.11; P = 0.020), MMP-9 (9 studies; SMD 1.54; P < 0.001) and MMP-12 levels (2 studies; SMD 1.33; P < 0.001) in AAD patients than in control subjects. CONCLUSION: High circulating MMP-9 levels are associated with AAD, and MMP-8 and MMP-12 levels may be related to AAD.

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