Safety and efficacy of balloon angioplasty compared to stent-basedstrategies with pulmonary vein stenosis:A systematic review and meta-analysis

BACKGROUND Pulmonary vein stenosis(PVS)is an uncommon but known cause of morbidity and mortality in adults and children and can be managed with percutaneous revascularization strategies of pulmonary vein balloon angioplasty(PBA)or pulmonary vein stent implantation(PSI).AIM To study the safety and efficacy outcomes of PBA vs PSI in all patient categories with PVS.METHODS We performed a literature search of all studies comparing outcomes of patients evaluated by PBA vs PSI for PVS.We selected all published studies comparing PBA vs PSI for PVS with reported outcomes of restenosis and procedure-related complications in all patient categories.In adults,PVS following atrial fibrillation ablation and in children PVS related to congenital etiology or post-procedural PVS following total or partial anomalous pulmonary venous return repair were included.The patient-centered outcomes were risk of restenosis requiring re-intervention and procedural-related complications.The metaanalysis was performed by computing odds ratios(ORs)using the random effects model based on underlying statistical heterogeneity.RESULTS Eight observational studies treating 768 severe PVS in 487 patients met our inclusion criteria.The age range of patients was 6 months to 70 years and 67%were males.The primary outcome of the re-stenosis requiring re-intervention occurred in 196 of 325 veins in the PBA group and 111 of 443 veins in the PSI group.Compared to PSI,PBA was associated with a significantly increased risk of re-stenosis(OR 2.91,95%CI:1.15-7.37,P=0.025,I2=79.2%).Secondary outcomes of the procedurerelated complications occurred in 7 of 122 patients in the PBA group and 6 of 69 in the PSI group.There were no statistically significant differences in the safety outcomes between the two groups(OR:0.94,95%CI:0.23-3.76,P=0.929,I^(2)=0.0%).CONCLUSION Across all patient categories with PVS,PSI is associated with reduced risk of re-intervention and is as safe as PBA and should be considered first-line therapy for PVS.

Superior safety of direct oral anticoagulants compared to Warfarin in patients with atrial fibrillation and underlying cancer: a national veterans affairs database study

Background Studies evaluating safety of warfarin and direct oral anticoagulants(DOACs) for prevention of stroke in patients with atrial fibrillation(AF) are lacking. Methods & Results All patients(n = 196,521) receiving care at veteran’s affairs with active cancer and AF from 2010–2015 were included. One-year mortality was significantly higher in unadjusted analysis with warfarin(44.9%) compared to dabigatran(25%, P < 0.001), rivaroxaban(24.4%, P < 0.001) and apixaban(30%, P < 0.001) and after adjusting for age, sex and type of cancer mortality(OR = 2.66, 95% CI: 2.52–2.82, P < 0.001). Risk of ischemic stroke(13.5% vs. 11.1%, 12.0%, 14.0%) was similar, however risk of hemorrhagic stroke was significantly higher among patients receiving warfarin(1.2%) compared to patients receiving dabigatran(0.5%), rivaroxaban(0.7%) and apixaban(0.8%) respectively, P = 0.04. Conclusions We demonstrated the superior safety profile of DOACs compared to warfarin among patients with underlying cancer and AF. Warfarin was associated with higher mortality, similar ischemic stroke risk but higher risk of hemorrhagic stroke.